The Arcadian

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual inspection visit. LPA met with facility administrator, Hardie Lin. The purpose of today's visit was discussed. The facility has a capacity of 120 residents. The facility is licensed to serve elderly residents aged 60 and above, approved for 120 non-ambulatory residents of which 21 may be bedridden. The facility has five (5) Hospice Waiver on file. Annual licensing fees are current. Today’s census is 103. LPA Vaid utilized the Compliance and Regulatory Enforcement (CARE) tools for today’s visit. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an Infection Control Plan, Updated 01/15/2026. 2. Operational Requirement: Liability Insurance is updated and in the amount of at least ($1,000,000) peroccurrence and ($3,000,000) in total annual aggregate is in place, expires 12/30/2026. 3. Physical Plant and Environmental Safety: The facility is located in a commercial area. It is a two-story building with 60 resident rooms. Facility consists of lobby/reception area, office, medication room, activity room, TV/entertainment room, beauty parlor, employee break room with lockers and time clock, laundry room, kitchen, and dining room. Residents' medications are centrally stored and locked in the medication room, inaccessible to residents in care. LPA Vaid inspected ten (10) residents’ rooms. Resident bedrooms have the following furniture; bed, chair, dresser, lighting fixture and personal storage space as required. Mattress pads were observed on all beds. Bathrooms inspected were clean, operable, and furnished with the required grab bars and skid proof materials in the shower. Hot water temperature was in a range of 106.8-117.6 degrees Fahrenheit which is within Title 22 Regulation guidelines. (Continue on 809C) All the cleaning supplies and chemicals are stored and locked in a cabinet in the laundry room area. Linen and towels are stored in housekeeping closets. Extra personal hygiene products are stored in the locked closet upstairs. The carbon monoxide detectors were inspected, and they are working properly. The facility has tables and chairs for residents to utilize outdoor activity. The Passageway, walkway and patio are free of obstruction. 4. Staffing: The facility has sufficient staff, and the night supervision staff have current CPR/first aid certification. 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. All the direct care staff have ongoing Medication Management and other required Training. However, training certificates are current. 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission agreements, Identification & emergency information, pre-admission appraisal/appraisal needs & services plan. 7. Resident Rights-Information: The Complaint, Ombudsman and CCLD poster and residents’ personal rights are posted by the main entry and upstairs next to elevators. Visiting hours are included in admission agreement. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be very clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Special diets and mechanical diets are prepared daily. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. 10. Incidental Medical and Dental: The medication is centrally stored and locked in the medication room behind the reception office. Seven (7)) centrally stored resident medications were reviewed, which contained 30-day supply of medications. 11. Disaster preparedness: Fire drills are conducted every quarter. 11/22/25, last drill conducted. The facility has an Emergency Disaster Plan (LIC610E). The facility has three alternative temporary shelter locations. 12. Resident with Special Health Needs: No resident is currently on postural support. Individual Service Plans and Appraisals are on file. No deficiencies were observed during today’s visit. An exit interview was held. A copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Apr 6, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vaid conducted an unannounced quarterly inspection visit. LPA met with Administrator Hardie Lin who assisted with the visit. The facility has a capacity of 120 residents. It is licensed to serve elderly residents age 60 and above, approved for 120 non-ambulatory residents of which 21 may be bedridden. The facility has five (5) Hospice Waiver for on file. LPA discussed the purpose of today's visit. During the visit today, LPA conducted a walkthrough of the facility with Administrator Lin. LPA inspected the common areas, kitchen, and seven (7) resident bedrooms. LPA inspected Resident room # 119, 216, 228, 213, 231,238 and 201. Resident rooms have the required furnishing. Water temperatures measured within 105-120 deg F. Kitchen has sufficient food supplies of 2-day perishable and 7-day non-perishables. Cleaning supplies are locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers were fully charged, and the last service date was 06/23/2025. No health and safety concerns observed. An exit interview was held, and a copy of this report was given to Administrator Hardie Lin.the state’s words, verbatim · CDSS document, Mar 5, 2026

Allegation investigated: Staff did not prevent resident from developing pressure injuries Staff are not following reporting requirements

