The Berkshire

Type of visit: Office

The California Department of Social Services (CDSS) Community Care Licensing (CCL) Santa Rosa Regional Office conducted an in office, Legal Non-Compliance meeting today 07/29/2026 with The Berkshire, facility number 286804030. Present in the meeting were: Regional Manager, Carla Nuti-Maritnez, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst, Julie Florio, Licensees Babita Dhawan and Anu Wadhwa, Administrator, Manuel Baldeo, and Previous Staff, Lia Miller. The purpose of this office meeting was to discuss areas of concern in the operations of the facility as the result of substantiated complaint received by the Department on 12/12/2025 and putting The Berkshire facility on a Non-Compliance Conference (NCC) plan. On 05/28/2026 Licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87465(a)(1) Incidental Medical and Dental Care and California Code of Regulations (CCR) Title 22, § 87615(a)(1) Prohibited Health Conditions. Parties present during the meeting agreed to a NCC plan for 2 years ending 07/29/2028 to bring the facility into compliance. Items addressed during the meeting include, but are not limited to, areas of concern: Compliance with California Title 22 Regulations and Community Care Licensing (CCL) Requirements Recent substantiated CCL complaint Incidental Medical and Dental Care Prohibited Health Conditions Staff Training Adequate staffing Timely Medical Continued on LIC809C... Continued from LIC809... Technical Support Provider (TSP) assistance was offered to Licensees during this meeting. Licensee and applicant were notified that this NCC plan may roll over to the new application under review by the department. Administrator/Licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49(f), 1548, or 1568.0822. Exit interview conducted with Administrator/Licensee, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 29, 2026

Allegation investigated: Due to staff neglect, resident sustained severe injuries. Staff retained a resident with a prohibited health condition.

On 05/28/2026, at approximately 10:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20251212082305, which was received by Community Care Licensing (CCL) on 12/12/2025. Reporting Party alleges due to staff neglect, resident sustained severe injuries and staff retained a resident with a prohibited health condition. LPA met with Manuel Baldeo, Designated Responsible Party (DRP). On 12/8/2025, Resident 1 (R1) presented to the hospital with an unstageable pressure wound to their coccyx area, stage II pressure wound to their left hip, and fluid-filled blisters on both heels. R1’s recurrent coccyx injury was present but almost fully healed upon their admission to the facility (9/24/2025). No other wounds were present at the time. Continued on LIC9099C... Substantiated Continued from LIC9099... Staff reported they repositioned R1 every two hours and home health services were requested but not approved until 12/4/2025. Certified Wound and Ostomy Nurse RN, W1, reported it likely took “Some time” for the wounds to develop. W1 believed staff should have sought medical attention sooner based on the smell and appearance alone. The Berkshire Director of Operations, Lia Miller reported that the severity of the wounds were not properly reported to her. Lia further stated, “People (care staff) were seeing and not saying…” Concerns with staffing deficiencies were also shared by staff and residents’ family members. Conflicting staff reports regarding the severity of the wounds, concerns related to staffing deficiencies, and the emergence of severe additional pressure wounds support the allegations (see LIC9099D). An immediate civil penalty in the amount of $500 if being issued during today's visit as the result of neglect/lack of care and supervision due to resident R1 sustaining severe injuries (see LIC421IM). After sustaining severe pressure injuries at The Berkshire, R1 subsequently died on 12/31/2025. According to R1’s death certificate, a significant condition which contributed to their death was acute sepsis syndrome. Prior to R1’s passing, W1 reported that it was clear to them that R1’s injuries and condition could hasten R1’s end of life outcome. Based on interviews conducted and records obtained, the allegations that due to staff neglect, resident sustained severe injuries and staff retained a resident with a prohibited health condition are SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from Title 22 Regulations, Division 6, (see LIC9099D). DRP was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49(f). Exit interview conducted. Copy of report discussed and provided to DRP, whose signature on form confirms receipt of documents. Appeal rights provided.the state’s words, verbatim · CDSS document, May 28, 2026 · control 21-AS-20251212082305

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 29, 2026

Incidental Medical and Dental Care 87465(a)(1) The licensee shall arrange, or assist in arranging, for medical...care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on facility not ensuring R1 was sent out for timely medical evaluation of observed changes to R1's condition, resulting in the emergence of severe additional pressure wounds which ultimately contributed to R1's acute sepsis syndrome and death, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Licensee to submit self-certification that regulations 87465 Incidental Medical and Dental Care and 87466 Observation of a Resident have been reviewed with facility staff and are understood to CCL by Plan of Correction (POC) due date 05/29/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: May 29, 2026

87615 Prohibited Health Conditions: (a) Persons who require health services... specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3...pressure injuries. This requirement was not met as evidenced by: Based on record review and interviews conducted, staff did not ensure the above regulation as evidenced by R1 sustaining an unstagable pressure injury while in care which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Licensee to submit a written statement that they understand the regulation 87615(a)(1) and shall be in future compliance to CCL by Plan of Correction (POC) due date 05/29/2026.

