St Paul's Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Ellenich and Interim Executive Director LaTeressa Downing. The facility serves two hundred (200) elderly residents age sixty (60) and above; six (6) of whom may be non-ambulatory and may use rooms #101- #106. There is an approved hospice waiver for three (3) residents. This is a 11 story complex, with no delayed egress and secured perimeters. LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected a sample of rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies are supplied by residents and facility will provide upon request. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medication management is not provided by the facility. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months and are present on each floor. First aid kit were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with ED Ellenich, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 22, 2025

Allegation investigated: -Licensee pursued unlawful eviction of resident. -Licensee did not reasonably accommodate resident’s needs/preferences.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Tim Jeffers and Resident Services Coordinator Carol Braun. The Complainant alleged that Licensee pursued unlawful eviction of Resident #1 (R1), and that Licensee did not reasonably accommodate R1’s needs/preferences. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews of R1, facility managers and staff, and Licensee’s attorney. [CONTINUED ON LIC 9099-C, 1 of 5] Substantiated [CONTINUED FROM LIC 9099] Interviews unanimously showed that on 04/10/2025, Licensee served R1 with a letter titled “Re: Notice of Termination of Resident Agreement.” The letter was addressed to R1 and delivered via personal service, E-mail, and US Mail. During this complaint investigation, Licensee told CCLD that the 04/10/2025 letter was not a written notice of eviction. The Department requested and received copies of said letter, both from R1 and from Licensee, which matched. The letter stated, in part: “Pursuant to Section VII (B)(1)(c), this correspondence services [sic] to notify you that The Manor on Bankers Hill (“The Manor”) will be terminating your Resident Agreement. Please accept this correspondence as your thirty (30) day notice of termination; please begin preparations on your end to vacate your residence.” It also stated, “The basis for this termination is your continued defiance of The Manor’s rules which directly impact the safety and security of the residents at The Manor.” It also stated, “Please ensure that you review your Resident Agreement and comply with your obligations set forth in Section VII (D)(1) with regard to vacating your residence.” The Department requested and received copies of R1’s signed Resident Agreement contract, both from R1 and from Licensee, which matched. According to this contract: Section VII (B) was titled, “Termination by Us,” and described multiple “eviction provisions,” of which (1)(c) was, “Your failure to comply with the general policies of the Manor.” Section VII (D)(1) was titled, “Vacating Apartment,” and read, in part, “If this Agreement is terminated, you or your estate must vacate the apartment and remove all your property from it,” and “We may also remove your property from the apartment and charge you or your estate a property storage fee if either you or your estate fails to vacate the apartment and remove your personal belongings from it by the effective termination date.” Based on the above, the Department determined that the 04/10/2025 letter which Licensee served upon R1, was indeed, a written 30-day notice of eviction. Missing in the letter were multiple elements/disclosures required by regulations, contributing to its unlawfulness. (These deficiencies will be addressed in a separate Case Management visit report). [CONTINUED ON LIC 9099-C, 2 of 5] [CONTINUED FROM LIC 9099-C, 1 of 5] Although Licensee’s 04/10/2025 letter did not specify the facility rule/policy R1 allegedly broke, interviews of R1 and facility attorney/managers and E-mails and letters exchanged between the parties aligned to show: The underlying conflict was Licensee’s expectation that R1 manually sign themselves out (using a pen and the three-ring binder atop a podium in the facility’s lobby) upon exiting the facility, and that R1 sign themselves back in upon reentering the facility. R1, however, conveyed to Licensee that they disagreed with signing themselves out/in. According to California Code of Regulations, Title 22, Section 87224, residents of Residential Care Facilities for the Elderly (RCFEs) may only be evicted from the facility for a few specified reasons, one of which is “(a)(3) Failure of the resident to comply with general policies of the facility.” This regulation states in the next sentence, “Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admissions agreement.” Section 87506 states, “(g) Admission agreements shall specify the following: (8) General facility policies that are for the purpose of making it possible for residents to live together.” Section 87468.2 states that residents in privately-operated RCFEs must “be fully informed, prior to or at the time of admission, of all rules that govern resident conduct and responsibilities while living at the facility, as evidenced by the resident’s written acknowledgement. All rules established by a licensee shall be reasonable…” On 01/31/2025, R1 and Licensee jointly signed the Resident Agreement contract, to go into effect on 02/28/2025. Per R1’s Face Sheet, they moved-in to the facility on 02/28/2025. The Resident Agreement contract did not discuss the facility’s expectation that R1 themselves use the sign in/out book, but in Section X (D) stated, “Resident Handbook: You agree to abide by the general policies of the Manor. A copy of the current Resident Handbook is attached as Appendix D and made part of this Agreement. We reserve the right to change the Resident Handbook at any time…” Interviews showed the “Resident Handbook” document was not provided to R1 on 02/28/2025 (the date of contract