Sunshine Villa Assisted Living and Memory Care

Allegation investigated: Staff allowed a non-resident to sleep in common area at facility. Staff worked while under the influence of marijuana, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care. Staff did not provide hygiene care to resident.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint visit to deliver complaint findings. LPA met with General Manger (GM) Candace Bolin. LPA stated the purpose of the visit. On 3/3/2026 the department received a complaint about the above allegations. On 3/11/26 the department interviewed the Reporting Party (RP). RP alleges in December 2025 he/she observed a staff from an outside agency allow his/her ‘boyfriend’ to sleep in the facility. RP stated he/she did not know the name of the staff, and he/she did not report this incident to Sunshine Villa management. . Page 1 of 3 Unsubstantiated On 3/9/2026 and 6/9/2026, the Department interviewed 8 Staff (S1 to S8). 7 Out of 8 staff stated he/she is not aware of and has not observed staff sleeping in the common areas at the facility. S6 stated he/she observed a staff asleep at the facility and reported to management. S6 did not provide additional information On 3/9/2026, the Department interviewed 6 Residents. 5 out 6 Residents stated he/she is not aware of and has not observed staff sleeping in the common areas at the facility. R2 declined to be interviewed. There are zero reports for December 2025 of staff sleeping in common areas at the facility. On 7/9/2026, the Department interviewed General Manager (GM) Candace Bolin. GM states she is not aware of and has not observed staff sleeping in the common facility areas in 2025 or 2026. Staff worked while under the influence of marijuana, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care On 3/11/26 the department interviewed the Reporting Party (RP). RP alleges he/she observed three facility staff under the influence of marijuana. RP stated he/she reported this incident to facility management on 1/10/2026. On 3/9/2026 the Department interviewed 6 Residents (R1 to R6). 6 Out Of 6 Residents stated he/she has never observed a staff to be under the influence of marijuana at any time. On 3/9/2026 and 6/9/2026, the Department interviewed 8 Staff (S1 to S8). 6 Out of 8 staff stated he/she has not observed staff under the influence of marijuana while providing care to residents at any time. S1 stated he/she is aware of an allegation of a staff being under the influence of marijuana in late January 2026. S1 stated the facility investigated the allegation, and no additional follow up was required. S7 states he/she observed a staff as acting 'different' on one occasion and reported to management. Review of correspondence dated 2/5/2026 notes facility management investigated the allegation of a staff being under the influence of marijuana. No date of the incident was noted, and no ‘evidence’ was discovered during the investigation. Page 2 of 3 On 7/9/2026 the Department interviewed GM Candace Bolin. GM stated she is not aware of staff being under the influence of marijuana at anytime. Staff did not provide hygiene care to residents On 3/11/26 the Department interviewed the Reporting Party (RP). RP stated facility staff did not provide hygiene care to residents. On 3/9/2026, the Department interviewed 6 Residents. 4 Out of 6 Residents stated he/she does not need assistance from staff. R2 declined to be interviewed. R3 did not respond to the question. On 3/9/2026 and 6/9/2026, the Department interviewed 8 Staff (S1 to S8). 8 Out of 8 staff stated he/she checks on and assists residents. S5 stated he/she checks on residents every 30 minutes to 1 hour. S6 states he/she checks on residents every hour. On 7/9/2026 the Department interviewed GM Candace Bolin. GM states she is not aware of staff not providing hygiene care to residents. GM states when residents call for assistance, if a caregiver is assisting with another resident, another caregiver will respond to the residents call for assistance. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with GM Candace Bolin and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 26-AS-20260303091811

Allegation investigated: Staff did not safeguard resident's personal belongings. Staff do not provide adequate meal service to resident. Staff are not meeting resident's toileting needs in a timely manner.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation to deliver complaint findings. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. On 6/23/2025 the Department received a complaint with the above allegations. On 6/24/2025 the Department interviewed the Reporting Party (RP). RP alleges a resident’s, referred to as R1, personal supplies were missing from R1’s room on 6/11/2025. Complaint investigation visits were conducted on 6/27/2025 and 10/7/2025. Page 1 of 4 Unsubstantiated Review of R1’s service plan dated 3/25/2025, notes R1 does not require assistance with dining services. Staff are not meeting residents’ toileting needs in a timely manner. On 6/24/2025 the Department interviewed the Reporting Party (RP). RP stated he/she visited with R1 on 6/23/2025 from 9:30AM to 11:30AM and no staff checked on R1. RP states he/she went to the front desk about this incident. RP states he/she was also reporting another incident on 6/24/2025 where R1 required toilet assistance at 9:30AM. RP states he/she visited R1 at approximately 9:30AM, and hospice was providing care to R1. RP stated he/she observed R1’s bed and floor to be soiled and ‘believed’ it was from the night before. The Department conducted complaint investigation visits on 6/27/2025 and 10/7/2025 and interviewed 8 Staff (S1 to S8). 7 Out of 8 staff state he/she checks on residents at least every 2 hours. S7 stated he/she has observed a resident to be soiled, and he/she changed the resident. S7 did not provide additional information regarding this incident. S4 states he/she is a medtech and does not provide toileting assistant but will tell staff to check on residents every two hours. On 6/27/2025 and 10/7/2025 the Department interviewed 8 Residents (R1 to R8). 4 Out of 8 Residents stated he/she has no issues/concerns with the care he/she is receiving. R4 and R8 stated he/she does not need toileting assistance, R6 stated he/she did not know about toileting assistance, R1 did not respond to questions. Review of R1’s Service Plan dated 3/25/2025, Evaluation Section: Toileting: Moderate: Resident requires standby assistance for toileting tasks, not a two person assist. Review of R1’s progress notes dated from 6/1/2025 to 6/27/2025 note on 6/27/2025 at 2:08PM a request was made to hospice for R1’s supplies. This request was made during the complaint investigation visit on 6/27/2025. Review of R1’s hospice care plan dated 4/29/2025, notes “Supplies provided by Hospice: incontinent needs diapers…” Page 3 of 4 The Department interviewed 8 Staff (S1 to S8) and 8 Residents (R1 to R8). 6 Out of 8 staff stated they are not aware about resident’s supplies going missing. S3 and S4 states he/she has heard about resident’s supplies going missing (diapers, wipes). The Department interviewed 8 Residents (R1 to R8). 5 Out of 8 Resident stated he/she has not had personal supplies go missing. R2 stated his/her belongings are up in a top cabinet in the room. R3 stated ‘things disappear, but it is not the staff.” R3 did not provide additional information. R1 did not respond to questions. On 7/9/2026 the Department interviewed General Manager (GM) Candace Bolin. GM stated she is not aware of resident’s personal belongings or incontinence supplies being missing on 6/11/2025. GM states if a resident is missing personal belongings, the facility has a Theft and Loss protocol in place to help residents. Review of the Facility Theft and Loss policy dated 5/1/2028, the facility will document an Incident Report for resident property reported stolen or lost, assist resident in searching for the missing item(s) in his/her apartment, offer to assist resident with filing a police report, and notifying state agencies as required. Staff do not provide adequate meal service to residents. On 6/24/2025 the Department interviewed the Reporting Party (RP). RP stated a resident, referred to as R1, did not have lunch on 6/14/2025. RP states ‘cafeteria’ staff told him/her that R1 did not have lunch. The Department conducted complaint investigation visits on 6/27/2025 and 10/7/2025 and interviewed 8 Staff (S1 to S8). 4 Out of 8 Staff stated he/she is not aware of residents missing his/her meals. 4 Out of 8 staff stated he/she has heard about residents missing a meal. S3 stated R1 prefers to sleep until 10AM, and once R1 is awake, he/she will escort R1 down for breakfast. S5 stated residents sometimes refuse to go to the dining hall, and staff will request room service for the residents. On 6/27/2025 and 10/7/2025 the Department interviewed 8 Residents (R1 to R8). 6 Out of 8 residents stated he/she has no issues/concerns with meal service. R3 stated he/she walks to his/her meals. R1 did not respond to questionss. Page 2 of 4 Review of R1’s Nursing Progress Notes, R1 was visited by hospice on 4/30/2025, 5/22/2025, 5/29/2025, 6/4/2025, 6/5/2025, 6/6/2025, 6/9/2025, 6/12/2025, 6/19/2025, 6/24/2025. Hospice Aide Progress Notes dated 5/2/2026, 5/6/2025,5/17/2025, 5/20/2025, 5/24/2025, 5/27/2025, 5/31/2026, 6/7/2025, specifically note ‘incontinence care’ was provided to R1. 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, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with GM Candace Bolin and a copy of this report was providedthe state’s words, verbatim · CDSS document, Jul 9, 2026 · control 26-AS-20250623161542

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with GM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. The facility was observed to be clean, safe, sanitary and in good repair. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed refrigerator temperature at 40 F and Freezer at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. The facility fire system was last inspected on 7/1/2026 by an outside agency and passed inspection. Fire extinguishers were last serviced on 9/5/2025. The facility emergency drill log was reviewed. The facility's last drill was on 07/1/2026. Page 1 of 2 LPA toured 10 random resident rooms with the GM. LPA tested water in 10 resident bathrooms, with a range from 105 F to 120 F. 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. All 10 bathrooms had hand soap, paper towels, and covered trash bins. LPA toured the facility Garden House (Memory Care) with GM and inspected 8 resident rooms and bathrooms. LPA observed 8 Out of 8 Resident's bathroom cabinets were unlocked. In Resident R1's bathroom cabinet, LPA observed a cabinet contained personal grooming supplies and cleaning supplies (disinfectant wipes, and acetone nail polish remover). In Resident R2's bathroom cabinet and bathroom sink cabinet, LPA observed three bottles of dishwashing soap. Per R1's physician's report dated 12/14/2023, R1 is at risk if allowed access to hygiene items. Per R2's physicians report dated 4/26/24, R2 has neurocognitive disorder. A deficiency is being issued. All exits in the Garden House are alarmed, and functioned properly when tested by the GM. LPA reviewed 8 resident records. Resident records included emergency contact information, physician’s report, needs and service plans, and personal rights. LPA reviewed 5 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA observed staff were not documenting the start dates on the centrally stored logs, and 1 medication was not documented. A Technical Violation was issued, see LIC9102. LPA reviewed 8 staff records. A deficiency and Technical Violation are being cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with General Manager (GM) Candace Bolin and a signed copy of this report was provided. Appeal rights were also provided.the state’s words, verbatim · CDSS document, Jul 9, 2026

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: Staff are not administering medications to resident as prescribed.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced compliant investigation visit to deliver complaint findings. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. On 8/25/2025 the Department received a complaint with the above allegation. On 8/26/2025 the Department interviewed the Reporting Party (RP). RP stated he/she observed a 'little cup, with powder" in a resident's, referred to as R1, room on 8/16/2025. RP states he/she informed facility management about the cup with powder. Page 1 of 2 Substantiated On 5/14/2026 the Department interviewed 5 Residents (R1 to R5). 4 out of 5 residents state he/she does not have any issues or concerns with the care he/she is receiving. R2 states he/she does not require assistance, R2 stated he/she is independent. Facility does not have enough staff to meet residents needs On 8/26/2025 the Department interviewed the Reporting Party (RP). RP stated the facility was short staffed, and facility staff had told him/her the facility was short staffed. On 9/4/2025 and 10/7/2025 the Department conducted complaint investigation visits, and interviewed General Manager (GM) Candace Bolin, and 6 Staff (S1 to S6). GM stated the facility is not short staffed. GM stated the facility uses an outside agency for support on days when there are staff call outs. On 9/4/2025 and 10/7/2025 the Department interviewed 6 Staff (S1 to S6). 4 Out of 6 staff stated the facility is short staffed. S4 and S5 did not provide information about staffing. S6 stated the facility uses an outside agency to bring in additional staff for support. On 5/14/2026 the Department interviewed 5 Residents (R1 to R5). 4 out of 5 residents stated he/she does not have any issues or concerns with the care he/she is receiving. R1 states "it's pretty amazing here." R2 stated he/she does not require any assistance, and is independent. R2 stated "staff are great at accommodating." Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with General Manger (GM) Candace Bolin and a copy of this report was provided. Page 2 of 2 END OF REPORT On 9/4/2025 and 10/7/2025 the Department conducted complaint investigation visits, and interviewed General Manager (GM) Candace Bolin, and 6 Staff (S1 to S6). 3 out of 6 Staff stated he/she is aware or had heard about staff not administering medications to residents as prescribed. S6 stated he/she was informed by RP on 8/16/2025 at approximately 11:44AM regarding a cup with powder in R1's room. S6 stated the powder in the cup was a prescribed powdered medication for R1, that was left in the room by a medtech. S6 stated on 8/16/2025, he/she told the medtech to remove the medication out of R1's room. Review of R1's Medication Administration Record (MAR) R1 is prescribed one medication in powder form. The MAR notes on 8/16/2025 R1 was administered the powdered medication at 8:00AM by facility staff. R1's Physician's Report dated 5/16/2023, R1 can store and administer his/her medications. R1's Care Plan dated 3/25/2025, R1's 'Medication Level of Assistance' states 'Total: Resident is not able to take medications without assistance.' R1's Medication' Additional Information' Supervision states "Resident requires assistance/supervision for medications." Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations (Title 22), are being cited on the attached LIC 9099 D. An exit interview was conducted with GM Candace Bolin, and a copy of this report and appeal rights were provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, May 14, 2026 · control 26-AS-20250825104758

