Strawberry Cottage

Allegation investigated: Staff made inappropriate comments towards resident.

On 10/08/2025 Licensing Program Analysts (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above mentioned allegations. LPA arrived to the facility and was granted access by Staff #2 (S2). S2 contacted Monica Gory, the administrator by telephone and LPA explained the purpose of the visit. An entrance interview was conducted with the administrator. Administrator arrived at 3:50 p.m. During the course of the investigation, LPA conducted an initial visit on 02/25/2025. During the initial visit, LPA interviewed the administrator and Staff #2 (S2). From approximately 10:54 a.m. to 1:26 p.m., LPA reviewed resident records and obtained copies, including but not limited to: Resident #1’s (R1’s) Resident Report and Observations, Unusual Incident/Injury Reports, Physician’s Report, and the facility’s Infection Control Plan. LPA also interviewed Resident #1 (R1), Resident #2 (R2) and attempted to interview Resident #5 (R5); however, Resident #5 (R5) did not respond to questions. (Continue to LIC9099-C) Substantiated On 09/09/2025, while conducting the unannounced annual required visit, at approximately 10:25 AM, LPA interviewed R4. During an unannounced subsequent complaint visit conducted on 09/29/2025, LPA interviewed Resident #3 (R3) and conducted telephone interviews with Staff #1 (S1) and Staff #3 (S3). Allegation: Staff inappropriately isolated resident. Regarding the allegation is was reported that R1 has been isolated in their room for a month without an explanation. LPA's interview with R1 on 02/25/2025 indicated that they had been isolated for little over a week. R1 stated they only coughed once in a while and had a severe infection before that. R1 did not recall the date they were sick. Interview with the Administrator on 02/25/2025 confirmed R1 was isolated towards the end of January as a precaution because R1 had Covid-19 or flu-like symptoms such as constant cough with extreme phlegm. Administrator stated she contacted R1's responsible party to have R1 taken to the hospital to be examined and rule out covid-19 but they refused to take R1 and have R1 transported via ambulance. According to the Administrator they were following their infection control plan to minimize the spread of infection. LPA's interview with R2 on 02/25/2025 confirmed they had been sick with vomiting, cold, and pain recently and had been isolating in their room. According to R2 prior to getting sick they observed R1 was "very sick" and isolated for a week. Interview with three staff including the administrator corroborate R1 was exhibiting flu like symptoms and was isolated no more than a week. Interview with four (04) out (05) five residents with one (01) resident not responding to questions corroborate R1 had flu like symptoms coughing during mealtimes. LPA’s review of the facilities infection control plan verbatim “Facility will ensure separation and care of residents whose illness requires separation, including minimizing group and public activities and ensure residents are eating meals in their rooms. Based on interviews conducted and record review there is insufficient evidence R1 was isolated for over a month therefore the allegation is deemed Unsubstantiated at this time. Allegation: Staff are not responding to resident's call button. It is alleged that staff are not responding to Resident #1’s (R1’s) calls for assistance. On 02/25/2025, during LPA’s physical plant tour, LPA tested R1’s call button and observed it to be functional. In an interview conducted by LPA, R1 denied the allegation. R1 stated they had no issues with getting assistance but that staff had complained that R1 was pushing their call button all the time. R1 denied this stating they only push it when they need assistance. Interview with the Administrator and three (03) staff denied the allegation. Page 2 of 3 (Continue to LIC9099-C) (Continued from LIC9099-C)According to S1 the button needed new batteries at some point (date unknown) but they would make their usual rounds anyway to check on residents. Interview with the Administrator revealed they had received complaints from staff alleging R1 was constantly pushing their call button after they had already provided assistance and the topic was discussed with R1. Interview with four (04) out