Summerset Assisted Living

Allegation investigated: Staff did not meet the resident's toileting care needs Staff interfered with the resident's visitations Staff restricted telephone services to resident in care

On September 10, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct a follow-up complaint investigation regarding the allegations noted above. LPA met with the current Executive Director/Administrator, Erica Diala (AD), and stated the purpose of the visit. Complaint overview: The reporting party (RP) alleged that the facility did not allow them to visit R1. The RP stated they were not allowed to see R1 in their room and were asked to leave. RP also reported that two friends were told they could not visit and later claimed they “snuck in” and saw R1 sitting in feces with swollen legs. RP said these friends were later told they could not visit because of the POA. RP also alleged that R1 was not allowed to have a phone. {1} Unsubstantiated Allegation – Staff did not meet resident’s toileting care needs The investigation into this allegation consisted of interviews with facility staff, record review of resident (R1)’s records, and observed R1’s room and condition. Staff reported that R1 receives scheduled toileting assistance as per Needs and Services Plan. Per interview, staff conduct incontinent checks and respond promptly when hygiene care is requires, such as when R1 soiled themselves. Former Administrator reported there were no documented incidents indicating R1 was found soiled, left in feces, or had untreated swelling. Administrator denied knowledge of any neglect regarding toileting or personal hygiene and stated R1’s care needs were being met as required. In another interview, staff said that R1 had bottled water available at all times, received toileting checks every two to three hours, and showered after soiling themselves. In this same interview, staff reported that law enforcement inspected R1’s room, spoke with R1 and found no signs of dehydration or neglect. Staff also stated the Ombudsman visited and confirmed that R1’s condition and care were appropriate. Record review showed consistent documentation of bowel movements, two-hour checks, and toileting assistance. Physician’s Report and Resident Assessment confirmed R1 requires assistance with toileting and regular status checks. LPA Valerio’s observation on 10/31/25 found R1 clean, groomed, and living environment odor-free and hazard-free. Based on the available information collected, there was insufficient evidence to support that staff did not meet R1’s toileting care needs. Therefore, the allegation is unsubstantiated. {2} Allegation - Staff interfered with the resident’s visitations. The investigation into this allegation consisted of interviews and record reviews. The former Administrator said the facility sometimes limited visits based on instructions from R1’s Power of Attorney (POA). The POA asked the facility to restrict certain visitors from going into R1’s room, including some R1’s friends. The Administrator said the facility only followed the POA’s directions and did not create its own restrictions. The former Memory Care Director (S1) said R1 normally had no limits on visitors. She described an incident in 2025, when she saw one of R1’s friends trying to get R1—who has dementia—to sign papers that R1 did not understand. The visitor refused to show staff the papers. S1 escorted the visitor to a common area and reported the incident to R1’s POA. After this, the POA asked that visits take place only in open common areas, not in R1’s private room. S1 said R1 was still allowed visitors, and the POA did not ban anyone. Certain visitors simply had to visit in shared areas after that incident. In an interview with another staff (S2), visitors always sign in when they enter. Per interview with POA, which POA confirmed that for the safety of R1, POA restricted some individuals to visit R1 after the incident of trying to have R1 sign a document and R1 was unable to fully comprehend what they were signing. Record review showed the Admission Agreement requires visitors to sign in and follow facility rules. Evidence shows the facility allowed R1 to have visitors. The changes to R1’s visitation procedures were made based on the POA’s request for R1’s safety, not because facility tried to interfere with visitation. Therefore, the allegation that staff interfered with the resident’s visitations were unsubstantiated. {3} Allegation - Staff restricted the resident’s telephone services. The investigation into this allegation consisted of interviews and record reviews. According to the former administrator, R1 did not have their own phone because the POA asked the facility to limit phone access because the POA was worried that phone calls made R1’s confused or upset. The administrator said that the facility followed the POA’s instructions and did not limit phone access to R1. According to the former memory care director, the POA had given R1 a phone but R1 dropped it into the toilet twice and broke it. The POA talked about installing a landline but did not happen. Alternatively, the facility can accommodate phone calls for residents. R1 could still receive calls. According to interviews, med techs are supplied with their own cellphones to be used while on duty. When a person calls for R1, the front desk would route the call to a med tech’s cellphone and give the phone to R1. On the other hand, interviews also revealed that if R1 needs to make a phone call, the med techs can provide their cellphone to R1 to use. According to POA’s knowledge, the facility staff did not restrict R1 from receiving or making phone calls. Record review of the Power of Attorney documents showed R1’s POA authority was properly assigned. Based on the available information that were collected, there is insufficient evidence that the facility staff restricted R1’s telephone services. Therefore, this allegation was unsubstantiated. Note that a finding that was unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited from today’s visit. Exit interview was conducted with Erica Diala. A copy of this report and the appeal rights were provided. {4}the state’s words, verbatim · CDSS document, Sep 10, 2026 · control 27-AS-20251023142539

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with Administrator Erica Diala, and explained the purpose of the visit. LPA Valerio and Administrator Erica toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed all floors of the building and inspected eight (8) bedrooms. All bedrooms were observed to have their own bathroom/shower. 7 out of 8 residents rooms were observed to clean, fully furnished, and exit doorsways were free from obstructions. One resident bathroom was observed to have blood stains in the bathroom. According to Administrator, the resident has dialysis and sometimes has leakage of blood. Administrator stated, housekeeping would clean the floors. LPA Valerio inspected the hallways, laundry room, kitchen area, and dinning room. No health or safety concerns observed on the floor. The fire extinguishers located in the hallway were observed to be fully charged with the last date of inspection on July 9, 2026. The second floor is the memory care area. The elevator was observed to be in working condition. During the tour, LPA Valerio smelled an odor on the second floor. Staff explained that a resident had an accident and was taken to take a shower. All areas were observed to be free from hazardous items accessible to residents in care. LPA Valerio observed residents and staff engaging in a shark craft activity. LPA Valerio observed the third floor of the facility. This floor is considered the "independent living" floor. LPA Valerio observed no odors and the common areas to be fully furnished. Continues on LIC 809 - C... LPA Valerio observed the laundry rooms to have washers that were not in good repair. The facility was cited on a subsequent visit for complaint 27-AS-20260714174144 on today's date of 07/21/2026. LPA Valerio observed the main kitchen area. LPA Valerio observed the food supply. LPA Valerio observed lunch to be the following: beef and cheese quesadilla, Spanish rice, refried beans, turkey & rice Soup, and assorted dessert. LPA Valerio observed pie being offered for dessert. For dinner, the menu stated the residents would be served breaded veal cutlet, mash potatoes with gravy, broccolini, turkey & rice soup, and pie. In the Assisted Living (AL) dining room area, LPA Valerio observed an all day breakfast menu, which can be ordered as a second option. All day breakfast items include: pancakes, waffle, French toast, avocado toast, breakfast sandwich, omelets, assorted cereals, toasted bread, bacon, eggs, ham, hash browns, sausages, applesauce, fruit, pudding, and yogurt. LPA Valerio observed the lobby area to have apples and oranges next to the coffee bar. LPA Valerio reviewed facility files, which were observed to current with up to date annual documentation. The date of the last fire drill was on July 13, 2026 LPA Valerio requested the following annual documentation be sent to christina.valerio@dss.ca.gov: - LIC 500 - LIC 308 - LIC 610D - Copy of Liability Insurance Per California Code of Regulation (CCR) - Title 22 - no deficiencies were cited on this visit. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 21, 2026

Allegation investigated: Staff are not allowing resident to choose their own hospice agency.

On 12/15/2025 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to continue this investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak to the Designated Facility Administrator/Executive Director (ED) Danielle Barry. Danielle Barry was not longer working at the facility. LPA met with Desingee,Terri Henry and a brief interview followed. LPA Observed holiday decorations upon entering the facility and staff were in the processing of removing taped train tracks off the carpeting in the main lobby after a morning activity. LPA also observed staff sporting holiday antlers with bells while they interacted with 2 residents in the front lounge area. Later during the visit, LPA observed 6 residents playing cards at a gaming table set up in the lobby with staff supervising while acting as dealer. Regarding the above allegation: Staff are not allowing resident to choose their own hospice agency. Unfounded LPA conducted a review of files for residents on hospice during a visit on 5/21/25. LPA received the information for 14 Residents R1 - R14. 12 residents were receiving hospice services from hospice agency (H1), 1 (H2), and 1 from (H3). From the list provided today, this LPA learned that there were 10 residents, 4 of whom were included on the original list, receiving hospice and that other residents had transitioned and were receiving hospice services now. A total of 6 were receiving hospice services from H1, 1 from H3, 1 from H4, 1 from (H5), and 1 from (H6). LPA conducted 4 phone interviews with the responsible parties for 4 residents: (R1, R2, R3, and R19). None of the responsible parties interviewed stated that they were not allowed to choose their own hospice agency. The standard for the preponderance of evidence was not met and the department determined the allegation to be UNFOUNDED. A determination of unfounded means that the allegation was false, could not have happened, and/or is without a reasonable basis. According to the California Code of Regulations Title 22, there were no other deficiencies observed or cited during today's visit. A copy of this report was provided and an exit interview was conducted with Designee, Terri Henry.the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 27-AS-20250520123144

