Summerfield of Fresno

Allegation investigated: Staff yells at residents Staff does not treat residents with dignity/respect

On 07/22/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation and deliver complaint findings. LPA met with Administrator Sheree Addison and stated the purpose of the visit. During the course of the investigation, the facility was toured, interviews were conducted, and records were received. Staffs were observed talking to the residents in kind matter. Based on interviews conducted and observation, staff alleged to yells at residents and do not treat the residents with dignity and respect, the preponderance of evidence standard has not been met. Therefore, the above allegations are found to be UNSUBTANTIATED. Exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 22, 2026 · control 24-AS-20260715100500

Allegation investigated: Untrained staff administering medication to residents Staff are mismanaging residents medication Staff did not prevent resident from wandering from the facility

On 07/18/26 Licensing Program Analyst, M. Garza arrived at the facility for an unannounced to deliver findings on a complaint. LPA met with Receptionist, Brenda Ruvalcaba explained reason for visit and was permitted entry into the facility. Executive Director (ED), Sheree Addison was contacted and arrived some time later. LPA toured the facility and completed a health and safety check on residents in care. During complaint LPA completed tours, interviews, requested and reviewed documentation. Allegation: Untrained staff administering medication to residents Interviews were conducted and records reviewed. Interviews disclosed the activities staff was passing medication without the proper training. Review of records disclosed the activities staff did not have the required initial and ongoing training required to provide medications to the residents. CONT... Substantiated CONT... Allegation: Staff are mismanaging residents medication LPA observation of the medical technician- during medication pass the medical technician was observed transferring medication from one container to another for several residents and signing prior to providing and verifying medications were taken by the resident. Pictures provided and interviews conducted disclosed medications were being found in resident rooms and on the floors of the facility after medications were given. Allegation: Staff did not prevent resident from wandering from the facility Interviews conducted and special incident reports were reviewed. During interviews it was disclosed R1 walked away from the facility on at least 2 separate occasions. Fresno PD returned R1 to the facility on 1 occasion. Review of special incident reports provided to the department shows the facility did not report these incidents. The allegations listed above are SUBSTANTIATED. The preponderance of evidence standard has been met per California Code of Regulations, Title 22. Deficiencies cited on 9099D. If not corrected, deficiencies have a direct impact to residents in care. ****Immediate civil penalty in the amount of $500 assessed**** Exit interview completed with ED, Sheree. A plan of correction was provided by ED and reviewed by LPA. A copy of this report provided.the state’s words, verbatim · CDSS document, Jul 18, 2026 · control 24-AS-20251118140904

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Jul 20, 2026

87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them... (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met as evidence by: interviews conducted and records reviewed. Interviews disclosed an untrained staff was providing medication. This poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 18, 2026

Plan of correction: ED stated staff observed is no longer working at the facility. Resident Care Director that was allowing this to occur is no longer working at the facility as well. In-service sign in sheet and training material will be provided to CCL as proof of correction.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 20, 2026

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by: LPA observation of the medical technician- during medication pass the medical technician was observed transferring medication from one container to another for several residents and signing prior to providing and verifying medications were taken by the resident. Pictures provided and interviews conducted disclosed medications were being found in resident rooms and on the floors of the facility after med pass. This poses an immediate health safety and or personal right risk to residents in care.the state’s words, verbatim · CDSS document, Jul 18, 2026

Plan of correction: ED stated medical technician has been retrained and will provide documentation of this training to CCL as proof of correction.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(5) · Plan of correction due date: Jul 20, 2026

87705 Care of Persons with Dementia (5) Facility staff shall ensure the continued safety of residents if they wander away from the facility... This requirement was not met as evidence by: interview conducted and records reviewed. Licensee did not comply with the section cited above in that R1 wandered from the facility and without staff ensuring continued safety and being returned by law enforcement. This poses an immediate health safety and or personal rights risk to residents in care. *****Immediate civil penalty in the amount of $500 assessed.*****the state’s words, verbatim · CDSS document, Jul 18, 2026

Plan of correction: ED stated they have increase elopement drills for all three shifts. Documentation of the drills will be provided to CCL as proof of correction.

Allegation investigated: Staff poses a risk to residents in care.

On 07/8/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation and deliver complaint findings. LPA met with Business office manager Bryant Ward and stated the purpose of the visit. Administrator Sheree Addison was called and arrived shortly during visit. During the course of the investigation, records were revied and interviews were conducted. S1 whose is alleged to pose risk for the resident, is fingerprinted cleared and associated to the facility on Guardian. Based on records reviewed, the above allegation is UNFOUNDED, meaning they were false, could not have happened, and/or are without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted. A copy of this report was provided to Administrator. Unfoundedthe state’s words, verbatim · CDSS document, Jul 8, 2026 · control 24-AS-20260701093322

Type of visit: Case Management - Deficiencies

On 07/08/26, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced complaint investigation and met with Administrator Sheree Addison. During the course of the investigation, LPA reviewed records and conducted interviews. S1 is not fingerprinted cleared and not associated with the facility. S1 is working at the facility providing resident care and supervision. A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report. California Code of Regulations, Title 22, Division 6, Chapter 6 are being cited on the attached LIC 9099D. An immediate Civil Penalty of $500 is hereby assessed. An exit interview was conducted. A copy of this report and appeal rights was provided to the Administrator, whose signature on this report confirms receipt of this report.the state’s words, verbatim · CDSS document, Jul 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jul 9, 2026

87355(e)(2) Criminal Record Clearance (e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance… This requirement was not met as evidence by: Based on records reviewed and interview conducted, S1 is not fingerprinted cleared and not associated to the facility provided resident care and supervision, which poses/posed an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: S1 is not permitted on the premises until fingerprinted cleared and associated with the facility. S1 was taken off the facility schedule immediately. POC cleared during visit.

Allegation investigated: Staff inappropriately handle residents. Staff communicate inappropriately with residents. Staff do not ensure residents are treated with dignity and respect.

On 06/17/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation and deliver complaint findings. LPA met with Administrator Sheree Addison and stated the purpose of the visit. During the course of the investigation, the facility was toured, and interviews were conducted. Based on interviews conducted, allegation alleging staff inappropriately handle residents, staff communicate inappropriately with residents, and staff do no ensure residents are treated with dignity and respect, the preponderance of evidence standard has not been met, therefore, the above allegation are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 17, 2026 · control 24-AS-20260617084358

Allegation investigated: Unlawful eviction

On 05/27/2026 Licensing Program Analyst (LPA) M. Garza arrived at the facility unannounced visit to deliver complaint findings. LPA met with Office Manager, Bryant Ward, explained reason for visit and was permitted entry into the facility. Executive Director, Sheree Addison was contacted and informed LPA was present at the facility. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. Residents observed in common areas, hallways and in rooms. During complaint investigation LPA requested and reviewed documentation and completed interviews. During records review, LPA observed Medical Technicians daily charting notes. Notes indicated R1 was requiring a higher level of care prior to being sent out to the hospital on 08/02/2026. Documentation noted that the responsible party was refusing skilled nursing and requesting the resident returned to the facility. Based on medical documentation the resident required a higher level of care. Although the allegation may or may not have occurred the allegation above did not meet the preponderance of evidence standard per California Code of Regulations, Title 22. No deficienices cited during todays visit. Exit interview completed with Executive Director, Sheree. A copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 27, 2026 · control 24-AS-20250805164343

Type of visit: POC

On 05/27/2026 Licensing Program Analyst (LPA) M. Garza arrived at the facility unannounced case management visit. LPA met with Office Manager, Bryant Ward, explained reason for visit and was permitted entry into the facility. Executive Director, Sheree Addison was contacted and informed LPA was present at the facility. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. Residents observed in common areas, hallways and in rooms. This case management visit is being conducted to review Plan of Corrections for deficiencies issues during a visit conducted on 05/16/2026. During a tour of the facility LPA observed a gate that was locked with a pad lock requiring a key near the front entrance of the facility. Facility does not have a fire clearance for a locked perimeter. Deficiency cited per California Code of Regulations, Title 22 on 809D. If not corrected, this poses a direct impact to health safety and or personal rights to the residents in care. Exit interview completed with Executive Director. A plan of correction was developed by ED, Sheree and reviewed by LPA. A copy of this report, deficiency and appeal rights provided.the state’s words, verbatim · CDSS document, May 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: May 28, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidence by: LPA observation the licensee did not comply with the section cited above in that perimeter gate exiting to the front of the facility was observed locked requiring a key to open without the proper fire clearance. This poses an immediate health safety and or personal rights risk to residents in care. *** An immediate civil penalty in the amount of $250 has been assessed for failure to correct. ***the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: ED stated they will have a conversation with Maintenance Director to walk the perimeter to verify all locks have been removed. Once all locks have been removed pictures will be sent to CCL as proof of correction.