signing). Instead, the Resident Handbook was first given to R1 during New Resident Orientation, which occurred on 03/06/2025, after R1 had already moved in, as confirmed by the manager who led that meeting. [CONTINUED ON LIC 9099-C, 3 of 5] [CONTINUED FROM LIC 9099-C, 2 of 5] According to R1’s latest LIC602 Physician’s Report (dated 12/27/2024): R1 was ambulatory with no diagnosis of cognitive impairment. R1’s doctor wrote that R1 was not confused, not depressed, able to follow instructions, able to communicate, able to care for all personal needs, able to store and administer their own medications, able to manage their own cash, and able to safely leave the facility unassisted. Interviews of R1, managers, and staff unanimously showed: R1 was their own payee and responsible person, independent in Activities of Daily Living (ADLs), able to walk without cane or walker, able to safely drive a car, was gainfully employed, and time and again safely managed themselves in public and consistently returned to the facility on their own. According to interviews of facility managers on 05/06/2025, all 106 residents of the facility (including R1) were ambulatory, cognitively-independent, independent in ADLs and medications, and were capable of safely leaving and returning from the facility on their own. Facility managers were unable to convey to the Department how R1’s not singing themselves out/in at the lobby podium precluded any other resident from doing so if they wished, or how it precluded R1 from living peaceably with their peers. All managers and frontline staff interviewed confirmed R1 owned and carried a cell phone, and that they knew how to call R1’s cell phone if they needed to reach R1. Staff confirmed that Licensee also employed other methods to provide passive observation to their independent residents, such as a daily meal attendance checklist and an “I’m Okay” door hanger, which residents reaffix to their front doorknob every day to show they are alive and well. (These latter practices were also described in Licensee’s Absentee Notification Plan.) R1 was agreeable to and cooperating with both the checklist and door hangar methods. Facility managers stated the main objective of the sign out/in book was for staff/first responders to know how many persons were present inside the building in the event of a fire or similar disaster. CCLD recognizes the practical value that a sign out/in log has. However, the Department is bound to the regulations as they are currently written. California Code of Regulations and Health and Safety Code currently neither require nor prohibit a resident sign out/in log. Per correspondence from the office of the Fire Marshal for the City of San Diego, they too do not require the facility to maintain a resident sign out/in log. They, along with CCLD, do require Licensee to maintain an up-to-date list/register of residents in care with notations about those who are incapable of self-evacuation (i.e. those who are classified as “non-ambulatory” or “bedridden”). [CONTINUED ON LIC 9099-C, 4 of 5] [CONTINUED FROM LIC 9099-C, 3 of 5] The facility’s “Resident Handbook” stated, “Residents are requested to sign in and out whenever entering or leaving our community.” A subsequent 04/10/2025 written memorandum from Licensee to all residents on this same topic similarly used the word “asked.” Such permissive language is congruent with current regulations. On 04/11/2025, the day after R1 received their 30-day notice letter, R1 wrote to Licensee, explaining that they are sometimes in a hurry to leave the facility and cannot afford to wait behind other residents who are also singing out at the same book. (R1 is gainfully employed, frequently commuting to their nearby office or meeting clients by appointment). R1 offered going forward to sign out verbally or via phone call to the receptionist, in lieu of manually writing in the book. (The facility staffs a receptionist at their front desk 24/7). On 04/13/2025, Licensee wrote back denying R1’s proposed compromise. R1 then attended an in-person meeting with facility managers on 04/27/2025, reiterating their willingness to sign out/in verbally but not manually; R1's request was again denied. During CCLD’s first site visit for this complaint on 05/06/2025, LPA asked facility management why R1’s request for accommodation was untenable if it represented a step forward in the direction of Licensee’s stated goal of “fire safety.” Managers replied that their lobby receptionists were too busy with daily job tasks to write down that R1 left the building, and that they did not intend to rescind their 04/10/2025 letter to R1. Per manager interviews, as of that date, no residents beside R1 were known to either oppose or to consistently forget to manually sign themselves out. In other words, R1’s request for accommodation regarding the sign out/in book was the only such one. LPA subsequently interviewed multiple facility receptionists, each of whom confirmed they daily write their observations as they occur in the “St. Paul’s Manor Daily Log,” an electronic document which they keep updated via their front desk computer. LPA subsequently studied a sampling of this log spanning six (6) consecutive shifts, finding the receptionist team wrote ninety-seven (97) bullet-point style entries during this span, of which twenty-six (26) were directly concerning residents coming or going from the facility. They also wrote about numerous individuals’ package deliveries and pickups, lost and found items, and even the trash utility company coming to empty the facility’s trash. [CONTINUED ON LIC 9099-C, 5 of 5] [CONTINUED FROM LIC 9099-C, 4 of 5] Based on records and interviews, a preponderance of evidence exists to show that Licensee pursued unlawful eviction of R1, and that Licensee did not reasonably accommodate R1’s needs/preferences. Both allegations were therefore Substantiated, and two (2) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Jeffers and Braun, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 8, 2025 · control 08-AS-20250430143006