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a one year required/annual visit. LPA met with the Executive Director Danielle Barry and explained the reason for the visit. Census:84 The facility is licensed for a capacity of 135 Non-ambulatory residents of which 20 may be bedridden. Hospice Waiver approved for 25. LPA Lund and Executive Director Danielle Barry toured/inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The most recent emergency drill was conducted on 8/1/24. LPA observed 2-day perishables and 7-day non-perishables. Facility utilizes a wander guard system for residents in need of more assistance. Facility has required postings which include Oxygen in Use. The temperature thermostats inside was continuously observed to be at 73*F throughout the facility which is within the required range of 68-85*F. LPA obtained information that the facility houses 4 water heaters. The hot water temperature was measured between 106.5*F and 112.3*F in a random six residents rooms, which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and pull alarm system in the facility and is in compliance. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 7 staff and 8 resident files during today’s visit and were in compliance. LPA Lund went over the stipulation order and staff are continued to be trained every six months. No deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Aug 29, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a collateral visit. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit. LPA Moleski interviewed a client (R1) and R1's responsible party. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Barry.the state’s words, verbatim · CDSS document, Jul 7, 2025

Type of visit: Case Management - Incident

On 06/18/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit regarding a death report sent to Community Care Licensing on 05/16/25. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designee, Terri Henry. The Executive Director, Danielle Barry, had informed this LPA that they would be out of the office this week and that Henry would be the point of contact. An updated LIC 308 was sent the morning of 06/17/25. LPA Viarella met with Henry and a brief interview followed. During this visit Bingo for approximately a dozen residents was facilitated in the main lobby by the Activities Assistant. LPA Viarella observed the end of the Welcome Luncheon for new residents to the community in the dining room. Toward the end of the visit, LPA observed musicians setting up in the main lobby for an event beginning later in the afternoon. Documents pertaining to this resident's condition and death were collected and reviewed with the Designee. Best practices for reporting the death of a resident were also discussed. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided. Exit interview.the state’s words, verbatim · CDSS document, Jun 18, 2025

Allegation investigated: Facility is not allowing residents to get mail.

On 05/16/25 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open a complaint into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak to the Designated Facility Administrator/Executive Director (ED) Danielle Barry. LPA met with the ED and a brief interview followed. LPA requested the following documents: LIC 602 for Resident (R1) Copy of Personal Rights provided to residents Copy of conservatorship of R1 Emergency Contact/ID information As part of this investigation, LPA reviewed the above documents and conducted interviews. LPA found based on a review of documents that the resident was conserved and living in memory care. Based on Substantiated Based on conversations with 5 staff members (S1-S5), there was a process in place for mail for the memory care residents as they did not have mailboxes on the main level. This LPA was told that their mail was dropped off at the reception desk where it was sorted and then the medication technicians (MedTechs) on the send floor were notified to pick it up. They would then deliver the mail to the individual residents in the memory care community. If the resident had a conservator, there was a special area in the locked medication room where this mail was labeled and stored. The MedTechs would then call the conservator to alert them that mail had arrived for the resident and then the conservator would be asked to come and pick it up. If there was no response to their call or messages, the MedTech would text the conservator, and then document with post it notes the dates when their contact attempts were made. LPA asked the Director of Care what process was in place if they could not reach a conservator in a timely manner. LPA was told that there was a number they could call that for the Conservator of the Day that would assist them. In this particular case, this LPA learned through personal observations, that residents' mail, not just the items that were the responsibility of the conservator (i.e. medical and/or financial) were stored in the medication room. LPA observed personal letters and cards from April 2025, in a sorting container on top of a cabinet. The sorter was labeled, "Residents Mail for POA." Through interviews, this LPA learned that staff (S3) had withheld all mail because they thought that legally they had to give it directly to the conservator. LPA explained to S3 that was a violation of the resident's personal rights and that their personal mail should have been delivered to them directly. The allegation: Facility not allowing residents to get mail, was SUBSTANTIATED and this deficiency was cited on the LIC 9099D page. According to the California Code of Regulations, Title 22, no other deficiencies were observed or cited during today's visit. ED stated that a training has been scheduled for the medication technicians in memory care next week on what mail to deliver, and what to hold for a residents' responsible parties. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted.the state’s words, verbatim · CDSS document, May 16, 2025 · control 27-AS-20250508151929

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: May 30, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to 87468.1, ...the elderly shall have all of the following personal rights:(1) To have ...in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations... The licensee did not ensure that the above regulation was met when: Based on personal observations and interviews, mail for residents in memory care was being held until conservators could pick it up. This posed a potential threat to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: ED stated that a training will be held with all medication technicians by 5/30/25 regarding what mail should be delivered and what shoudl be held for responsible parties. ED will submit a outline of training along with signature sheets for participants to CCLASCPSacrementoRO@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kimberly Viarella and Sommer Hayes arrived on 04/17/25 for an unannounced inspection to follow up on a substantiated complaint investigation. LPA Viarella met with facility administrator Danielle Barry and explained the purpose of the visit. On July 1, 2024, the Department concluded a complaint investigation regarding the following allegations: resident fell sustaining fractures due to staff neglect, staff did not seek medical attention for resident, staff did not notify resident’s authorized representative of incident, and staff are not meeting a resident’s hygiene needs. The licensee was cited for California Code of Regulations (CCR) 87468.1(a)(2) Personal Rights of Residents in All Facilities, 87465(g) Incidental Medical and Dental Care, and 87211(a)(1)(B) Reporting Requirements, and 87464(f)(4) Basic Services. At the time of the complaint visit on July 1, 2024, substantiated findings were delivered to the facility. On September 5, 2024, this report was amended to include issuance of an immediate civil penalty in the amount of $500 and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code Section 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or a mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the administrator not providing R1 with an updated needs and services plan to address their risk status due to multiple falls, to include increased observation of R1, fall prevention measures and implementing a fall prevention plan. As a result, R1 suffered a fall which resulted in multiple fractures. A subsequent fall occurred where R1 fell and reopened the surgical site and was not sent out for a medical assessment until the following day. Today, April, 17, 2025, the Department will be issuing a civil penalty per Health and Safety Code Section 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously assessed on September 5, 2024, the amount of the civil penalty assessed today will be $9,500. Exit interview conducted. A copy of this report and the LIC 421D were signed and given to Danielle Barry. Appeal rights were provided. Barry’s signature on this report acknowledges receipt of the appeal rights, which are found on page two of the LIC 421D.the state’s words, verbatim · CDSS document, Apr 17, 2025

Allegation investigated: Staff did not provide adequate hygiene care to resident.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed a resident (R1), a resident’s conservator, six staff members (S1-S6), and Barry. LPA Moleski reviewed an incident reported dated 11/17/24 which described R1 as having a change of condition. R1 was off baseline, and the left side of their face was swelling, according to the report. R1 was sent to a hospital for further evaluation. Shortly after R1 was sent to the hospital, the Community Care Licensing Division (CCLD) received a report alleging R1’s general hygiene was poor, and in particular that R1 had dead skin and other skin breakdown on their palms. [continued on 9099-C] Unsubstantiated LPA Moleski reviewed ongoing communication log notes from the days immediately preceding R1’s hospital visit on 11/17/24. No notes were recorded regarding R1 between 11/14 and 11/16. LPA Moleski reviewed shower sheets for R1 for the month of November and observed three sheets dated from before R1 was sent out, dated 11/3, 11/6, and 11/13. In an interview, S3, who provided care to R1 on the morning on 11/17, said that they had to try multiple times to get R1 up, and when they did get up, R1 was resistant to care. S3 said that R1 appeared clean and hygienic, and it looked as if the previous shift had showered R1. S3 said that they also personally cleaned R1 after getting R1 up using wet wipes, and also put lotion on R1. S3 said they observed a “rash” on R1’s hands, but they could not put lotion on R1’s hands because R1 would eat it off their hands. S3 said that they notified the medication technician on duty (S1) that R1 was off baseline. LPA Moleski reviewed a home health referral for R1 dated 6/20/24. According to the referral, R1 had "very dry and leathery" skin, and R1 was experiencing "skin shedding." R1 was admitted to home health for "complex disease management/prevention of skin breakdown." LPA Moleski reviewed prescription orders written by R1’s nurse practitioner (NP) dated 10/28/24 for Aquaphor Blue. The NP diagnosed R1 with dry skin. LPA Moleski reviewed a visit report written by home health, dated 11/13/24. The reason for the visit was to conduct a skin assessment on R1. Home health staff instructed facility staff to continue monitoring R1’s hands and skin and to report any changes. LPA Moleski reviewed home health reports dated 11/7 and 11/4 with largely the same reason and result. The report on 11/4 noted "severe dryness" of R1’s skin. LPA Moleski reviewed a visit report from R1’s NP dated 11/4. R1’s NP noted dry skin on R1’s face and fingers. The NP wrote that staff had used the Aquaphor Blue on R1, but R1’s skin appeared more dry afterward. The note continued to say that R1 was sucking on their fingers frequently, making application of ointment to R1’s hands impossible. Multiple staff interviews suggested R1 has a persistent behavior which involves sucking and/or biting on their own hands, and sometimes on their clothing, causing dry skin. S1, the medication technician who responded to S3’s summons when they observed R1 was off baseline, said that R1 was very sleeping on the morning of 11/17/24. S1 said that R1 had slept in their clothes from the night before, and was not changed before being sent out to the hospital, due to R1’s unusual sleepiness. S1 said that they did not notice any unusual odor from R1 that morning, and had not observed any general issues with regard to R1’s hygiene. [continued on 9099-C] In an interview, R1’s conservator said they were aware of R1’s skin condition, and their habit of sucking on their hands, and had been working closely with staff to address it. R1’s conservator said they had zero concerns regarding R1’s care at this facility, and complemented facility staff for sending out R1 whenever issues are observed. None of the six staff members interviewed (S1-S6) reported observing R1 dirty or unhygienic at any time. LPA Moleski attempted to speak with R1, but R1 was not able to verbally respond to questioning. LPA Moleski observed R1’s skin, clothes, and bedding to be clean. LPA Moleski did not observe an odor from R1. R1 was still hospitalized during LPA Moleski’s initial visit on 11/25/24, and by the time of LPA Moleski’s meeting with R1 on 1/28/25, R1’s conservator and facility staff had acquired large, padded mittens meant to prevent R1 from sucking on or biting their own hands. The department has determined the following as it relates to the allegation that staff did not provide adequate hygiene care to a resident. Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Barry.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 27-AS-20241120164437