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 15, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidenced by: Based on observation, record review and interview, on 8/16/2025 a powdered prescription medication was left in R1's room by facility staff, which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 14, 2026

Plan of correction: Licensee states she will submit a plan of correction regarding how she will ensure staff do not leave prescription medications in residents rooms, to include staff training on centrally storing medications (locked and inaccessible). Licensee to submit POC to CCLD by POC due date of 5/15/2026.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management incident visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. On 1/15/2026 the Department conducted a complaint investigation visit for an unrelated complaint. During interviews, it was alleged that a staff, referred to as S1, had inappropriately used a mirror while assisting a resident, referred to as R1, during toilet assistance, on an unknown date in 2025. On 1/15/2026, the Department interviewed 10 Residents (R1 to R10). 9 Out of 10 Residents stated he/she does not have any issues or concerns with staff. R7 declined to be interviewed. On 4/6/2026 the Department conducted an interview with Witness 1 (W1). W1 stated while helping R1 with care on an unknown date in 2025, R1 told him/her that S1 was helping with toileting, when R1 used a mirror to check R1’s private area. W1 states R1 stated he/she was ‘irritated’ due to S1 ‘giggling’ during the incident. W1 does not remember the date of the incident. W1 stated R1 did not provide additional information regarding this incident. W1 stated this incident was reported to facility management. On 4/17/2026 the Department interviewed Witness 2 (W2). W2 stated he/she spoke with R1 regarding the incident with S1. W2 stated R1 told S1 that he/she was having pain when using the bathroom. W2 stated S1 used a mirror to check R1’s private area. W2 stated he/she believed it was reasonable for R1 to use a mirror at that time. Page 1 of 2 W2 stated he/she reported this incident to facility management and did not know additional information regarding this incident. W2 stated he/she also spoke with R1 about the incident, but R1 did not provide additional information about this incident. On 4/28/2026 the Department interviewed Witness (W3). W3 states he/she was informed of the incident by W2. W3 states there was no documentation for an internal investigation into this incident. W3 stated he/she did not have any additional information regarding this incident. Review of R1’s Physician’s Report dated 1/22/2025, R1 is incontinent of bowel and bladder, unable to care for his/her toileting needs. R1 has major neurocognitive disorder. Review of S1’s file, there are no incidents noted regarding S1 being involved in abuse of residents in care. R1’s training record was reviewed, training records are dated 11/29/2023 to 1/1/2026, to include but not limited to dementia care, bladder care, incontinence care, and perineal care. On 5/14/2026, the Department reviewed Physician Fax Communications dated 12/27/2024, 12/30/2024, and 12/31/2024, which note the facility informed R1’s physician about R1 having bowel issues, with R1 requesting a change to his/her medications for bowel incontinence. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit view was conducted with GM Candace Bolin and a copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, May 14, 2026

Allegation investigated: Facility staff did not ensure that resident's room was maintained clean

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver the findings of the complaint investigation. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. On 9/8/2025 the Department received a complaint with the above allegation. On 9/8/2025 the Department interviewed the Reporting Party (RP). RP states on 9/2/2025 and 9/3/2025 he/she observed a resident, referred to as R1, room to not be clean. RP states he/she placed a trash can next to the area that needed to be clean, for facility staff to notice the area. RP states he/she did not inform facility staff that an area of the room needed to be cleaned. RP states he/she emailed facility management regarding this incident on 9/3/2025. Page 1 of 2 Unsubstantiated On 9/10/2025 the Department conducted the initial complaint investigation visit and interviewed General Manager (GM) Candace Bolin, 3 Staff (S1 to S3), 9 Residents (R2 to R9). GM states each resident has his/her own housekeeping schedule per his/her care plan. GM states she was notified by RP on 9/4/2025 that an area in R1's room needed to be cleaned. GM states housekeeping cleaned the area in R1's room on 9/4/2025. On 9/10/2025 the Department interviewed 3 Staff (S1 to S3). 3 Out of 3 staff state he/she has not observed a resident's room to not be maintained clean. 3 out of 3 staff state he/she will clean a resident's room when needed. On 9/10/2025, the Department interviewed 9 Residents (R2 to R10). 9 Out of 9 residents stated he/she has housekeeping once a week. Review of R1's care plan dated 3/25/2025, R1 does not have additional housekeeping services 'outside what is included in rent." On 4/24/2026, GM states included in each resident's admission agreement is 1 scheduled laundry service, additional laundry services can be included for a fee in the plan if a resident chooses. On 9/10/2025, the Department inspected 10 resident rooms (102, 103, 105, 107, 111, 115, 227, 225, 223, and 219) and observed all 10 resident rooms to be clean, safe and sanitary. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with GM and a copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Apr 24, 2026 · control 26-AS-20250908083929

Allegation investigated: Resident sustained injury while in care

On 4/24/2026 Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint visit to deliver complaint findings. LPA met with General Manager (GM) Candace Bolin LPA stated the purpose of the visit. On 11/18/2025 the Department received a complaint with the above allegation. On 11/18/2025 the Department interviewed Reporting Party (RP). RP stated on 11/14/2025 while facility staff were repositing a resident, referred to as R1, facility staff hit R1's head on his/her headboard. RP stated facility staff informed him/her about this incident on 11/15/2025. RP stated he/she visited R1 on 11/15/2025 and saw a bandage on the top of R1’s head. Page 1 of 2 Substantiated On 11/19/2025 the Department conducted a complaint investigation visit and interviewed 8 Staff (S1 to S8) and 1 Resident (R1). 8 Out of 8 staff stated he/she had heard about R1 sustaining an injury to his/her head on 11/14/2025. S7 stated he/she observed R1 ‘down the bed" on 11/14/2025 during the evening shift (2:45PM to 11:00PM). S7 stated he/she placed a bed sheet underneath R1 and then began pulling R1 up, when R1 stated “we bumped my head.” S7 stated a pillow was placed at the top of the bed before he/she moved R1 in the bed. S7 stated he/she then checked R1’s top of the head and observed a ‘red spot, less than an inch large’ and the area was not open (not an open wound). S7 stated he/she reported this incident to the MedTech on duty on 11/14/2025. On 11/19/2025 the Department interviewed R1. R1 stated a staff ‘pulled him/her up, hit on the wall.” R1 did not provide additional information regarding this incident. R1 was observed with a bandage on the top of his/her head during the interview. Review of R1’s physicians report dated 5/16/2023, R1 does not have a history of skin breakdown and is able to follow instructions. Review of R1’s care plan dated 3/25/2025, for transferring, R1 level of assistance is noted as ‘extensive-Resident requires frequent hands-on assistance with transfers and or changes in position. The care plan also does not require a two person assist with transfers. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations Title 22, are being cited on the attached LIC 9099 D. An exit interview was conducted with GM Candace Bolin, and a copy of this report and appeal rights were provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Apr 24, 2026 · control 26-AS-20251118105256

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

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidenced by: Based on observation, record review and interview, R1 sustained an injury to the top of his/her head when being repositioned by S7 on 11/14/2025 which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2026

Plan of correction: Licensee states she will submit a plan of correction regarding how the facility will ensure residents are reposititioned safely by staff to avoid injury, to include an in-service training on repositioning. Licensee to submit POC by POC due date 4/25/2026.

Allegation investigated: Staff mishandled resident's medication

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. On 4/20/2026 the Department received a complaint with the above allegation. It has been alleged the the staff mishandled a resident's medication, resulting in a resident, referred to as R1, being administered another resident's medication on 4/14/2026. On 4/24/2026 the Department conducted the intial complaint investigation visit, and interviewed General Manager (GM) Candace Bolin, and 2 Staff (S1 to S2). GM states she is aware of the medication error that occurred on 4/14/2026 with Resident R1. Page 1 of 2 Substantiated GM states R1's was given another resident's medication in error by S1 on 4/14/2026. GM states all responsible parties were notified of the incident on 4/14/2026. GM states R1 was monitored for possible side effects. GM states R1 did not have any side effects during this incident. On 4/24/2026 the Department interviewed 2 Staff (S1 to S2). 2 Out of 2 staff state he/she is aware of the medication error that occurred on 4/14/2026 where S1 gave R1 another resident's medication. S1 states he/she assessed R1 on 4/15/2026, taking R1's vitals, which were 'normal.' S1 states he/she also called R1's family regarding the incident. On 4/20/2026 the Department received an incident report of the medication error for R1. The incident report states "Medication error noted: resident administered 2 medications in error. contacted after hours MD emergency line...advised to observe resident...POA and HSD notified via phone...care conference held with resident's POA on 4/16/2026." Review of R1's physician's report dated 10/5/2023, R1 has neurocognitive impairment and cannot administered his/her own medications. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations Title 22, are being cited on the attached LIC 9099 D. An exit interview was conducted with GM Candace Bolin and a copy of this report and appeals rights were provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Apr 24, 2026 · control 26-AS-20260420133442

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

87411 Personnel Requirements - General (a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by: Based on observation, record review and interviews,on 4/14/2026 Staff S1 gave another resident's medications to R1 which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2026

Plan of correction: Licensee will submit a plan of action on how the facility with work to prevent medication errors, to include in-service medication traiing by POC due date of 4/25/2026.