four (04) residents interviewed deny the allegation stating they have no issues or concerns with getting assistance. Two (02) residents that also use the call button state they do not have any issue with response time once they push their button. Based on interviews conducted and LPA's observation there is insufficient evidence staff are not responding to resident's call button, therefore the allegation is deemed Unsubstantiated at this time. Allegation: Staff are not providing adequate food service to resident. It is alleged that R1 was not provided dinner on 01/20/2025. Additionally, when meals are served in R1’s bedroom, staff reportedly remove the food before R1 has finished eating and attempt to control what R1 eats. During LPA's interview with R1, R1 denied missing any meals or being prevented from finishing them. However, R1 did confirm that staff have attempted to regulate their sugar intake, limiting it to either three tablespoons or a sprinkle. Interview with R2 stated they had witnessed R1 pour sugar until it is all gone. Interview with the administrator and three staff corroborate R1 would pour what they believed was an excessive amount of sugar but would not deny R1 when they requested sugar because R1 does not have a physician's dietary restriction however they provided a smaller container of sugar for R1 to pour sugar from. Interview with three (03) out of four (04) residents interviewed deny a meal had not been provided or removed before they finished it and staff control what they eat. Based on the interviews conducted, there is insufficient evidence to support the allegation that staff are not providing adequate food service to the resident. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report provided. On 09/09/2025, while conducting the unannounced annual required visit, at approximately 10:25 AM, LPA interviewed R4. During an unannounced subsequent complaint visit conducted on 09/29/2025, LPA interviewed Resident #3 (R3) and conducted telephone interviews with Staff #1 (S1) and Staff #3 (S3). During todays visit LPA conducted follow-up interviews with three (03) out three (03) residents regarding this allegation. Allegation: Staff made inappropriate comments towards resident. It is alleged that S1 made an inappropriate comment towards R1. LPA's interview with R1, confirmed the allegation stating, S1 told R1 if their family member came to the facility again, they would be arrested and it would be R1’s fault. R1 stated it was not the only time S1 spoke to them inappropriately and made them uncomfortable. LPA's interview with S1 denied the allegation stating R1's Family Member (FM) arrived to the facility when S1 was working and FM was aggressive and yelling. S1 warned them they would call the "cops because they did not feel safe". When S1 was on the phone with the police FM left the facility. S1 says the incident started with R1 and FM having an argument about a new phone. LPA's interview with two (02) out of four (04) residents interviewed corroborate the allegation that S1 has spoken to R1 inappropriately. One (01) out of four (04) residents denied witnessing S1 make inappropriate comments but that S1 had been rude without providing specific examples. LPA's interview with the administrator and two (02) other staff state they work different shifts and only see each other during shift changes. However the administrator and one (01) staff were not surprised by the allegation believing words may have been exchanged since FM was threatening staff. According to the administrator, there had been ongoing issues between R1 and FM. It was recommended to the administrator by Long Term Care Ombudsman (LTCO), and Libertana the Assisted Living Waiver (ALW) case worker to contact law enforcement if FM was threatening staff. Additionally, administrator was advised by LTCO to contact APS if they believed FM was verbally abusive towards R1. Even though FM was exhibiting aggressive behavior the administrator and two (2) staff confirmed that R1 had complained about S1’s treatment toward them. Based on LPA's interviews with residents and staff there is sufficient evidence to support the allegation, staff made inappropriate comments to R1. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Appeal Rights provided. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 31-AS-20250221124252