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on a complaint investigation, but observed an unrelated deficiency to be addressed in this case management report. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit. LPA Moleski attempted to interview a resident (R1) in their room, and observed R1 lying in bed, rocking back and forth, and chewing and sucking on large off-white padded mittens wrapped onto R1's wrists. R1 was not able to verbally respond to LPA Moleski. In an interview, Barry said that R1 came back from a recent hospital visit with the mittens, which were meant to prevent R1 from biting and sucking on their own hands. In an interview, the facility's memory care director (S1) said R1 returned to this facility from a hospital visit on 1/13/25 with the mittens. S1 said that R1's conservator has authorized the use of the mittens. LPA Moleski asked for physician's orders for the use of the mittens. S1 said there were no physician's orders on file for the mittens. 22 CCR Section 87608(a)(3) states that "a written order from a physician indicating the need for the postural support shall be maintained in the resident’s record" and that "the licensing agency shall be authorized to require other additional documentation if needed to verify the order." However, 22 CCR Section 87608(a)(5) indicates that "under no circumstances shall postural supports include ... depriving, or limiting the use of a resident's hands..." LPA Moleski asked S1 if R1 was able to remove the padded mittens independently. S1 said that R1 has on occasion been able to remove the mittens by using their mouth to remove the fastener holding the bindings in place. 22 CCR Section 87608(a)(2) states that "postural supports shall be fastened or tied in a manner that permits quick release by the resident." This facility is hereby cited per 22 CCR Section 87608(a)(5). If this facility wishes to use these sorts of devices in the future, the facility administrator should provide a physician's order, written consent from the resident and/or responsible parties, and a written request for an exception to the facility's assigned LPA. An exit interview was held with Barry. Appeal rights and a copy of this report were left with Barry.the state’s words, verbatim · CDSS document, Jan 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5) · Plan of correction due date: Jan 29, 2025

"(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet." This requirement was not met as evidenced by: Based on interview and observation, a resident (R1) was limited in the use of their hands by large padded mittens, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jan 28, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a written plan regarding the use of these supportive devices, either discontinuance or requesting an exception from CCLD by POC due date. vincent.moleski@dss.ca.gov

Allegation investigated: Facility staff are not dispensing medications as prescribed Facility staff are falsifying resident records

On 01/10/25 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open a complaint into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak to the Designated Facility Administrator/Executive Director (ED) Danielle Barry. LPA met with the ED and a brief interview followed. This LPA requested a copy of the schedule for carestaff and med techs along with contact information as well as a copy of the resident roster. The LPA then toured the facility and observed 3 residents sitting in the conversation area of the lobby chatting, 2 kitchen staff cleaning the dining room while 3 residents finished their meals, an activities staff member packing up holiday decorations, and a housekeeping servstaff member servicing resident rooms. In memory care, this LPA observed 7 residents sitting in the common area watching TV and being supervised by 1 caregiver. LPA observed another caregiver assisting a resident in their room and a 3rd caregiver was on Unfounded break. LPA spoke with the Director of Memory Care who assisted auditing the medication cart. LPA observed as a sample of 6 residents' medications were counted to ensure that all were accounted for and logged properly. As part of this investigation, this LPA conducted interviews with 4 carestaff: S1 - S4. Each stated the med techs administered medications properly in a timely fashion. S4 stated that, "the med techs are always responsive. Our residents can't always speak up for themselves to tell us they are in pain so sometimes they act out and whether it is because they are in pain, or are agitated, the med techs always come right away." This LPA also reviewed the Electronic Medication Record (EMAR) for the month of December for 6 residents in memory care. The reporting party alleged that med techs were inputting that medications were being given that were not. Through the medication cart audit and review of the EMAR, this LPA found no evidence the EMAR being falsified. All were in compliance at the time of this inspection. Based on interviews with staff, a record review of the EMAR and Controlled Substance Log, as well as the audit of the medication cart, a preponderance for the standard of evidence was not met and the department found the allegations: Facility staff are not dispensing medications as prescribed, Facility staff are falsifying resident records, UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened or is without a reasonable basis. While reviewing the EMAR, this LPA observed a statement to describe why a resident did not receive their medication, "Physically unable to take." Each occurrence was investigated. Residents were not administered medications if they had loose stools and the medication would worsen conditions. Medications were not administered it the resident was out of the facility. A medication was not administered due to a resident being unable to swallow. This notation was also used if the facility was waiting for a script to be refilled. This LPA provided technical assistance in this area and the ED has stated that they will be putting a new process in place to address this issue and new terminology and/or additional notes would be included in the future. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided. Exit interview.the state’s words, verbatim · CDSS document, Jan 10, 2025 · control 27-AS-20250103102458

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 11/22/2024 at 10:30am. LPA met with Terri Henry, Business Office Manager and stated the purpose of the visit. LPA inquired if staff #1 (S1) was presently on the premises during this visit. Terri Henry, Business Office Manager stated the staff does not work in the facility any longer. S1 last worked in the facility on 4/10/2023. LPA was provided a copy of the payroll employment information document from Paychex Oasis that indicates that S1 was terminated on 4/10/2023 due to a violation of company policies. LPA served notice of "ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY" for S1 who was not present at the time of visit. Terri Henry, Business Office Manager was advised an immediate removal is warranted and requested the Personnel Report (LIC500) and Guardian account be updated to remove S1 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL). LPA provided a copy of the most current Guardian roster during this visit. LPA informed Terri Henry, Business Office Manager that S1 is not allowed to be employed and/or on any facility premises. The Order to Individual of Immediate Exclusion From All Facilities will be in effect as of 12/2/2024 upon receipt of the letter. A copy of the letter was given to the facility during this visit. The facility understands this is an Immediate Exclusion and has agreed S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services unless otherwise ordered by the Department. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held, A Copy of report given.the state’s words, verbatim · CDSS document, Nov 22, 2024

Allegation investigated: Resident sustained unexplained injuries while in care Staff did not report incident to resident's responsible party

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Administrator Danielle Barry. and explained the reason for the visit. Census: 93 Resident sustained unexplained injuries while in care - LPA Lund reviewed facility records, Resident’s (R1) medical records and interviews with staff. Based on reviewed facility records, Resident’s (R1) medical records and interviews with staff. Unusual Incident/Injury Report (LIC624) dated 6/7/2024 that R1 was sent to Kaiser Roseville for evaluation and treatment on 6/3/2024. Kaiser Admission paperwork dated 6/3/2024 stated that R1 was admitted to the Emergency Room (ER). Hospital admission physical exam states note acute distress and R1’s appearance is well- developed. Report states no unexplained injuries to R1. Unsubstantiated Based on reviewed facility records, Resident’s (R1) medical records and interviews with staff, on the information provided, it was unclear if resident sustained unexplained injuries while in care, therefore the allegation was deemed UNSUBSTANTIATED. Staff did not report incident to resident's responsible party - LPA Lund reviewed facility records, and interviews with staff. Based on reviewed facility records and interviews with staff. Unusual Incident/Injury Report (UIR-LIC624) dated 6/7/2024 that Resident (R1) was sent to Kaiser Roseville for evaluation and treatment on 6/3/2024. The UIR also indicates that the facility reported to the POA and Community Care Licensing (CCL). Facility records indicated that the facility called the POA on 6/3/2024 to notify the R1 was sent to Kaiser Roseville but the POA didn’t answer, so the facility left a message. Based on reviewed facility records and interviews with staff, on the information provided, it was unclear if staff did not report incident to resident's responsible party, therefore the allegation was deemed UNSUBSTANTIATED. As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 27-AS-20240613163034