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(3) · Plan of correction due date: May 9, 2025

87224 Eviction Procedures: “(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)… (3) Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement.” This requirement was not met, as evidenced by: Based on records review and interviews, Licensee served an eviction notice to 1 of 106 residents (R1) for failure to comply with a general policy of the facility, but said policy was not for the purpose of making it possible for residents to live together and was not fully disclosed at the time the admissions agreement was signed. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(14) · Plan of correction due date: May 9, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (14) To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility…” This requirement was not met, as evidenced by: Based on records review and interviews, Licensee did not reasonably accommodate the individual need/preference of 1 of 106 residents (R1) regarding their life at the facility, when the specific accommodation that R1 requested was reasonable with regard their safety and those of peers. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee agreed to immediately allow R1 the options of signing out/in manually, OR verbally / by phone call with the receptionist, when they are leaving/returning to the facility building. Licensee agreed to provide R1 written notice of such, and to E-mail a copy of said correspondence to LPA, by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Tim Jeffers and Resident Services Coordinator Carol Braun. The Department’s investigation involved records review and interviews of pertinent facility managers, other sources, and Resident #1 (R1). [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The evidence showed on 04/10/2025, Licensee served a 30-day notice eviction letter upon R1, but did not notify CCLD within five (5) days of service, as required. The Department subsequently obtained a copy of the eviction letter, finding it deficient in the following ways: -Licensee did not specify the “effective date of the eviction,” as required. -Licensee cited in the letter R1’s “continued defiance” of facility rule(s), but did not specify in the letter which specific rule(s) were violated nor provide “specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons,” as required. -Licensee did not specify in the letter “resources available to assist in identifying alternative housing and care options,” to include “referral services” and “case management organizations,” as required. -Licensee did not include “a statement informing residents of their right to file a complaint with the licensing agency…including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office,” as required. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] -Licensee did not include the required disclaimer paragraph from California Health and Safety Code Section 1569.683(a)(4), which reads, "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Additionally, during a facility evaluation visit on 09/18/2023, LPA learned that Licensee had about six months earlier installed a new facility administrator / Executive Director, Staff #1 (S1), who was different from the administrator on record with CCLD (the latter person was no longer working at the facility). (Per regulation, Licensees must notify the Department in writing within thirty (30) days of hiring a new administrator.) Instead of citing Licensee for failing to notify CCLD as required, the Department recognized S1 was adjusting to their new role and afforded Licensee an opportunity to self-correct. LPA issued written Technical Assistance (TA) to Licensee providing detailed instructions on the specific paperwork/forms which Licensee needed to submit to the Department by 09/28/2023 to change the administrator on record to S1. However, as of LPA’s 05/06/2025 site visit, Licensee still had not corrected the violation, so a deficiency was issued for it. Seven (7) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Jeffers and Braun, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(f) · Plan of correction due date: May 9, 2025