Allegation investigated: Staff did not ensure resident's incontinence needs were being met Staff did not ensure resident had clean bedding Staff did not ensure resident's showering needs were being met

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver the findings of the complaint investigation received by the Department on 10/30/2025. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. It was alleged that staff did not ensure Resident R1’s incontinence needs were not being met on 10/20/2025. The Department interviewed Reporting Party (RP) on 10/31/2025. RP stated he/she observed R1 to be soiled and needed to be changed on 10/20/2025. RP stated at the same time, a staff member came into the room. RP stated he/she thinks the staff was there to change the bedding. RP did not provide additional information. Page 1 of 3 Unsubstantiated On 11/4/2025 the Department conducted the initial complaint investigation visit and interviewed 3 Staff (S1 to S3), and 4 Residents (R2 to R5). The Department interviewed 3 Staff (S1 to S3). 3 Out of 3 staff stated he/she changes residents with incontinence more frequently than every 2 hours. S3 stated he/she was called to R1’s room for assistance. S3 did not remember the date of this incident. S3 stated he/she was called to R1’s room while he/she was passing medications, and it took him/her approximately 6 minutes to get to R1’s room. S3 stated he/she did not observe R1 to be soiled. The Department interviewed 4 Residents (R2 to R5). 3 Out of 4 Residents stated he/she does not require toileting assistance from staff. R2 stated he/she did not know about staff assisting residents with toileting. On 11/25/2025 the Department 2 additional staff (S4 and S5). S4 stated he/she was not working on 10/20/2025. S5 did not provide additional information regarding this incident. Review of R1’s Physician’s Report dated 2/12/2023 states R1 can manage his/her own toileting needs, incontinence was not indicated/noted for R1. Review of R1’s care plan dated 6/19/2025, R1 does not require assistance with toileting, and self manages his/her incontinence. Staff did not ensure resident had clean bedding The Department interviewed Reporting Party (RP) on 10/31/2025. RP stated he/she observed R1’s bedding to be soiled and needed to be changed on 10/20/2025. RP states at the same time, a staff member came into the room. RP stated he/she thinks the staff was there to change the bedding. RP did not provide additional information. The Department interviewed 3 Staff (S1 to S3). 3 Out of 3 staff stated the facility has a laundry schedule, and each resident has a specific laundry day. S2 stated if residents have soiled items (clothing, bedding, etc), he/she will take the soiled items to the laundry for housekeeping to wash. S3 stated he/she was called to R1’s room for assistance on 10/20/2025. Page 2 of 3 S3 stated he/she was passing medications, and it took him/her approximately 6 minutes to get to R1’s room. S3 states he/she did not observe R1's bedding to be soiled. The Department interviewed 4 Residents (R2 to R5). 4 Out of 4 Residents stated his/her bedding is changed/washed by the facility. On 11/25/2025 the Department 2 additional staff (S4 and S5). S4 stated he/she was not working on 10/20/2025. S5 did not provide additional information regarding this incident. Review of R1’s care plan dated 6/19/2025, R1 does not have additional laundry services besides what is included in rent. Per R1’s admission agreement dated 3/16/2022, R1's laundry is scheduled once a week. Staff did not ensure resident's showering needs were being met The Department interviewed Reporting Party (RP) on 10/31/2025. RP stated he/she is not sure if R1 was bathed and did not know R1’s shower schedule. RP stated it ‘appears’ that R1’s hair was 'greasy’ on 10/20/2025. The Department interviewed 3 Staff (S1 to S3). 3 Out of 3 staff stated each resident has his/her own shower schedule and staff bathe resident’s according to the shower schedule. On 11/25/2025 the Department interviewed 2 additional staff (S4 and S5). S4 stated he/she was not working on 10/20/2025. S5 did not provide additional information regarding this incident. The Department interviewed 4 Residents (R2 to R5). 3 Out of 4 Residents stated his/her bathing needs are being met. R3 stated he/she does not need assistance with bathing/showering. Review of R1’s care plan dated 6/19/2025, R1’s ‘bathing frequency’ 1-2 times weekly and requires ‘hands-on assistance’ with bathing. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during today’s visit. An exit interview was conducted with GM, and a copy of this report was provided. Page 3 of 3 END OF REPORT On 11/25/2025 the Department 2 additional staff (S4 and S5). S4 stated he/she was not working on 10/20/2025. S2 statesd he/she did not see any documentation that R1’s physician was notified about R1 not feeling on 10/16/2025 and 10/19/2025. S5 stated R1 was assessed (vitals taken) by a MedTech on 10/16/2025 and 10/19/2025 when R1 stated he/she was not feeling well. S5 stated R1 was assessed at ‘baseline’ by a Medtech on 10/16/2025 and 10/19/2025. S5 states it is the responsibility of the Medtech to inform a resident’s physician about a change in condition. GM states on 10/16/2025, the physician was not notified due to the MedTech assessing R1 and determining R1 to be at ‘baseline.’ Review of R1’s progress notes dated 10/12/2025 to 10/25/2025, notes on 10/16/2025, a progress note category at 2:00PM ‘Alert Charting’ R1 was noted as ‘might be sick’. On 10/19/2025, a progress note category at 5:40AM ‘Change of Condition’ notes R1 to have change in bowel movements. The Department requested documentation of the dates and times when R1’s responsible parties were notified about R1 not feeling well on 10/16/2025 and the change of condition noted on 10/19/2025. The facility was unable to provide documentation that R1’s responsible party and physician had been notified. Review of R1’s emergency room discharge paperwork dated 10/20/2025 to 10/22/2025, R1 was noted with discharge on the eyelids, conjunctivitis was listed as one of the diagnoses. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of Regulations (Title 22), are being cited on the attached LIC 9099 D. An exit interview was conducted with General Manager (GM) Candace Bolin and a copy of this report was provided. Appeal rights were also provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Apr 13, 2026 · control 26-AS-20251030133710

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Apr 20, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning...When changes such as... a physical health condition are observed, *continued below* the licensee shall ensure that such changes..are brought to the attention of the resident's physician and the resident's responsible person, if any. This was not met as evidenced by:the state’s words, verbatim · CDSS document, Apr 13, 2026

Plan of correction: GM states she will submit a plan on how she will ensure resident's physicians and responsible parties are notified of any changes in a resident's physical, mental, emotional and social functioning. GM will submit POC by POC due date 4/20/2026. Based on record reviews and interviews, the facility did not inform R1’s responsible parties of a change in condition on 10/16/2025 and 10/19/2025. This poses/posed a potential health, safety or personal rights risk to persons in care.

Allegation investigated: Facility staff are not treating residents with dignity and respect

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit to deliver case findings. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. On 1/13/2026 the Department received a complaint about the above allegation. On 1/13/2026 the Department conducted a complaint investigation visit and interviewed 7 Staff (S1 to S7) and 10 Residents (R1 to R10). 7 Out of 7 staff stated he or she treats residents with dignity and respect. S2 stated he/she is aware of a staff having issues with residents. S5 and S6 stated a resident stated that a staff member did not move when he/she was trying to get water from a water dispenser in December 2025. Page 1 of 2 Substantiated On 1/13/2026 the Department interviewed 10 Residents (R1 to R10). 9 out of 10 residents state staff treat him/her with dignity. R1 states that S8 did not move out of the way when he/she was trying to get water from a water dispenser. R1 did not remember the date of this event. R1 states during this incident, he/she asked S8 to move, and the S8 did not respond or move from the dispenser. R1 states he/she was unable to get water from the dispenser. R1 states after this incident he/she informed facility management via email and requested that S8 not come to his/her apartment. Review of documentation dated 11/23/2025 to 12/23/2025, LPA observed that R1 informed S2 on 11/23/2025 about the incident at the water dispenser with S8. S2 responded on 11/25/2025 and stated management would address the incident with S8. Review of additional documentation provided by S2 on 3/26/2026, S2 stated that he/she spoke with S8, with S8 reporting that S1 had asked him/her to ‘move with an attitude, that S8 asked S1 to say ‘please’ and that he/she then moved out of the way so the resident could fill his/her water bottle.” The documentation also notes that S8 was provided with education through training and did not receive any disciplinary action for the interaction with R1 on 11/23/2025. S8 was also instructed not to use the 4th floor of the facility for staff breaks or as a quiet area. On 3/13/2026, 3/19/2026, and 3/27/2026, the Department reached out to S8 for an interview. As of 4/13/2026, S8 has not returned the Department’s request for an interview. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of Regulations (Title 22), are being cited on the attached LIC 9099 D. An exit interview was conducted with GM and a copy of this report was provided. Appeals rights also provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Apr 13, 2026 · control 26-AS-20260113082819

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 14, 2026

87468.1 Personal Rights of Residents in All Facilities (a) (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on records reviewed and interviews conducted, S8 stated to S2 that he/she told R1 on 11/23/2025 to say ‘please’ before S8 moved out of the way for S1 to fill a water bottle.” This poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 13, 2026

Plan of correction: GM states she will submit a plan of action to ensure staff are treating residents with dignity and respect, to include an all staff training regarding personal rights. POC to be submitted to CCL by POC due date 4/14/2026.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin arrived at the facility unannounced to conduct a case management – Other visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. The purpose of the visit is to hand deliver an immediate exclusion letter for one individual (S1) who the Department determined engaged in conduct inimical. ADM stated S1 no longer works at the facility and was terminated on 3/12/2026. The immediate exclusion letter for S1 was handed to the GM. GM was informed to remove S1 from having any contact with residents and S1 was not allowed to be physically present in the facility. GM was advised to separate S1 from the facility roster. LPA requested a copy of the updated LIC 500 to be sent to CCL by 5PM on 4/13/2026. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager (GM) Candace Bolin and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 13, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management visit regarding an incident that occurred on 3/7/2026. LPA met with General Manager (GM) Candace Bolin and Health Services Director (HSD) Heather Spears. LPA stated the purpose of the visit. On 3/9/2026 the Department received an Incident Report (IR) and SOC 341 regarding an incident between Staff S1 and Resident R1 that occurred on 3/7/2026. During visit, LPA obtained pertinent documentation to include but not limited to staff records, resident records, progress notes and staff schedule for 3/7/2026. LPA determined this incident requires further investigation. No deficiencies were cited during today's visit. An exit interview was conducted with General Manager (GM) Candace Bolin and copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 9, 2026

Allegation investigated: Staff do not permit resident to have visitors. Staff do not permit resident to leave the facility. Staff did not assist resident with obtaining medical care.

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a complaint investigation visit to deliver the complaint findings. LPA met with General Manager (GM) Candace Bolin and stated the purpose of the visit. On 7/7/2025 the Department received a complaint with the above allegations. On 7/11/2025, 9/17/2025, 10/3/2025, and 10/7/2025 the Department conducted complaint investigation visits and interviewed 6 Staff (S1 to S6), 2 Residents (R1 to R2), and 3 Witnesses (W1-W3). The Department interviewed Reporting Party (RP) on 7/11/2025. RP states on 6/23/2025 the facility did not allow him/her to visit a resident (Referred to as R1). RP states he/she was allowed to visit on 6/23/2025 to 6/25/2025. RP states the facility only allowed him/her to visit with R1 within the facility. Unfounded The Department interviewed 6 Staff (S1 to S6). 6 Out of 6 staff state there has never been a time a visitor was not permitted to visit with his/her loved one. The Department interviewed 2 Residents (R1 to R2). 1 Out of 2 residents state there has never been a time his/her visitors were not permitted to visit with him/her. R2 did not respond to questions due to neurocognitive disorder. The Department interviewed 3 Witnesses (W1 to W3). 3 Out of 3 Witnesses state he/she has no concerns about the care his/her loved one is receiving at the facility. Staff do not permit resident to leave the facility. The Department interviewed 6 Staff (S1 to S6). 6 Out of 6 staff state there has never been a time a resident was not permitted to leave the facility. The Department interviewed 2 Residents (R1 to R2). 1 Out of 2 residents states there has never been a time when the facility did not allow him/her to leave. R2 did not respond to questions due to neurocognitive disorder. The Department interviewed 3 Witnesses (W1 to W3). 3 Out of 3 Witnesses state he/she has no concerns about the care his/her loved one is receiving at the facility. Based on review of R1's physician's report dated 4/26/2024, R1 cannot leave the facility unassisted. Staff did not assist resident with obtaining medical care. It has been alleged by RP that the facility did not obtain care for R1's cracked lens on a pair of eyeglasses on 6/23/2025 to 6/25/2025 when RP visited with his/her loved one. The Department interviewed 6 Staff (S1 to S6). 6 Out of 6 staff state there has never been a time a resident was not assisted with obtaining medical care. Page 2 of 3 The Department interviewed 3 Witnesses (W1 to W3). 3 Out of 3 Witnesses state he/she has no concerns about the care his/her loved one is receiving at the facility. W3 states the facility communicates when his/her loved one needs anything at the facility. This agency has investigated the complaint alleging staff do not permit resident to have visitors, staff do not permit resident to leave the facility, staff did not assist resident with obtaining medical care. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with GM Candace Bolin and a signed copy of this report was provided. Page 3 of 3 END OF REPORTthe state’s words, verbatim · CDSS document, Jan 15, 2026 · control 26-AS-20250707103827

Allegation investigated: Facility staff did not administer resident medication as prescribed. Staff handled resident in a rough manner.