Type of visit: Case Management - Deficiencies

On 05/27/2026 Licensing Program Analyst (LPA) M. Garza arrived at the facility unannounced case management visit. LPA met with Office Manager, Bryant Ward, explained reason for visit and was permitted entry into the facility. Executive Director, Sheree Addison was contacted and informed LPA was present at the facility. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. Residents observed in common areas, hallways and in rooms. This case management visit is being conducted for deficiencies observed during complaint investigation for complaint #24-AS-20250805164343. During investigation review of facility e-fax inbox incident reports for R1 were not observed. Review of e-fax file showed that there were no special incident reports received from the facility from 06/20/25 through 08/20/25 for R1. Deficiency cited on reporting requirements per California Code of Regulations, Title 22 on 809D. If deficiency not corrected, it could have a direct impact to the health, safety and or personal rights to the residents in care. Exit interview conducted with Executive Director, Sheree. A plan of correction was developed by ED, Sheree and reviewed by LPA. A copy of this report, deficiency and appeal rights provided.the state’s words, verbatim · CDSS document, May 27, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Jun 5, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:... This requirement was not met as evidence by: LPA review of records, the licensee did not comply with the section cited above in that review of facility e-fax file inbox show the facility did not have any special incident reports reported to the Department from 06/20/25 through 08/20/25 for R1. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: ED stated they will make phone calls for incidents that are occurring and send the written reports within the required timeframes. In service training will be completed with Resident Care Director and Business Office Director on reporting requirements. In service sign in sheet and training material will be provided to CCL by POC date as proof of correction.

Allegation investigated: Staff yelled at resident Staff handle resident in a rough manner

On 03/16/26 Licensing program Analyst (LPA) M. Garza arrived at the facility for an unannounced complaint visit. LPA met with Executive Director, Sheree Addison, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in rooms in common areas and in kitchenettes getting ready for lunch. During visits interviews were conducted and documentation was requested and reviewed. Interviews did not support the allegation of staff yelling at resident(s) or handling resident(s) in a rough manner. Although the allegation may or may not have occurred, the preponderance of evidence standard has not been met per Title 22. The allegations listed above are UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, Mar 16, 2026 · control 24-AS-20250821085106

Allegation investigated: Staff do not ensure resident has access to drinking water Staff did not prevent resident from obtaining a sharp object

On 03/16/26 Licensing program Analyst (LPA) M. Garza arrived at the facility for an unannounced complaint visit. LPA met with Executive Director, Sheree Addison, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in rooms in common areas and in kitchenetts getting ready for lunch. During visits for this complaint, LPA completed tours of the facility, completed interviews and requested documentation (medical assessments, staff schedules, needs and services plans, charting notes, staff and resident rosters and reviewed video). LPA observed meal service on 4 of 4 dates (8/6/25, 8/26/25, 11/24/25 and 2/24/26) and observed residents in their rooms that required assistance. R1 was observed on 8/6/25, 11/24/25 and 2/24/26 with an empty water cup on top of their beside table. Interviews conducted disclosed that each visit staff had recently checked on R1 (15 minutes or less) without filling up their water cup. R1 is bedridden and relies on others for assistance with their needs. 4 of 4 interviews conducted disclosed that R2 was found with a knife that had to be removed by staff. The location R2 found the item is unknown. LPA observed video of R2 with a knife that was removed from their hands by staff. Review of records (medical assessment dated 02/27/24) and needs and services plan) disclosed that R2 is aggressive and should not have access to sharp items. The allegations listed above have met the preponderance of evidence standard per California Code of Regulations, Title 22.the state’s words, verbatim · CDSS document, Mar 16, 2026 · control 24-AS-20250821085106

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 17, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: LPA observation and interviews conducted. The licensee did not comply with the section cited above in that interviews conducted disclosed that R2 had a knife in their possession. LPA reviewed video of R2 having a knife in their possession and staff attempting to remove it from them. This poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2026

Plan of correction: ED stated they will provide a plan of correction in writing by POC date, to include all staff training on resident safety. In-service sign in sheet and training material will be provided to CCL as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(6)(A) · Plan of correction due date: Mar 27, 2026

87633 Hospice Care of Terminally Ill Residents (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan. (A) The training shall include but not be limited to typical needs of hospice patients, such as turning and incontinence care to prevent skin breakdown, hydration, and infection control. This requirement was not met as evidence by LPA observation, review of records and interviews conducted. The licensee did not comply with the section cited above in that in R1's water cup was observed empty on 8/6/25, 11/24/25 and 2/24/26. Interviews with staff on schedule at the time stated R1 was recently (15 minutes or less) been checked on. Hospice file reviewed indicated training was completed but does not have an in-service sign in sheet or what was covered in this training. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2026

Plan of correction: ED stated they will complete all staff training to include basic services that should be provided to all residents in care. In-service sign in sheet and training material will be provided to CCL by POC date as proof of correction.

Allegation investigated: Resident sustained pressure sore while in care. Staff left resident soiled in urine for a period of time.

On 03/16/26 Licensing program Analyst (LPA) M. Garza arrived at the facility for an unannounced complaint visit. LPA met with Executive Director, Sheree Addison, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in rooms in common areas and in kitchenetts getting ready for lunch. During viists interviews were conducted and documentation was requested and reviewed. Review of records indicated that R1 was bedridden and receiving hospice services. Care plan indicated that R1 was a high risk for pressure injuries and noted pressure injuries being treated at time of initiation of services. Interviews indicated that R1 was being turned per hospice directions. Hospice notes further stated that the pressure injuries for R1 were not increasing/becoming worse. During visits LPA completed random room checks each visit. Visits conducted on 8/6/25, 8/26/25, 11/24/25, 2/24/26 and 3/16/26. During each visit LPA did not observe an odor of urine in the facility/rooms checked. Interviews did not disclose an issue with residents being changed in a timely manner. Although the allegations may or may not have occurred the preponderance of evidence standard has not been met. The allegations listed above are UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, Mar 16, 2026 · control 24-AS-20250804105800

Allegation investigated: Staff not providing resident with meal(s) in a timely manner.

On 03/16/26 Licensing program Analyst (LPA) M. Garza arrived at the facility for an unannounced complaint visit. LPA met with Executive Director, Sheree Addison, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in rooms, in common areas, and in kitchenettes getting ready for lunch. During visits for this complaint, LPA completed tours of the faciilty, completed interviews and requested documentation (medical assessments, staff schedules, needs and services plans, charting notes, staff and resident rosters). LPA observed meal service on 4 of 4 dates (8/6/25, 8/26/25, 11/24/25 and 2/24/26) and observed residents were not getting the required assistance in eating as needed. Meals were observed at bedside, in kitchenette refrigerators and in front of residents requiring assistance. Interviews disclosed that residents requiring assistance should be assisted prior to meal service beginning and "change of faces" should be provided to residents in an effort to get them to eat, if previously declined. Interviews conducted disclosed that this is not occurring. This allegation has met the preponderance of evidence standard per California Code of Regulations, Title 22. The allegation listed above is SUBSTANTIATED. Deficiency cited on 9099D. If not corrected, the deficiency poses a direct impact to residents in care. Exit interview completed with Executive Director (ED), Sheree. A plan of correction was developed by ED and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Mar 16, 2026 · control 24-AS-20250804105800

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Mar 27, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidence by: interviews conducted and LPA observations. The licensee did not comply with the section cited above in that meals were observed at bedside, in kitchenette refrigerators and in front of residents requiring assistance. Interviews disclosed residents requiring assistance should be assisted prior to meal service but is not occurring. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2026

Plan of correction: Per ED, all staff training will be conducted to reiterate all residents requiring assistance with feeding will be completed prior to meal services. In-service sign in sheet and training material will be sent to CCL by POC date as proof of correction.