The purpose of today's visit 12/04/25 is to gather additional information regarding the allegation, Staff did not prevent resident from developing pressure injuries. Today 12/04/25 the following was done: Staff S1- Staff S2 were interviewed. Administrator was interviewed and Home Health Representative was interviewed telephonically. The initial visit was conducted on 09/30/25 and included the following: Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Hardie Lin and explained the reason for the visit. Shortly after Licensee Amber Branconier arrived. The investigation consisted of the following: LPA obtained copies of Resident and Staff rosters, reviewed Resident R11's file and collected Physician's Report, Admissions Agreement and Emergency ID page. conducted interviews with Licensee, Administrator, Staff S1 and Residents (R1-R10). . (Continued on LIC9099-C) Unsubstantiated Interviews were also conducted with the Home Health and Primary Care Physician for Resident R11. Interview also conducted with Power of Attorney (POA) for Resident R11. The investigation revealed the following: Allegation: Staff did not prevent resident from developing pressure injuries. Based on interviews conducted and information gathered the Home Health Representative stated that Resident R11 was being seen 3x a week Monday, Wednesday and Friday. Stated R11 was seen on 09/12/25, 09/15/25 and 09/17/25 by Home Health and went into the hospital on 09/19/25. Said that the wound on the coccyx was little measuring 0.5 height, 0.5 width and 0.2 depth. Stated that was the only open wound being treated and that there was not an open wound on the knee. Said staff were instructed on how to provide wound care and there have been no issues. Stated that the wound was healing pretty well. Interview with the POA for Resident R11 who stated that the wound for Resident R11 was not new and he did know about it. Stated Home Health has been providing care and that there is no wrong doing by the facility. Spoke with the Primary Care Physician for Resident R11 who stated that R11 was seen on 07/05/25 and didn't observe a pressure injury. Stated facility is doing a good job. Spoke with Resident's R1- R10 who all stated that staff are doing a great job providing assistance. Said their response time is quick and they call 911 immediately. R1 stated having a fall and staff acted right away and knew what to do. Also had a wound and saw Home Health and staff did a great job cleaning, drying and wrapping it. Staff S1 stated that with R11 they would always keep the skin clean. Said it was a little teeny small wound. Stated that Home Health trained them and they always wash with soap and water, put creme on and keep it dry. Staff S1, S2 and the Administrator stated that Home Health was taking care of the wound to the coccyx and didn't observe any other open wounds. All stated there was no wound on the knee. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Allegation: Staff are not following reporting requirements Based on interviews conducted and information gathered POA for Resident R11 stated that he knew of the wound and that it is the same old one. Also knew that R11 was being seen by the Home Health agency. Stated he doesn't feel that the facility has done anything wrong. Feels the facility has been providing good care and supervision. Interview with Licensee who stated that POA knew of the wound being that it was the same one that R11 has had. Also stated that POA always had known of Home Health assisting Resident R11 3x a week for wound care. Interview with Resident's R1- R10 who all stated that the facility will report everything to their designated representative. Also stated that facility report everything to their doctor and other agencies. It should be noted that Resident R11 is currently at skilled nursing as stated by POA for R11. It should be noted that the findings will remain Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Administrator and copies provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 28-AS-20250922160450

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vaid conducted an unannounced quarterly inspection visit. LPA met with Administrator Hardie Lin who assisted with the visit. The facility has a capacity of 120 residents. It is licensed to serve elderly residents age 60 and above, approved for 120 non-ambulatory residents of which 21 may be bedridden. The facility has five (5) Hospice Waiver for on file. Annual licensing fees are current. LPA discussed the purpose of today's visit. The facility is a two-story building with 60 resident rooms. Facility consists of Lobby/Reception Area, office, medication room, Activity Room, TV/Entertainment Room, Beauty Shop, Employee Room with lockers, laundry room, kitchen, and dining room. Medications were centrally stored. Medications room was locked and inaccessible to residents in care. Eight (8) residents’ medication records were reviewed. Hallways were clean and free of obstructions. Common areas were well organized and free of hazards. LPA inspected Resident room # 106, 110, 116, 209, 220, 229, 230 237 and 233. Resident bedrooms had furniture, lighting fixtures and personal storage space as required, mattress pads observed on all beds, the required amount of linen also observed. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 105-120 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. Signal systems were tested in resident rooms, the system was operable, and staff responded to resident rooms within 6(six) minutes. Last Fire Drill was conducted on 10/06/2025. Administrator certificate is current with expiration date on 5/30/2026. CONTINUED ON 809C.......... Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean,cutlery and utensils for residents use. Residents are served meals in accordance to their dietary requirements. A comfortable temperature of 74 degrees Fahrenheit maintained throughout the entire facility. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged, and the last service date was 06/23/2025. Audio devices were tested and are operable. First aid kits were fully stocked with manual. All mandated documents and signages are posted in common areas. Side and front yards are well maintained and free of debris. There is shaded outdoor area with ample seating. No bodies of water observed. An exit interview was conducted. This report was discussed , signed and provided to the administrator.the state’s words, verbatim · CDSS document, Oct 14, 2025

Allegation investigated: Staff did not prevent resident from developing pressure injuries Staff are not following reporting requirements