Allegation investigated: Staff are not providing adequate supervision of resident to reduce injuries Staff did not seek medical attention for resident in a timely manner Staff did not address resident's skin issues in a timely matter

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Danielle Barry and explained the purpose of the visit. The investigation consisted of interviews with staff, interviews with responsible parties, observation of the facility, review of medical records, review of hospice records, review of facility documentation, and review of documentation provided by the Reporting Party (RP). Staff are not providing adequate supervision of resident to reduce injuries / Staff did not seek medical attention for resident in a timely manner According to the Reporting Party (RP), Resident 1 (R1) "is prone to wander, fall, and suddenly injure [themselves] should [R1] be left unsupervised or not be properly cared for." RP also stated that R1 has fallen and injured R1's face on three separate occasions and Summerset has not done enough to ensure R1 is safe. Unsubstantiated According to R1's LIC 602 Physician's Report dated 04/04/2023, R1 is diagnosed with dementia, max supervision is needed, and it is noted to have wandering behavior in bedroom only. R1 is ambulatory. According to a Resident In-House Assessment dated 02/26/2024, R1 is on status checks 4 times per shift and ambulates independently with or without device, needs assistance with ADLs, and is not on a special care plan. The Resident In-House Assessment was updated on 05/21/2024 with minor changes. Status checks remained at 4 times per shift and ambulation requires 1 person total assist or wheelchair escort. Facility documentation and documentation provided by the RP show that R1 sustained falls on March 11th, March 24th, and April 9th. During those days, the staff scheduled showed a total of four (4) staff members on AM and PM shift to work in the memory care living area. According to facility documentation, an incident report dated 03/08/2024 showed that staff was on the way to an elevator when staff heard a thud. Staff turned their head and saw R1 on the floor. Staff responded and the medication technician was notified. Hospice and R1's conservator was notified of the incident. First aid was administered and it was noted that the resident did not go to the hospital. Hospice records show that a nurse conducted a follow up visit on 03/11/2024 to care for the injuries for the fall. R1 had cuts on face, Band-Aids were replaced, and R1 appeared at baseline. Another hospice entry was documented for a routine visit on 03/11/2024. The nurse wrote, "Pt fell on Friday, injuries to leg, bandage take off. No bleeding notes. No signed of infection. Checked for cut to face from fall, they are superficial cuts from the fall. Left it open to air." On 03/24/2024, the hospice nurse was notified of a fall. The nurse documented the following: "Assess skin tears - wound to right side of face after fall this AM. Will send nurse tomorrow to cleanse and dress laceration." On 03/25/2024, the noted stated "Routine visit - checked Pt in hallways, calm/quiet, S/P fall with injuries, no signed of infection." After 03/24/2024, LPA did not observe any additional notes from Bristol Hospice. According to an interview with the administrator, the hospice agency was not always consistent with notes and R1 was in process of changing hospice companies. According to a Kaiser After Visit Summary dated 04/09/2024, resident was seen for preventing falls, cellulitis, and scabies. On 04/23/2024, resident was seen at Kaiser Hospital for fall and rash. According to an interview with R1's conservator (R1-C), R1-C stated the facility contacted R1-C each time R1 had fell at the facility. "They were pretty good about that." In regards to R1's rash, R1-C stated there was a delay because R1's medical power of attorney (R1-POA) was the initial person to converse with care staff due to the hospice company not recognizing the conservator. R1-POA told staff the rash was a food allergy. Staff were going by what the POA was saying and not a medical professional. However, according to R1-C, after emails were sent to confirm the conservatorship, R1 was able to get medical attention for the rash. Staff did not address resident's skin issues in a timely matter According to the Reporting Party (RP), the RP stated Resident 1 (R1) started to display signs of a skin rash in February of 2024. On April 9th, 2024, R1 was sent to the hospital for a fall and was diagnosed with Scabies. According to the RP, the facility did not address R1's skin issues in a timely manner. LPA Valerio contacted the RP on 05/21/2024 and 08/06/2024 to obtain additional information. LPA Valerio has yet to receive a response. According to facility Medication Records, the facility administered Hydrocortisone on the following dates for the reason of rash/itching: 02/27/2024, 03/04/2024, 03/05/2024, 04/04/2024, and 04/04/2024. According to facility Medication Records, the facility administered Benadryl Allergy 25mg tabs PO on the following dates for the reason of Rash/Itching: 02/27/2024, 02/28/2024, 03/05/2024, 03/21/2024, 03/25/2024, 04/04/2024, 04/07/2024. According to the MAR, comments shown that the medication "helps". According to facility records, R1 had multiple visits from a Bristol Hospice nurse. During those visits, the nurse who cared for R1 wrote notes to communicate services provided. LPA Valerio observed that Bristol Hospice did not document skin care treatment until 03/11/2024. Per Bristol Hospice Note dated 03/11/2024, nurse wrote, "Pt was calm, cooperative, good,… still rash continue, Benadryl and hydrocortisone helps." Per Facility Medication Room Records, a Medication Technician wrote a note on 04/09/2024 stating, "Patient has returned back to facility. New meds CATB, Acetaminophen 500mg, and body cream. Acetaminophen 500 mg did not come with other two items. CSM meds and put into QMAR. D/C paperwork to hospice. " Per Bristol Hospice Medication Orders dated 04/17/2024, the Medication order for Bactrim and Hydrocortisone order on 04/10/2024 had been discontinued. A new order for Bactrim DS-800mg-160mg tablet 1 tablet orally 2 times a day x 7 days a week for possible infection to elbow and an order for Triamcinolone Acetonide Topical Cream 0.1% Cream application applied topically 2 times a day x 14 day for rash was ordered. Per Bristol Hospice dated 04/11/2024, the nurse wrote, "Taking antibiotics injection on elbow. Right elbow healing. Scab notes. Pt. received meds. Scabies had shower. Spouse present." Per Bristol Hospice note dated 04/11/2024 PM, the nurse wrote, "Routine Nurse Visit - Right elbow healing scar noted. Pt received meds for scabies. Had shower. Spouse present." LPA Valerio interviewed 4 staff members. S1 stated that when a staff member observes a resident with a rash, the protocols were for the observing staff to notify the med tech, then the med tech will notify hospice or home health or responsible party, and then the med tech would notify memory care director. S1 admitted the previous Memory Care Director did not relay information to the Administrator timely. S2 remembers treating R1 with a topical cream for R1's rash. S2 stated the facility would communicate with R1's hospice team and R1's conservator about the rash. S3 stated if a caregiver staff sees a rash, they would take pictures and contact the doctor. If the facility has orders for medication cream, they will use it right away. S3 remember applying topical cream to R1 from the day S3 started work up until R1 left the facility. S4 could not recall treating resident for a rash. According to an interview with R1's conservator (R1-C), the facility was unaware of R1's conservatorship and was communication with R1's Power of Attorney (POA) when the initial rash was observed by staff. R1-C also stated that Bristol Hospice would not communicate with R1-C. Bristol Hospice was with R1 all the time. Per R1-C, the facility was only listening to the POA initially. The POA stated the rash was from a food allergy, so Hospice and the facility went with that and did not look into other options. Per R1-C, there was some confusion whether it was an issue for scabies or a rash from food allergy. . R1-C stated R1 was able to get care for R1's rash after R1-C sent a few emails and after R1 fell. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 27-AS-20240515152430

Type of visit: Case Management - Legal/Non-compliance

On 8/22/24 at 1:30pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a case management visit for the purpose of delivering an Order to Licensee/Facility of Immediate Exclusion from Facility. LPA Villanueva intially met with facility Receptionist, Gabriella Mendoza. The Administrator, Danielle Barry (ADM) was informed of the visit over the phone but is out of the facility during this visit. ADM gave permission to the facility Marketing Director, Victoria Olivares, to receive the documents and sign this report. LPA explained the purpose of today’s visit. Staff_1 (S1) and Staff_2 (S2) were excluded as a result related to this facility. LPA explained to ADM that S1 and S2 be immediately excluded from this facility upon receipt of the exclusion letters. Per interview of ADM, S1 and S2 no longer employed at this facility. LPA Villanueva served, via hand deliver, the Order to Licensee/Facility of Immediate Exclusion from Facility letter and Declaration of Service document to Victoria Olivares. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited during today's visit. Exit interview was conducted with Victoria Olivares and a copy of this report was provided at the conclusion of this visit.the state’s words, verbatim · CDSS document, Aug 22, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 8/21/24 at 9:30am. License Fees were sent to Community Care Licensing (CCL) prior to todays visit. LPA met with Danielle Barry, Executive Director and Terri Henry, Business Office Manager and stated the purpose of todays visit. Administrator certificate expires 6/5/26. The facility is licensed for a capacity of 135 Non-ambulatory residents of which 20 maybe bedridden. Hospice Waiver approved for 25. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. There is 13 resident receiving hospice care services and 4 bedridden at this time. The most recent emergency drill was conducted on 8/1/24. LPA observed 2-day perishables and 7-day non-perishables. Facility utilizes a wander guard system for residents in need of more assistance. Facility has required postings which include Oxygen in Use. The temperature thermostats inside was continuously observed to be at 72*F throughout the facility which is within the required range of 68-85*F. LPA obtained information that the facility houses 4 water heaters. The hot water temperature was measured between 106.5*F and 112.3*F in a random amount of rooms (135,139,217,303,308,310,327) which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and pull alarm system in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 4 staff and 4 resident files during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Submitted prior to todays visit Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Emergency Disaster Plan LIC610-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-Current First aid/CPR certificates-Current Liability Insurance-(if applicable)Submit Infection Control Plan-Submit if applicable Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Aug 21, 2024