Allegation investigated: Staff do not prevent provide adequate supervision resulting in resident elopement

On 2/24/25 Licensing Program Analyst (LPA) M. Garza completed an unannounced complaint visit. LPA met with Business Office Manager, Bryant Ward, explained reason for visit and was permitted entry into the facility. Executive Director, Sheree Addison was contacted and arrived some time later. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. Residents observed in common areas, hallways and in rooms. During visit LPA completed interviews and reviewed documentation (staff schedule, resident roster, needs and services plan, pre-placement appraisal, physicians report and charting notes). Charting notes documeted resident was found outside near facility sign on 7/25/25. On 8/2/25 resident exited a gate and was found by the street. Interviews with staff disclosed that resident was found in the parking lot walking and was returned to the facility. Resident medical assessment dated 04/17/25 indicated the resident had wandering behavior and was not allowed to leave the community unsupervised. The allegation above has met the preponderance of evidence standard. The allegation is SUBSTANTIATED. Deficiency cited per California Code of Regulations, Title 22 on attached 9099D. If not corrected, the deficiencies could have a direct impact to residents in care. Exit interview completed with Executive Director, Sheree. A plan of correction was developed by ED, Sheree and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Feb 24, 2026 · control 24-AS-20250728163307

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 25, 2026

87411 Personnel Requirements– General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required… This requirement was not met as evidence by: review of records and interviews completed. The licensee did not comply with the section cited above in that R1 eloped from the facility on 7/25/25 and 8/2/25 without staff supervision. This poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: ED stated that elopement drills are now being conducted and started in August 2025 upon their hire date. Staff training was completed on 11/24/25 on elopements for all staff. ED will provide a copy of the training material and in service sign in sheet as proof of correction.

Type of visit: Case Management - Deficiencies

On 2/24/25 Licensing Program Analyst (LPA) M. Garza completed an unannounced case management visit. LPA met with Business Office Manager, Bryant Ward, explained reason for visit and was permitted entry into the facility. Executive Director, Sheree Addison was contacted and arrived some time later. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. Residents observed in common areas, hallways and in rooms. This case management is being conducted for deficiencies found during investigation on complaint #24-AS-20250728163307 and visit conducted on 2/24/26. During review of records it was noted the facility did not supply the Department with incident reports for R1 eloping from the facility on 7/25/25 and 8/2/25. During visit for complaint listed above LPA observed the following deficiencies while touring the facility: Facility was observed with pad locks on all perimeter gates. Review of records did not show that a proper fire clearance was completed for a locked perimeter. Delayed egress door in Garden kitchenette took 38 seconds to open from inside the kitchenette to the outside courtyard area and would not open from the outside to the inside of the facility. This door did not open in the required time posing a harm for residents in care. Deficiencies cited per Title 22 on attached 809D. Exit interview completed with Executive Director, Sheree. A plan of correction was developed by ED and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Feb 25, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidence by: LPA observations. The licensee did not comply with the section cited above in that all facility gates were observed with pads locks on them preventing exiting. Review of records indicated the facility did not provide the Department with the proper paperwork to get an appropriate fire clearance approval. This poses an immediate health safety and or personal rights risk to residents in care. *****Immediate civil penalty in the amount of $500 assessed.*****the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Licensee will submit the appropriate fire clearance packet to CCL by POC date as proof of correction. *****Immediate civil penalty in the amount of $500 assessed.*****

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(5) · Plan of correction due date: Feb 25, 2026

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (5) Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely. This requirement was not met as evidence by: LPA observation. The licensee did not comply in the section cited above in that Delayed egress door in Garden kitchenette took 38 seconds to open from inside the kitchenette to the outside courtyard area and would not open from the outside to the inside of the facility. This door did not open in the required time posing a harm for residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Maintenance Director contacted Vortex for the door that will be serviced on 2/25/26. ED will submit a copy of the service order to CCL by POC date as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 10, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: review of records. The licensee did not comply with the section cited above in that the facility did not report R1 eloping from the facility on 7/25/25 and 8/2/25. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Training will be completed with all staff on reporting requirements. An in service sign in sheet and training material will be submitted to CCL by POC date as proof of correction.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Executive Director, Sheree Addison, Continual Administrator's Certification expires 10/16/2026. There are currently 48 residents who reside at this home and there is 10 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested in different areas of the facility at 108, 107, and 109 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Executive Director, Sheree Addison, and copy of report left at facilitythe state’s words, verbatim · CDSS document, Feb 10, 2026

Allegation investigated: Staff do not treat residents with dignity or respect

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA met with facility Executive Director, Sheree Addison, and explained the purpose of today's visit. Regarding the allegation Staff do not treat residents with dignity or respect The investigation determined that a conflict occurred between Resident 1 and staff 1 related to routine changes and the resident’s anxiety. While staff Staff 1 acknowledged telling the resident they did not wish to speak to them on one occasion following a heated interaction, there was no evidence staff engaged in verbal abuse, or ongoing disrespectful behavior. Unsubstantiated Resident 1 did not corroborate allegations of verbal abuse during interview. No witnesses or additional evidence supported that staff treated the resident in a manner that violated dignity or respect requirements. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director, Sheree Addison, and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 24-AS-20260204104644

Allegation investigated: Staff do not treat residents with dignity or respect

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA met with facility Executive Director, Sheree Addison, and explained the purpose of today's visit. Regarding the allegation Staff do not treat residents with dignity or respect The investigation determined that a conflict occurred between Resident 1 and staff 1 related to routine changes and the resident’s anxiety. While staff Staff 1 acknowledged telling the resident they did not wish to speak to them on one occasion following a heated interaction, there was no evidence staff engaged in verbal abuse, or ongoing disrespectful behavior. Unsubstantiated Resident 1 did not corroborate allegations of verbal abuse during interview. No witnesses or additional evidence supported that staff treated the resident in a manner that violated dignity or respect requirements. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director, Sheree Addison, and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 24-AS-20260204104644

Type of visit: Case Management - Deficiencies

On 11/24/25 Licensing Program Analyst (LPA) M. Garza completed and unannounced case management visit. LPA met with Executive Director, Sheree Addison, explained reason for visit and was permitted entry into the facility. A health and safety check was completed on residents in care. Residents were observed in common areas and in rooms. This case management visit is being conducted due to deficiencies observed during a complaint visit #24-AS-20251118140904, conducted on todays date. During visit LPA observed S1 working at the facility, who was not fingerprint cleared. S2 was observed working at the facility, who was not associated to the facility. Deficiencies cited on attached 809D per California Code of Regulations, Title 22. *****An immediate $500 civil penalty was assessed for S1 not having fingerprint clearance.**** *****An immediate civil penalty was assessed in the amount of $100 for S2 not being associated to the facility***** If not corrected, deficiencies will have a direct impact to the health safety and or personal rights of residents in care. Exit interview completed with Executive Director, Sheree. A plan of correction was developed by Executive Director and reviewed by LPA. A copy of this report, deficiencies, civil penalties and appeal rights were provided to Executive Director.the state’s words, verbatim · CDSS document, Nov 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Nov 25, 2025

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department… This requirement was not met as evidence by: S1 observed at the facility working around residents and not being supervised without being fingerprint cleared/associated to the facility. This poses an immediate health safety and or personal rights risk to residents in care. ***An immediate civil penalty in the amount of $500 was assessed.***the state’s words, verbatim · CDSS document, Nov 24, 2025

Plan of correction: S1 immediately left. Executive Director was advised S1 could not return to the facility or be placed back on the schedule until S1 had a fingerprint clearance or exemption. Finger print clearance request has been submitted as proof of correction. *POC cleared during visit

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(g)(2) · Plan of correction due date: Nov 25, 2025

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or ... This requirement was not met as eivdence by: LPA observation, the licensee did not comply with the section cited above in that Guardian Roster observved at 4:29 pm on 11/24/25 did not show S2 associated to the facility. If not corrected this poses an immediate risk to the health safety and or personal rights of residents in care. ***An immediate civil penalty of $100 was assessed***the state’s words, verbatim · CDSS document, Nov 24, 2025

Plan of correction: A review of Guardian Roster at 5:39 pm on 11/24/25, verifies Licensee has added S2 to their roster. *POC cleared during visit.