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a complaint investigation visit to deliver the complaint findings. LPA met with General Manager (GM) Candace Bolin and stated the purpose of the visit. On 3/14/2025 the Department received a complaint with the above allegations. On 3/18/2025 the Department interviewed the Reporting Party (RP). RP states the facility ‘misplaced’ resident (Referred to as R1) medication causing R1 to go without medication for at least one day. RP stated R1’s palliative agency mailed R1’s medication to the facility on 3/7/2025. RP states he/she ‘assumes’ the facility signed for the medication but states he/she does not have any documentation that the medication was received by the facility from the palliative agency on 3/7/2025. Page 1 of 2 Unsubstantiated The Department interviewed 7 Staff (S1 to S7), 8 Residents (R1 to R8) and 1 Witness (W1). 7 Out 7 staff state he/she is not aware of any residents sustaining a skin tear due to staff neglect. S4 states residents have ‘fragile skin.’ On 3/20/2025, 4/4/2025 and 10/7/2025 the Department interviewed 8 Residents (R1 to R8). 5 Out of 8 Residents stated he/she has no issues/concerns with staff. R3 did not respond to questions due to neurocognitive disorder. R7 and R8 declined to be interviewed On 3/20/2025, 4/4/2025 and 10/7/2025 the Department interviewed Witness 1 (W1). W1 states he/she has no issues with facility. Review of R1’s care plan dated 3/3/2025, under Skin Evaluation, R1 is noted to have ‘dry skin, ‘requires assistance with lotion to extremities.” Review of R1’s progress notes for 3/13/2025 state a Care Conference was held with R1, palliative care and R1’s responsibly party regarding ‘skin breakdown, potentially caused by the adhesive tape on briefs…facility will trial pull-up briefs.” This agency has investigated the complaint alleging that a resident sustained skin tear due to staff neglect. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted with General Manager (GM) Candace Bolin. A signed copy of this report was provided. Page 2 of 2 END OF REPORT On 3/20/2025, 4/4/2025 and 10/7/2025 the Department interviewed 8 Residents (R1 to R8). 5 Out of 8 Residents stated staff have never handled him/her in a rough manner. R3 did not respond to questions due to neurocognitive disorder. R7 and R8 declined to be interviewed. On 3/20/2025, 4/4/2025 and 10/7/2025 the Department interviewed Witness 1 (W1). W1 states he/she has no issues with facility. Review of R1’s progress notes for 3/16/2025 note an incident on 3/14/2025 that two staff from palliative care arrived for R1 at approximately 9:30PM. The Progress note states a Medtech, and two staff from palliative care provide care, during which R1 was repositioned onto his/her right side, and then onto his/her back. R1 noted to be upset during this incident. Management was notified of the incident. No injuries were noted during this incident. 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, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with GM Candace Bolin and a signed copy of this report was provided. Page 3 of 3 END OF REPORT On 3/20/2025, 4/4/2025 and 10/7/2025 the Department conducted complaint investigation visits. The Department interviewed 7 Staff (S1 to S7), 8 Residents (R1 to R8) and 1 Witness (W1). 5 Out 7 staff state residents are administered medications as prescribed. S1 states there was an issue with medications not being faxed to the pharmacy for R1, “medication list got lost in the fax server,” which resulted in R1’s medication not being administered. S3 states he/she has observed staff not administering medication to a resident as prescribed. S3 states this incident was reported to management sometime in June/July 2025. On 1/15/2026 LPA interviewed S1. S1 states the facility did not receive R1's medications from palliative care on 3/7/2025 due to the palliative agency mailing the medications to R1's home instead of the facility. S1 states this incident was noted on R1's progress notes. Review of R1's progress notes for 3/8/2025 notes the facility requested R1's medications from the palliative agency. On 3/20/2025, 4/4/2025 and 10/7/2025 the Department interviewed 8 Residents (R1 to R8). 5 Out of 8 Residents stated he/she receives medications as prescribed. R3 did not respond to questions due to neurocognitive disorder. R7 and R8 declined to be interviewed. On 3/20/2025, 4/4/2025 and 10/7/2025 the Department interviewed Witness 1 (W1). W1 states he/she has no issues with facility, and if he/she has issues facility management will address. Staff handled resident in a rough manner On 3/18/2025 the Department interviewed the Reporting Party (RP). RP states R1 was handled in a rough manner by staff on 3/15/2025. On 3/20/2025, 4/4/2025 and 10/7/2025 the Department conducted complaint investigation visits. The Department interviewed 7 Staff (S1 to S7), 8 Residents (R1 to R8) and 1 Witness (W1). 7 Out 8 staff state he/she has not observed staff handling residents in a rough manner. S3 states he/she heard R1 yell as he/she was passing R1’s room, and S3 observed staff from an outside agency transfer R1 without explaining the transfer process. S3 states he/she checked on R1 and R1 stated the staff hurt him/her. S3 states he/she informed Medtech on duty but did not provide any additional information. Page 2 of 3the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 26-AS-20250314154957

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to address an alleged incident of abuse of a resident reported during a complaint investigation visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. During a complaint investigation visit on 1/15/2026, an alleged incident of abuse of a resident was reported. During visit, LPA interviewed GM, staff and residents. LPA reviewed staff training, and staff files. LPA requested pertinent documentation to included but not limited to staff training records, resident progress notes, and resident care plans. LPA determined this case management required further investigation. No deficiencies were cited during today's visit. An exit interview was conducted with General Manager (GM) Candace Bolin. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 15, 2026

Allegation investigated: Resident not provided liquids, resulting in dehydration. Staff does not have training on handling infectious diseases.

This is an amended report 10/23/2025 to change the findings from unsubstantiated to unfounded. Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint visit to deliver the findings on the above allegations. LPA met with Administrator Candace Bolin. LPA stated the purpose of the visit. On 2/24/2025 the Department received a complaint with the above allegations. On 2/28/2025 LPAs conducted the initial unannounced investigation visit. On 2/28/2025, 3/20/2025 and 4/4/2025, LPAs interviewed 7 Staff (S1 to S7), 8 Residents (R2 to R9) and 3 Witnesses (W1 to W3). Page 1 of 3 Unfounded This is an amended report 10/23/2025 to change the findings from unsubstantiated to unfounded. Resident not provided liquids, resulting in dehydration It has been alleged by the Reporting Party (RP) that his/her loved one was not provided liquids by staff on 2/14/2025. RP stated at 6PM on 2/14/2025 he/she observed R1 had one half full glass of water next to him/her. RP stated he/she provided the facility with 4 supplemental drinks on 2/14/2025 for R1. RP states on 2/15/2025 he/she observed R1 “to seem like he/she didn’t have any fluids,” and observed 3 full unused supplemental drinks, with one bottle remaining, 1/3 full. On 2/28/2025, 3/20/2025, and 4/4/2025, LPAs interviewed 7 Staff (S1 to S7). 7 Out of 7 staff stated he/she provides liquids to residents. 7 Out of 7 Staff stated he/she encourages residents to drink liquids when he/she checks on residents. On 2/28/2025 and 3/20/2025 LPAs interviewed ADM. ADM stated staff check on residents every 2 hours and offer residents and encourages residents to drink water. ADM stated residents are offered liquids during meals and activities. ADM stated residents have access to water in the dining area and in the main lobby of the facility. LPA observed water dispensers in the facility lobby area during the complaint visit on 10/7/2025. LPA interviewed 8 (R2 to R9) residents. 5 Out of 8 residents stated he/she is provided with liquids by facility staff. R8 and R9 declined to be interviewed. R2 did not provide additional information due to neurocognitive disorder. LPAs interviewed 3 Witnesses (W1 to W3). W2 stated their loved one is being provided with liquids by the facility and has observed water accessible to residents in the dining and living room areas of the facility. W1 stated his/her loved one was not being provided with liquid but did not provide additional information regarding this incident. W3 stated he/she provides his/her loved one with all liquids, due to a personal preference. Staff does not have training on handling infectious diseases. It has been alleged that facility staff do not have training on handling infectious diseases due to an outbreak of COVID in February 2025. Page 2 of 3 This is an amended report 10/23/2025 to change the findings from unsubstantiated to unfounded. On 2/28/2025 and 3/20/2025, LPAs interviewed ADM. ADM stated staff have training on infection control. On 2/28/2025, 3/20/2025, and 4/4/2025, LPAs interviewed 7 Staff (S1 to S7). 7 out of 7 Staff stated he/she received training on infection diseases. 7 Out of 7 staff stated he/she provides liquids to residents if there is a GI illness as part of infection diseases training protocol. LPA interviewed 8 (R2 to R9) residents. 5 Out of 8 residents stated he/she is provided with liquids by facility staff, part of GI illness infection protocol. R8 and R9 declined to be interviewed. R2 did not provide additional information due to neurocognitive disorder. LPAs interviewed 3 Witnesses (W1 to W3). 1 out of 3 witnesses state he/she was not informed by the facility about Norovirus in February 2025 and became sick with Norovirus in February 2025 after visiting his/her loved one in the facility. W1 and W2 did not state if he/she was informed about the norovirus by the facility. LPAs reviewed staff training records dated 2/19/2025 to include the following topics Hand Hygiene, Personal Protective Equipment, GI illness. LPA observed staff signatures on the In-Service and Attendance documentation for the training. This agency has investigated the complaint alleging Resident not provided liquids, resulting in dehydration, Staff does not have training on handling infectious diseases. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with GM Candace Bolin, and a signed copy of this report was provided. Page 3 of 3 END OF REPORT Licensee did not adhere to licensing/other agency’s reporting requirements It has been alleged that the Licensee did not adhere to licensing/other agency reporting requirements. RP states R1 was sick with Norovirus in February 2025 and was not informed by the facility. On 2/28/2025 and 3/20/2025, LPAs interviewed ADM. ADM stated he/she did not know if incident reports were sent to the Department regarding residents with norovirus in February 2025. On 2/28/2025, 3/20/2025 and 4/4/2025, LPAs interviewed 7 Staff (S1 to S7). 6 out 7 staff did not provide additional information regarding reporting requirements. S7 stated he/she did not send incident reports to the Department regarding residents with norovirus in February 2025. S7 states he/she was aware that a couple of families were not notified of Norovirus in February 2025. On 2/28/2025, 3/20/2025 and 4/4/2025, LPAs interviewed 8 Residents (R2 to R9). 2 Out of 8 Residents state he/she was sick in February 2025. R3, R4, and R7 stated he/she was not sick in February 2025. R8 and R9 declined to be interviewed. R2 did not provide additional information due to neurocognitive disorder. LPAs interviewed 3 Witnesses (W1 to W3). 1 out of 3 witnesses stated he/she was not informed by the facility about Norovirus in February 2025. W3 states he/she was not notified by the facility and became sick with Norovirus in February 2025 after visiting his/her loved one in the facility. W1 and W2 did not state if he/she was informed about the norovirus by the facility. Based on LPAs observations, interviews and record reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED per California Code of Regulations, Title 22. A deficiency is being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 26-AS-20250224090439