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Hardie Lin and explained the reason for the visit. Shortly after Licensee Amber Branconier arrived. The investigation consisted of the following: LPA obtained copies of Resident and Staff rosters, reviewed Resident R11's file and collected Physician's Report, Admissions Agreement and Emergency ID page. conducted interviews with Licensee, Administrator, Staff S1 and Residents (R1-R10). Interviews were also conducted with the Home Health and Primary Care Physician for Resident R11. Interview also conducted with Power of Attorney (POA) for Resident R11. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not prevent resident from developing pressure injuries. Based on interviews conducted and information gathered the Home Health Representative stated that Resident R11 was being seen 3x a week Monday, Wednesday and Friday. Stated R11 was seen by Home Health 09/17/25 and went into the hospital on 09/19/25. Said that the wound was little measuring 0.5 height, 0.5 width and 0.2 depth. Said staff were instructed on how to provide wound care and there have been no issues. Stated that the wound was healing pretty well. Interview with the POA for Resident R11 who stated that the wound for Resident R11 was not new and he did know about it. Stated Home Health has been providing care and that there is no wrong doing by the facility. Spoke with the Primary Care Physician for Resident R11 who stated that R11 was seen on 07/05/25 and didn't observe a pressure injury. Stated facility is doing a good job. Spoke with Resident's R1- R10 who all stated that staff are doing a great job providing assistance. Said their response time is quick and they call 911 immediately. R1 stated having a fall and staff acted right away and knew what to do. Also had a wound and saw Home Health and staff did a great job cleaning, drying and wrapping it. Staff S1 stated that with R11 they would always keep the skin clean. Said it was a little teeny small wound. Stated that Home Health trained them and they always wash with soap and water, put creme on and keep it dry. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Allegation: Staff are not following reporting requirements Based on interviews conducted and information gathered POA for Resident R11 stated that he knew of the wound and that it is the same old one. Also knew that R11 was being seen by the Home Health agency. Stated he doesn't feel that the facility has done anything wrong. Feels the facility has been providing good care and supervision. Interview with Licensee who stated that POA knew of the wound being that it was the same one that R11 has had. Also stated that POA always had known of Home Health assisting Resident R11 3x a week for wound care. Interview with Resident's R1- R10 who all stated that the facility will report everything to their designated representative. Also stated that facility report everything to their doctor and other agencies. It should be noted that Resident R11 is currently at skilled nursing as stated by POA for R11. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 28-AS-20250922160450

Allegation investigated: Due to staff neglect, resident sustained a serious injury.

***This report supersedes the report dated 5/12/25 to correct the citation issued. The finding of the allegation did not change and remains substantiated. Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the complaint investigation. LPA met with administrator, Hardie Lin, and explained the purpose of the visit. On 1/23/25, LPA J. Villalobos conducted a health and safety visit and toured the physical plant. LPA did not observe any path obstructions or health and safety hazards in areas toured. Sufficient food supply was observed, and all toxins and sharps were observed to be stored and inaccessible to residents in care. No immediate health and/or safety concerns were noted during the visit. Documents were collected for Resident #1 and a staff was interviewed. During today’s visit, LPA Chan interviewed the administrator, 5 staff, and 8 residents. Substantiated Allegation – Due to staff neglect, resident sustained a serious injury. It is alleged that a caregiver closed the bathroom door while Resident #1’s (R1) hand was in the doorway on 2/21/2024. R1 sustained a serious injury to the right middle finger, resulting in part of the finger getting amputated. LPA interviewed the administrator, who acknowledged that the incident occurred at the facility. Administrator Lin stated that Staff #1 accidentally closed the bathroom door while the resident’s hand was placed on the edge of the door. Staff did not see the hand and closed it, causing injury to the finger. The administrator stated that all the care staff were provided a training immediately after the incident to prevent another accident from occurring. LPA Chan interviewed staff members who indicated that they are careful when handling residents. They ensure that their hands and feet are positioned so that they cannot be injured. Staff stated they try their best to make sure residents are safe. Staff #1 (S1) was interviewed and stated that the incident was accidental and did not see R1’s hand at the door. LPA reviewed R1’s hospital record dated 2/22/2024, and it indicated that R1 was to proceed with surgery to partially amputate the 3rd digit of the right finger. LPA interviewed 8 residents today. All the residents stated that the staff had not caused injury to them. They think the staff are attentive and well trained. According to the information gathered, staff did not carefully check to make sure the resident’s hand was not in the doorway. Although the incident was accidental, R1 sustained a serious injury that required surgery and partial amputation of the finger. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM*** An exit interview was held. A copy of this report, LIC421IM, and appeal rights were given to licensee Amber Branconier.the state’s words, verbatim · CDSS document, May 30, 2025 · control 28-AS-20250117122939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: May 30, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,..(8) To be free from neglect, financial exploitation,... Based on interviews and record review, staff did not notice R1's hand on the door and closed it, resulting in resident getting partial amputation of the finger, which posed an immediately health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: The licensee shall provide training to all staff to ensure the safety of residents. The in-service log shall be submitted to LPA. A civil penalty of $500 is assessed today. **Plan of correction has been cleared.***

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit due to the Stipulation, Waiver, and Order in place. LPA arrived unannounced and met with Administrator, Hardie Lin. The purpose of the visit was explained. During the visit today, LPA conducted a walk through of the facility. LPA inspected the common areas, kitchen, and 10 resident bedrooms. There are sufficient food supplies of 2 day perishable and a week orf non-perishables. Cleaning supplies are locked and inaccessible to residents. Resident rooms have the required furnishing. No health and safety concerns observed. An exit interview was held and a copy of this report was given to licensee, Amber Branconier.the state’s words, verbatim · CDSS document, May 20, 2025