Allegation investigated: Staff do not have adequate supplies to meet residents toileting needs

On this date Licensing Program Analyst (LPA) M. Garza met with Regional VP of Operations, Dan Gormley and delivered findings. Based on records reviewed, interviews completed and observations of LPA. The preponderance of evidence standard has been met per Title 22. The allegations listed above are SUBSTANTIATED. Deficiencies issued on complaint #24-AS-20250306091730. If not corrected, the deficiencies will have a direct impact to persons in care. Exit interview completed with Regional VP of Operations, Dan. A plan of correction was made by Dan and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250728163307

Allegation investigated: Facility did not prevent the spread of scabies.

On this date Licensing Program Analyst (LPA) M. Garza met with Regional VP of Operations, Dan Gormley and delivered findings. Based on records reviewed, interviews completed and observations of LPA. The preponderance of evidence standard has been met per Title 22. The allegations listed above are SUBSTANTIATED. Deficiencies issued on complaint #24-AS-20250609132723. If not corrected, the deficiencies will have a direct impact to persons in care. Exit interview completed with Regional VP of Operations, Dan. A plan of correction was made by Dan and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250728090807

Allegation investigated: Staff did not notify residents families of scabies outbreak

On this date Licensing Program Analyst (LPA) M. Garza met with Regional VP of Operations, Dan Gormley and delivered findings. Based on records reviewed, interviews completed and observations of LPA. The preponderance of evidence standard has been met per Title 22. The allegations listed above are SUBSTANTIATED. Deficiencies issued on 9099D. If not corrected, the deficiencies will have a direct impact to persons in care. Exit interview completed with Regional VP of Operations, Dan. A plan of correction was made by Dan and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250610142729

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Aug 8, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidence by: LPA observations, interviews conducted and records reviewed. The licensee did not comply with the section cited above in that there is verified outbreak and family was not notified. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Regional VP stated they will verify contact information for all RP's and a written notification will be provided to RP's if there is a need. Email will be sent to CCL by POC date as proof of correction.

Allegation investigated: Staff does not ensure resident's medical care needs are being met. Staff is not preventing the spread of a scabies outbreak. Staff does not ensure resident's are adequately fed. Staff does not ensure facility has adequate food supply. Staff does not ensure resident's are provided clean linen.

On this date Licensing Program Analyst (LPA) M. Garza met with Regional VP of Operations, Dan Gormley and delivered findings. Based on records reviewed, interviews completed and observations of LPA. The preponderance of evidence standard has been met per Title 22. The allegations listed above are SUBSTANTIATED. Deficiencies issued on complaint #24-AS-20250306091730. If not corrected, the deficiencies will have a direct impact to persons in care. Exit interview completed with Regional VP of Operations, Dan. A plan of correction was made by Dan and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250609132723

Allegation investigated: Staff do not have current training

On this date Licensing Program Analyst (LPA) M. Garza met with Regional VP of Operations, Dan Gormley and delivered findings. Based on records reviewed, interviews completed and observations of LPA. Although the allegations may or may not have occurrec, the preponderance of evidence standard has not been met per Title 22. The allegations listed above are UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250415090709

Allegation investigated: Staff left residents in soiled clothing for an extended period of time Staff did not provide shower assistance to residents in care Staff did not clean resident's room Staff did not provide adequate food service to residents in care Staff did not ensure resident's wound care needs were met Staff sleep while on shift Administrator is not present at the facility an appropriate amount of time

On this date Licensing Program Analyst (LPA) M. Garza met with Regional VP of Operations, Dan Gormley and delivered findings. Based on records reviewed, interviews completed and observations of LPA. The preponderance of evidence standard has been met per Title 22. The allegations listed above are SUBSTANTIATED. Deficiencies issued on complaint #24-AS-20250306091730. If not corrected, the deficiencies will have a direct impact to persons in care. Exit interview completed with Regional VP of Operations, Dan. A plan of correction was made by Dan and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250415090709

Allegation investigated: Facility has an odor Facility staff are not meeting resident's incontinence needs Residents personal rights are violated Facility does not respond to resident's authorized representative in a timely manner. Facility food is served frozen Night staff are sleeping during shift

On this date Licensing Program Analyst (LPA) M. Garza met with Regional VP of Operations, Dan Gormley and delivered findings. Based on records reviewed, interviews completed and observations of LPA. The preponderance of evidence standard has been met per Title 22. The allegations listed above are SUBSTANTIATED. Deficiencies issued on 9099D. If not corrected, the deficiencies will have a direct impact to persons in care. Exit interview completed with Regional VP of Operations, Dan. A plan of correction was made by Dan and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250306091730

From the deficiency page — Deficiency type: Type A · Section cited: CCR 8711(a) · Plan of correction due date: Aug 7, 2025

87411 Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met by: LPA observations and interviews conducted. The licensee did not comply with the section cited above in that facility is not meeting residents incontience needs, served frozen food, and night staff was sleeping during a working shift. This poses an immediate health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: POC provided during 8/6/25 office meeting.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 8, 2025

87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by LPA observation, interviews conducted and records reviewed. The licensee did not comply with the section cited above in that the facility had on overwhelming odor of incontinence during multiple visits, observation of residents room having feces on the wall and dirty laundry pilled in bathrooms. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: POC provided during 8/6/25 office meeting.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 8, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section... This requirement was not met as evidence by LPA observation, interviews conducted and records reviewed. The licensee did not comply with the section cited above in that Administrator did not respond to resident representives in a timely manner and was not at the facility an appropriate amount of time. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: POC provided during 8/6/25 office meeting.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a) · Plan of correction due date: Aug 8, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:... This requirement was not met as evidence by LPA observation, interviews conducted and records reviewed. The licensee did not comply with the section cited above in facility staff did not prevent incidents between residents. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: POC provided during 8/6/25 office meeting.

Allegation investigated: Resident’s wound worsened due to staff neglect Staff did not properly assist resident with dental prosthetic devices Staff left resident in the same clothing for extended period Staff did not safeguard resident’s personal belongings Staff did not assist residents with their meals

On this date Licensing Program Analyst (LPA) M. Garza met with Regional VP of Operations, Dan Gormley and delivered findings. Based on records reviewed, interviews completed and observations of LPA. The preponderance of evidence standard has been met per Title 22. The allegations listed above are SUBSTANTIATED. Deficiencies issued on complaint #24-AS-20250306091730. If not corrected, the deficiencies will have a direct impact to persons in care. Exit interview completed with Regional VP of Operations, Dan. A plan of correction was made by Dan and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250404114126