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Oct 21, 2025

87211(a)(2) Reporting Requirements (a) Each licensee shall furnish to the licensing agency...reports......outbreaks, which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours. This was not met as evidenced by: The facility did not report a norovirus outbreak on February 14th, 2025 to the Department, which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Facility ADM will submit a letter of understanding of the regulation cited. Facility ADM will conduct an in-service training on reporting requirements with management staff and submit proof of in-service training to CCLD by POC due date 10/21/2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management Incident visit. LPA met with General Manager Candace Bolin. LPA stated the purpose of the visit. On 10/6/2025 the facility reported a medication error that was discovered on 9/30/2025 for Resident R1, where a medication was discontinued on 08/15/2025 in error. The report states R1's physician and responsible parties were notified. During visit, LPA interviewed staff and requested pertinent documentation. LPA determined this incident requires further investigation. No deficiencies cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with GM Candace Bolin and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. On 8/1/2025 the Department received an incident report and an SOC341 regarding an incident involving Residents R1 and R2 that occurred on 7/31/2025. The incident reports states R1 and R2 were involved in a physical altercation, and staff intervened. The incident report states no injuries were observed and residents were assessed after the altercation, and all responsibly parties were notified. The incident report states the facility will continue to monitor R1 and R2. LPA interviewed GM. GM states R1 and R2 are being escorted to his/her rooms by staff after activities to prevent another altercation. LPA requested pertinent documentation to include but not limited to residents physician's reports, and care plans. No deficiencies cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with GM and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with GM to include but not limited to the kitchen, resident rooms, dining room, and kitchen. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the refrigerator temperature at 38 degrees F and Freezer at -15 degrees F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. The smoke detectors were last serviced and inspected on 3/25/2025. Fire extinguishers were last serviced on 9/13/2025. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 6/28/2025, drills are being conducted monthly. LPA toured 10 resident rooms with GM. All 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. Page 1 of 2 LPA toured 10 resident bathrooms. All 10 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature in 10 resident bathrooms with a range from 105 degrees F to 118 degrees F. LPA toured the memory care with GM. LPA observed all exit and delayed egress doors in memory care alarmed, and functioned properly when tested by GM. LPA reviewed 5 resident records. Resident records included emergency contact information, physician’s report, needs and service plans, and personal rights. LPA reviewed 3 Resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA observed 1 medication for R2 was not written down on the centrally stored log. A Technical Assistance was issued, see LIC9120 for more information. LPA reviewed 5 staff records. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record, and staff training. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with GM Candace Bolin and a signed copy of this report was provided. Page 2 of 2the state’s words, verbatim · CDSS document, Jul 28, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit regarding an incident that occurred on 5/27/2025 and met with Health Services Director (HSD) Heather Spears. LPA stated the purpose of the visit. HSD stated General Manager (GM) Candace Bolin was out sick. On 5/28/2025 the Department received an Incident Report. LPA interviewed staff. During visit, LPA requested documentation to include but not limited to physician's report, service plan, and emergency contact information. LPA determined this case management requires additional review/information. No deficiencies cited today per California Code of Regulations, Title 22. An exit interview was conducted with HSD Heather Spears and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management POC visit to follow up on deficiencies cited on 4/4/2025. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. ADM stated the facility has 101 residents and 48 staff. On 4/4/2025 LPAs Marcella Tarin and Manuel Monter conducted a Case Management visit to follow up on two elopements that were reported to the Department in December 2024. Two deficiencies were issued and the Plan of Correction (POC) was developed with the GM. The POC was due on 4/5/2025 and was received by the Department on 4/4/2025. During visit, LPA reviewed documentation of staff training for 4/16/2025 to include topics of elopement, exit seeking behavior, communication and redirection ideas. GM states the facility will also be conducting another staff training on 4/23/2025 on elopements. The facility provided LPA with documentation of staff training for 4/16/2025 and 4/23/2025. LPA cleared the deficiencies cited on 4/4/2025 during today's visit. A Letter of Deficiency Citations Cleared was printed and provided to GM during today's visit. No deficiencies were cited during todays visit. An exit interview was conducted with GM Candace Bolin and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter arrived unannounced to conduct a Case Management-Incident regarding 2 elopements that occurred on 12/8/2024 and 12/15/2024. LPAs met with Administrator Candace Bolin and stated the purpose of the visit. Elopement 12/8/2024 On 12/11/2024 the Department received an incident report for Resident R1, who eloped from the facility on 12/8/2024. The incident report stated: "Door 1 alarmed at 11:11 AM, Care giver looked out the window of Garden house and saw the resident walking outside. Staff Went out to escort resident back inside and the resident was no longer in site. Staff immediately initiated a search of the surrounding neighborhood...911 was called and police assisted with search...Police escorted resident back to the community at 12:20 PM. Police officer reports that the resident walked in the police station." On 12/11/2024 LPA Simi Rai spoke with ADM regarding the incident report of R1's elopement on 12/8/2024. ADM stated that the whole building has delayed egress doors except for one door, which R1 found and exited the facility from during the incident. ADM stated the door located on the main floor in the stairwell had an alarm and not a delayed egress. The facility has four floors with the memory care unit is the in the basement. ADM stated R1 has neurocognitive disorder. ADM stated R1 cannot leave the facility unassisted. R1 was found by the police when R1 entered the police department down the street from the facility. Based on a Google Maps search the Police Department is located 0.4 miles from the facility Page 1 of 3. On 12/19/2024, LPAs Marcella Tarin and Kenneth Madrigal interviewed the Administrator (ADM). ADM stated R1 does not have exit seeking behaviors and no history of wandering. ADM stated R1 has not expressed he/she wants to leave the facility, and resident does not have recollection of leaving the facility. LPAs Marcella Tarin and Kenneth Madrigal interviewed staff, S1-S2. Staff S1 stated, R1 often shows wandering behavior by the front door. S1 stated every day, R1 by the door looking out the door wanting to leave. On 2/20/2024 LPAs Marcella Tarin and Manuel Monter interviewed 11 staff (S3-S13). 6 out of 11 (S3-S6, S12, S13) staff stated R1 has wandering behaviors. 5 out of 11 (S7-S11) staff stated he/she does not know if R1 has wandering behaviors. Based on review of R1's service plan dated 12/06/2024 under Evaluation Item, Evaluation Section: Psychosocial: Wandering, states resident has a current or history of wandering within the residence or facility and may wander outside. R1’s physician’s report dated 5/9/2024 lists R1’s diagnosis as neurocognitive disorder. R1’s mental condition as confused/disoriented, has wandering behaviors and R1 cannot leave the facility unassisted. Elopement 12/15/2024 On 12/18/2024, the Department received an Incident Report regarding Resident R2 eloping from the facility on 12/5/2024. R2 was returned to the facility by local police that same day and was unharmed during the elopement. On 12/19/2024, LPAs Marcella Tarin and Kenneth Madrigal interviewed the Administrator (ADM). ADM states R2 wears a Wanderguard and has exit seeking behavior. ADM stated the facility was not aware R2 had eloped from the facility until police informed the facility that R2 was found at a grocery store, Trader Joes. Based on a Google Maps search, R2 was located 0.9 miles from the facility. On 2/20/2024 LPAs Marcella Tarin and Manuel interviewed Administrator (ADM) ADM stated R2 has eloped from the facility in the past but could not provide a date. Page 2 of 3. LPA’s interviewed 11 staff (S3-S13). 8 out of 11 (S3-S9, S12) staff stated R2 has wandering behaviors, and 4 out of the 8 (S7-S9, S12) staff state R2 has eloped or attempted to elope from the facility in the past. 3 out of 11 (S10, S11, S13) staff state they are not aware of R2 eloping from the facility of having wandering behaviors. Staff S6 stated the facility has a list of residents who can leave unassisted. S6 stated if a resident who can’t leave the facility unassisted tries to leave the facility, staff will redirect. Staff S6 acknowledged that resident R2 likes to come to the front door, but staff will redirect. On 4/5/2025 LPAs interviewed ADM. ADM stated staff at the front desk have a list of residents (with pictures) who can leave the facility unassisted. Based on evidence reviewed, on December 5, 2024, R2’s service plan dated 9/23/2024 under Evaluation Item, Evaluation Section: Psychosocial: Wandering, states resident has a current or history of wandering within the residence or facility and may wander outside. R1’s physician’s report dated 2/7/2023 lists R1’s diagnosis as neurocognitive disorder. R1’s mental condition as confused/disoriented, has wandering behaviors and R1 cannot leave the facility unassisted. Based on evidence reviewed, R2 walked out of the lobby’s front door by following an individual who was exiting the facility on 12/5/2024. As a result, the department issued an immediate civil penalty of $500 for an absence of supervision, which resulted in R1 and R2 eloping from the facility. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Administrator Candace Bolin and a copy of the report was provided. Appeal Rights was provided. Page 3 of 3the state’s words, verbatim · CDSS document, Apr 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 4, 2025

87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on record review and interviews, R1 and R2 cannot leave the facility unassisted. Both residents left the facility unassisted and were returned back to the facility by local law enforcement, which poses an immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: ADM stated facility has installed egress doors, the facility will conduct on-going elopement training and elopement drills, and ensuring front desk staff re-direct residents. ADM will submit the Plan of Correction (POC) of planned staff training to the Department by 4/5/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.2(a)(4) · Plan of correction due date: Apr 4, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision... delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews, the facility staff did not re-direct R1 and R2 when they eloped from the facility. Facility staff were also unaware that R2 had eloped from the facility, which poses an immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: ADM stated the facility will conduct on-going elopement training and elopement drills, and ensuring front desk staff re-direct residents and call for help with re-directing residents. ADM will submit Plan of Correction (POC) of planned staff to the Department by 4/5/2025.

Allegation investigated: The facility staff did not ensure that residents’ rooms are clean, safe, sanitary at all times.

Licensing Program Analyst (LPA) Marcela Tarin and Manuel Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Candace Bolin On February 27, 2025, The Department received a complaint alleging the facility staff did not ensure that residents’ rooms are clean, safe, sanitary at all times. On February 27, 2025, the Department interviewed Witness W1. W1 stated his/her family members room is often not cleaned properly. W1 stated he/she noted issues such as feces in or on the toilet, trash on the floor and throughout the room, and the bed not being made regularly. W1 stated that he/she has reported these issues to the general manager, but no corrections have been made. Page 1 Out of 3. Unsubstantiated On February 28, 2025, LPA Manuel Monter interviewed staff S1-S6. Staff S1-S6 stated the Housekeeper cleans residents bedrooms once a week. S1-S6 stated the care givers are supposed to maintain the rooms clean during the week. 5 Out of 6 staff interviewed (S2-S6) stated they have not seen any bedrooms that are not clean or unsanitary or rooms that clearly are neglected and need to be cleaned. Staff S1 stated he/she has seen residents’ rooms that aren’t clean. S1 stated from his/her memory, he/she has seen two bedrooms as dirty/ that have been neglected. ADM stated resident bedrooms are cleaned weekly. ADM stated resident bedrooms Have assigned once a week housekeeping. ADM stated Care givers clean daily and remove trash each shift. ADM stated she has not seen any residents bedroom that were dirty, unclean or unsanitary. On February 27, 2025, LPA Manuel Monter toured the facility assisted living section of the facility and randomly toured the following bedrooms: 105, 111, 143, 206, 207, 217, 226, 230, 309, 315, 321, 410, 412, 423, 425. While touring these bedrooms, LPA Monter observed the bedrooms as clean, safe and sanitary. LPA Monter toured the following bedrooms in the memory care section of the facility: 1,3,5,7,9, 11. (Note all the bedrooms in the memory care are odd numbers by design.) LPA Monter observed the bedrooms as clean, safe and sanitary. On March 14, 2025, LPA’s Manuel Monter and Marcella Tarin interviewed residents R1-R10. LPA’s attempted to interview resident R1, but R1 did not respond to LPA’s questions. R1 would digress to unrelated topics. 9 Out of 10 residents (R2-R10) stated they have no issues with the apartments cleanliness and stated their living space is clean. LPA’s interviewed staff S7. Staff S7 stated housekeeping cleans residents’ bedrooms once a week. S7 stated If residents have an accident, then a care giver will clean the resident up and the area up. S7 stated, then housekeeping will come to sanitize the area as well. S7 stated he/she has not seen any resident bedrooms in an unclean/dirty state. S7 stated if he/she sees an accident in a residents bedroom, then he/she will notify staff to clean it up or he/she will clean it up herself. Page 2 Out of 3. On March 20, 2025, LPA Manuel Monter and Marcella Tarin toured the facility assisted living section of the facility and randomly toured the following bedrooms: 101, 103, 204, 218, 223, 247, 314, 333, 341, 345, 412, 414, 421. While touring these bedrooms, LPA Monter and Tarin observed the bedrooms as clean, safe and sanitary. LPA Monter and Tarin toured the following bedrooms in the memory care section of the facility: 1,3,5,7,9, 11. LPA Monter and Tarin observed the bedrooms as clean, safe and sanitary. Based on investigation, interviews conducted and records reviewed , the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 3 Out of 3. END OF REPORT.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 26-AS-20250227150414