Allegation investigated: Due to staff neglect, resident sustained a serious injury.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the complaint investigation. LPA met with administrator, Hardie Lin, and explained the purpose of the visit. On 1/23/25, LPA J. Villalobos conducted a health and safety visit and toured the physical plant. LPA did not observe any path obstructions or health and safety hazards in areas toured. Sufficient food supply was observed, and all toxins and sharps were observed to be stored and inaccessible to residents in care. No immediate health and/or safety concerns were noted during the visit. Documents were collected for Resident #1 and a staff was interviewed. During today’s visit, LPA Chan interviewed the administrator, 5 staff, and 8 residents. (Continue on LIC9099C) Substantiated Allegation – Due to staff neglect, resident sustained a serious injury. It is alleged that a caregiver closed the bathroom door while Resident #1’s (R1) hand was in the doorway on 2/21/2024. R1 sustained a serious injury to the right middle finger, resulting in part of the finger getting amputated. LPA interviewed the administrator, who acknowledged that the incident occurred at the facility. Administrator Lin stated that Staff #1 accidentally closed the bathroom door while the resident’s hand was placed on the edge of the door. Staff did not see the hand and closed it, causing injury to the finger. The administrator stated that all the care staff were provided a training immediately after the incident to prevent another accident from occurring. LPA Chan interviewed staff members who indicated that they are careful when handling residents. They ensure that their hands and feet are positioned so that they cannot be injured. Staff stated they try their best to make sure residents are safe. Staff #1 (S1) was interviewed and stated that the incident was accidental and did not see R1’s hand at the door. LPA reviewed R1’s hospital record dated 2/22/2024, and it indicated that R1 was to proceed with surgery to partially amputate the 3rd digit of the right finger. LPA interviewed 8 residents today. All the residents stated that the staff had not caused injury to them. They think the staff are attentive and well trained. According to the information gathered, staff did not carefully check to make sure the resident’s hand was not in the doorway. Although the incident was accidental, R1 sustained a serious injury that required surgery and partial amputation of the finger. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM*** An exit interview was held. A copy of this report, LIC421IM, and appeal rights were given to licensee Amber Branconier.the state’s words, verbatim · CDSS document, May 12, 2025 · control 28-AS-20250117122939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 13, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by: Based on interviews and record review, staff did not notice R1's hand on the door and closed it, resulting in resident getting partial amputation of the finger, which posed an immediately health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: The licensee shall provide training to all staff to ensure the safety of residents. The in-service log shall be submitted to LPA by 5/13/25. A civil penalty of $500 is assessed today.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual inspection visit. LPA met with facility director, Hardie Lin and Licensee, Amber Branconier arrived a short time later. The purpose of today's visit was discussed. The facility has a capacity of 120 residents. It is licensed to serve elderly residents aged 60 and above, approved for 120 non-ambulatory residents of which 21 may be bedridden. The facility has five (5) Hospice Waiver on file. Annual licensing fees are current. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirement: Liability Insurance is updated and in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. 3. Physical Plant and Environmental Safety: The facility is located in a residential area. It is a two-story building with 60 resident rooms. Facility consists of Lobby/Reception Area, office, medication room, Activity Room, TV/Entertainment Room, Beauty Shop, Employee Room with lockers and time clock, laundry room, kitchen, and dining room. Residents' medications are centrally stored and locked in the medication room. LPA Lopez inspected ten (10) residents’ rooms. Resident bedrooms had most furniture, lighting fixture and personal storage space as required. Mattress pads were observed on all beds. Bathrooms inspected were clean, operable, and furnished with the required grab bars and some rooms were missing non-skid materials in the shower. Hot water temperature was in a range of 112.2 – 123.4 degrees Fahrenheit which is not within Title 22 Regulation guidelines. (Continue on 809C) All the cleaning supplies and chemicals are stored and locked in a cabinet in the laundry room area The linen and towels are stored in housekeeping closet The extra personal hygiene products are stored in the locked closet upstairs. The carbon monoxide detectors were inspected, and they are working properly. The facility has table and chairs for resident to utilize outdoor activity. The Passageway, walkway and patio are free of obstruction. 4. Staffing: The facility has sufficient staffing, and the night supervision staff have current CPR/first aid certification. 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. All the direct care staff did not have ongoing Medication Management and other required Training. However, training certificates were not in their files. 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Pre-admission appraisal/Appraisal Needs & Services Plan. 7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster and Residents personal rights are posted by the main entry. Visiting hours are included in admission agreement. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be very clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. 10. Incidental Medical and Dental: The medication is centrally stored and locked in the medication cabinet in the hallway. Five (5) centrally stored resident medications were reviewed, which contained 30-day supply of medications. One resident (R5) was out of one medication and had not been administer for at least 1 week. Disaster preparedness: The last fire drill was conducted on 03/27/2025. The facility has an Emergency Disaster Plan (LIC610E) that needs to be updated. The facility has three alternative temporary shelter locations. 12. Resident with Special Health Needs: 48 residents are receiving home health services. No resident is currently on postural support. Individual Service Plans and Appraisals are on file. Deficiencies observed during today’s visit. Technical Advisory provided. An exit interview was held. A copy of this report, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 8, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tao conducted an unannounced Case Management- Incident visit in response to resident#4 (R4) Incident Report, dated 09/09/24. The incident was regarding resident who jumped off the balcony. LPA explained the purpose of today's visit to Hardin Lin, Director, who assisted with this visit. During today's visit LPA toured the facility, interviewed staff/residents/responsible party, conducted physical plant and reviewed R4's file. The incident report stated R4 jumped off the the balcony from resident's room. Per interviews with staff, it revealed that the facility investigated this incident and the resident was not sober at the moment of the incident. Per interviews of residents, residents indicated staff did not neglect residents while in care. Per responsible party interview, R4 was not sober and thought resident could go to Mar for lunch after jumping off the balcony. Responsible party indicated that incident was resident's fault. Police came to investigate. (no report# was provided.) LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. LPA obtained copies of the following documents: · Staff / Resident roster · R4’s Identification/Emergency Contact Information (facesheet) · Unusual Incident Report · Physician Report No deficiencies were observed and cited during this visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Resident sustained a hematoma while in care. Staff did not provide adequate supervision.