Type of visit: Office

On this date, an office meeting was conducted to discuss concerns identified by the Department, the operations of the facility, and the number of complaints received for Summerfield of Fresno. Present during the meeting were: Brenda White, Regional Manager See Moua, Licensing Program Manager Mary Garza, Licensing Program Analyst Dan Gormley, Regional VP of Operations newly hired Executive Director/Administrator, effective 8/4/25 Steve Kregel, COO/Owners On 2/12/25, a Non-compliance meeting (NCC) was conducted to discuss the citations issued by the Department. At this time, issues regarding care and supervision, meeting resident’s personal and hygiene needs, safe guarding resident’s personal belongings, ensuring that hazardous items and materials were inaccessible, and staff training were discussed. The Department also addressed concerns related to Food Services, staff and resident’s records, staffing, and seeking timely medical attention. During the NCC, the facility representatives provided plan of corrections to the Department to address the issues. It was stated that the facility had hired a new Administrator/Executive Director and LVN who would address these issues. CONT... CONT... Since the NCC, in the span of 6 months, the Department received 14 complaints. The complaints alleged concerns related to care and supervision, staffing, resident’s hygiene, a Scabies outbreak, staff training, and food. In addition, case management deficiencies were issued for: Reporting Requirements, Fire Clearance with Civil Penalty, and Reappraisals. During today’s meeting, findings were delivered for complaints. Allegations where the preponderance of evidence were met were Substantiated. Civil penalties were issued. During the meeting, the facility representatives were asked to provide Proof of Corrections for the deficiencies cited and addressed the concerns observed by the LPA. The concerns were: lack of management oversight, staffing, staff accountability, Executive Director/Administrator’s Qualifications and Duties to be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. COO and VP of Operations stated former Administrator/ED Rob and LVN Gabe wasn’t transparent and did not communicate issues. Proof of corrections provided were: The facility will submit a plan regarding the proof of corrections below by 8/20/25 – 1. Care and Supervision: Hygiene Needs/Incontinence Care 2. Resident’s Files and Re-assessment 3. Staff Training 4. Food 5. Buildings and Grounds -Regarding the Scabies: Local CDPH was contacted and are following Infection Control, Clinical Oversight Nurse by Allen Flores is coming in, skin checks will be done -Staffing and Communicate with Families – townhall meeting with resident’s families, -Accountability and Administrator Qualifications – Leadership member will work past regular hours, ED stated work hours as reflected on the LIC 500, Hired outside service for Satisfaction Surveys effective July 2025 -Implement Stand up and Stand down -Implement Communications log The facility was informed that at this time, the Department will be seeking appropriate Administrative Actions. An exit interview was conducted and appeal rights were provide for citations issued for the complaints.the state’s words, verbatim · CDSS document, Aug 6, 2025

Allegation investigated: Staff left resident in a wheelchair overnight Staff does not ensure adequate supervision is provided to manage behavioral changes in residents

On 7/15/25 Licensing Program Analyst (LPA) M. Garza completed and unannounced case management visit. LPA met with Executive Director, Robert Huntley, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in common areas, bedrooms and in activity room. Currently there are 5 residents on hospice. During investigation LPA completed interviews and reviewed documentation ((physicians report, admission agreements, pre-placement appraisals, needs and services plans, reassessments, medication lists, CSMR/MARS, charting notes, SIRs for month of June/July 2025, resident information sheets). Interviews conducted disclosed that R1 was left in their wheelchair on the evening of 7/13/25 by staff. Records review of R2s file shows R2 has a history of anxeity/agression. Interviews conducted disclosed R2 became verbally aggressive with residents and staff on 7/14/25. Review of facitliy schedule show call offs were covered with limited staff. CONT... Substantiated CONT... The allegations listed above have met the preponderance of evidence standard per Title 22. The allegations are SUBSTANTIATED. Deficiencies cited per Title 22 on attached 9099D. If deficiencies are not corrected they pose a health safety and or personal rights risk to persons in care. A plan of correction was provided by Executive Director, Robert and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 24-AS-20250714144938

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 1, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) 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 evidence by interviews conducted. The licensee did not comply with the section cited above in that the staff on duty left R1 in their wheelchair at night. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: ED stated they will have documeted conversations with the care staff on the schedule on day of incident. In-Service training will be completed on 30-minute checks for residents. In-service sign in sheets and training material will be provided to CCL by POC date as proof of correction

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 1, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenceew of facitliy schedule show call offs we by LPA interviews and record review. The licensee did not comply with the section cited above in that R2 became verbally aggressive with residents and staff on 7/14/25. Review covered with limited staff.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: ED stated an in-service training will be completed for all staff on residents with behaviors and how to handle them. In-service sign in sheets and training material will be provided to CCL by POC date as proof of correction.

Type of visit: Case Management - Deficiencies

On 7/15/25 Licensing Program Analyst (LPA) M. Garza completed and unannounced case management visit. LPA met with Executive Director, Robert Huntley, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in common areas, bedrooms and in activity room. Currently there are 5 residents on hospice. This case management visit is being conducted due to observations made during a subsequent complaint visit (#24-AS-20250714144938) conducted on 7/15/25. R2's file was reviewed and documentation was gathered (physicians report, admission agreement, pre-placement appraisal, needs and services plan, reassessment, medication list, CSMR/MARS, charting notes, SIRs for month of June/July 2025). File review disclosed R2 has a history of anxiety/aggression. Interviews conducted disclosed R2 became verbally aggressive with residents and staff on 7/14/25. File review does not indicate R2 has had a recent needs and service plan/reappraisal completed within the last year per regulation. Deficiency cited per Title 22 on attached 809D. If not corrected, this poses a health, safety and or personal rights risk to residents in care. A plan of correction was developed by Executive Director, Robert. LPA reviewed plan. A copy of this report deficiency and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 1, 2025

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement was not met as evidence by interviews conducted and record review. The licensee did not comply with the section cited above in that file review disclosed R2 has a history of anxiety/aggression. Interviews conducted disclosed R2 became verbally aggressive with residents and staff on 7/14/25. File review does not indicate R2 has had a recent needs and service plan/reappraisal completed within the last year per regulation.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: ED stated Resident Care Director will generate a list of all residents and updated forms needed. Resident Care Director will work with Resident Care Coodinator to work on updating this list. A copy of this list will be submitted to CCL by POC date as proof of correction.

Allegation investigated: Staff did not seek medical attention to resident. Staff do not follow resident's diet. Staff is not administering medications as prescribed.

On 7/12/25 Licensing Program Analyst (LPA) M. Garza completed an unannounced initial complaint visit. LPA met with Senior Memory Care Director, Krystle Rodriguez, explained reason for visit and was permitted entry into the facility. Executive Director, Robert Huntley was contacted and arrived some time later. LPA completed a tour of the facility inside and out. A health and safety check on residents in care was completed. Residents observed in common areas and in their rooms. During visit LPA requested and reviewed documentation (physicians reports, central stored medication logs, hospice care plans, hospice notes, dietary orders, staff scheduled for 6/2025 and 7/2025, staff roster, daily charting notes, resident roster, training records, face sheets, weight records, discharge notes) and completed interviews. CONT... Substantiated CONT... Allegation: Staff did not seek medical attention to resident. During visit LPA reviewed records and completed interviews. Interviews disclosed that R1 had an un-witnessed fall (date, time, details unknown). S1 notified S2 a fall occurred and hospice was contacted. Hospice records indicate R1 has an “unsteady gait” and “requires assistance as R1 is a fall risk”. EMS was not contacted after the fall occurred. Daily charting and hospice notes reviewed do not indicate R1 was assessed for this fall. Interviews indicated R1 is in pain, observed limping and not wanting to walk. Allegation: Staff do not follow resident's diet. R2's file was observed to have a dietary preference/orders form dated 5/5/25. Form indicates R2 was required to have a pureed diet. Interviews conducted disclosed R2’s food from the kitchen is pureed but other snacks eaten (ex: apples, cookies, etc.) are not. A special diet list was observed by LPA in the kitchen to include R2 as having a pureed diet. Allegation: Staff is not administering medications as prescribed. LPA reviewed MARS for R1. MARS indicates R1 did not receive their evening medications (Buspirone 5 mg and Senna/Docusate 8.5/50 mg) prescription on 7/2/25 and 7/4/25. Prescription for weight on resident noted every 1st Monday of every month was not completed. The allegations listed above have met the preponderance of evidence standard per Title 22. The allegations are SUBSTANTIATED. Deficiencies cited on 9099D. If not corrected the deficiencies pose a direct health, safety and or personal rights risk to persons in care. A plan of correction was provided by Executive Director, Robert and reviewed with LPA. A copy of this report, deficiencies and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 12, 2025 · control 24-AS-20250709100532

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jul 25, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidence by: LPA observation and record review. The Licnesee did not comply with the section cited above in that R1 had an unwitnessed fall (date and details unknown). Incident was not documented or reported and R1 did not receive timely medical care.the state’s words, verbatim · CDSS document, Jul 12, 2025

Plan of correction: ED to contact Hospice and/or send R1 to ER for assessment. For any future falls ED/LVN will assess and send out if needed. In-service will be completed with medical technicians and all care staff for unwitnessed falls/incidents. In-service sign in sheets and training material will be provided to CCL by POC date as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(10) · Plan of correction due date: Jul 12, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (10) Where indicated, food shall be cut, chopped or ground to meet individual needs. This requirement was not met as evidence by file review and LPA observation. Records reviewed indicate R2 is on a pureed diet. Interviews conducted indicated R2 is being provided with food that is not always pureed. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 12, 2025

Plan of correction: ED stated all staff will be provided with notification of special diets. Kitchen will be instructed to supply snacks to match diet needs. In-service will be completed with all staff. In-service sign in sheets and training material will be sent to CCL by POC date as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jul 25, 2025

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: review of records. The licensee did not comply with the section cited above in that R1's MARS was reviewed and indicated R1 did not receive 2 medications (Buspirone 5 mg and Senna/Docusate 8.5/50 mg) on 7/2/25 and 7/4/25. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 12, 2025

Plan of correction: ED stated medication training will be completed with all medical technicians. In-service sign in sheets and training material will be sent to CCL by POC date as proof of correction.