Allegation investigated: Resident fell sustaining a fractures due to staff neglect Staff did not seek medical attention for resident Staff did not notify resident's authorized representative of incident Staff are not meeting resident's hygiene needs

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. According to facility notes, incident reports, and medical records, a resident (R1) suffered numerous falls at this facility between 9/10/18 and 11/10/23. Falls documented during this time period include the following: On 9/10/18, R1 fell while family members were visiting. On 5/21/20, R1 fell on their right hand, and swelling and bruising were observed. R1’s physician was notified. On 6/22/23, R1 suffered an unwitnessed fall and complained of knee pain. R1 was sent to the hospital and R1’s physician was notified. [continued on 9099-C] Substantiated LPA Moleski reviewed R1’s file and other medical records and observed no indication that R1 had ever suffered from bed sores or diaper rashes. None of the staff members interviewed reported having observed bed sores or diaper rashes on R1. Multiple staff interviews indicated that R1 is able to notify staff when toileting assistance is needed. LPA Moleski reviewed a fax dated 3/14/23 sent from facility staff to R1’s physician which described a fungal infection observed on R1’s anus. LPA Moleski interviewed the author of the fax, S5, who said that the infection resolved shortly after receiving cream prescribed by R1’s physician. S5 had not observed any bed sores or diaper rashes present on R1. The department has determined the following as it relates to the allegations that staff are not meeting a resident’s diapering needs, resulting in sores, and that staff made inappropriate comments toward a resident: Based on record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Barry. According to medical records, R1 was diagnosed with a fracture of the right kneecap and multiple fractures of the right side of the ribcage on 6/22/23. R1 underwent surgery on 6/24/23 to address this injury. R1 was sent to a rehabilitation center and returned to this facility on 7/15/23. On 7/18/23, R1’s home health nurse noted that a surgical wound on R1’s knee appeared to be infected, and instructed staff to send R1 to the hospital if the wound became redder in coloration. A fax was sent by facility staff to R1’s physician on the same day, stating that if the condition of the wound worsened, R1 would be sent out. According to facility notes, on 7/19/23, R1 fell, opening the pre-existing wound on their knee. A facility staff member cleaned and bandaged the wound, but R1 was not sent to the hospital until the next day, 7/20/23. No documentation exists that R1’s physician was notified when the fall occurred, and no documentation exists to show that R1’s responsible party (RP) was notified. In an interview, R1’s RP said that they were not notified after the incident. On 8/15/23, R1 suffered an unwitnessed fall. R1 was taken to the hospital and R1’s physician was notified. According to medical records, R1 was diagnosed with a fracture to the right kneecap on 9/4/23. An incident report dated 9/4/23 states that R1 fell onto their knees at the facility. R1 was taken to the hospital, and R1’s physician was notified. On 9/21/23, staff note that R1 had returned from their last hospital visit, and note that staff must make sure R1 does not fall again. On 10/29/23, R1 suffered an unwitnessed fall and was placed back into bed. On 10/30/23, R1 suffered an unwitnessed fall. R1’s physician was notified.¬¬ On 11/10/23, R1 suffered an unwitnessed fall. R1’s physician was notified. The Community Care Licensing Division (CCLD) received only two incident reports regarding any the above incidents: one, dated 8/15/23, and another, dated 9/4/23. Despite the number of falls suffered by R1 between 9/10/18 and 11/10/23, R1 did not receive an updated needs and services plan to address R1’s fall risk. R1’s most recent needs and services plan was dated 11/17/19 at the time this complaint investigation was opened. Interviews with current and former staff show that staff were aware R1 was a fall risk and that they were told to watch R1 closer, but were not asked to implement fall prevention measures, and no fall prevention plan was in place. [continued on 9099-C] LPA Moleski interviewed eight staff members (S1-S8) regarding R1’s hygiene care. S1 said a podiatrist trims residents’ toenails about once every two months. S3 was not sure who is responsible for trimming residents’ nails. S4 said R1’s RP cuts R1’s toenails, and also that a podiatrist is responsible for trimming residents’ toenails, but did not know how often the podiatrist comes. S5 said they had observed R1 with long, unkempt toenails twice, once around June 2023 and once around August 2023. S5 said that they raised concerns to management about the situation, but nothing was documented. S6 said that they were not sure who was responsible for trimming R1’s nails, and said they had observed R1’s nails long on one occasion, around fall 2023. S8 said they had seen many residents with long and unkempt nails, and said R1 was likely one of them. S8 said residents must be added to a special list to receive nail trimming services, and said the podiatrist will visit about once every two months. S8 said that R1’s hair was also sometimes dirty. R1’s RP said they had observed R1 with long and unkempt nails previously. The department has determined the following as it relates to the allegations that a resident fell sustaining fractures due to staff neglect, that staff did not seek medical attention for a resident, that staff did not notify a resident’s authorized representative of an incident, and that staff are not meeting a resident’s hygiene needs: Based on interviews, observation, and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87468.1(a)(2), 87465(g), 87211(a)(1)(B), and 87464(f)(4). An exit interview was held with Barry. Appeal rights and a copy of this report were left with Barry. This report was amended on 9/5/24 to include the following: A civil penalty in the amount of $500 is hereby assessed due to a violation resulting in injury to a resident, as described above. Additional civil penalties are currently being evaluated by the Department, pursuant to Health and Safety Code § 1569.49(f). An exit interview was held with Barry. Appeal rights, a copy of the civil penalty assessment, and a copy of this amended report were left with Barry.the state’s words, verbatim · CDSS document, Jul 1, 2024 · control 27-AS-20231204145833

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 2, 2024

“Residents in all residential care facilities for the elderly shall have all of the following personal rights: … To be accorded safe, [and] healthful … accommodations…” This requirement was not met as evidenced by: Based on interviews and record review, no fall prevention plan was developed or implemented for R1, despite suffering numerous falls between 9/10/18 and 11/10/23, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee agrees to develop a written fall prevention plan for R1 by POC due date. Vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jul 2, 2024

“(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…” This requirement was not met as evidenced by: Based on interviews and record review, R1 physician was not notified after suffering a fall on 7/19/23 which re-opened a surgical wound, and immediate professional medical attention was not provided for this wound, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee agrees to conduct a staff training regarding injury response procedures and will send LPA Moleski an agenda of training topics by POC due date and a sign in sheet after completion. Vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Jul 15, 2024

“(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.... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.” This requirement was not met as evidenced by: Based on interviews and record review, R1’s RP was not notified after R1 suffered a fall on 7/19/23, and an incident report was not submitted to licensing, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee agrees to conduct a staff training regarding reporting requirements and will send LPA Moleski an agenda of training topics by POC due date and a sign in sheet after completion. Vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jul 15, 2024

“(f) Basic services shall at a minimum include: … (4) Personal assistance and care as needed by the resident…” This requirement was not met as evidenced by: Based on interviews, sufficient personal assistance and care with regard to nail care was not provided to R1, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jul 1, 2024

Plan of correction: Licensee agrees to provide a written plan regarding nail care and podiatry care by POC due date. Vincent.moleski@dss.ca.gov

Allegation investigated: Staff do not ensure resident rooms are kept clean. Staff do not ensure that resident has a working call button. Staff do not follow infection control practices. Resident developed a stage 3 pressure injury while in care. Staff retained resident with a prohibited health condition.