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 31, 2025

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on LPA’s interviews, the licensee did not comply with the section cited above, as Staff #1 (S1) spoke inappropriately to Resident #1 (R1), posing a potential risk to the health, safety, or personal rights of individuals in care.the state’s words, verbatim · CDSS document, Oct 8, 2025

Plan of correction: The Administrator agreed to conduct an in-service training to all staff on the cited section and submit a proof of completion with staff submit sign-in sheet to LPA by the POC due date 10/31/2025.

Allegation investigated: Staff are not safeguarding resident's personal belongings Staff are not meeting resident's toileting needs

On 09/29/2025 Licensing Program Analysts (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above mentioned allegations. LPA arrived to the facility and was granted access by Celsa Castaneda, Staff #2 (S2). S2 contacted Monica Gory, the administrator by telephone and LPA explained the purpose of the visit. An entrance interview was conducted with the administrator. Administrator would not arrive in time to meet with LPA. S2 was designated to sign today's report. On 02/25/2025 LPA Rios conducted an initial visit to investigate the allegations. During initial visit LPA conducted an interview with the administrator and S2. From approximately 10:54 a.m. to 1:26 p.m., LPA reviewed resident records and obtained Resident #1's (R1's) documents such as but not limited Assisted Living Waiver documentation, Resident Report and Observations, Unusual Incident / Injury Reports, Physician's Report, Resident Appraisal and Bowl and Bladder logs. At 2:00 p.m., while conducting the physical plant tour LPA attempted to interview Resident #3 (R3), but they refused to be interviewed. (Continue to LIC9099-C) Unsubstantiated LPA attempted to interview Resident #4 (R4) but they were sleeping. LPA attempted to interview Resident #5 (R5) but they did not respond to LPA's questions. From approximately 2:25 p.m. to 2:40 p.m., LPA conducted interviews with two (2) residents, Resident #1 (R1) and Resident #2 (R2). LPA documented observations of R1's bedroom. On 09/09/2025, while conducting the unannounced annual required visit, at approximately 10:25 AM, LPA interviewed R4. On todays unannounced subsequent visit to continue the investigation on the allegations, LPA Rios while conducting a tour at approximately 1:10 p.m., interviewed Resident #3 (R3). From 2:17 to 2:45 p.m., LPA interviewed Staff #1(S1) and Staff #3 (S3) by telephone. Allegation: Staff are not safeguarding resident's personal belongings. It was alleged that 24 bananas, purchased by R1's family member, were gone in three days. To investigate the allegation, LPA Rios interviewed four (4) out of five (5) residents that resided in the home, the administrator, and three (3) staff members. Interview with R1 confirmed they had received several bunches of bananas but they were gone in a short amount of time. R1 was not able to recall how long after receiving the bananas they were gone or how often they ate bananas. The administrator and three (03) staff members revealed that R1 ate bananas with every meal sometimes two at a time with meals. Staff and three (3) resident out of the four (04) residents interviewed corroborate they did not eat R1's bananas and did not witness anyone eating R1's bananas. According to S2 they write resident's names on food items residents personally bring for themselves to consume. During physical plant tour on 02/25/2025 and on subsequent visits LPA observed resident's names on food items. Based on interviews, and observation there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC9099-C) Page 2 of 3 (Continued from LIC9099-C) Allegation: Staff are not meeting resident's toileting needs. It is alleged, R1 uses a portable urinal then dumps it into a bucket next to their bed because staff will not respond to call button for assistance. During the investigation, LPA Rios interviewed four (4) out of five (5) residents that resided in the home, the administrator, and three (3) staff members. LPA's interview with R1 revealed they wear incontinent undergarments because they do not like to sit on a toilet. According to R1 the sitting position is not ideal for emptying their bladder or bowl movements. R1 states they have no issues regarding their portable urinal and bucket. Stating to LPA that staff empty the bucket several times a day with no issues. According to R1 they prefer to "dump the urine" in the "commode bucket" and have staff empty the bucket. Interview with three (3) staff and the administrator corroborate R1's preference. According to the administrator and staff they have encouraged R1 to use the toilet or commode but R1 refuses. LPA's interview with four (4) out of five (5) residents corroborate no issues or concerns regarding toileting needs. Based on interviews, and observation there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided. Appeal rights provided. Page 3 of 3the state’s words, verbatim · CDSS document, Sep 29, 2025 · control 31-AS-20250221124252

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide resident with a 60 day rent increase notice