Type of visit: Case Management - Deficiencies

On 7/12/25 Licensing Program Analyst (LPA) M. Garza completed an unannounced case management visit. LPA met with Senior Memory Care Director, Krystle Rodriguez, explained reason for visit and was permitted entry into the facility. Executive Director, Robert Huntley was contacted and arrived some time later. LPA completed a tour of the facility inside and out. A health and safety check on residents in care was completed. Residents observed in common areas and in their rooms. This case management is being conducted for observations made by LPA during a complaint visit conducted on 7/12/25. The following issues were observed: A broom was jammed into the Garden Kitchenette door handle, preventing the door from being accessed/used. Garden and Seaside kitchenette observed to take 25 (Garden) and 43 (Seaside) seconds to unlock the delayed egress door to exit. Perimeter gates observed to be locked with a chain and pad lock, preventing gates from being accessed. Deficiencies cited on 809D. If not corrected the deficiencies pose a direct and immediate health, safety and or personal rights risk to persons in care. A plan of correction was provided by Executive Director, Robert and reviewed with LPA. A copy of this report, deficiencies and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 12, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Jul 14, 2025

.87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as eivdence by: LPA observation. The licensee did not comply with the section cited above in that the Garden Kitchenette was observed with a broom jammed in the door handle, preventing the door from being accessed/used. Garden and Seaside kitchenette observed to take 25 (Garden) and 43 (Seaside) seconds to unlock the delayed egress door to exit. Perimeter gates observed to be locked with a chain and pad lock, preventing gates from being accessed. This poses an immediate health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 12, 2025

Plan of correction: Broom, pad locks and chains were immediately removed. ED stated they will contact Vortex to reprogram the doors to be within the 15 second window for doors to open and be accessible. An email will be sent by ED to CCL, including date of repair as proof of correction.

Allegation investigated: Staff inappropriately restrains resident.

On 5/19/2025 Licensing Program Analyst (LPA) M. Garza completed an unannounced complaint visit. LPA was informed Executive Director (ED), Robert Huntley and Licensed Vocational Nurse (LVN), Gabriel Facio were out of the facility and unavailable currently. LPA met with Business Office Manager, Bryant Ward, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents were observed in rooms and common areas. ED and LVN arrived some time later. During investigation LPA completed interviews with staff, resident family members and residents. LPA collected and reviewed documentation (Resident roster and room numbers, staff schedule, special incident reports for R1, pre-placement appraisals, admission orders, physicians reports, hospice care plans, and review of physicians prescriptions). During visit it was disclosed R1 is utilizing a soft tie while in the wheelchair. Review of physicians orders do not show a prescription for a soft tie to be used. The preponderance of evidence standard has been met and the allegation above is SUBSTANTIATED.the state’s words, verbatim · CDSS document, May 19, 2025 · control 24-AS-20250514141753

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a) · Plan of correction due date: May 30, 2025

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions... This requirement was not met as evidence by: LPAs review of resident records, observations and interviews conducted, the licensee did not comply with the section cited above in LPA observation of resident(s) observed with soft ties. Interviews disclosed soft ties are being utilized by resident(s) and review of records did not obtain a physicians prescription to be used. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 19, 2025

Plan of correction: ED stated physicians will be contacted to obtain prescriptions, training will be completed with all staff in using soft ties, in-service sign in sheet and training material will be sent to CCL as proof of correction.

Type of visit: Case Management - Deficiencies

On 4/18/2025 Licensing Program Analyst (LPA) M. Garza completed an unannounced Case Management visit. LPA met with Executive Director, Robert Huntley and explained reason for visit was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in rooms, common areas and in dining rooms. During a visit being conducted for a complaint on todays date, R1, R2 and R3 were observed by LPA. LPA observed R1 sitting in the hallway in Garden. R1 was observed with a large bandage on left shin area. Medical Technicians (MT 1 and MT 2) interviewed, it was stated R1 caught their leg on the side of their wheelchair (4/11/25) when getting up causing a skin tear. MT 1 stated "due to the tear looking infected R1 was seen by the physician". During review of charting notes, medical attention was sought 4/18/25. During review of Special Incident Reports this incident was not observed reported to CCL. R2 was observed sitting in the hallway near dining. R2 was observed with bruising under both eyes and a old bandage that was falling off on right elbow. During review of charting notes it was observed that R2 had 4 falls (3/27/25, 3/28/25, 3/31/25 and 4/5/25) where EMS services were contacted and transported R2 to the hospital for follow up. Interview with MT 2 disclosed that R2 was falling and was transported to hospital with a diagnosis of a UTI. Facility does not have a special incident report noting these falls/EMS being called/trips to the hospital. Facility did not report these incidents to CCL. R3 was observed coming out of Rm #410 with care giver. R3 was observed with wet hair and what appeared to be skin irritation needing to be looked at by a physician. MT 2 was unaware of the issue. A special incident report was not completed on this or reported to CCL. Deficiencies cited per Title 22. Exit interview completed with Executive Director, Robert. A copy of this report and appeal right provided.the state’s words, verbatim · CDSS document, Apr 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 2, 2025

87211 Reporting Requirements Each licensee shall furnish to the licensing agency … (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events ... This requirement was not met as evidence by LPA interviews with staff, record review and observation of residents. The licensee did not comply with the section cited above in that R1, R2 and R3 incidents were not reported to CCL as required. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2025

Plan of correction: ED stated they will be doing a performance write up for LVN and go over requirements with them. ED stated they will complete a weekly audit to ensure reporting is being completed to all appropriate parties. In-service to be compelted with LVN and sent to CCL as proof of correction by POC date.

Allegation investigated: Staff are not mitigating the spread of scabies in the facility

On 4/14/25 Licensing Program Analyst (LPA) M. Garza completed an unannounced complaint visit. LPA met with Executive Director, Robert Huntley, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety tour for resident in care. LPA observed residents in activities area, common areas and in rooms. Facility currently has 9 residents receiving hospice services. During visit LPA reviewed documentation and completed interviews. LPA completed review of their medical records and SIRs. During records review on 3/28/25, notes show there were 3 residents receiving treatment for rashes. Interviews conducted with staff indicate there are 3 residents that received treatment of some sort but staff was unable to say what for. Further review of MARS/CSMR did not indicate treatment was being received for scabies. Although the allegation may or may not have occurred, the allegation does not meet the preponderance of evidence standard per Title 22. The allegation is UNSUBSTANTIATED. Exit interview completed with Executive Director, Robert. A copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 14, 2025 · control 24-AS-20250326091020

Type of visit: Case Management - Deficiencies

On 2/12/25 a Case Management visit is being conducted during the NCC meeting. Present at this meeting was Regional VP of Operations, Dan Gormley, Executive Director, Robert Huntley, Regional Manager, Brenda White, Licensing Program Manager (LPM), See Moua, Licensing Program Analyst (LPA) Mary Garza. This case management is being conducted and associated to complaint #24-AS-20240906130954. During the investigation additional information was received. During documentation review it was observed that the facility did not obtain medical care for R1 in a timely manner. Deficiencies cited per Title 22. Should civil penalties need to be assessed after further review, they will be cited at a later date. Exit interview completed with Regional VP of Operations, Dan and Executive Director, Robert. A copy of this report, deficiencies and appeal right provided.the state’s words, verbatim · CDSS document, Feb 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Feb 21, 2025

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement was not met as evidence by record review. The licensee did not comply with the section cited above in that the facility did not obtain medical care for R1 in a timely manner, resulting in R1 being placed on hospice and passing. This poses an immediate health, safety and or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 12, 2025

Plan of correction: In servive training for all staff will be completed for observation of residents and seeking timely medical attention. In service sign in sheet and training material will be provided to CCL as proof of correction by POC date.