***This report serves as an amendment and supersedes the original complaint investigation report created on 04/11/24. The purpose of this report is to re-issue citations. The finding remains as Substantiated. *** Today, Licensing Program Analyst (LPA) Bonnie Tao conducted a subsequent complaint visit to re-issue citations regarding the allegations listed above. LPA Tao met with Martha, manager and discussed the purpose of the visit. On 03/18/22, LPA Tao conducted the initial visit. During the visit, LPA obtained a copy of staff roster, resident roster, Resident #1 (R1) and Resident #8 (R8) facility file, facility house rules and R1’s incident reports relating to falls. LPA conducted a physical plant with Office manager and did not observe any signs of neglect, abuse or other immediate health and safety threats. (-continued in LIC 9099C-) Substantiated ***This report serves as an amendment and supersedes the original complaint investigation report created on 04/11/24. The purpose of this report is to re-issue citations. The finding remains as Substantiated. *** On 04/11/24 visit, LPAs Tao and Reyes continued the investigation, interviewed Administrator, staff, and residents, conducted a physical plant with staff#9 (S9), and delivered the complaint investigation findings. Regarding allegation: Resident sustained a hematoma while in care. It is alleged that a resident fell twice in the facility and was hospitalized for two days after the second fall. Upon return to the facility, a resident was placed in a seat belt for fall prevention; however, staff failed to secure the resident’s seat belt, resulting in a subsequent fall causing serious injury to the resident. The investigation consisted of the following. Per resident interviews, seven (7) out of seven (7) residents could not corroborate the allegation and revealed they were not aware of any resident sustain of hematoma. R1 was not interviewed due to R1’s medical condition. Per staff interviews, seven (7) out of nine (9) staff revealed that staff were aware R1 had fallen in the facility and two (2) of nine (9) staff denied knowledge that R1 fell in the facility. Eight (8) of nine (9) staff reported there was adequate care and supervision provided at the facility. One (1) of nine (9) staff reported staff left R1 alone and R1 sustained a fall. Review of incident report dated 08/24/21, indicated R1 fell in the facility and was taken to the hospital for medical treatment, and discharged to a Rehab for continued care. Review of 09/23/21 incident report, indicated R1 fell in the facility a second time and was sent to the hospital for medical treatment. The facility notified the department of R1 falls in a timely manner. On 08/24/21 around 11PM, R1 fell in the facility and was transferred to the hospital on 08/24/21 for medical treatment, R1 was discharge from the hospital on 08/25/21 and returned to the facility; however, R1 complained of pain and was sent back to the hospital on 08/25/21. R1 sustained a right shoulder fracture and subdural hematoma. On 08/31/21, R1 was transferred to a different hospital for rehabilitation. On 09/15/21, R1 returned to the facility. On 09/23/21, R1 sustained a subsequent fall in the facility while sitting in R1 wheelchair. R1 was transported to the hospital on 09/23/21 for medical treatment. R1 hospital records, dated 09/23/21, indicated R1 sustained an acute chronic bilateral subdural hematoma. (-continued in LIC 9099C-) ***This report serves as an amendment and supersedes the original complaint investigation report created on 04/11/24. The purpose of this report is to re-issue citations. The finding remains as Substantiated. *** Therefore, the investigation revealed the facility did not conduct a reappraisal of R1’s fall risk after R1 fell in the facility on 08/24/21; the facility did not update R1’s care plan for fall prevention; R1 sustained a fall on 08/24/21 resulting in injury and sustained a subsequent fall on 09/23/21, which resulted in R1 sustaining injury/aggravation to R1’s previous injuries. Regarding allegation: Staff did not provide adequate supervision. It is alleged that a resident fell three times in the facility. Resident was hospitalized after the second fall for two days and returned to the facility; however, due to staff not providing adequate supervision, the resident sustained a third fall. The investigation consisted of the following. Per resident interviews, seven (7) out of seven (7) residents could not corroborate the allegation and revealed they were not aware of any resident fall at the facility and residents