Type of visit: Required - 1 Year

At approximately 3:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Manuel Baldeo III, Designated Responsible Party (DRP). Facility is a Residential Care Facility for the Elderly (RCFE) with twenty-two (22) residents in care. Facility is approved for 72 residents and has a Dementia Care Plan. Facility has a Hospice waiver for fifteen (15), is approved for 52 non-ambulatory residents, 20 of whom may be bedridden. Facility is currently undergoing a change of ownership and renovations throughout. At approximately 4:00 PM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. LPA observed egress devices activated on all but one exterior door. DRP activated it immediately and agreed to ensure the facility maintains activated egress devices on exterior doors at all times in order to operate in compliance with regulation. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are shaded seating areas in two courtyards with outdoor space for activities. LPA observed residents resting in their rooms or watching TV in the common areas. Continued on LIC809-C... Continued from LIC809C... Facility has internet service and DRP agrees to ensure the facility has at least one internet access device designated for resident use as required per regulation. The telephone was tested and was operational during inspection. Fire extinguishers were observed fully charged and were last inspected 03/2026. LPA will return at a later date to conduct medication and file review. No deficiencies cited during today's inspection. Exit interview conducted with DRP whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 14, 2026

Allegation investigated: Staff neglect resulted in resident sustaining a fracture

On 12/09/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250701084339 investigation findings and met with Lia Miller, Director of Operations. Reporting Party (RP) alleges that staff neglect resulted in resident sustaining a fracture. LPA Florio conducted 10-day complaint investigation visit on 07/01/2025 and obtained documents, made observations, and conducted interviews. On 6/25/2025, at about 1927 hours, Resident 1 (R1) was admitted to a local emergency department (ED) with complaints of a swollen leg and was diagnosed with a right femur fracture and a hip fracture. On 6/26/2025, R1 had surgery for a hip fracture where a cephalomedullary nail was inserted. R1 was diagnosed with a comminuted proximal femur fracture with a non displaced neck component. Several staff interviews revealed consistent statements of not knowing how R1 had sustained an injury given that R1 was bed bound and unable to get out of bed on their own. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Staff 1 (S1) learned that R1 had a controlled fall on 6/24/2025 when Staff 2 (S2) and Staff 3 (S3) were waking R1 up. S1 assumed that staff had R1 slide from the bed to the floor. R1 did not have any indications of pain at this time. R1 would not be able to say if they were in pain. Staff 4 (S4) stated that S2 was responsible for waking R1 up and changing their incontinent briefs. S2 told S4 that they dropped R1 while changing their briefs. S3 was unaware of R1 falling but stated that it was possible for S2 to have changed R1 alone resulting in R1 falling. S2 denied knowing anything about R1 being dropped or sliding to the floor. All of the staff knew that R1 was to be changed or moved with two staff present for a two person transfer. Based on observations made, interviews conducted, and records reviewed, the Department received conflicting information regarding the above allegation. Based on interviews conducted, observations made, and records obtained, the allegation staff neglect resulted in resident sustaining a fracture is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that 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 cited. Exit interview conducted with Director of Operations, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 21-AS-20250701084339

Type of visit: Case Management - Incident

On 12/09/2025, at approximately 12:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident visit and met with Lia Miller, Director of Operations. LPA is conducting a case management visit to obtain more information regarding an incident report received by the Department on 12/08/2025 for an incident that occurred on 12/01/2025, involving Resident 1 (R1). LPA conducted an interview with Staff 1 (S1). No deficiencies were cited during todays visit. Exit interview was conducted with Director of Operations, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 9, 2025