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter arrived unannounced to conduct a case management visit to follow up on a medication error. LPAs met with General Manager (GM) Candance Bolin and stated the purpose of the visit. On 3/4/2025 the Department received an Incident Report for a medication error of Resident R1 that occurred on on 2/27/2025. The incident report states: "On Thursday, February 27th. It was reported that the Staff S1 administered two doses of Medication (referred to as M1) to resident R1. The medication order specified 10mg of M1 to be given at 4:00PM and 8:00PM. M1 was supplied in syringes as 10mg/5mL. However, two syringes were administered during each scheduled time, resulting in the resident receiving a total of 20mg at 4PM and another 20mg at 8PM. This is confirmed by the med tech (referred to as staff S1) signatures and sign-out on the record. indicating the admin of 2 syringes at both 4PM and 8PM and the M1 count, showing 2 additional syringes being removed...S1 will undergo retraining on medication administration, focusing on dosages calculation, concentration awareness and the importance of double-checking orders...and an inservice will be provided to all Med techs on Medication errors and their prevention." LPAs interviewed Health Services Director (HSD), who stated Staff S1 admitted to giving two doses of M1 to R1 on 2/27/2025. HSD states S1 did not conduct the required medication checks before administering M1 to R1. A deficiency is being issued during today's visit per California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted with General Manager, Candace Bolin and a copy of this report was provided. Appeal rights were also provided.the state’s words, verbatim · CDSS document, Mar 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 20, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by Based on investigation, on 2/27/2025, Staff S1 administered 2 incorrect doses of medication M1 to R1 which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2025

Plan of correction: Administrator stated the facility conducted an in-service for staff on medication training on 2/28/2025. ADM provided documentation of in-service training conducted on 2/28/2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit. LPA Tarin met with General Manager, Candace Bolin and explained the purpose of the visit. On 3/5/2025, the Department received an Incident Report and SOC341 for Resident R1 who was noted to have bruising on the left eye and sides of neck on 3/5/2025. The Incident Report states the neck bruising was discoloration due to 'dye transfer' from a necklace worn by R1 on 3/4/2025 and an unknown cause for the bruising on R1's left eye. The Incident Report states the facility sought medical care for R1, and all responsible parties and physician were informed about the incident on 3/5/2025. During visit, LPA interviewed 7 staff, observed R1 and toured R1's room. Based on interviews, the discoloration/'bruising' observed on R1 on 3/5/2025, was green dye that transferred onto R1's neck from beaded necklaces worn during a Mardi Gras event on 3/4/2025. Staff were able to wipe away the green discoloration from R1's neck on 3/5/2025. LPA did not observe bruising or discoloration on R1's neck during visit. LPA observed R1 to have bruising under the left eye. The facility does not know how R1 obtained bruising under the left eye on 3/5/2025. After this incident, the facility's plan of action is to provide more frequent checks on R1, including recognizing any areas of discoloration. The facility is also providing additional training for staff on recognizing bruising and discoloration. LPA requested the following documentation: photos from the events on 3/4/2025, R1's service plan and physician's report, staffing roster for 3/4/2025 and 3/5/2025. No deficiencies were issued during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with General Manager, Candance Bolin and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 6, 2025

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter arrived unannounced to conduct a Case Management-Incident regarding 2 elopements that occurred on 12/8/2024 and 12/15/2024. LPAs met with Administrator Candance Bolin and stated the purpose of the visit. During visit LPAs toured and tested the exit doors where R1 had allegedly eloped. LPAs interviewed 3 staff and the ADM. LPAs attempted to interview R2 who declined be interviewed. LPAs requested additional pertinent documentation and a copy of security video footage for elopements. Due to insufficient information, this investigation requires additional review. This report was reviewed with Administrator Candace Bolin and a signed copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 20, 2025

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Marcella Tarin and Kenneth Madrigal conducted an unannounced Case Management visit to follow up on two incident reports involving two elopements. LPAs met with Administrator Candace Bolin and explained the purpose of the visit. On 12/11/2024, the Department received an Incident Report regarding resident R1 eloping from the facility on 12/08/2024. R1 was returned back to the facility by local police and was unharmed during the elopement. On 12/18/2024, the Department received a second Incident Report regarding resident R2 eloping from the facility on 12/15/2024. R1 was returned to the facility by local police and was unharmed during the elopement. LPAs toured the interior and exterior of the facility and inspected the alarm panel in the Garden House Medroom for 13 alarmed exit doors in the facility. 13 out of 13 doors were alarmed, with all buttons on the panel indicating that the doors were alarmed. LPAs inspected Garden House Door #1 and Stairwell Exit Door #3, and Garden House Gate. LPAs interviewed 3 staff, and attempted to interview 2 residents during visit. LPAs requested R1 and R2's needs/service plan, R1 and R2's physician's report, staffing roster for 12/08/2024 and 12/15/2024, maintenance service records, a copy of security video footage and resident roster. Due to insufficient information, this investigation requires additional review. This report was reviewed with Administrator Candace Bolin and a signed copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2024

Allegation investigated: Facility staff do not respond to the email of complaints from family members of residents. Facility does not have directors of health service and resident service to manage and supervise caregivers to provide care and supervision to residents.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and Met with Administrator (ADM) Candi Bolin. On 5/22/2024, the Department received a complaint with the above allegations. On 5/28/2024, the Department conducted an initial investigation visit. LPA interviewed ADM and 6 staff. LPA toured the facility and interviewed 8 residents. LPA request roster of clients, LIC500 Personnel summary report. Continue on LIC9099-C. Page 1 of 3. Unsubstantiated Facility staff do not respond to the email of complaints from family members of residents: The allegation is that the facility Administrator did not respond to the email of complaints from family members of residents. On 5/28/2024, LPA interviewed Administrator (ADM) Candi Bolin. ADM stated he/she replied to all emails of complaints from family members of residents. ADM stated he/she was the second line to respond to the complaints or requests from the family member of residents before Health Service Director and Resident Care Director left the facility. ADM stated he/she received some enquiries from family members of residents regarding billings or request something after the 2 directors left the facility, and he/she replied to all of them. ADM stated he/she did not receive any complaint regarding care and supervision from family members of residents after the 2 directors left the facility. LPA interviewed the Facility Nurse (S1). S1 stated before the two directors left the facility, he/she was the second line to receive the complaints from residents or family members. S1 stated he/she did not receive any complain form residents or family members after the two directors left the facility on 5/21/2024. On 11/17/2024, LPA called two family members (FM1, FM2) of residents and left message. LPA did not any response back. Based on the interview, there is no evidence to indicate the facility Administrator did not respond to the email of complaint from family members of residents. Facility does not have directors of health service and resident service to manage and supervise caregivers to provide care and supervision to residents: On 5/28/2024, LPA interviewed Administrator (ADM). ADM stated the facility Health Service Director and Resident Service Director left the facility on 5/21/2024, and the two position are still vacancies. ADM stated the facility is seeking for candidates to fill the two positions. ADM stated he/she and the Facility Nurse S1 share the workloads of the two directors. ADM stated a Med Tech (S2) is assigned as Head of Med Tech to schedule and group Med Techs and Caregivers to provide care and supervision to residents which was part of the two directors' workload. Continue on LIC9099-C. Page 2 of 3. ADM stated a Health Service Specialist (S3) from corporate comes to the facility today to help him/her to operate the facility. ADM stated there is no impact on the facility to provide care and supervision to residents. LPA interviewed the Facility Nurse (S1). S1 stated he/she, ADM and Head of Med Tech S2 share the workload of the two directors who left the facility on 5/21/2024. S1 stated there is no impact for the leaving of the two directors. LPA interviewed the Head of Med Tech S2. S2 stated he/she schedules and groups Med Tech and caregivers to provide services to residents, and he/she also conducts the work of Med Tech when he/she is available. S2 stated he/she can handle it and there is no impact for the leaving of the two directors. LPA interviewed the Health Service Specialist from Corporate (S3). S3 stated he/she comes to help the facility. S3 stated his/her job is to make sure residents receive good care and to audit the facility. LPA interviewed another 3 staff. 3 Out of 3 staff stated there is no impact for the leaving of the 2 directors. LPA interviewed 8 residents. 8 Out of 8 residents stated they do not have complaint against the facility. 2 Out 8 residents stated they there is no impact for the leaving of the 2 directors. 6 Out of 8 residents stated they don't know if any of the facility director left. Based on the interview, no evidence to indicate the facility has impact to provide care and supervision to residents due to 2 directors left the facility. Based on investigation, interviews conducted and records reviewed , the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM. Page 3 of 3.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 26-AS-20240522084737

Allegation investigated: Facility is not following COVID protocols. Staff are not answering residents call buttons timely. Residents are not getting medications timely.

On 11/09/2024 at 1:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Community Relation Assistant Jennifer Gleitsmann and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 107. A brief interview with conducted with 107. Allegation were made that the facility is not following COVID-19 protocols. The investigation included a review of records and interviews with residents and staff. The facility’s Mitigation Plan, dated January 14, 2021, was reviewed and is within CDC guidelines. LPA Lee interviewed all 7 residents, none of whom expressed concerns about the facility's adherence to COVID-19 protocols. Residents confirmed that those who test positive are required to quarantine in their rooms. Additionally, LPA Lee interviewed all 3 facility staff members, who stated that the facility follows CDC guidelines and denied the allegations. Continuded LIC 9099-C Unsubstantiated Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that the facility is not following COVID-19 protocols. Allegation were made that staff are not answering residents' call buttons in a timely manner. The investigation included a review of records and interviews with residents and staff. The records indicated that response times vary by situation, averaging between 22 seconds and 57 minutes after the call buttons are pressed. LPA Lee interviewed 6 out of 7 residents, none of whom expressed concerns about the timeliness of staff responses. Residents noted that staff make good efforts to answer calls promptly. Additionally, it was learned that care staff sometimes forget to clear the resident’s call pendant while attending to other needs. LPA Lee interviewed all 3 facility staff members, who denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that staff are not answering resident’s call buttons in a timely manner. Allegation were made that residents are not receiving their medications in a timely manner. The investigation included a review of records and interviews with residents and staff. LPA Lee reviewed the facility's eMAR Summary for August 2024, September 2024, and October 2024, which was complete. Additionally, LPA reviewed medications of 7 residents along with their corresponding eMARs and found no discrepancies. LPA Lee interviewed all 7 residents, none of whom expressed concerns about receiving their medications late. Furthermore, all 3 facility staff members denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that residents are not receiving their medications in a timely manner. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. According to R1’s care plan, R1 is scheduled to receive one shower per week, every Wednesday. However, the records showed that R1 received: • August 2024: 2 showers • September 2024: 2 showers • October 2024: 1 shower This is below the required four showers per month as outlined in R1’s care plan. LPA Lee interviewed 6 out of 7 residents, all of whom stated they are receiving showers on time. Administrator Candi Bolin clarified that if no staff initials are recorded on a task log, it indicates that the assigned caregiver did not initials and it is unclear if R1 received showers; however, the Task logs indicated that R1 only received 1 to 2 shower for the month of August to October 2024. As a result, it was determined the facility was not meeting residents' hygiene needs. However, no additional notes were found to explain the lack of staff initials for R1’s showers; therefore, LPA Lee was able to corroborate the allegation that resident are not receiving showers in a timely manner. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20220118113048

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 16, 2024

Basic Services 87464(f)(1): Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on interviews, and file review, the licensee did not ensure R1 was received showers. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Nov 9, 2024

Plan of correction: Licensee agrees to conduct staff training on basic services by plan of correction (POC) date 11/16/2024. Licensee agrees to email training documents and staff sign in sheets to LPA Lee on POC date 11/16/2024 end of day 5:00 PM.

Allegation investigated: Facility staff is neglecting to assist residents during falls. Facility is not quarantining COVID-19 positive residents.