On 6/21/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Danielle Barry who assumed her on position on 2/16/24. At the time census was 83 with 30 residing in memory care. LPA conducted a walkthrough of the facility. LPA observed 7 residents in the assisted living dining room having breakfast and the Resident Services Director distributing medications. In memory care, LPA observed a med tech distributing medications room-to-room. LPA also observed 7 residents finishing breakfast in the dining area and another 7 residents watching T.V. in the common area. LPA observed the DFA assisting a resident to the elevator as they were being picked up for a doctor's appointment. There were 2 care staff in the kitchenette area cleaning up, and the Director of Maintenance was steam cleaning the floors and carpeting throughout the area. LPA also observed 1 housekeeper cleaning the bistoro area. Substantiated until a later time to be addressed since the care staff was needed to provide direct support and supervision to the residents. The preponderance for the standard of evidence has been met and the department finds the allegation, "Staff do not ensure resident rooms are kept clean," to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099 D page. Regarding the allegation: "Staff do not ensure that resident has a working call button." Based on interviews with 3 staff members, residents in memory care do not have a working call button to alert staff that they need assistance. There were no call buttons located at their bedsides and S7 stated, "That is probably why we had so many unwitnessed falls; they don't have a way to ask for help when they want to get out of bed." On 6/14/24, this LPA observed the alert system set up in the bathrooms in memory care including room 225. The pull cords were wrapped around the units and therefore could not be activated. The units also had a button that could be pushed, but as there was no signage or markings on the plain gray circle, it was not obvious that it was a button or what would happen if it was pushed. LPA took photos for documentation purposes. Based on interviews and observations the allegation, "Staff do not ensure that resident has a working call button," has been SUBSTANTIATED. The preponderance for the standard of evidence has been met and this deficiency has been cited on the LIC 9099 D page. Regarding: "Staff do not follow infection control practices." Based on a review of the housekeeping schedule and interviews with 3 staff members at a supervisory level, at the time of the complaint, staff were wearing necessary PPE when required due to the health status of residents in care. However, due to limited staffing, rooms were not being cleaned immediately following resident's toileting accidents and staff were not preventing residents from wandering the floor and touching surfaces that had not been disinfected. 2 of the 3 staff members interviewed stated that the restrooms in the common areas of memory care were not being disinfected between resident use. Their own infection control plan stated on page 2 section 2 that: "Blood and body fluids clean up shall be cleaned up immediately and disinfected. Gloves and proper PPE to be worn and all items put in biohazard bag (red bag)." Based on the information above, the preponderance for the standard of evidence has been met and the allegation, "Staff do not follow infection control practices," has been SUBSTANTIATED. This deficiency is cited on the LIC 9099 D page. Regarding the allegation: "Resident developed a stage 3 pressure injury while in care." The department learned through a review of records, that on 11/04/23, it was noted that resident (R1), had a "black mark on R1's coccyx area. Per staff, the protocol is to contact the resident's doctor if an unusual mark is noticed on a resident's body the day the mark is noticed. On 11/07/23, it was noted that R1 had a telephone appointment with their doctor, (D1) and there were no notes indicating that the mark on R1's coccyx was discussed. D1 was not notified of the mark until 11/08/23 via fax. LPA reviewed the fax that indicated R1 had an "open sore." A response was not received from D1. Records also indicated that on 11/13/23, 9 days after a spot was first observed, R1 was sent to Kaiser Permanente Roseville for an "open sore" and it was noted that R1 had an unstageable wound on her coccyx. On 11/15/23, R1 was discharged from Kaiser Permanente Roseville with a diagnosis of "pressure ulcer of sacrum, unspecified stage." Staff reported R1 was incontinent and bedbound after R1 went to the hospital in October 2023 for a fall. Staff reported that R1 was on a two-hour rotation. In an interview with the Memory Care Director at the time of the incident, (S4) the department learned about the body checks conducted by the care staff. S4 stated that if a caregiver notices a rash, pressure injury, or skin tear than the caregiver will advise the med tech on shift. The med Tech will then fax the resident's doctor and determine what they need to do for care. If the med Tech does not get a response from the doctor, then the resident would be sent to the hospital if its regarding a pressure injury. S4 was asked how long a med tech should wait to hear back from the doctor. S4 stated, "about 3 days". After 3 days, if the med tech has not received a response, then the med tech should follow up with the doctor via telephone. S4 was asked what would happen if the pressure injury got worse during the 3 days. S4 stated that the resident Regarding the allegation: "Staff do not ensure resident rooms are kept clean." On 11/29/23, this LPA visited 3 resident rooms (R4, R5, R6) in memory care. In R4's room, LPA observed that there was visible dust on surfaces and there were scattered candies and bits of tissue on the floor. R5's room was very basic; no personal items were present. The air was stale, but not malodorous. R6's room was clean and organized. 11/29/23 was a Wednesday and one of the scheduled housekeeping days. 1 out of 3 rooms was not clean. This LPA requested a copy of the housekeeping schedule for the month of November 2023 and was told that the schedules were handwritten and copies were not kept. LPA requested the hours-worked logged for that time period with the intent of interviewing specific housekeeping staff. The Designated Facility Administrator stated that the hours worked log would still not show which housekeepers were assigned to which area as they all rotate throughout the building. LPA was provided a schedule for March 2024 and was told it was the template that was used during the time of the complaint. Through interviews, this LPA learned that there was a designated housekeeper assigned to memory care Sunday for 4 hours and Monday, Tuesday and Wednesday for 8 hours each day. The housekeeper assigned for Sunday was responsible for cleaning and dusting the common areas. Resident rooms were cleaned once a week. This LPA reviewed a cleaning schedule provided by the Housekeeping Department. On Mondays and Wednesdays, there were 10 resident rooms to be serviced. Tuesdays, the housekeeper was assigned 6 resident rooms, and that person was also responsible for mopping the sitting area and the kitchen in memory care. There was no housekeeping coverage in memory care Thursday, Friday, or Saturday. Through interviews it was also learned that regular sweeps of rooms were not done and that if a resident had a toileting accident, spilled something or had vomited, it might go unnoticed for an unspecified period of time. If one of these accidents happened after housekeeping staff had gone home, it would be up to the care staff on duty to clean up. LPA learned through interviews that at the time of this complaint, there were concerns that additional care staff were needed to meet the needs of the residents in care. At that time, the PM shift consisted of 2 care staff and 1 med tech. There were 33 residents living in memory care at that time. Depending upon the needs of the residents at that time, any mess in a room, may have had to wait would be sent to the hospital and would return to Summerset Assisted Living with Home Health services to provide wound care. Staff were unable to provide a time frame as to when R1's pressure injury got worse. On 11/10/23, staff (S1) saw R1's pressure injury and stated that R1's pressure injury had a band aid on it and that it was an open wound. S1 believed that R1 should have been sent to the hospital on 11/10/23. However, R1 was not sent to the hospital until 11/13/23. S1 believed that R1 was neglected and that R1's pressure injury could have been prevented. Residents were interviewed and did not have any complaints about Summerset Assisted Living. Based on the interviews conducted along with a review of shower logs, photographs of R1's wound, Medication Technicians Communication Log notes, and medical records from Kaiser Permanente, the above allegation was found to be SUBSTANTIATED. This deficiency is cited on the LIC 9099 D page. The department may assess additional civil penalties at a later date. Regarding: Staff retained resident with a prohibited health condition Based on the substantiated allegation above, this facility retained R1, a resident with a prohibited health condition. Per the interview with S4, if the doctor could not be reached, the resident should have been sent out to the hospital for medical assessment and treatment. Any change in condition requires an assessment and an updated care plan. The facility waited 9 days before sending R1 to the hospital. The facility did not seek a medical assessment of R1's pressure injury in a timely manner and R1 developed a stage 3 pressure injury, a prohibited condition. Based on the information above, the preponderance for the standard of evidence has been met and the allegation, "Staff retained resident with a prohibited health condition,” has been SUBSTANTIATED. This deficiency is cited on the LIC 9099 D page. According to the California Code of Regulations and Title 22, all deficiencies were cited on the LIC 9099 D pages. Civil penalties were also assessed today in the amount of $500.00. Additional penalties may be assessed at a later date. A copy of this report was provided along with Appeal Rights. Exit interview.the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 27-AS-20231128084622

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 22, 2024

Maintenance and Operation 87303 (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include... services and procedures for the safety and well-being of residents, employees and visitors. The Licensee did not meet the above requirement as evidenced by: Based on a records review, interviews, and observations, there were no housekeeping services assigned on 3.5 days out of 7. Care staff scheduled were not able to immediately clean and disinfect when accidents happened, and 1 out 3 rooms observed needed to be cleaned.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: Administrator has already increased housekeeping hours in memory care. This POC has been cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Jun 22, 2024

Maintenance and Operation 87303 (i) Facilities shall have signal systems...(1) All facilities...16 or more...shall have a signal system which shall: (A) Operate from each resident's living unit. The Licensee did not meet the above requirement as evidenced by: Based on interviews and observations, none of the residents were provided call pendants and the did not have call alerts in their living spaces, only in the bathrooms. The unit in R1's bathroom was inoperable because the cord was wrapped around the unit.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: Administrator will provide LPA with a list of all Memory Care residents with call pendants/ room buttons and a roster for comparison. This information will be emailed to kimberly.viarella@dss.ca.gov by 6/22/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(2)(A) · Plan of correction due date: Jun 22, 2024

Infection Ctrl Requirements: 87470(2)(A) (2) Environmental cleaning & disinfection activities... (A) Surfaces ...shall be sani-tary ... soiled with blood or body fluids or other potentially infectious material. The Licensee did not meet the above requirement as evidenced by: Based on interviews, 2 of 3 staff members stated the restrooms in the common areas were not being cleaned and disinfected between resident use.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: Administrator has already stocked disinfecting and cleaning solutins in a locked cabinet in each common area bathroom and completed a re-training on handwashing. This POC has been cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Jun 22, 2024

Prohibited Health Cond: 87615(a)(1) (a) Persons ... shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. The Licensee did not meet the above requirement as evidenced by: R1 was a resident the care at Summerset Assisted Living diagnosed with a stage 3 pressure injury, which by regulation, is a prohibited health condition.the state’s words, verbatim · CDSS document, Jun 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 22, 2024

Incidental Medical & Dental: 87465(a)(1) (a) A plan for incidental medical and dental care shall be developed... (1) The licensee shall arrange, or assist in arranging, for medical ...appropriate to...needs of residents. The Licensee did not meet the requirements above as evidenced by: Based on a review of medical records, shower and communication logs, interviews and photographs, the facility did not send R1 out for medical assessment and treatment of a pressure injury in an appropriate and timely manner resulting in it becoming a stage 3 pressure injury.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: Administrator has hired a new Director of Memory Care, (start date 4/16/24). Administrator has scheduled an in-service with First Call Hospice to train on pressure wounds and injuries on 7/8/24. This POC has been cleared.