On 09/09/2025 Licensing Program Analysts (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above mentioned allegation. LPA met with Monica Gory, the administrator and explained the purpose of the visit. An entrance interview was conducted with the administrator. Present in the home was staff #1 (S1) and two (02) out of three (03) residents. A third resident arrived at approximately 2:15PM. Allegation: Staff did not provide resident with a 60 day rent increase notice. It was alleged that Resident #1’s (R1’s) responsible party received a notification of rate increase on 02/06/2025 with effective date 01/01/2025. To investigate the allegation LPA Rios conducted an initial visit on 02/25/2025. During initial visit LPA conducted an interview with the administrator and staff present. From approximately 10:54 a.m. to 1:26 p.m., LPA reviewed resident records and obtained documents such as but not limited to R1’s admission agreement, Assisted Living Waiver documentation, and a resident's copy of rate increase notification. Substantiated (Continued from LIC9099) At 2:00 p.m. LPA conducted a physical plant tour to ensure the health and safety of the residents in care. While conducting the physical plant tour LPA attempted to interview resident #3 (R3), but they refused to be interviewed. LPA attempted to interview resident #4 (R4) but they were sleeping. LPA attempted to interview resident #5 (R5) but they did not respond to questions. From approximately 2:25 p.m. to 2:40 p.m., LPA conducted interviews with two (2) residents, Resident #1 (R1) and Resident #2 (R2). LPA’s interview with the administrator revealed that R1 receives Supplemental Security Income (SSI) and is an Assisted Living Waiver (ALW) participant. The administrator stated that the facility planned to increase its fees in alignment with Social Security rate adjustments for 2025. According to the administrator, R1’s ALW case worker advised that a 30-day notice would be sufficient, and the facility subsequently issued a rate increase notice to R1 and their responsible party on 02/06/2025 with effective date 01/01/2025. According to the administrator a payment for R1 was actually received on April 2025 after a notice of failure to pay the increased rate was sent to R1 and their responsible party in March 2025. LPA reviewed the Non-Medical Out-of-Home Care (NMOHC) Payment Standard for Individuals in Licensed Facilities, which confirmed that the payment standard did increase effective January 1, 2025. While the rate increase itself was appropriate, the facility’s own admission agreement with the resident’s representative verbatim states: “The facility reserves the right to increase the basic monthly fee, its rate structure for services including its fees for its levels of care by providing a 60-day written notice”. Furthermore, Effective January 1, 2025, Health and Safety Code section 1569.655 requires that written notice of any rate increase be provided no less than 90 days in advance to residents or their representatives. Based on interviews and record review, the allegation is deemed Substantiated at this time. Exit interview conducted. Copy of report provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Sep 9, 2025 · control 31-AS-20250221124252