On 11/09/2024 at 10:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee met with Community Relation Assistant Jennifer Gleitsmann and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 107. A brief interview with conducted with Jennifer Gleitsmann. Allegation were made that facility staff is neglecting to assist residents during falls. The investigation involved a review of records and interviews with residents and staff. LPA Lee reviewed the facility’s operational plan and confirmed that a fall prevention plan is in place. Interviews were conducted with all 7 residents, who expressed no concerns regarding staff neglecting to assist residents during falls. Residents also reported witnessing staff assisting another resident who had fallen. Additionally, LPA Lee interviewed all 3 staff members, each of whom denied the allegations. Based on statements obtained during the investigation process, LPA was unable to corroborate the allegation that facility staff is neglecting to assist residents during falls. Continued LIC 9099-C Unsubstantiated Allegation were made that the facility is not quarantining residents who test positive for COVID-19. The investigation included a review of records and interviews with residents and staff. The facility's Mitigation Plan, dated January 14, 2021, was also reviewed and is within the CDC guidelines. LPA Lee interviewed all 7 residents, none of whom expressed concerns about the facility's quarantine practices for COVID-19 positive residents. Residents indicated that those who test positive are required to quarantine in their rooms. Additionally, LPA Lee spoke with all 3 staff members, who confirmed that the facility adheres to CDC guidelines and denied the allegation. Based on the interviews and evidence collected during the investigation, LPA Lee was unable to corroborate the allegation that facility is not quarantining residents who test positive for COVID-19. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20220527131408

Allegation investigated: Staff are not allowing medical professional to treat residents without a 24-hour covid test. Staff are not allowing visits by family members without a 24-hour covid test. Staff is not assisting resident with incontinence in a timely manner. Staff is not feeding the resident his meals. Staff is not responding to call lights in a timely manner.

On 11/09/2024 at 12:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Community Relation Assistant Jennifer Gleitsmann and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 107. A brief interview with conducted Jennifer Gleitsman. Allegations were made that staff are not allowing medical professionals to treat residents without a 24-hour COVID test and staff are not allowing visits by family members without a 24-hour covid test. The investigation included a review of records and interviews with residents and staff. The facility's Mitigation Plan, dated January 14, 2021, was reviewed and was within CDC guidelines. LPA Lee interviewed all 7 residents, none of whom expressed concerns regarding the allegations. Additionally, LPA Lee spoke with all 3 facility staff members, who stated that the facility adheres to CDC guidelines and denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegations. Continued LIC 9099-C Unsubstantiated Allegation were made that staff are not assisting residents with incontinence care in a timely manner. The investigation included observations, a review of records and interviews with residents and staff. On 10/12/2024, LPA Lee observed a caregiver assisting a resident with incontinence care the resident stated no concerns. LPA Lee reviewed three residents Task Logs, which included incontinence care for the month of August 2024, September 2024 and October 2024 and it was complete. It was also learned that each resident has an individual schedule but are usually checked and changed two to three times per shift. LPA Lee interviewed all 7 residents, none of whom expressed concerns regarding staff assistance for incontinence. Furthermore, resident 1 (R1) had no concerns with staff not assisting R1 with incontinence needs in a timely manner. Additionally, all 3 facility staff members denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that staff are not assisting residents with incontinence care in a timely manner. Allegation were made that staff are not providing meals to residents. The investigation included observations, interviews with residents and staff. Based on observation on 10/13/2024, LPAs Lee and Pascua observed a caregiver bring lunch to residents in his/her room. It was also learned that for those residents that can’t go to the dining room for meals the facility staff will make a room service order and deliver the meals to the residents. LPA Lee interviewed all 7 residents, none of whom expressed concerns about staff failing to provide meals. Additionally, all 3 facility staff members denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegations that staff are not providing meals to residents. Allegation were made that staff are not responding to call lights in a timely manner. The investigation included a review of records and interviews with residents and staff. The records showed that response times vary by situation, with an average response ranging from 22 seconds to 57 minutes after the call buttons are pushed. Additionally, the E-Call system log indicated that R1’s calls were responded to within 22 seconds to 30 minutes. LPA Lee interviewed 6 out of 7 residents, none of whom expressed concerns about the timeliness of staff responses to call lights. Residents noted that staff makes a good effort to answer calls promptly. It was also learned that sometimes care staff forget to clear the resident’s call pendant while attending to their needs. LPA Lee interviewed all 3 facility staff members, who denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that staff are not responding to call lights in a timely manner. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20220120113339

Allegation investigated: Staff do not provide proper assistance to residents in care.

On 11/09/2024 at 10:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Community Relation Assistant Jennifer Gleitsmann and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 107. A brief interview with conducted with 107. Allegation were made that staff do not provide proper assistance to residents in care. The investigation included a review of records and interviews with residents and staff. The records revealed that the facility organizes walks, field trips and outings for residents. According to R1's LIC 602 Physician’s Report, R1 is unable to leave the facility unassisted. However, it was noted that R1’s son visits regularly to take R1 for walks and to the community library. LPA Lee interviewed all 7 residents, none of whom expressed concerns about staff not providing proper assistance. Continued LIC 9099-C Unsubstantiated Although LPA Lee was unable to interview R1, 3 staff members were interviewed and denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that staff do not provide proper assistance to residents in care. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20221229105947

Allegation investigated: Staff are not safeguarding resident’s personal property. Staff are not preventing resident from being a victim of financial abuse by an unknown perpetrator.

On 11/09/2024, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee met with Community Relation Assistant Jennifer Gleitsmann and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 107. A brief interview with conducted with Jennifer Gleitsmann. Allegations were made that staff are not safeguarding residents' personal property and are not preventing residents from being victims of financial abuse by an unknown perpetrator. The investigation involved a review of records and interviews with residents and staff. The records indicated that resident 1 (R1) and R2 do not have an LIC 621 document for resident personal property and valuables, as both residents chose to waive the documentation of their belongings. LPA Lee interviewed 7 out of 7 residents, all of whom expressed no concerns regarding staff not safeguarding personal property and staff not preventing residents from being victims of financial abuse by an unknown perpetrator. Continued LIC 9099-C Unsubstantiated Furthermore, R2 also stated that no one is financially abusing R2. All 7 residents also stated that they all have their own keys to their apartment and are responsible to lock their own apartment when leaving their room. LPA Lee also interviewed all 3 facility staff members, who denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20230224090352

Allegation investigated: Staff do not ensure that resident is administered their medication(s) as prescribed. Staff do not respond to resident(s) requests for assistance in a timely manner.

On 9/11/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced investigation visit to deliver the investigation findings. LPA met with General Manager (GM) Candi Bolin and explained the purpose of the visit. On 11/14/2023, the Department received a complaint with the above allegations. On 11/20/2023, the Department conducted an initial investigation visit. LPA interviewed the Health Service Director, Resident Care Director, Facility Nurse, 4 staff, a resident and a resident's family. LPA requested resident's physician report, appraisal needs and service plan, physician orders, and medication administration records. On 2/16/2024, the Department conducted an investigation visit. 4 staff and 5 residents were interviewed. LPA requested call button log, POA in health and financial documents, resident medications document, medications training log, communication logs, Medication Administrations Records (MAR), resident physician reports, email communications, and resident vital sign chart document. page 1 of 5 Substantiated Staff do not ensure that resident is administered their medication(s) as prescribed: The facility was alleged that the facility staff delivered the wrong insulin to resident R1 for the bedtime medications on 11/09/2023, around 8:00PM. From 11/19/2023 to 3/8/2024, the Department conducted investigation including interviews with residents and staff, records reviewed and touring of the facility. On 11/19/2023 and 11/2023, LPA interviewed resident R1’s family member (FM). FM stated he/she received a phone call from R1 on 11/09/2023 at 9:00PM that the facility staff delivered the wrong insulin to R1 and R1 was waiting for the correct insulin to be delivered to R1’s bedroom. On 11/20/2023, LPA interviewed resident R1. R1 stated on 11/09/2023 evening, the facility staff delivered the insulin for meals to him/her, and he/she told the staff that it should be a long-acting insulin for the bedtime medications. R1 stated he/she waited for long time and the staff brought back the correct long-acting insulin for his/her bedtime medications, then he/she injected the insulin by self. On 11/20/2023 and 11/25/2023, LPA interviewed 8 staff. 2 staff (S1, S2) stated there was an incident that the wrong insulin was delivered to R1 for the bedtime medications on 11/09/2023 evening around 8:00PM. On 2/16/2024, LPA interviewed 4 staff. 2 staff (S3, S4) stated the facility staff delivered incorrect insulin to resident R1 on 11/09/2023 evening. On 2/25/2024, LPA interviewed staff S1. S1 stated he/she delivered the same insulin as R1’s insulin for dinners (the fast-acting insulin) to R1 on 11/09/2023 around 8:00PM and R1 found the insulin was wrong. S1 stated he/she changed the wrong insulin to the long-acting insulin and delivered to R1 later, and R1 injected the long-acting insulin for the bedtime medications. Reviewing R1's doctor prescription dated 10/19/2023 which specifies fast-acting insulin to administer to R1 15 minutes before breakfast, lunch, and dinner, and long-acting insulin to administer to R1 at bedtime. page 2 of 4 Based also records review of R1s progress notes, there were instances where the wrong insulin was given to R1 for administration. Said dates are 1/1/2024 & 1/3/2024. Based on a review of R1's doctor orders and interviews, the facility staff delivered the wrong insulin to R1 on 11/9/2023 evening. Facility staff did not ensure to deliver resident's medications as prescribed. Staff do not respond to resident(s) requests for assistance in a timely manner: The facility is alleged that the facility staff delivered the wrong insulin to resident R1 on 11/09/2023 around 8:00PM for R1’s bedtime medications and R1 found the insulin was wrong. R1 told the staff that the bedtime insulin was wrong, and the staff stated he/she would bring the correct insulin back later. But R1 was waiting for more than one hour to get the correct insulin on 11/9/2023 between 9:00Pm – 9:30PM. On 11/19/2023 and 11/20/2023, LPA interviewed resident R1’s family member (FM1). FM1 stated R1’s scheduled insulin bedtime medication time is 7:30PM. FM1 stated on 11/09/2023, the facility staff delivered the wrong fast-acting insulin to R1 for the bedtime medications and R1 found the insulin was wrong. FM1 stated R1 called the front desk more than one time that R1 was waiting for the correct insulin to deliver to him/her. FM1 stated he/she called the facility on 11/9/2023 at 9:00PM that R1 was waiting for the correct insulin. FM1 stated the facility delivered the correct long-acting insulin by 9:30PM. On 11/20/2023, LPA interviewed R1. R1 stated his/her scheduled insulin for bedtime medications is 7:30PM. R1 stated on 11/9/2023, he/she found the staff delivered the wrong insulin for his/her bedtime medications, and the staff stated he/she will double check and bring the correct insulin. R1 stated he/she waited for long time and called the facility two times that he was waiting for the correct insulin. On 11/24/2023, LPA interviewed staff S1. S1 stated on 11/09/2023 at 8:00PM, he/she delivered the fast-acting insulin to R1 for R1’s bedtime medications. S1 stated after he/she finished delivering medications to other residents, he/she delivered the correct long-acting insulin to R1 around 8:45PM on 11/9/2023 for R1’s bedtime medications. page 3 of 4 On 2/16/2024, LPA interviewed staff S4. S4 stated on 11/09/2023 between 8:30PM - 9:00PM, he/she received a phone call from R1 that R1 was waiting for the correct insulin. S2 stated he/she received a phone call from R1's family member around 9:00PM on 11/9/2023 that R1 was waiting for the correct insulin, and between 9:00PM - 9:30PM, he/she received another phone call from R1 that he/she was waiting for the correct insulin. On 2/25/2024, LPA interviewed staff S1 regarding the time he/she returned to R1's bedroom and administration of the correct insulin for bedtime. S1 stated he/she was unable to remember the exact time because it was long time ago. S1 stated on 11/09/2023 roughly between 8:30PM to 9:30PM that he/she delivered the long-acting insulin to R1 and R1 injected self. Reviewing R1's doctor order dated 10/19/2023, which specifies long-acting insulin to administer to R1 at bedtime. But it did not specify the exact time to administer the insulin for bedtime. R1’s physician order dated 11/20/2023 which specifies starting on 10/22/2023 to administer long-acting insulin for R1’s bedtime medications at 8:00PM. Based on the records reviewed and interviews, from R1’s the first oral request for the correct insulin and through several calls from R1 and R1’s family, it took more than one hour for the facility to deliver the correct long-acting insulin to R1 on 11/09/2023 evening which did not meet R1’s health needs. The Department has investigated the above allegations. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview was conducted with GM. This report and LIC9099-D were provided to GM for signature. A copy of the report and appeal rights was provided to GM. page 4 of 4 Staff do not respond to resident's request(s) for communication in a timely manner: The facility is alleged that the facility staff did not respond to the email sent by resident R1’s family member (FM1) for R1 to request a meeting with appropriate health service staff in a timely manner. A review of the email communication between Resident Care Director (RCD) and FM1 between 11/09/2023 and 11/14/2023. The email was sent out by FM1 to the facility Resident Care Director, Health Service Director (HSD) and the facility Nurse on 11/09/2023 Thursday at 10:40PM to request a meeting with the facility health service staff and to have FM1 present in the meeting. On 11/12/2023, Sunday, at 3:49PM RCD replied to FM1’s email that he/she already met with R1 one on one on 11/12/2023 and replied and explained to FM1 about FM1’s concerns in the email. The email RCD also reveals RCD’s conversations/advice/recommendations with R1. On 11/13/2023 at 1:51PM FM1 replied to RCD’s email with the questions why RCD had an unscheduled meeting with R1 without FM1 and ignored R1’s requesting a meeting and to have FM1 present. On 11/14/2023, at 9:30AM, RCD replied to FM1 via email that RCD called FM1 and had a conversation on 11/14/2023 at 9:25AM that RCD would like to set up a in person meeting with R1 and FM1 but without success. RCD provided his/her phone number for FM1 to contact RCD when FM1 ready to have a meeting. On 11/20/2023, LPA interviewed HSD, RCD and facility Nurse. RCD’s working hours is Sunday 9:00AM – 6:00PM to Thursday 9:00AM – 6:00PM. The working hours of HSD and the facility Nurse are Monday 9:00AM – 5:00PM to Friday. RCD stated the first day he/she came back to the office, 11/12/2023 around 1:10PM, he/she met with R1 because R1 complained received insulin late. RCD stated he/she and FM1 had email communication on 11/12/2023 and 1/13/2023. RCD stated on 11/114/2023 at 9:25AM he/she called FM1 and had a conversation to set up a meeting but without success. RCD stated he/she sent email to FM1 on 11/14/2023 at 9:30AM and leaving his/her phone number for FM1 to call to set up a meeting. But did not get any response from FM1. page 2 of 4 On 2/16/2024, LPA interviewed the general manager (GM). GM stated the facility had R1’s evaluation meeting with FM1’s signature on 12/29/2023. Based on the records reviewed and interviews, the facility staff did not follow up resident R1's request for a meeting and the facility had a care plan meeting with R1 and R1's representative one month after R1's requesting meeting with the facility staff, but R1 already spoke to RCD in person on 11/12/2023. Staff do not ensure that resident's representative is able to participate in decision making regarding the care and services to be provided to the resident while in care: The facility is alleged that the facility staff did not notify resident R1’s representative to present in R1’s care plan/service meeting on 11/12/2023. On 11/20/2023, LPA interviewed Resident Care Director (RCD). RCD stated on 11/14/2023, at 1:10PM, he/she happened to see R1 at the front desk complaining about he/she did not get insulin at 12:15PM. RCD stated he/she explained to R1 that staff might sometimes arrive late, like around 12:30PM, because there are some instances that other residents might cause staff delays. RCD also provide some advice and recommendation to R1 that R1 should reduce the consummation of sweet snacks because his/her blood sugar fluctuates. RCD stated R1’s care plan/service plan did not change, and the conversion and advice were emailed to FM1 around two hours later. RCD stated during the conversation with R1, R1 did not ask FM1 to present. On 2/16/2024, LPA interviewed Health Service Director (HSD). HSD stated the facility always notifies resident representatives to attend resident’s care conference meeting. HSD stated if there is a time conflict for resident representatives, then the facility will reschedule the meeting. LPA interviewed general manager (GM). GM stated the facility always invite resident representative to join the care conference meeting. GM provided evidence of R1's care plan/service plan meeting with R1's family member FM's signature on 12/29/2023. page 3 of 4 A review of R1’s progressive notes, on 11/12/2023, RCD met with resident R1 because R1 complained about did not getting insulin at 12:15PM. RCD replied to R1’s complaint and provided the explanation and provided some education and recommendation. There was no change in the care plan/service plan. Based on the interviews and records reviewed, there was no change in R1's care plan/service plan on 11/12/2023. There was no any decision was made regrading R1's care plan/service plan when the facility met with R1 on 11/12/2023. R1 did not ask FM1 to present when the facility staff met with R1 on 11/12/2023 afternoon. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No citations noted. Exit interview conducted with GM. The report was provided to GM for signature. A copy of this report was provided to GM. page 4 of 4the state’s words, verbatim · CDSS document, Sep 11, 2024 · control 26-AS-20231114122603