87224 Eviction Procedures : “(f) A written report of any eviction shall be sent to the licensing agency within five (5) days.” This requirement was not met, as evidenced by: Based on records review, Licensee did not send a written report of eviction regarding 1 of 106 residents (R1) to the licensing agency within five (5) days. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(d)(1)(A) · Plan of correction due date: May 9, 2025

87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (A) The effective date of the eviction.” This requirement was not met, as evidenced by: Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include the effective date of the eviction. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: May 9, 2025

87224 Eviction Procedures : “(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.” This requirement was not met, as evidenced by: Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not set forth specific facts to include date, place, witnesses, and circumstances concerning the reason(s) for eviction. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(d)(1)(B) · Plan of correction due date: May 9, 2025

87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (B) Resources available to assist in identifying alternative housing and care options…” This requirement was not met, as evidenced by: Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include resources available to assist in identifying alternative housing and care options, to include referral services and case management organizations. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(1)(C) · Plan of correction due date: May 9, 2025

87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (C) A statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office.” This requirement was not met, as evidenced by: Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include a statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(d)(1)(D) · Plan of correction due date: May 9, 2025

87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): ‘In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing.’” This requirement was not met, as evidenced by: Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include the following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): “In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing.” This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(g) · Plan of correction due date: May 16, 2025