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: Sep 19, 2025

(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents... the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure to provide a written notice to R1 and their residents’ representatives at least 90 days prior to increasing rates of fees which posses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Administrator shall read the cited Health and Safety Code and submit a statement of understanding to LPA by POC due date.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 09/09/2025 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual required visit. LPA was greeted by Staff #1 (S1) who granted access. S1 contacted the administrator, Monica Gory to let them know LPA was at the facility. LPA informed the administrator by telephone the purpose of the visit. Administrator met LPA shortly after. LPA reviewed the register of facility residents, and the staff schedule. LPA initiated a physical plant tour at approximately 10:20AM, and the following was observed: Bedrooms: There are four (4) total bedrooms for resident use. Two (2) out of the four (4) bedrooms are designated to be shared. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient lighting. LPA observed hallway cabinets used as storage for facility supplies such as linens. LPA observed a closet by room #4 that was locked. In the closet LPA observed emergency water, a first aid kit and residents' medication. Bathrooms: There are three (3) bathrooms. One (1) bathroom is located in a shared bedroom for private use. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, and nonskid matts. LPA observed proper fixtures such as grab bars. Hot water temperature was measured at 10:54AM in the bathroom closest to the bedrooms and it read 105 degrees Fahrenheit, within regulation. Common Areas: These include the living room and dining room. The areas were clean and clear of clutter. Passageways were free from obstructions. LPA did not observe any tripping hazards. The dining table and chairs sits the capacity of the facility. (Continue to LIC809-C) Kitchen: At 10:31AM LPA toured the kitchen. S1 was observed cleaning the area. The appliances used such as stove/oven, microwave, and refrigerator appeared functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility. LPA observed repackaged food properly labeled and in appropriate food storage containers. LPA observed fire extinguisher by the kitchen fully charged with purchase date 10/22/2024. Garage/Laundry: The garage was observed locked. In the garage the facility stores supplies, has an extra refrigerator, deep freezer, washer and dryer. LPA also observed cleaning supplies and chemicals stored in the garage that is maintained locked. The washer and dryer were observed operable. Backyard: The backyard is fenced in. LPA observed outdoor furniture and a patio with shade for residents. The backyard is sufficient in space for outdoor activities. Records: LPA reviewed three (03) of three (03) resident records and three (03) staff records for compliance with licensing forms. LPA also reviewed facility's Emergency Disaster Plan(LIC610E) that was reviewed by administrator on 03/01/2025. The facility last conducted an emergency disaster fire drill on 07/22/2025. LPA reviewed the facility's Liability Insurance which is current. Medication: Medication and Centrally Stored Medication Records were reviewed for accuracy and completeness. LPA Rios observed the administrator test the dual smoke and carbon monoxide detectors at 12:52PM. They were observed operational through out the facility. No deficiencies issued. Exit interview conducted. Report provided.the state’s words, verbatim · CDSS document, Sep 9, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Evelin Rios made an unannounced case management- annual continuation to continue an Annual Required Visit that was started on 9/10/2024. LPA was granted entry by staff and met with the administrator shortly after. LPA explained the reason for this visit. From 10:26 a.m. to 12:54 p.m. LPA continued with a review of resident and staff files. From 1:27 p.m. to 1:50 p.m. LPA reviewed medication and medication documentation. No deficiencies cited during this visit. Exit Interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 25, 2025

Allegation investigated: Staff does not provide nutritious meals. Staff does not provide an adequate amount of food. Resident’s toilet is in disrepair.