Type of visit: Required - 1 Year

At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by facility Staff. Babita Dhawan, Licensee/Administrator was contacted via telephone and arrived at approximately 11:30 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with nineteen (19) residents in care. Facility has a Dementia Care Plan and is approved for 72 non-ambulatory residents, of which fifteen (15) may be Hospice and twenty (20) may be bedridden. At approximately 11:45 AM, LPA initiated a tour of the facility with Licensee/Administrator and observed the following: Facility is one story, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets/closets containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are multiple shaded outdoor seating areas with space for activities. LPA observed residents watching TV or engaged in games and crafting activities in the common area of the facility. LPA observed books and games available to residents as well as a daily activity schedule posted. Facility has internet service but does not currently have an internet access device designated for resident use. Licensee/Administrator agrees to provide a designated internet access device for resident use to bring the facility back into compliance with regulation. The facility telephone was tested an operational during inspection. Continued on LIC809-C... Continued from LIC809... Facility's fire extinguishers were observed charged and were last serviced 03/2025. Smoke and Carbon Monoxide detectors were last inspected by the local fire department 06/2024. Facility does not currently have delayed egress doors surrounding their memory care unit but will submit for the proper permits once they decide to move ahead with installation. Facility conducts quarterly disaster drills, and the most recent drill was conducted 02/2025. LPA observed the facility's infection control plan, several first aid kit, PPE, and emergency supplies. Facility has a generator for emergency preparedness. LPA reviewed facility's emergency disaster plan last updated 04/2022. LPA reviewed five (5) resident files and five (5) staff files, and observed the following: Staff 2 (S2) and Staff 3 (S3) were missing proof of the required annual training hours, (see LIC809D). Staff 4 (S4) and Staff 5 (S5) were observed missing proof of the required first aid training. Licensee/Administrator states that both staff members are currently enrolled in first aid training and agrees to ensure that both staff members have proof of completion before their next scheduled shift. All of the remaining required documents were observed in the staff files per regulation. Five (5) of five (5) resident files were observed missing appraisal needs and services plans which comply with Title 22 regulation 87463(a), (see LIC809D). All other required documents were observed in the resident files reviewed. LPA reviewed medications and medication logs which were observed stored and maintained in compliance with regulation. Licensee/Administrator agrees to ensure that staff are aware of the required documentation standards and that all centrally stored medication and destruction records are complete. Facility assists families with coordinating medical and dental appointments as needed and uses third party transportation services for these appointments. Facility does not manage P&I. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC610D - Emergency Disaster Plan (updated) LIC500 Personnel Roster/Report (updated) continued on LIC809C... Continued from LIC809C... Deficiencies cited from the California Code of Regulations, Title 22, Division 6 and/or the Health and Safety Code. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. Exit interview was conducted with Licensee/Administrator, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 25, 2025

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff handled residents in a rough manner Staff left residents in wet briefs for extended periods of time Staff bathed resident with cold water Staff overmedicated residents

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation Staff, residents and persons responsible for the residents were interviewed. Four unannounced site visits were conducted and pertinent documents obtained and reviewed. The following determinations are made: No evidence of medication errors or abuse of residents was found; The "Incontinent Care & Toileting Residential Documentation logs for a 60 day period before and after receipt of the complaint indicate residents were checked and changed appropriately; Three of the four showers on site are functioning properly with hot water; All family members with residents in care that were interviewed have indicated satisfaction with the care provided; The Hospice nurses notes for the two Hospice patients interviewed indicate no abuse and good care being provided by staff. Although the allegations may be true, based on statements and documents, there is not a preponderance of evidence to prove or, disprove, the allegations. Therefore, the allegations are found to be UNSUBSTANTIATED. No citations issued today. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 20, 2024 · control 21-AS-20240419124724

Allegation investigated: Staff did not treat resident with dignity and respect. Staff interfered with resident’s visits.

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:30AM to deliver findings regarding the above allegations. LPA was greeted by staff, and Administrator, Babita Dhawan arrived shortly after. LPA and Administrator discussed the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents. Complaint alleges that staff did not treat resident with dignity and respect. Residents interviewed indicated that they are treated well at the facility. Staff interviewed indicated that they have not witnessed other staff treating residents poorly. Continued on LIC9099-C Unsubstantiated Continued from LIC9099 Complaint alleges that staff interfered with resident’s visits. Residents interviewed indicated that they have not had staff interfere with their visits. Staff interviewed stated that they do have recommended visitation hours, and they try to encourage visitors to not come during mealtimes. However, they do not monitor or interfere with visitation. Interviews revealed that there is one resident (Resident 1, R1) who cannot have two specific individuals visit due to a restraining order that was filed against them. Documentation reviewed revealed that the restrained persons shall not contact the individual directly or indirectly, in any way, including but not limited to: in person, by telephone, in writing, by public or private mail, by interoffice mail, by email, by text message, by fax, or by other electronic means. Staff interviews indicated that R1 still had visitors, but staff encouraged those visitors not to use their phone with R1 present in order to mitigate indirect contact from those restrained from R1. Based on interviews conducted and observations made, and while the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 21-AS-20240125155602

Allegation investigated: Insufficient staffing Food is not being served at appropriate temperature