stated staff treated them fine. R1 was not interviewed due to R1’s medical condition. As mentioned above, per staff interviews, seven (7) out of nine (9) staff revealed that staff were aware R1 had fallen in the facility and two (2) of nine (9) staff denied knowledge that R1 fell in the facility. Eight (8) of nine (9) staff reported there was adequate care and supervision provided at the facility. One (1) of nine (9) staff reported staff left R1 alone and R1 sustained a fall. Review of incident report dated 08/24/21, indicated R1 fell in the facility and was taken to the hospital for medical treatment, and discharged to a Rehab for continued care. Review of 09/23/21 incident report indicated R1 fell in the facility a second time and was sent to the hospital for medical treatment. The facility notified the department of R1 falls in a timely manner. The investigation revealed, on 08/24/21 around 11PM, R1 fell in the facility and was transferred to the hospital on 08/24/21 for medical treatment, R1 was discharge from the hospital on 08/25/21 and returned to the facility; however, R1 complained of pain and was sent back to the hospital on 08/25/21. R1 sustained a right shoulder fracture and subdural hematoma. On 08/31/21, R1 was transferred to different hospital for rehabilitation. On 09/15/21, R1 returned to the facility. On 09/23/21, R1 sustained a subsequent fall in the facility while sitting in R1 wheelchair. R1 was transported to the hospital on 09/23/21 for medical treatment, R1 hospital records dated 09/23/21, indicate, R1 sustained an acute chronic bilateral subdural hematoma. (-continued in LIC 9099C-) ***This report serves as an amendment and supersedes the original complaint investigation report created on 04/11/24. The purpose of this report is to re-issue citations. The finding remains as Substantiated. *** Therefore, the investigation revealed the facility did not provide adequate care and supervision to R1, resulting in R1 sustaining multiple falls on 08/24/21 and 09/23/21, both falls resulted in R1 sustaining injury. Additionally, the facility failed to conduct a reappraisal to R1’s fall risk after R1 fell in the facility on 08/24/21 and did not update R1 care plan for fall prevention. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, and Chapter 8), are being cited on the attached LIC 9099D. An immediate $500 civil penalty is being issued during today's visit due to the neglect/lack of care and supervision resulting in resident sustaining serious injuries. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). Exit interview conducted with Amber, Licensee. Appeal Rights were discussed, and a copy of Licensing Report and Appeal Rights were given during visit. ***This report serves as an amendment and supersedes the original complaint investigation report created on 04/11/24. The finding remains as unsubstantiated. *** On 04/11/24 visit, LPA Tao and Reyes continued the investigation, interviewed Administrator, staff, and residents, conducted a physical plant with staff#9 (S9), and delivered the complaint investigation findings. The investigation consisted of the following. Regarding allegation: Resident was restrained. It was alleged that resident was tied into a wheelchair. The investigation revealed of the following. Per resident interviews, seven (7) out of seven (7) residents could not corroborate the allegation and revealed they were not aware of any resident being tied to residents’ wheelchairs. R1 was not interviewed due to R1’s medical condition. Per staff interviews, all staff denied the allegation and revealed staff did not tie residents to their wheelchairs. Review record revealed the facility did not allow restraining residents in any form. Per LPAs’ observation, no residents were being tied to the wheelchairs when conducting the physical plant. Therefore, there’s not sufficient evidence showed resident was restrained at the facility. Regarding allegation: Licensee has been suspended by the franchise tax board. It was alleged that the franchise tax board suspended the Licensee. The investigation revealed of the following. Per record review, the Franchise Tax Board had received and confirmed the licensee had filed tax to the board for the last two years and current year. Therefore, the franchise tax board did not suspend the licensee. Although the allegation may have happened or is valid, there’s not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Amber, Licensee. A copy of Licensing Report was given during the visit.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 28-AS-20220317135152