On 09/10/2024 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Staff #4 (S4) who granted access. S4 contacted the administrator, Monica Gory to let them know LPA was at the facility. Administrator met LPA shortly after. LPA explained the purpose of the visit. At 1:40 p.m. LPA conducted a physical plant tour to ensure the health and safety of the residents in care. On 01/12/2024 LPA Rios conducted an unannounced initial complaint visit for the above allegations. During the initial visit LPA conducted a physical plant tour, interviews with staff #1 (S1), the administrator designee at the time Ricky De Sahagun and staff #2 (S2). LPA also conducted interviews with three (3) out of six (6) residents at the facility able to respond to LPA’s questions. LPA reviewed and obtained copies of the staff calendar, meal calendar and staff’s daily notes. (Continued on LIC9099-C) Unsubstantiated On a subsequent visit on 2/12/2024 LPA conducted another physical plant tour, interviewed resident #1 (R1), and another resident not interviewed on the initial visit, staff #3 (S3), the administrator at the time David Taylor and administrator designee Monica Gory. During the subsequent visit LPA obtained copies of the staff calendar. Allegation: Staff does not provide nutritious meals. It is alleged the food served is mostly canned and vegetables are not provided. To investigate this allegation LPA conducted a physical plant tour on 01/12/2024 and 02/12/2024 of the kitchen and garage where food is stored. LPA observed one (1) refrigerator and one (1) pantry in the kitchen and a second refrigerator with deep freezer in the garage. LPA observed a sufficient supply of two day perishable and seven day nonperishable food, such as vegetables, meats, eggs, fruit, bread, cans of beans, and soups. According to LPA’s interview with two (2) staff they revealed residents have their preference of food and they will try to cook various meals to satisfy what the resident likes to eat. According to both staff, resident #1 (R1) has a preference of what they like to eat, and it does not always include meals that are necessarily nutritious. Interview with staff and the administrator revealed that R1 has purchased their own groceries such as frozen dinners and meats because they do not like what is served at the facility. Both staff deny not providing residents with options or nutritious meals. According to the administrator, David Taylor the menu has been updated to include residents’ preferences. LPA’s interview with resident #1(R1) revealed they purchase their own groceries because the facility does not provide nutritious meals and they do not like staff's cooking. LPA’s interview with resident #2 (R2) revealed they will sometimes have to “force” staff to provide vegetables, a starch and meat. R2 does not deny being provided the meals once requested. Interview with two other residents’ have no issues with the meals being provided. Based on interviews and observation although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated at this time. Allegation: Staff does not provide an adequate amount of food. It is alleged resident #1 (R1) has to purchase their own groceries because there is an inadequate amount of food at the facility. Interview with staff and the administrator revealed that R1 has purchased their own groceries because they do not like what is served at the facility. Both staff deny not providing residents with enough food when preparing their meals. (Page 2 of 3) LPA’s interview with resident #1 (R1) revealed they purchase their own groceries because the facility does not provide nutritious meals and there are not enough food options. Interview with three (3) out of six (6) residents revealed they have no issues with the amount of food provided for meals. Based on interviews and observation although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated at this time. Allegation: Resident’s toilet is in disrepair. It was alleged the facility has a broken toilet seat. To investigate the allegation, LPA conducted a physical plant tour of three (3) out of three (3) bathrooms on 01/12/2024. On the initial visit LPA observed in one (1) of three (3) bathrooms a raised toilet seat secured to the toilet. According to LPA’s interview with Ricky De Sahagun the toilet seat was changed to assist residents with the use of the toilet and because they had received a complaint from resident #1 (R1) about the toilet seat. LPA’s Interview with R1 stated they purchased a toilet seat because the toilet seat was broken. According to facility notes obtained on 01/12/2024 it shows staff documented that R1 had complained about the toilet seat on 01/02/2024. LPA’s Interview with Ricky corroborates that R1 did purchase a toilet seat without informing staff or the administrator. Ricky went on to say the toilet seat currently being used is not the one R1 purchased and that they informed R1 to use the second bathroom while the facility addressed the issue. LPA could not find another witness to corroborate the toilet seat was broken. Based on LPA’s observation the toilet was not broken during time of visit and according to the facility they replaced the toilet seat based on a complaint made by R1 and not because it was broken. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of report provided. (Page 3 of 3)the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 31-AS-20240103165416

Type of visit: Required - 1 Year

On 09/10/2024 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual required visit. LPA was greeted by Staff #4 (S4) who granted access. S4 contacted the administrator, Monica Gory to let them know LPA was at the facility. Administrator met LPA shortly after. LPA explained the purpose of the visit. This is a Residential Care Facility for the Elderly licensed for six (6) residents of which five (5) may be non-ambulatory and one (1) may be bedridden. Facility has been approved for a hospice waiver for two (2). LPA reviewed the register of facility residents, and the staff schedule. LPA initiated a physical plant tour at 1:40 p.m. the following was observed: Bedrooms: There are four (4) total bedrooms for resident use. Two (2) out of the four (4) bedrooms are designated to be shared. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient lighting. LPA observed hallway cabinets used as storage for facility supplies. Bathrooms: There are three (3) bathrooms. One (1) bathroom is located in a shared bedroom for private use. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, nonskid matts and grab bars. Hot water temperature was measured at 2:00 p.m. and was within regulation. Kitchen: The kitchen appliances and fixtures appeared functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility; properly stored. LPA observed fresh fruit and resealed food properly labeled. Due to time restraints, LPA was unable to complete the annual visit at this time. LPA did not review any staff or resident records or medication documentation at the time of this visit. A follow-up visit will be conducted at a later date to complete the annual inspection.the state’s words, verbatim · CDSS document, Sep 10, 2024

Allegation investigated: Staff mishandling residents medication. Staff not maintaining a comfortable room temperature for resident. Staff does not provide resident grab bars for safe showering. Call button not accessible to resident.