Allegation investigated: Staff handled resident in a rough manner.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit. This investigation consisted of observation, interviews, and record review. During the course of this investigation, LPA Moleski interviewed eight staff members (S2-S9), a resident's responsible party (R1's RP), a hospice nurse (R1's RN), and a resident (R1). During an interview, R1's RP claimed to have observed a male staff member kick R1's knees out from under R1 in order to get R1 to sit on a toilet. During an interview, R1's hospice nurse said that they had not observed any such maneuvers being used at this facility, and had no suspicions of physical abuse committed by the staff. R1's hospice nurse said they had not observed any unusual or suspicious injuries on R1. [continued on 9099-C] Unsubstantiated In interviews, staff members S2-S9 said they had not witnessed any such incident as described by R1's RP. Staff members S2-S9 said they had not seen other staff members handling R1 in a rough or abusive manner. All staff members interviewed described providing minimal assistance for R1's toilet use, such as verbal prompting and reminders. In an interview, R1 said R1 liked the facility's staff, but was not able to answer follow up questions regarding how the staff have treated R1. LPA Moleski reviewed R1's file. LPA Moleski reviewed an LIC 602, dated 12/27/23. R1 has dementia, according to the LIC 602. The department has determined the following as it relates to the allegation that staff handled a resident in a rough manner: Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Barry.the state’s words, verbatim · CDSS document, Apr 24, 2024 · control 27-AS-20240220140418

Allegation investigated: Staff do not follow infection control protocols. Staff are not addressing a scabies outbreak. Staff did not report a scabies outbreak as required.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit. LPA Moleski toured the second floor and met with a resident (R2). LPA Moleski reviewed hospital discharge paperwork for R2. R2 was diagnosed with scabies on 4/9/24, according to the discharge paperwork. R2 returned to this facility on 4/10/24. LPA Moleski visited R2's room and observed two caregivers (S2 and S3) applying ointment to R2 in bed. S2 and S3 were wearing gloves, but were not wearing gowns or masks. LPA Moleski observed gloves discarded in an uncovered trash can inside R2's room. LPA Moleski observed S3 discard used gloves in an uncovered trash can in a common area. [continued on 9099-C] Substantiated In an interview, Barry said she had not been in contact with public health regarding infection control requirements since R2's return to the facility. Barry was not aware that R2 had been diagnosed with scabies while at the hospital. 22 CCR Sections 87470(b)(1)(A) and 87470(b)(2)(A) state that the licensee shall report to a local health department or similar authority for guidance on proper PPE usage and proper environmental cleaning practices when one or more residents are diagnosed with a contagious disease. LPA Moleski interviewed a hospice nurse for a resident (R1). The nurse said R1 did not have scabies, but reported seeing several residents with wounds and itchy. R1 was treated with permethrin. In an interview, S1 said that the facility was instructed to use the permethrin as a precaution. S1 said that there were two other residents as of early March also taking permethrin (R3 and R4). S1 said that there was a scabies outbreak in 2023, and the same residents still had rashes. In an interview, S2 said that there was a scabies outbreak in 2023. S2 said there were a small number of residents with rashes as of March 2024. In an interview, S3 said that there were two residents with rashes (R2 and R5). In an interview, Barry said R1, R3, R4, and R5 were not diagnosed with scabies, and either had rashes of unknown origin or were being treated with permethrin as a precaution. The department has determined the following as it relates to the allegations that staff do not follow infection control protocols, that staff are not addressing a scabies outbreak, and that staff did not report a scabies outbreak as required: Based on interviews, observation, and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Sections 87470(b)(2)(A), 87470(b)(2), and 87470(b)(2)(B). An exit interview was held with Barry. Appeal rights and a copy of this report were left with Barry.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 27-AS-20240220140418

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(2)(A) · Plan of correction due date: Apr 16, 2024

"(A) The licensee shall consult with a medical professional, local health official, health department, or other research-based medical authority to determine the type of PPE to be used based on the contagious disease present in the facility." This requirement was not met as evidenced by: Based in interview, Barry admitted not having contacted public health or other like public health authority for guidance on the use of PPE, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Licensee agrees to contact public health by POC due date for guidance on PPE use, and other guidance as required by Title 22. Licensee shall include LPA Moleski in correspondence with public health. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(2) · Plan of correction due date: Apr 16, 2024

" (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection." This requirement was not met as evidenced by: Based on observation, S2 and S3 were not wearing gowns, which are appropriate to prevent the spread of scabies, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Licensee agrees to immediately implement the use of gowns when caring for R2. Licensee shall provide photos of PPE stations to LPA Moleski by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(2)(B) · Plan of correction due date: Apr 16, 2024

" (B) PPE shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately following the assisting with direct care for each resident." This requirement was not met as evidenced by: Based on observation, staff members discarded used PPE in uncovered waste receptacles, which pose an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: Licensee agrees to conduct a staff training regarding the proper use of PPE by POC due date. Licensee shall provide LPA Moleski a copy of the staff sign-in sheet. vincent.moleski@dss.ca.gov

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident received unlawful eviction notice

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced along with ombudsman Suhair Siraj to open this complaint investigation. LPA Moleski met with Danielle Barry and explained the purpose of the visit. LPA Moleski reviewed a copy of an eviction notice served to a resident (R1) on February 9, 2024. According to the notice, R1 was being evicted "due to inappropriate behavior that occurred in the facility." No further description of the alleged behavior was provided. The notice does not include, as required by 22 CCR Section 87224(d)(1)(B-D), specific facts to permit determination of the date, place, witnesses and circumstances concerning the reasons relied upon for the eviction, nor does it contain resources available to assist in identifying alternative housing and care options, nor does it include a statement informing residents of their right to file a complaint with the licensing agency, nor does it contain contact information for the licensing agency or for the ombudsman's office, nor does it include the statements required per HSC Section 1569.683(a)(4) regarding unlawful detainers and legal rights to contest the unlawful detainer action in writing and through a hearing. [continued on 9099-C] Substantiated The department has determined the following as it relates to the allegation that a resident was served an unlawful eviction notice: Based on record review, this allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87224(d). An exit interview was held with Barry. Appeal rights and a copy of this report was left with Barry.the state’s words, verbatim · CDSS document, Mar 4, 2024 · control 27-AS-20240223134826

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Mar 5, 2024

"(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons." This requirement was not met as evidenced by: Based on record review, R1 was served an unlawful eviction notice, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Licensee agrees to rescind the eviction notice, and to send notice of having rescinded the notice to the resident and/or resident's responsible parties by the POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with Danielle Barry and explained the purpose of the visit. LPA Moleski reviewed Guardian records and observed that Barry has not, to this date, been associated to this facility roster. Barry said she was at the facility on 2/16/24, 2/19/24, and 2/20/24, and was present today, 2/21/24. This facility is being cited per 22 CCR Section 87355(e)(2). A civil penalty in the amount of $100 per day for the four days Barry was present without being associated to this facility was assessed, for a total of $400. An exit interview was held with Barry. Appeal rights and a copy of this report were left with Barry.the state’s words, verbatim · CDSS document, Feb 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Feb 22, 2024

"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 as specified in Section 87355(c) ..." This requirement was not met as evidenced by: Based on review of Guardian records and interview with Barry, Barry was not associated before starting work at this facility, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Feb 21, 2024

Plan of correction: Licensee agrees to either associate Barry through Guardian or submit appropriate transfer documents to sacasctransferrequest@dss.ca.gov by the POC due date. Licensee shall send LPA Moleski a copy of the updated roster and/or cc LPA Moleski on the email to sacasctransferrequest.dss.ca.gov. vincent.moleski@dss.ca.gov

Allegation investigated: Staff does not ensure resident receives assistance with wheelchair Staff does not ensure resident is brought down for meal service