87211 Reporting Requirements: “(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: (1) Name and residence and mailing addresses of the new administrator. (2) Date he/she assumed his/her position. (3) Description of his/her background and qualifications, including documentation of required education and administrator certification. (A) A photocopy of the documentation is acceptable.” This requirement was not met, as evidenced by: Based on LPA observation and manager interviews: Licensee did not notify the Department in writing within thirty (30) days of the hiring of a new administrator. This posed a potential health, safety, and personal rights risk to 1 of 106 residents (R1 though R106) in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: By the POC due date, Licensee agreed to E-mail copies of the following to the CCLD San Diego Regional Office at CCLASCPSanDiegoRO@dss.ca.gov (and CC’ing LPA Dang Nguyen): 1. A signed and dated cover letter from the Licensee: The letter will state that a change in administrator occurred, the effective date of the change, S1’s full name, their contact information, and residence and business mailing addresses; 2. Form LIC308 Designation of Facility Responsibility signed by Licensee; 3. Form LIC508 Criminal Record Statement for S1; 4. From LIC501 Personnel Record and resume for S1; 5. A current RCFE Administrator Certificate for S1; and 6. A copy of S1’s current California’s Driver’s License.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Domingo was granted entry into the facility by Resident Services Coordinator, Carol Braun, after identifying herself and stating the purpose of the inspection. The facility serves two hundred (200) elderly residents age sixty (60) and above; six (6) of whom may be non-ambulatory and may use rooms #101- #106. There is an approved hospice waiver for three (3) residents. This is a four story complex, with no delayed egress and secured perimeters. LPA was accompanied by Resident Service Coordinator Carol Braun during a tour of the facility. The tour was conducted within the interior and exterior and included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. No bodies of water are on premises. Passageways were free from obstructions. According to executive director, there are no weapons and/or ammunition stored on the premises. Call box was available in each resident unit and were tested for functionality. Resident's room temperatures were within a comfortable 72 degree F range. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in rooms or in locked hall closet. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked cabinet. Clients are independent and do not require medication management. Resident records reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, and Admission Agreement. Administrator’s certification is current. Transportation procedures were reviewed and complaint. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. LPA interviewed staff and he interview did not raise any significant licensing concerns. LPA reviewed records/files. Staff are current on training requirements. Client files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted, this report was discussed with Carol Braun, Resident Services Coordinator, and a copy along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Carol Braun, Resident Services Coordinator.the state’s words, verbatim · CDSS document, Oct 23, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Tim Jeffers and Resident Services Coordinator Carol Braun. LPA briefly toured the facility and performed a health and safety welfare check on residents in care, finding they were safe. LPA spoke with facility management regarding the completion of a recent heating and air conditioning repair. The facility’s ambient internal air temperature was comfortable and compliant during today’s visit. No deficiencies were observed or cited. An exit interview was conducted with Braun and Jeffers, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 28, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced, subsequent Case Management visit to cite deficiencies resulting from an incident self-reported by the licensee. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Resident Services Coordinator Carol Braun. LPA also met with Executive Director Tim Jeffers. On 09/05/2023, the CCLD San Diego Regional Office received an LIC624 Incident Report from the licensee. Per the LIC624: On 08/31/2023 around 4:00 PM, Resident #1 (R1) fell at the facility, requiring them to be sent to a hospital emergency room for medical care. [See LIC 811 Confidential Names List for a description of person identifiers used]. CCLD’s investigation involved a brief facility tour on 09/18/2023, followed by welfare check on R1 via a collateral visit. CCLD also interviewed relevant residents, staff, and outside sources, and reviewed pertinent care records and correspondence. According to R1’s LIC602 Physician’s Report and corroborated by the appraisals/assessments which Licensee performed on R1: for most of R1’s residency at the facility (which began in 2017), R1 was historically independent with Activities of Daily Living (ADLs), to include walking and transferring, and required no assistive device such as a cane, walker, or wheelchair. Records and interviews of residents and staff, aligned to show: On 08/29/2023, R1’s spouse and roommate, Resident #2 (R2) approached facility management to tell them that R1 was falling frequently inside their bedroom, and that this new trend had occurred over the last “couple of weeks.” R2 admitted that they initially did not report R1’s falls to staff, but now recognized staff help was needed to maintain R1’s safety. Then on 08/31/2023, R1 fell at the facility, sustaining a nosebleed, skin lacerations on forehead and knee, and bruising to face, buttock, and leg. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Medical records showed R1 was diagnosed with a fracture of “C5 endplate” (i.e., a bone in their neck), for which R1 had to wear a collar device. R1 told CCLD they also experienced changes in their visual perception / processing, which lasted for a few weeks after the fall. Records, interviews, and E-mails further showed: From the time Licensee received constructive knowledge of R1’s new fall-risk on 08/29/2023, until the time R1 fell and was hospitalized on 08/31/2023, Licensee verbally told R2 that R1 needed to relocate to another care facility since R1’s now required caregiving assistance. However, Licensee’s staff did not meet with R1 in person to perform a written reappraisal of their care needs, nor notify R1’s physician of what R2 reported to them about R1. Licensee also did not assign any caregiver to R1 to help mitigate fall risk, either from its own staff pool or from a contracted outside source (such as a home care agency). On 09/01/2023, hospital staff determined R1 was ready to be discharged back to the facility, but facility management told hospital staff that R1 could not return to the facility to due needing a higher level of care. R1 instead went to a skilled nursing facility (SNF). On 09/02/2023, facility management referred R2 to a third-party placement/referral agent, who subsequently helped R1 move from the SNF to another permanent residence. Licensee did not issue R1 a 30-day written notice to move-out from the facility, as was required. E-mail and interviews showed R1’s move-out occurred under duress: R2 appealed to the SNF to extend R1’s stay to allow the more time to research and find another residence for them, but that appeal was denied. Unable to return to St. Paul’s Manor, R1 was discharged to their new residence on 09/12/2023. Based on records and interviews, a preponderance of evidence exists to show: a) Upon receiving constructive knowledge of a change in condition, Licensee did not observe/reappraise R1, report changes to R1’s physician, and provide appropriate assistance for R1’s unmet need, as were required; and, b) Licensee evicted R1 from the facility without giving them the required 30-day written notice. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). One of the violations was material to R1 sustaining serious bodily injury; an immediate civil penalty of $500 was also assessed (refer to the LIC421-IM). Plans of Correction was jointly developed with the licensee. An exit interview was conducted with Braun and Jeffers, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 11, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 12, 2024