On 02/12/2024 Licensing Program Analysts (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Staff #1 (S1) who granted access. S1 contacted the administrator David Taylor and administrator designee Monica Gory to let them know LPA was at the facility. Administrator and administrator designee met LPA shortly after. LPA explained the purpose of the visit. At 1:00 p.m. LPA conducted a physical plant tour to ensure the health and safety of the residents in care. Allegation #1: Staff mishandling resident medication. It was alleged staff have given resident #1 (R1) an incorrect dosage of medication on different occasions. To investigate the allegation LPA Rios conducted an initial visit on 01/12/2024, during this visit LPA interviewed residents and staff from approximately 11:50 a.m. to 3:00 p.m. LPA also reviewed six (6) of six (6) Centrally Stored Medication and Destruction Records (CSMDR) and Medication Administration Records (MAR). (Continued on LIC9099-C) Unsubstantiated Records revealed Mirtazapine 45 mg has been provided to R1 in the morning at approximately 8:00 a.m. even though medication label reads “evening”. According to Ricky De Sahagun administrator designee on 01/12/24 he gave medication at a different time because R1 had requested multiple times to give them the medication in the morning, Ricky complied so as not to upset R1. LPA interview with Eugenia (Gina) Galindo who signed the report on 01/12/24 revealed they followed the medication label and provided medication to R1 as directed although R1 was upset about it. LPA review of MAR for days in question revealed R1 was provided medication Mirtazapine in the morning. Based on medication records, interviews and observation although medication was not provided on directed time, there is not enough evidence, the wrong dosage was given to R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Allegation #2: Staff not maintaining a comfortable room temperature for resident. It is alleged the temperature in resident’s #1 (R1’s) bedroom is uncomfortable at 68 degrees Fahrenheit. To investigate the allegation LPA observed the thermostat in the house on 01/12/24, the temperature read 73 degrees Fahrenheit. On today’s visit the thermostat read 71 degrees Fahrenheit. On 01/12/24 LPA interviewed three (3) out of six (6) residents. Interview with R1 revealed they felt their room was cold and the licensee would direct staff to turn off the heater, however the temperature was fine during interview. During the interview LPA observed R1 wearing a shirt without sleeves. Interview with two (2) residents able to communicate with LPA revealed the temperature in their room and in the facility feels comfortable and may get warm. Furthermore, resident #2 (R2) stated they turn on their ceiling fan and close the vents when it becomes too warm. They do not mind the temperature because they know R1 feels cold. Interviews with three (3) staff denied the allegation. According to Ricky he believes the resident’s medication may be the reason the R1 may feel cold at times. Based on the temperature on the thermostat, interviews with staff and residents, the allegation is deemed UNSUBSTANTIATED at this time. Allegation #3: Staff does not provide resident grab bars for safe showering. It is alleged resident #1 (R1) lost their balance and fell getting into the shower due to no grab bars to hold onto. To investigate the allegation LPA reviewed previous complaint control #31-AS-20230908152350. Facility had a grab bar and added a second grab bar entering the shower due to previous allegation in complaint. According to the licensee they got R1’s feedback on placement of grab bar added. Based on observation this allegation is deemed UNSUBSTANTIATED at this time. Allegation #4: Call button not accessible to resident. It is alleged resident #1 (R1) had requested a call button be installed in the bathroom for assistance. To investigate the allegation LPA reviewed facility requirements for a capacity of 6. According to staff they check on residents routinely depending on needs and services and as needed. For residents requiring further assistance they have been provided pendants they can wear or keep at reach to call for assistance. Resident #1 (R1) has a pendant they can take with them through out the facility. On 01/12/24 LPA tested R1's pendant and the receiver made a load sound heard though out the facility. Based on the information provided through interviews and observations made this allegation is deemed UNSUBSTANITATED at this time. Due to time constraints LPA was unable to address issues observed during physical plant tour. LPA informed administrator an unannounced case management visit will be made to address issues and concerns observed. Exit interview conducted. Copy of report providedthe state’s words, verbatim · CDSS document, Feb 12, 2024 · control 31-AS-20240103165416

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.