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 18, 2024

87411 - Personnel Requirements - (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews and records reviewed, staff S1 was not competent or lacked training to deliver/administer correct insulin to residents based on doctor's prescription. This poses health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: Licensee has already submitted POC to LPA regarding in-service training about insulin and medication management.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 18, 2024

87468.2 Additional Personal Rights of Residents...(a) In addition to the rights ... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on the interviews and records reviewed, the facility staff took longer than one hour to administer the correct insulin to R1.The facility does not have sufficient staff or staff lack training to provide care to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: Licensee has already submitted POC to LPA regarding in-service training about insulin and medication management.

Allegation investigated: Staff neglect resulted in the death of a resident in care. Staff are not following medication orders. Facility is not safeguaring resident's personal belongings. Facility is not maintaining a comfortable temperature for residents in care.

On 9/11/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced investigation visit to deliver the investigation findings. LPA met with Executive Director Candi Bolin and explained the purpose of the visit. Regarding the allegation of staff neglect resulted in the death of a resident in care, reporting party (RP) stated that R1 died on May 28, 2023 after getting a UTI in April. Staff does not encourage them to drink water and the rooms are too hot. R1 was left unattended on May 19, 2023, left in chair with feet on the floor in clothes with dentures all night long. R1 was only a level one care at when R1 entered because R1 was independent had all his/her wits and used a walker and administered own medications and dressed himself/herself. After the UTI R1 couldn't do those things never bounced back very well so we increased R1s level of care. However, they did not provide the level of care that was assigned as neglecting R1 that evening. page 1 of 3 Unsubstantiated According to the same statement that RP provided, the facility did make a note about the occurrence on May 19, 2023, when they found R1 that way. They have banned the resident assistant that was supposed to help R1 that night. Based on records review, the facility provided the LPA with Progress Notes. In these progress notes, the facility was already observing R1’s changes in conditions. A new assessment was done on April 27, 2023. In this assessment, it was noted that R1 is at risk for injury which may cause permanent disability or be life threatening. The following interventions/practices are recommended to enhance the safety of your family member. Reminders to use call system for needed assistance. Also in these progress notes from April 2023 – May 2023, it is noted in several entries that R1 has been eating less and less and has been experiencing pain and was being monitored continuously. R1 was entered into hospice on May 24, 2023. Regarding the allegation of Staff are not following medication orders, RP observed two of the medication technicians did not follow the orders. One staff member (S1) brought a 5 mg Valium and called it a hydrochlorothiazide. Another medication technician (S2) brought a whole Vicodin when the orders were to crush it into applesauce, but S2 brought the entire pill. Based on records review in the progress notes, on 05/23/2023 9:48AM (Late Entry) states that R1s family member (F1) gave R1 a Vicodin medication and is not on R1s med list. R1s MD was faxed, and a staff member (S3) is aware and R1 will be monitored for any allergic reactions or behavior changes. LPA was also able to obtain this report. Regarding the allegation that Facility is not safeguarding resident's personal belongings, RP stated that there is also a thief there that stole from R1 in December when R1 first moved in, a very valuable diamond ring and then on R1s deathbed, gold chain with charms. LPA spoke to the Executive Director (ED), and it was stated that the facility did an internal investigation and did not find any proof that a staff stole the valuables. page 2 of 3 Regarding the allegation of Facility is not maintaining a comfortable temperature for residents in care, RP stated that they had to ask facility to put an air conditioner in and it took weeks even though RP offered to buy it. R1s room was 90° on Easter even though the thermostat was set on 50°. During the interview, ED mentioned that the facility has not reached that temperature. While the rooms don’t have air conditioning system, the facility does have portable aircons which they can provide to residents if requested. According to RP, although it took quite some time, the facility did provide air-conditioning in the room. Based on interviews & records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 3 of 3the state’s words, verbatim · CDSS document, Sep 11, 2024 · control 26-AS-20230619142154

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff S1, Hilda Bejar. During the visit, S1 stated there are 88 residents in Assisted Living and 6 residents in Memory Care. Staff S1 stated facility Administrator is on vacation. LPA toured the facility inside out with staff S1, which included the 1st-4th floor, including the basement, which is being used as memory care. LPA and S1 also toured the kitchen, dining room, activity room, restrooms and residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 114 degrees F in resident bathrooms. Fire extinguisher was serviced in September 6, 2023. The facility was equipped with smoke and carbon monoxide detectors. Sprinkler system last maintenance was on June 27, 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 5/18/2024. LPA reviewed facility records for 3 staff and 4 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed resident R1's medications, while cross referencing the Centrally Stored Medication Log, LPA observed the medication start date for medications M1-M7 was not listed in the centrally stored medication log. LPA reviewed resident R2's medications, while cross referencing the centrally stored medication log. LPA observed the medication start date for medications M1-M4 was not listed in the Centrally Stored Medication Log. Page 1 Out of 2. LPA conducted interviews with 3 staff and 3 residents. While reviewing resident R3’s file, LPA observed a physician fax communication. The form stated R3 had a fall, June 1st, 2024, and was sent out to the emergency room. Staff S1 showed LPA incident tracking log on his/her computer. The log stated the responsible party was contacted, R3's physicians was contacted, and a text was sent to the ADM. Under the section, "Reported to State", the website states no. (Photographs were taken.) Staff S1 contacted facility ADM via phone call, (at 1:30pm), and ADM stated he/she did send an incident report. ADM stated a fax confirmation is in her office. ADM stated she will try to get someone to find the fax confirmation received form. LPA was not given documentation that the incident report was sent to CCL by the end of the annual inspection visit. While touring the facility, LPA observed resident R2's bedroom has quarter sized bed rail. While reviewing R2's records, LPA did not find a doctors order for the bed rails. Staff S2 stated he/she has been working on it with the doctor. Staff S2 reviewed R2's file to find the doctors order but could not provide LPA with the doctors order. Staff S2 stated he/she would send LPA documentation for the bed rails. Deficiencies cited during today's visit. This report was reviewed with S2 Sharon Carollo. A copy of the signed report was provided. Appeal Rights were provided Page 2 Out of 2. END OF REPORTthe state’s words, verbatim · CDSS document, Jul 18, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - Incident visit and met with General Manger (GM) Candi Bolin and Health Services Director (HSD) Daris Duong. LPA addressed the purpose of today's visit to GM and HSD. On 10/06/2023, the Department received a notice from the facility that a resident (R1) left the facility without notice on 10/01/2023. R1 was brought back to the facility by the spouse on the same day. LPA interviewed 3 staff (HSD, S1, S2). LPA toured R1's bedroom with HSD, R1 was took out with R1's spouse at 9:30AM today. LPA reviewed documents with HSD. Deficiencies were noted today. LIC809-D was provided. Exit interview was conducted with GM and HSD. The reports were provided to GM and HSD for signature. A copy of the reports was provided to GM and HSD.the state’s words, verbatim · CDSS document, Oct 24, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 25, 2023

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced: Based on the interviews and documents reviewed, resident R1 left the facility without notice, and R1 was brought back to the facility after 6:00PM on the same day.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: General Manager stated the facility to submit a plan of correction on how to prevent future elopement to happen in the facility for all residents.