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(1) · Plan of correction due date: Apr 29, 2024

(a)…reappraisals shall document changes in the resident's physical, medical,…condition… (1) A physical trauma... This requirement is not met as evidence by: Facility failed to provide Resident#1 (R1) with re-appraisal, failed to develop a care plan based on the resident’s specific needs and failed to address the resident’s fall risk after R1 sustained falls which poses an immediate Health, Safety, Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Licensee will review Title 22 Regulations, Section 87463 and submit a written plan to ensure staff would re- appraise residents upon re-admission, develop care plan detailing resident’s fall risk and document the changes of the residents’ physical and medical condition by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 1, 2024

(a)(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 is not met as evidence by: Facility staff failed to provide Resident#1 (R1) adequate care and supervision based on R1’s specific needs and failed to address R1’s fall risk after sustained falls which poses a Potential Health, Safety, Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Licensee will review Title 22 Regulations, Section 87468.2 and provide a written statement explaining how facility will deliver care to residents by staff that are sufficient in numbers, qualifications, and competency to meet residents’ needs. Besides, Licensee will provide in-service training educating staff regarding the care/supervision that necessary to meet residents’ needs by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1) · Plan of correction due date: May 1, 2024

(d) The administrator shall have the qualifications…(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidence by: Administrator failed to provide Resident#1 (R1) adequate care and supervision based on R1’s specific needs which poses a Potential Health, Safety, Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Licensee will review Title 22 Regulations, Section 87405. Licensee will provide a statement to ensure administrator would have the knowledge providing care and supervision appropriate to the residents by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Bonnie Tao and Tyler Reyes conducted an unannounced annual inspection visit. LPA met with facility director, Hardie Lin and Licensee, Amber Branconier. The purpose of today's visit was discussed. The facility has a capacity of 120 residents. It is licensed to serve elderly residents age 60 and above, approved for 120 non-ambulatory residents of which 21 may be bedridden. The facility has five (5) Hospice Waiver on file. Annual licensing fees are current. During the visit, the CARE tool was used, physical plant/facility tour was conducted, food supply was reviewed, staff/residents’ files were reviewed, and medications were reviewed. The facility is located at the residential area. The premise is a two-story building with 60 resident rooms. Facility consists of Lobby/Reception Area, office, medication room, Activity Room, TV/Entertainment Room, Beauty Shop, Employee Room with lockers and time clock, laundry room, kitchen, and dining room. Residents' medications are centrally stored and locked in the medication room. LPA Tao inspected twelve (12) residents’ rooms. Resident bedrooms had furniture, lighting fixture and personal storage space as required. Mattress pads were observed on all beds. Bathrooms inspected were clean, operable, and furnished with the required grab bars and non-skid materials in the shower. Hallways were clean and free of obstructions. Common areas were well organized and free of hazards. Hot water temperature was in a range of 109.8 to 113.7 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. Signal systems were tested in resident rooms and operational. Sufficient supplies of perishable and non-perishable foods were observed. Smoke detectors and carbon monoxide detectors were tested and operational. Fire extinguishers were fully charged. Auditory alarm devices at exits were working. Deficiencies were cited per California Code of Regulations, Title 22. See LIC 809D for details. An exit interview was conducted. This report and appeal rights were discussed and provided to facility Licensee, whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Apr 26, 2024

Allegation investigated: Staff Member handles resident in a rough manner. Staff did not treat resident with dignity and respect.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Hardie Lin and Manager Martha Garcia and explained the reason for the visit. Shortly after Licensee Amber Branconier arrived and also assisted with the visit. The investigation consisted of the following: LPA obtained copies of Resident and Staff rosters, colleted documentes pertaining to above allegation, reviewed the personnel file for Staff #1 (S1) and conducted interviews with 6 Staff (S1-S6) and 10 Residents (R1-R10). (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff Member handles resident in a rough manner. It is alleged that S1 handles R1 roughly during movements or care. LPA reviewed S1’s personnel file an S1 has all proper training documented that include assisting residents with transfers from bed to wheelchair and two person assists. There are no incident reports on file of injuries to residents due to rough handling by staff. LPA interviewed 6 staff and 6 out of 6 staff stated that denied the above allegation and stated that they have not observed S1 be rough with residents while providing care. LPA interviewed 10 Residents and 8 out of 10 residents stated that they have never experienced being held in a rough manner by staff and have never seen any staff handle other residents in a rough manner while providing care. Allegation: Staff did not treat resident with dignity and respect. It is alleged that Staff mistreat R1 by mocking resident and calling them names. LPA interviewed a total of 10 residents and 9 out of 10 residents stated that they have never been made fun of or mocked by staff and have never overheard staff making fun of or call any resident names. LPA interviewed 6 staff and 6 out of 6 staff state that they have never made fun of a resident and have never overheard another staff make fun of or call a resident any names. LPA interviewed S3 and staff stated that law enforcement was at the facility 3 days prior to todays visit and they investigated the same allegations, the officer did not find anything suspicious during investigation therefore no police report was filed. Based on statements and interviews conducted with staff and residents, review of S1 files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Licensee Amber Branconier.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 28-AS-20240416092400

Allegation investigated: Resident sustained a hematoma while in care. Staff did not provide adequate supervision.