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:30AM to deliver findings regarding the above allegations. LPA was greeted by staff, and Administrator, Babita Dhawan arrived shortly after. LPA and Administrator discussed the purpose of the visit. Complaint alleges there is insufficient staffing. Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents. Administrator and staff confirmed that there are multiple residents who require a two person assist. Based on document review, there is one staff on during night shift. Facility has a memory care unit as well as an assisted living unit. In order for staff to assist residents in one department, it requires them to leave residents in another department unattended. Based on document review and interview, facility does not have sufficient staffing to meet resident needs. Continued on LIC9099-C Substantiated Continued from LIC9099-A Complaint alleges that facility is not providing adequate laundry service because items go missing and clean laundry still smells. LPA toured the facilities laundry room and observed the washer and dryer to be operational. LPA observed a drying rack to allow clothes to air dry. Interviews conducted revealed that residents drop off their laundry outside of their rooms and it is washed overnight. Interviews with residents revealed that 2 of 3 residents confirmed that their laundry has gone missing, however their laundry got switched with other residents of a similar name. Residents interviewed denied that their laundry was malodorous. Based on interviews conducted and observations made, and while the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. Continued from LIC9099 Complaint alleges that food is not being served at appropriate temperature. LPA observed facility to have electric warmers that meals are served out of. Staff confirmed that it is their procedure to preheat the warmers before mealtimes. Interviews conducted revealed that meals do not always come out hot, and that there has been a time when vegetables came out with frost still on them. Based on documentation reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (Title 22, Division 6). Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 21-AS-20240216103748

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 3, 2024

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 has not been met as evidenced by: Based on document review, facility has one overnight staff despite having multiple residents who require a two person assist.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Administrator agrees to submit self certification stating that they will hire an additional overnight staff by POC due date of 05/03/2024. Once an overnight staff is hired, proof of updated staff schedule to be provided to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: May 3, 2024

87555 General Food Service Requirements (a) ...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement has not been met as evidenced by: Based on observation and interview, food is served cold on occasion and there was a time when residents observed vegetables to have frost on them.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Administrator agrees to implement a system in which staff are ensuring that food warmers are operational and that food is cooked thoroughly before serving. Updated serving system to be provided to LPA by 05/03/2024.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced at approximately 9:30AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit, Administrators, Lia Miller and Babita Dhawan arrived shortly after. LPAs initiated a tour of the facility around 9:45AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 111, 108, 107, 110 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the pantry. Personal Protective Equipment is stored in PPE closet. Fire extinguishers were last serviced March 27, 2024. Facility has combination smoke and carbon monoxide detectors as well as a sprinkler system that is serviced by an outside vendor. Most recent fire/disaster drill was conducted 02/07/2024. Five staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Staff have required training. Administrator Certificate for Administrator, Lia Miller (6025709740) on the departments pending list. Medications and medication records were reviewed. LPAs observed 24 hours of pre poured medications. LPA and Administrators discussed that meds are no longer to be pre poured. Continued on LIC809C Continued from LIC809 Administrator to submit updates of the following documents by 05/12/2024: LIC 500 Personnel Summary Copy of Liability Insurance LIC 9020 Register of Residents Emergency Disaster Plan (If any changes) Infection Control Plan (If any changes) No deficiencies cited during inspection. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on forms confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 12, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff left the medication room door open making medications accessible to residents in care

At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Administrator Babita Dhawan, toured the building, reviewed records and interviewed staff. On a previous visit, 07/18/2023, LPA toured the building and observed the door to the medication room did not close securely. The door swung closed, but did not latch, causing the door to be left unsecured. LPA observed the door was left unsecured when staff left the area. LPA advised the facility to address the issue immediately. LPA observed during this visit the door has been repaired and it closes securely. LPA observed the medication technician ensure the door is secured before they leave the area. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Babita Dhawan and Appeal rights were given. Substantiated Also to emailed to each of the managers. LPA tested this process and left a message with the answering service. LPA received a return call within 15 minutes. LPA made another attempt approximately 30 minutes later, the telephone was answered by staff. LPA observed a telephone available for residents to use to make private telephone calls. Based on interviews conducted with residents, LPA was informed the facility has suggested visiting hours but if a visitor wishes to come before or after, they are able to do so as long as they do not cause disruptions to other residents. Residents told LPA they have not had any situations where their visitor was told leave before they were ready. 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.the state’s words, verbatim · CDSS document, Oct 2, 2023 · control 21-AS-20230711112325

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(H)(2) · Plan of correction due date: Oct 3, 2023

87465 Incidental Medical and Dental Care:(h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on LPA observation, the medication room door was not secured. This poses an immediate Health or Safety risk to residents.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: Licensee repaired the medication room door immediately. POC cleared at time of visit.