Smg Residential Care

Type of visit: Required - 1 Year

On 11/21/25 at 2PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA observed ADM has current RCFE certificate# 7034121740 which expires on 09/15/2027 At 2:15PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 72 deg F. Hot water temperature was measured at 118 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged and last inspected on 05/13/25. LPA reviewed 3 staff and 5 resident files. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 21, 2025

Allegation investigated: Staff did not properly report an incident involving the residents Staff did not prevent the residents from engaging in a physical altercation

On 03/27/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information on the allegations and delivered investigation findings. LPA explained the purpose of the visit with ADM. During investigation, the department obtained the following documents from administrator – personnel record (LIC500), residents’ roster, admission agreements, physician's reports, re-appraisals, medical records and incident report. Continued on next page, LIC9099-C Substantiated ALLEGATION: Staff did not properly report an incident involving the residents INVESTIGATION FINDING: Substantiated During investigation, the department conducted interviews of facility staff (ADM), residents (R1, R2), reporting party (RP) and reviewed R1 & R2 documents. On 03/24/25 at 10AM, LPA interviewed reporting party (RP) who stated that R1 and R2 had a physical altercation the evening of 02/16/25 and also the next morning before breakfast in their bedroom resulting in R2 sustaining bruising in his right cheek and a cut to his nose. On 03/27/25 at 1PM, ADM confirmed with LPA that they failed to timely report the incident to Community Care Licensing (CCLD) and Ombudsman (OMB) within the required 48 hours timeline. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not properly report an incident involving residents. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated. Continued on the next page, LIC 9099-C pg2 ALLEGATION: Staff did not prevent the residents from engaging in a physical altercation INVESTIGATION FINDING: Substantiated On 03/24/25 at 10:30AM, LPA interviewed reporting party (RP) who stated that R1 and R2 had a physical altercation on the evening of 02/16/25 resulting in R1 sustaining bruises to his face and a cut to his nose. On 03/27/25 at 1PM, LPA interviewed administrator (ADM) who stated that R1 & R2 had an argument inside their bedroom again in the morning before breakfast. ADM stated R1 punched R2 in the face which bruised his right cheek and cut his nose. On 03/27/25 at 2:35PM, R1 and R2 both confirmed with LPA that no staff redirected them when the incidents occurred inside their bedroom. ADM stated that she did not know about the incident until she noticed R2’s bruised face and cut nose the next morning during breakfast. ADM stated R2 did not want to go to the hospital to treat his nose and bruises. ADM treated him with cold compress and was offered ibuprofen which he refused. With the residents' consent, ADM moved R2 to another bedroom with another roommate to avoid reoccurrence of the incident. R1 remained in his room without any roommate. On 02/18/25, ADM stated R1 was re-evaluated by his primary care physician and was prescribed increased Olanzapine medication. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not prevent the residents from engaging in a physical altercation. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 15-AS-20250321142651

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(c) · Plan of correction due date: Apr 18, 2025

Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by staff’s failure to timely report incidents to Community Care Licensing (CCL) and Ombudsman which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: By POC due date, ADM agrees to complete and submit in-service staff retraining certifications on reporting requirements in compliance with Section 87211 (a)(1)(c).

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 18, 2025

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by staff’s failure to redirect aggressive residents which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: By POC due date, ADM agrees to complete and submit in-service staff retraining certifications on residents’ personal rights in compliance with Section 87468.2 (a)(4).

Type of visit: Case Management - Incident

On 09/05/2024 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/28/2024. LPA met with Administrator (ADM) and explained the purpose of the visit. The incident report received stated that on 08/27/24 resident (R1) threatened to use stolen hospital syringes on staff due to aggressive behaviors. Staff notified police who placed him under custody due to prior arrests. When R1 came back to the facility, he requested staff to take him to the local bank and leave him there. Review of R1's physician's report show he is able to leave the facility unassisted. Since R1 did not return from the bank to the facility, administrator (ADM) filed a missing person's report with police. ADM continues to work with R1's case manager and primary care physician in addressing his needs. ADM also issued a written 30 day notice of eviction to R1 (see attached) effective 09/30/24. j.zier incident report 2024-08-27 s.pdf eviction notice j.zier.pdf Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 6, 2024

Type of visit: Required - 1 Year

On 09/22/23 at 10AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 76 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged and last inspected on 07/21/24. LPA reviewed 3 staff and 5 resident files. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 6, 2024