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with Danielle Barry and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed a resident (R1) and five staff members (S1-S5). LPA Moleski reviewed R1’s file. R1’s assessment states that R1 is to receive two-person assistance with transfers. R1’s preplacement appraisal states that R1 needs assistance getting into R1’s wheelchair. R1 is unconserved and has no powers of attorney documented. R1 was admitted to the facility as of December 11, 2023. In an interview on January 25, 2024, R1 said that R1 was not comfortable with transferring out of bed upon admission, that R1 suffered pain when trying to get up, and that R1 suffered from nausea when out of bed for too long. [continued on 9099-C] Unsubstantiated R1 said staff are able to assist with transfers when requested, and said that staff are “great.” R1 said staff use a Hoyer lift to transfer R1. R1 said that R1 did not mind having meals delivered rather than eating in the dining room. During the interview, R1 raised concerns regarding staffing levels and regarding bathing services, which were addressed on complaint #27-AS-20231204145833. Corrective action regarding those allegations has been initiated. The Community Care Licensing Division received an incident report dated 1/29/24 which stated that R1’s Hoyer lift broke on 1/25/24. LPA Moleski interviewed R1 again on 2/1/24 while R1 was in a wheelchair in the dining room. R1 said that staff were able to transfer him to the wheelchair without the Hoyer lift. During interviews, S1-S5 said that R1 was assisted with transfers when R1 asked for transfers, but R1 did not often want to be transferred due to pain and weakness when attempting to do so. Staff said that R1 often preferred to stay in bed and have meals delivered. The department has determined the following as it relates to the allegations that staff does not ensure resident receives assistance with wheelchair and that staff does not ensure resident is brought down for meal service: Based on interviews and observation, the above allegation is UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. This report was amended on 2/21/24 to reflect that this report is a public document. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Barry.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 27-AS-20240119151219

Allegation investigated: Licensee does not ensure facility has sufficient staffing to meet the care needs of residents Staff do not ensure residents receive bathing service in a timely manner

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Elisa Weathers and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Weathers and 15 staff members (S1-S15). S1, S6, S7, S8, S10, S11, S12, and S13 work in memory care. S3, S4, S5, and S11 work in assisted living. LPA Moleski interviewed seven residents (R1-R7). R1, R2, R3, R5, R6, and R7 live in assisted living. R4 lives in memory care. In an interview, Weathers said staff hours had been reduced recently. LPA Moleski reviewed staff schedules and resident rosters for this facility. [continued on 9099-C] Substantiated Based on interviews, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Weathers. In memory care during December 1-15, there were two caregivers and one med tech scheduled most days for the morning and evening shifts, and two caregivers scheduled for most night shifts. There were 32 residents in memory care as of 12/11/23. In assisted living during the month of December, there were three caregivers and one med tech scheduled most days for morning shifts, two caregivers and one med tech scheduled most days for evening shifts, and two caregivers scheduled for most night shifts. There were 52 residents in assisted living as of 12/11/23. In interviews, S1, S3, S4, S5, S6, S7, S8, S10, S11, S12, S13, and S15 said there were not enough staff at the facility to sufficiently meet residents’ needs. These same staff members said that residents were not being showered adequately due to the insufficient staffing. S1 said staff cannot always complete scheduled showers, and said they could “guarantee” that there weren’t enough showers being done. S3 said residents have to wait for staff to become available to receive assistance, and said that scheduled showers are skipped when they get too busy. “There’s showers that ain’t getting done,” S4 said. S5 said scheduled showers are sometimes skipped when staff are busy. “Sometimes we’re not able to give them a shower when they need to,” S6 said. “We don’t have time to do a lot of the care that we’re supposed to,” S7 said. S7 said that sometimes showers are put off until the next day, or whenever staff are able to complete them. S7 also said that staff have to chase after residents who attempt to leave the memory care unit. “It’s hard to get a shower in,” S8 said. S10 said staff will skip showers if busy and try to complete them the next day. S11 said residents have to wait for staff to provide assistance to them, and also that scheduled showers cannot always be done. S11 said that staff “hope for the best” that the next shift will be able to take care of the missed showers. “It’s hard to get showers in while being behind,” S12 said. S12 said the insufficient staffing levels were “unfair” to the residents. S12 said staff cannot get to all of the scheduled showers about three days out of the week. “We’ve fallen behind on all the showers,” S12 said. S13 said that staff try to give residents their scheduled showers, but they often have to delay them when other residents need more immediate attention. In interviews, R3, R4, R5, R6, and R7 said the facility was not sufficiently staffed. R3, R5, and R7 said they had not received showers as needed, and had not received showers when scheduled. R3 said staff are difficult to get assistance from, and residents have to wait for assistance. R4 said it was “impossible” to get assistance from staff. R5 said residents wait significant time periods for assistance, and said scheduled showers have been skipped for several days in a row before finally receiving a shower. R6 said there aren’t enough caregivers, and residents are waiting longer for assistance. R7 said the facility was understaffed, and that scheduled showers have been skipped multiple times as a result. [continued on 9099-C] LPA Moleski reviewed shower day skin inspection sheets for residents of this facility. These sheets indicate when showers or bed baths were performed by hospice staff or other outside agencies, and when residents refuse showers. LPA Moleski found that residents in both assisted living and memory care did not receive sufficient showers or bed baths during the period of November 1 through December 11, 2023, including, but not limited to, the findings as described below. R5 and R7 live in assisted living. R8-R13 live in memory care. No further shower sheets were available to account for additional showers or bed baths of these residents: During the time period surveyed, R8 received a shower on 11/29/23, according to the shower sheets. R9 received a shower on 11/8/23, according to the shower sheets. R10 received a shower from hospice staff on 11/8/23, according to the shower sheets. R11 received a shower on 11/28/23, according to the shower sheets. R12 received showers on 11/27/23, 12/3/23, and 12/4/23, according to the shower sheets. R13 received showers on 11/8/23, 11/11/23, and 11/15/23, according to the shower sheets. R5 received showers on 11/2/23, 11/12/23, 11/19/23, 11/21/23, 11/23/23, 11/28/23, 12/5/23, according to the shower sheets. LPA Moleski reviewed 30 days’ worth of shower sheets for R7. R7 moved into the facility on 12/11/23, according to R7’s admission agreement. R7 received showers on 12/21, 12/27, 1/5, 1/8, and 1/21, according to the shower sheets. R7 refused a shower on 12/31/23, according to a shower sheet. LPA Moleski reviewed the most recent assessments for R5, R7, and R8-R13. R8 and R11 are to receive standby assistance with two showers per week. R9, R12, R5, and R7 are to receive total assistance with two showers per week. R13 is to receive assistance preparing items for showers two times per week. R10’s assessment indicates that she receives showers from an outside agency. LPA Moleski reviewed a shower schedule for memory care dated 11/12/23. R8 is scheduled to receive showers every Monday, Wednesday, and Friday. R11 is scheduled to receive sponge baths every Tuesday and Thursday. R12 is scheduled to receive showers on Mondays, Wednesdays, and Saturdays. R13 is scheduled to receive showers every Monday, Wednesday, and Saturday. LPA Moleski reviewed a shower schedule for assisted living dated 1/15/24. R5 is scheduled to receive showers on Tuesdays, Thursdays, and Sundays. LPA Moleski observed a printed schedule posted to the wall in R7’s room. R7 is scheduled to receive showers on Wednesdays and Sundays. [continued on 9099-C] During a previous visit on 12/5/23 regarding an unrelated complaint investigation, LPA Moleski toured the memory care unit on the second floor of the facility. LPA Moleski observed several unsupervised residents in common areas and hallways. LPA Moleski observed that the staff on the second floor were preoccupied with tasks inside resident rooms, while the majority of residents were in a common living room, unattended. During a previous visit to this facility on 12/26/23, LPA Moleski observed S15 leading R14 back into the facility from an exterior exit door. S15 said that R14 lives in memory care and had wandered outside the facility alone. R14 was not able to answer questions regarding where he had been. S15 said R14 “escapes” frequently, and other residents do as well. S15 said such incidents occur at least once a week. S14 was a witness to the incident, and said that after hearing an alarm go off, S14 looked outside and found R14 walking around. LPA Moleski reviewed R14’s LIC 602. R14 has dementia and is unable to leave the facility unassisted, according to the LIC 602. The department has determined the following as it relates to the allegations that the licensee does not ensure the facility has sufficient staffing to meet the care needs of residents, and that staff do not ensure residents receive bathing service in a timely manner: Based on interviews, observation, and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Sections 87411(a) and 87464(f)(4). An exit interview was held with Weathers. Appeal rights and a copy of this report were left with Weathers.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 27-AS-20231201144701

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 2, 2024

"(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 evidenced by: Based on interviews, observations, and record review, staffing was not sufficient to meet the needs of residents, which poses an immediate health, safety and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: Licensee agrees to develop a written plan addressing staffing needs at this facility, which shall rectify the insufficient staffing levels as described in this report. Licensee shall send a copy of this plan to LPA Moleski by the POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Feb 2, 2024

"(f) Basic services shall at a minimum include: ... Personal assistance and care as needed by the resident ... with those activities of daily living such as ... bathing ..." This requirement was not met as evidenced by: Based on interviews and record review, bathing services were not provided as needed and/or as indicated on resident assessments, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: Licensee agrees to develop a written plan addressing bathing needs. Licensee agrees to send LPA Moleski a copy of this plan by POC due date. vincent.moleski@dss.ca.gov