Allegation investigated: Staff did not prevent resdent from physically assaulting other residents in care.

On 1/7/24 Licensing Program Analyst (LPA) M. Garza arrived at the facility for an unannounced complaint visit. This visit is being conducted to deliver complaint findings. LPA met with Executive Director, Beronica Galindo. LPA explained reason for visit and was permitted entry into the facility. During the investigation LPA completed interviews, requested/reviewed documentation (facility roster, staff schedules, physicians report, pre-placement appraisals, resident assessment, medication list, MARS, care plan, police report numbers, admission agreement and incident reports for R1). Review of records show R1 had a care plan from their previous placement (VA) indicating R1 had aggressive behaviors. Interview with staff indicated R1 would physcially assult other residents without warning. Review of SIRs showed 4 incidents occurred with other residents (8/8/24, 9/6/24, 9/15/24 and 10/6/24) within 2 months. The allegation listed above is SUBSTANTIATED. The preponderance of evidence standard has been met per Title 22. Deficiency cited on 9099D. Exit interview completed with Executive Director, Beronica. A copy of this report, deficiency and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Jan 7, 2025 · control 24-AS-20241028091528

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 17, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, ...shall have all of the following personal rights: (4)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 evidence by: based on LPA record review and interviews conducted. The Licensee did not comply with this section cited above in that: R1 was involved with 4 altercations involving other residents in a period of 2 months. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Training was completed by the Allen Flores Group for proper assessments on residents in an effort to meet their needs and keep staffing. Training records will be provided to CCL by POC date as proof of correction.

Type of visit: Required - 1 Year

On 1/7/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Executive Director, Beronica Galindo. LPA introduced self, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. There was 10 residents on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operate on a system. Fire extinguisher last serviced 09/12/24. Last fire drill conducted on 12/17/24. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps and chemicals were located in locked closets/rooms. LPA observed sufficient seating under covered patio areas. The following issues were observed during todays visit: personal rights, additional personal right, non-discrimination and complaint information not posted. Room #407 observed with sagging mattress in need of replacement. Carpet in Apple kitchenette torn at transition observed in need of repair. Apple kitchenette cabinet handle broken and in need of repair. Room #310 toilet in need of cleaning. Chemicals observed in resident room #210 unlocked and accessible. Sidewalk in courtyard in need of debris removal. Hand railing in Garden wing in need of cleaning. Refrigerator/freezer in Garden wing in need of cleaning/repair. Spider webs observed throughout the facility in need of removal. Touch up paint needed in hallways in Garden wing. Seaside kitchenette flooring sticky and in need of cleaning. Wall in room #428 in need of patching/touch up. CONT... CONT... LPA requested the following documents to be submitted to CCL by 1/17/25 : current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. Exit interview completed with Executive Director, Beronica. A copy of this report, deficiencies and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 7, 2025

Type of visit: Case Management - Other

On 12/31/24 Licensing Program Analyst (LPA) M. Garza arrived for an unannounced case management visit. LPA met with Executive Director, Beronica Galindo, explained reason or visit and was permitted entry into the facility. This case management visit is being conducted to return a file of a resident (R1) This file was removed from the facility in order to review and make copies on a previous complaint (24-AS-20240906130954). Additional records were requested (MARS, Central Stored Medication Log, medication list, Hospice records, daily notes for R1). No deficiencies cited during todays visit. Exit interview completed with Executive Director, Beronica. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 31, 2024

Allegation investigated: Staff do not meet residents diapering needs

On 12/23/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced to deliver complaint findings. LPA met with Executive Director, Beronica Galindo, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms. During the investigation documentation was reviewed (physicians reports, pre-admission appraisals, needs and services plans, hospice care plans, central stored medication logs, MARS, staff schedules, staff trainings, employment records, emergency contact information, admission agreement, hospital records, special incident reports, resident and staff roster), tours completed (9/10/24, 9/16/24 and 10/30/24) and interviews were conducted. Based on records reviewed, pictures observed, tours completed and interviews conducted with staff and family the information indicates personal care needs (incontinence, grooming, bathing) are not being met. CONT... Substantiated CONT... The above allegation met the preponderance of evidence standard per Title 22. During previous complaint visit on 12/20/24 (Complaint #24-AS-20240906130954) findings were delivered on this allegation. Deficiencies were not cited during this visit. Exit interview completed with Executive Director, Beronica. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 24-AS-20240911161625

Allegation investigated: Staff do not ensure that residents are adequately fed Staff do not ensure that residents receive fluids (water) Resident's toilet is in disrepair

On 12/23/24 Licensing Program Analyst (LPA) M. Garza completed and unannounced complaint visit to deliver findings. LPA met with Executive Director, Beronica Galindo, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms. During the investiagation LPA requested and reviewed documentation (Resident roster, staff roster with contact information, staff schedule for month of September 2024, physicians report for R1 and R2, pre-admission appraisals for R1 and R2, needs and assessment appraisals for R1 and R2, medication list for R1 and maintenance log for September 2024 and incontinence plan for R1 and R2), completed tours and completed interviews. During tours of the facility (9/16/24, 10/31/24 and 12/23/24) LPA observed a 2-day perishable and 7-day non-perishable supply of food as per Title 22. CONT... Unsubstantiated CONT... Interviews conducted with residents and family members disclosed there was an adequate food source for the residents to eat. Interviews with Rps family member disclosed they were "getting enough to eat and drink" and "sometimes even too much". During interviews with staff, residents and administration they indicated that repairs are requested and completed in a timely manner. During tour of the facility LPA observed the facility (9/16/24, 10/31/24 and 12/23/24) to be in good repair. Although the allegations may or may not have occurred, the preponderance of evidence standard has not been met per Title 22. The allegations listed above were found to be UNSUBSTANTIATED. No deficiencies cited during this visit. Exit interview completed with Executive Director, Beronica. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 24-AS-20240911161625

Type of visit: Case Management - Other

On 12/23/24 Licensing Program Analyst (LPA) M. Garza arrived at the facility unannounced to complete a case management visit. LPA met with Executive Director, Beronica Galindo, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms. This case management visit is being conducted to obtain resident (R1's) file. The file is being removed from the facility and will be returned in 3 business days. No deficiencies issued during todays visit. Exit interview completed with Executive Director, Beronica. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 23, 2024

Allegation investigated: Lack of care and supervision resulted in the resident being found unresponsive in the sun

On 12/20/24 Licensing Program Analyst (LPA) M. Garza arrived to complete an unannounced complaint visit to deliver findings. LPA met with Executive Director, Beronica Galindo, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in rooms and common areas. The Department has investigated the above allegations. Based on the interviews conducted and records reviewed, R1 was left in the sun on 7/22/24 for an unknown amount of time. R1 was tachycardic, in respiratory distress, and their skin was warm to the touch upon arrival to the hospital. The admitting diagnosis was heat exposure. All staff interviewed stated the temperature that day was over 100 degrees and the staff failed to routinely check on R1 which resulted in R1 being found outside on the ground unresponsive. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Citation is issued according to Title 22 on the attached LIC. 9099D. An immediate civil penalty of $500 is assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. Exit Interview conducted with Executive Director, Beronica. A copy of this report, deficiency, civil penalty and appeal Rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Dec 20, 2024 · control 24-AS-20240724124724

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 21, 2024

87411(a) Personnel Requirements – General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Interviews and record review indicated R1 was left in the sun on 7/22/24 for an unknown amount of time resulting in R1 becoming unresponsive and requiring medical attention. This poses an immediate health, safety and or personal rights risk to residents in care. An immediate civil penalty in the amount of $500 was assessed per Title 22.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Executive Director stated they have implemented 30 minute checks that staff sign off stating they are aware of the location of each resident. All staff completed heat exposure and egress alarms was competed. In-serivce sign in sheets and training material and a sample of 30 minute checks will be submitted to CCL as proof of correction by POC date.