87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical…functioning and that appropriate assistance is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented and brought to the attention of the resident’s physician…” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 64 residents (R1), Licensee did not ensure that changes in physical functioning were observed, documented, and brought to the attention of their physician, and that appropriate assistance was provided for an unmet need. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Per manager interviews, Licensee does not self-employ caregivers, due to residents of the facility being independent in ADLs at the time of their admission. Licensee thus agreed to choose and formally retain (i.e., sign contracts with) three licensed home care organizations (HCOs) that it can partner with to hire contracted caregivers, on an as-needed basis. Licensee also agreed to utilize a third-party source to facilitate training for its managers. The training will cover: 1. A debrief of the incident, b. Regulations 87466 Observation of the Resident and 87463 Reappraisals, and c. where the contact info for its three preferred HCOs will be posted. By the POC due date, Licensee agreed to E-mail to LPA: a) the names and phone numbers of its three preferred HCOs, and b) the planned date for the manager training. By 02/10/2024, Licensee agreed to E-mail LPA a copy of the training sign-in sheet.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(a) · Plan of correction due date: Feb 10, 2024

87224 Eviction Procedures: “(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).” This requirement was not met, as evidenced by: Based on records and interviews, Licensee evicted 1 of 64 residents (R1) without providing thirty (30) days written notice to the resident.” This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Licensee agreed to utilize a third-party source to facilitate training for its managers. The training will cover Regulation 87224 Eviction Procedures. By the POC due date, Licensee agreed to E-mail to LPA a copy of the training sign-in sheet.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Executive Director, Timothy Jeffers after identifying herself and stating the purpose of the inspection. The facility serves two hundred (200) elderly residents age sixty (60) and above; six (6) of whom may be non-ambulatory and may use rooms #101- #106. There is an approved hospice waiver for three (3) residents. This is a four story complex, with no delayed egress and secured perimeters. LPA was accompanied by Executive Director, Jeffers and Resident Service Coordinator Carol Braun during a tour of the facility. Tour was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. The last disaster drill was conducted in October 2023. No bodies of water are on premises. Passageways were free from obstructions. According to executive director, there are no weapons and/or ammunition stored on the premises. Call box was available in each resident unit and were tested for functionality. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in rooms or in locked hall closet. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked cabinet. Clients are independent and do not require medication management. Staff records review verified that at least one staff member, per shift, has a First Aide/CPR certificate, Criminal Record Clearance, Personnel Record, TB clearance, and Health Screening Report. Resident records reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, and Admission Agreement. Administrator’s certification is current. Transportation procedures were reviewed and complaint. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted, this report was discussed with Executive Director ,Jeffers copy along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Executive Director, Timothy Jeffers.the state’s words, verbatim · CDSS document, Oct 24, 2023