Licensing Program Analysts (LPAs) Bonnie Tao and Tyler Reyes conducted a subsequent complaint visit regarding the allegation listed above. LPAs Tao and Reyes met with Staff#9 (S9) and Licensee, Amber Branconier and discussed the purpose of the visit, which was to continue the investigation and deliver complaint investigation findings. On 03/18/2022, LPA Tao conducted the initial visit, during visit, LPA obtained a copy of staff roster, resident roster, Resident #1 (R1) and Resident #8 (R8) facility file, facility house rules and R1’s incident reports relating to falls. LPA toured the physical plant, along with Office manager and did not observe any signs of neglect, abuse or other immediate health and safety threats. On todays visit, LPA Tao and Reyes interviewed Administrator, staff, and residents, and toured the physical plant with staff#9 (S9). (-continued in LIC 9099C-) Substantiated Regarding allegation: Resident sustained a hematoma while in care. It is alleged that a resident fell twice in the facility and was hospitalized for two days after the second fall, upon return to facility, a resident was placed in a seat belt for fall prevention; however, staff failed to secure the resident’s seat belt, resulting in a subsequent fall causing serious injury to resident. The investigation consisted of the following. Per resident interviews, seven (7) out of seven (7) residents could not corroborate the allegation and revealed they were not aware of any resident sustain of hematoma. R1 was not interviewed due to R1’s medical condition. Per staff interviews, seven (7) out of nine (9) staff revealed that staff were aware R1 had fallen in the facility and two (2) of nine (9) staff denied knowledge that R1 fell in the facility. Eight (8) of nine (9) staff reported there was adequate care and supervision provided at the facility. One (1) of nine (9) staff reported staff left R1 alone and R1 sustained a fall. Review of incident report dated 08/24/21, indicated R1 fell in the facility and was taken for the hospital for medical treatment, and discharged to a Rehab for continued care. Review of 09/23/21 incident report, indicated R1 fell in the facility a second time and was sent to hospital for medical treatment. The facility notified the department of R1 falls in a timely manner. On 08/24/21 around 11PM, R1 fell in the facility and was transferred to the hospital on 08/24/21 for medical treatment, R1 was discharge from the hospital on 08/25/21 and returned to the facility; however, R1 complained of pain and was sent back to the hospital on 08/25/21. R1 sustained a right shoulder fracture and subdural hematoma. On 08/31/21, R1 was transferred to different hospital for rehabilitation. On 09/15/21, R1 returned to the facility. On 09/23/21, R1 sustained a subsequent fall in the facility while sitting in R1 wheelchair. R1 was transported to the hospital on 09/23/21 for medical treatment. R1 hospital records, dated 09/23/21, indicated R1 sustained an acute on chronic bilateral subdural hematoma. Therefore, the investigation revealed the facility did not conduct a reappraisal of R1’s fall risk after R1 fell in the facility on 08/24/21; the facility did not update R1 care plan for fall prevention; R1 sustained a fall on 08/24/21 resulting in injury and sustained a subsequent fall on 09/23/21, which resulted in R1 sustaining injury/aggravation to R1’s previous injuries. Regarding allegation: Staff did not provide adequate supervision. It is alleged that a resident fell three times in the facility. Resident was hospitalized after the second fall for two days and returned to the facility, however, due to staff not providing adequate supervision, the resident sustained a third fall. (-continued in LIC 9099C-) The investigation consisted of the following. Per resident interviews, seven (7) out of seven (7) residents could not corroborate the allegation and revealed they were not aware of any resident fall at the facility and residents stated staff treated them fine. R1 was not interviewed due to R1’s medical condition. As mentioned above, per staff interviews, seven (7) out of nine (9) staff revealed that staff were aware R1 had fallen in the facility and two (2) of nine (9) staff denied knowledge that R1 fell in the facility. Eight (8) of nine (9) staff reported there was adequate care and supervision provided at the facility. One (1) of nine (9) staff reported staff left R1 alone and R1 sustained a fall. Review of incident report dated 08/24/21, indicated R1 fell in the facility and was taken for the hospital for medical treatment, and discharged to a Rehab for continued care. Review of 09/23/21 incident report indicated R1 fell in the facility a second time and was sent to hospital for medical treatment. The facility notified the department of R1 falls in a timely manner. The investigation revealed, on 08/24/21 around 11PM, R1 fell in the facility and was transferred to the hospital on 08/24/21 for medical treatment, R1 was discharge from the hospital on 08/25/21 and returned to the facility; however, R1 complained of pain and was sent back to the hospital on 08/25/21. R1 sustained a right shoulder fracture and subdural hematoma. On 08/31/21, R1 was transferred to different hospital for rehabilitation. On 09/15/21, R1 returned to the facility. On 09/23/21, R1 sustained a subsequent fall in the facility while sitting in R1 wheelchair. R1 was transported to the hospital on 09/23/21 for medical treatment, R1 hospital records dated 09/23/21, indicate, R1 sustained an acute on chronic bilateral subdural hematoma. Therefore, the investigation revealed the facility did not provide adequate care and supervision to R1, resulting in R1 sustaining multiple falls on 08/24/21 and 09/23/21, both falls resulted in R1 sustaining injury. Additionally, the facility failed to conduct a reappraisal to R1’s fall risk after R1 fell in the facility on 08/24/21 and did not update R1 care plan for fall prevention. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, and Chapter 8), are being cited on the attached LIC 9099D. An immediate $500 civil penalty is being issued during today's visit due to the neglect/lack of care and supervision resulting in resident sustaining serious injuries. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). Exit interview conducted with Amber, Licensee. Appeal Rights were discussed and a copy of Licensing Report and Appeal Rights were given during visit. The investigation consisted of: Regarding allegation: Resident was restrained. It was alleged that resident was tied into a wheelchair. The investigation revealed of the following. Per resident interviews, seven (7) out of seven (7) residents could not corroborate the allegation and revealed they were not aware of any resident being tied to residents’ wheelchairs. R1 was not interviewed due to R1’s medical condition. Per staff interviews, all staff denied the allegation and revealed staff did not tie residents to their wheelchairs. Review record revealed the facility did not allow restraining residents in any form. Per LPAs’ observation, no residents were being tied to the wheelchairs when conducting the physical plant. Therefore, there’s not sufficient evidence showed resident was restrained at the facility. Regarding allegation: Licensee has been suspended by the franchise tax board. It was alleged that the franchise tax board suspended the Licensee. The investigation revealed of the following. Per record review, the Franchise Tax Board had received and confirmed the licensee had filed tax to the board for the last two years and current year. Therefore, the franchise tax board did not suspend the licensee. Although the allegation may have happened or is valid, there’s not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Amber, Licensee. A copy of Licensing Report and Appeal Rights were given during visit.the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 28-AS-20220317135152

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Apr 13, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement is not met as evidence by: Facility failed to provide Resident#1 with medical evaluation and care plan for fall prevention after sustaining falls which poses an immediate Health, Safety, Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 11, 2024

Plan of correction: Facility will provide in service training to educate staff regarding the providing of medical assistance and evaluation to residents by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 17, 2024

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidence by: Facility failed to provide Resident#1with proper supervision a medical on a timely basis after sustaining a fall which poses a potential Health, Safety, Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 11, 2024

Plan of correction: Facility will provide (1) in-service training educating staff regarding the services necessary to meet the needs of residents who were in wheelchair by the POC due date.