Allegation investigated: Staff do not ensure that residents' medications are stored locked and inaccessible to residents Staff do not ensure that residents take medications as prescribed Facility is not maintained in good repair

On 12/20/24 Licensing Program Analyst (LPA) M. Garza completed an unannounced complaint visit to deliver findings. LPA met with Executive Director, Beronica Galindo, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in rooms and common areas. During the investigation documentation was reviewed (physicians reports, pre-admission appraisals, needs and services plans, hospice care plans, central stored medication logs, MARS, staff schedules, staff trainings, employment records, emergency contact information, admission agreement, hospital records, special incident reports, resident and staff roster), tours completed (9/10/24, 9/16/24 and 10/30/24) and interviews were conducted. During visits LPA observation of medication carts showed they were locked and inaccessible to residents in care. Rooms were toured during visits and medications were not observed accessible. MARS and CSMR and resident’s medical records were reviewed. All records indicated that resident was not prescribed medication as indicated in the complaint. CONT... Unsubstantiated CONT... During tour of the facility LPA observed the facility to be in good repair. Interviews with staff and administration indicated the repairs requested and completed are done in a timely manner. Although the allegations may or may not have occurred, the preponderance of evidence standard has not been met per Title 22. The allegations listed above were found to be UNSUBSTANTIATED. No deficiencies cited during this visit. Exit interview completed with Executive Director, Beronica. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 24-AS-20240906130954

Allegation investigated: Licensee does not ensure that residents are supervised Staff do not assist residents with personal care needs Licensee does not ensure that staff receive required training Staff do not safeguard a resident's personal belongings Staff did not ensure that hazardous items were inaccessible to residents

On 12/20/24 Licensing Program Analyst (LPA) M. Garza completed an unannounced complaint visit to deliver findings. LPA met with Executive Directior, Beronica Galindo, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in rooms and common areas. During investigation LPA completed interviews, toured the facility (9/10/24, 9/16/24 and 10/30/24) and reviewed records (physicians reports, pre-admission appraisals, needs and services plans, hospice care plans, central stored medication logs, MARS, staff schedules, staff trainings, employment records, emergency contact information, admission agreements, hospital records, special incident reports, resident and staff roster). Allegation: Licensee does not ensure that residents are supervised Record review of SIR’s, staff schedules and interviews with staff were completed. These disclosed the facility did not have coverage during the NOC shift in 1 of 4 units due to call-ins. CONT.... Substantiated CONT... Allegation: Staff do not assist residents with personal care needs Pictures observed, tours completed, and interviews conducted with staff and family indicate personal care needs (incontinence, grooming, bathing) are not being met. Allegation: Licensee does not ensure that staff receive required training LPA reviewed training records and observed staff on the schedule was not properly trained for their job. Record review showed that there were 1 staff (PM caregiver) that did not complete their training prior to being placed on the floor without supervision. Allegation: Staff do not safeguard a resident's personal belongings Interviews conducted with staff disclosed incontinent supplies are not properly being accounted for and going missing. LPA observed the storage room did not contain residents supplies. Allegation: During tour completed on 9/10/24 and 9/16/24 various areas of the facility were observed with items that pose a danger to residents in care unlocked and accessible. The allegations listed above are SUBSTANTIATED. The preponderance of evidence standard has been met per Title 22. Deficiencies cited on 9099D. Exit interview completed with Executive Director, Beronica. A copy of this report, deficiencies and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 24-AS-20240906130954

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(e) · Plan of correction due date: Jan 3, 2025

1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidence by record review of SIR’s, staff schedules and interviews with staff. These disclosed the facility did not have coverage during the NOC shift in 1 of 4 units. This posed a potential health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: All shifts will be covered and none left vacant. Staggering of time for shifts to begin has began (12/1/24) so shifts overlap. ED stated they will provide the schedule that is now being used as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Jan 3, 2025

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidence by: review of documentation, tours completed and interviews conducted which all indicate personal care needs (incontinence, grooming, bathing) are not being met. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: ED stated Resident Care Director was provided diciplinary action for performance as they are the lead and direct report for these issues. A replacement RCD will be found if improvement is not made. Copies of any disciplinary actions for RCD will be provided to CCL as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d) · Plan of correction due date: Jan 3, 2025

87411 Personnel Requirements - General (d)All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement was not met as evidence by: review of records. Files review show that staff did not have the required training prior to being placed on the schedule without supervision for the NOC shift. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: ED stated staff are provided 5 days of initial training and 4 days on the floor of hands on. Orientation responsibilities have been reassigned from the RCD to ED and Business Office Manager to ensure proper training is being completed prior to staff being on the floor unsupervised. A copy of the schedule with orientation days listed will be submitted to CCL as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jan 3, 2025

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement was not met as evidence by: Interviews conducted disclosed incontinent supplies are not properly being accounted for and going missing. LPA observation of storage room disclosed residents supplies were missing. This poses a health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: ED stated that residents on hopice are now having supplies kept in their rooms instead of the supply area. All other residents are kept in storage. ED stated they will request hopice agencies to provide a list of items provide for their residents. Sample copy of list to be provided to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Jan 3, 2025

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidence by: LPA observation during tours completed on 9/10/24 and 9/16/24. Various areas of the facility were observed with items (sharps and chemicals) that pose a danger to residents in care unlocked and accessible.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: ED stated that keys were distributed for the locked cabinets in the residents room. Training will be completed with all staff. In-service sign in sheet and training material to be provided to CCL by POC date.

Allegation investigated: Staff does not prevent outbreak of scabies.

On 11/14/24 Licensing Program Analyst (LPA) M. Garza completed an unannounced complaint visit. LPA was met by Business Office Manager, Michelle Reyburn due to Executive Director, Beronica Galindo being in a meeting. LPA explained reason for visit and was permitted entry into the facility. LPA completed a tour of the facility and completed a health and safety check on residents in care. Executive Director, Beronica Galindo joined later. During visit LPA completed interviews and reviewed records. Interviews and record review disclosed the facility had an outbreak with residents in 1 of 4 wings of the facility. At this time the facility has 0 residents presenting symptoms or being treated. The Department found that the preponderance of evidence standard has been met per Title 22. The allegation is SUBSTANTIATED. Deficiencies issued on attached 809D. Exit interview completed with Executive Director, Beronica. A copy of this report, deficiencies and appeal rights have been provided. Substantiatedthe state’s words, verbatim · CDSS document, Nov 14, 2024 · control 24-AS-20241104154046

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(b)(1) · Plan of correction due date: Nov 22, 2024

87470 Infection Control Requirements (b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (1) In addition to the requirements of subsection (a)(2) assigned staff and volunteers, regardless of having direct contact with residents, shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment and to prevent, contain, and mitigate the transmission of the contagious disease... This requirement was not met as evidence by: record review and interviews conducted disclosed 1 of 4 wings at the facility had an outbreak. This poses a potential health, safety and or personal right risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Staff was trained on infection control. In-sevice sign in sheet to be provided to CCL as proof of correction.

Allegation investigated: Questionable Death

The Department reviewed records for R1. Based on records reviewed, the allegation is Unfounded. We have therefore dismissed the complaint and no citation was issued. Unfoundedthe state’s words, verbatim · CDSS document, Mar 6, 2024 · control 24-AS-20230829115053

Type of visit: Required - 1 Year

On 1/18/2024 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Executive Director, Beronica Galindo. LPA introduced self, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. There were 11 resident on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operate on a system. Fire extinguisher last serviced 09/25/23. Last fire drill on 12/26/23. Water temperature taken and measured in 8 rooms. Water temperature varied from 110.3 to 119.2 degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Chemicals are located in chemical closet in hallways of each unit. Medications were located in locked medication carts in each hallway. LPA requested the following documents to be submitted to CCL by 1/26/2024: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. No deficiencies were cited during the inspection. Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with Executive Director, Beronica Galindo. A copy of this report was given.the state’s words, verbatim · CDSS document, Jan 18, 2024