The Bluffs at Hamilton Hill

Allegation investigated: Staff member worked while under the influence of alcohol, impairing their ability to provide adequate care and supervision, which poses a risk to residents in care Staff member sleeps at the facility while on shift

On 07/23/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Executive Director, Corey Cruppi. During the course of the investigation, LPA reviewed records, conducted interviews, and made observations. Compliant alleges staff member worked while under the influence of alcohol, impairing their ability to provide adequate care and supervision, which poses a risk to residents in care. Interviews conducted with 6 out of 7 staff stated they are not aware of any staff coming into work under the influence of alcohol. LPA was unable to get in contact with 1 out of 7 staff and left multiple messages with no response. Complaint alleges staff member sleeps at the facility while on shift. Interviews conducted with 6 out of 7 staff stated they have not seen any staff member sleeping during NOC shift. LPA was unable to get in contact with 1 out of 7 staff and left multiple messages with no response. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 23, 2026 · control 21-AS-20260423140001

Allegation investigated: Staff did not respond to resident's call for assistance in a timely manner Staff did not provide proper medication assistance to residents in care

On 07/23/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegations. LPA arrived and met with Executive Director, Corey Cruppi. During the investigation, LPA conducted interviews, reviewed documents and made observations. Complaint alleges staff did not respond to resident’s call for assistance in a timely manner. Facility was previously cited for regulation 1569.269(a)(6) on 12/30/2025, however review of alarm response reports on the following dates 4/14/2026 and 4/24/2026 show that residents (R1, R2, and R3) had to wait approximately 2 – 4.5 hours for assistance. *civil penalty in the amount of $250 is being assessed for repeat violation in a 12 month period* Complaint alleges staff did not provide medication assistance to residents in care. Review of residents (R4) MARs record shows a blank box with no staff initials on the following dates, 06/05, 06/06, 06/13, 06/14, 06/26, 06/27 at 4:00pm and 8:00pm indicating that medication was not given. Per R4s MARs record shows that R4 is supposed to take 0.125 of morphine every 4 hours for pain. Review of residents (R5) MARs record shows on 06/20 (Saturday) and 06/24 (Wednesday) , R5 did not receive their medication as no staff initials were marked, leaving the box blank indicating medication was not given. R5 is to take one tablet Monday, Wednesday, and Saturday. Based on LPAs observations and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given. Substantiatedthe state’s words, verbatim · CDSS document, Jul 23, 2026 · control 21-AS-20260423140001

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Aug 7, 2026

§1569.269 Enumerated rights... (a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by...... ....licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, R1, R2, and R3s response time for assistance was between 2 - 4.5 hours, which poses a potentional risk to the health and safety of residents in care. *civil penalty in the amount of $250 is being assessed for repeat violation*the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Licensee shall conduct training for all care staff on how residents pendant calls will be responded to in a timely manner and shall submit proof of completed training for all staff to Community Care Licensing (CCL) by 08/07/2026.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87465(a)(4) · Plan of correction due date: Aug 24, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on record review, R4 and R5 did not receive their mediciation, which poses a potentional risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Licensee shall conduct training on medication management for all medication technicians. Proof of completed training shall be submitted to Community Care Licensing (CCL) by 08/24/2026.

Type of visit: Required - 1 Year

07/07/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. There are currently 79 residents in care. Facility has a fire clearance approval for 95 non-ambulatory of which 14 may be bedridden. Facility has an approved hospice waiver for 10. LPA toured the building and grounds with Executive Director. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated and freezer food was found to be stored in a safe manner being labeled and dated. Facility has four floors, the first and second being designed for Memory Care. The third and fourth floor are designed for Assisted Living. Facility has common areas including business offices, gym, a salon and activity rooms. Extra hygiene products and linens are available. Water temperature in sinks accessible to residents in care in both assisted living and memory care were measured and found to be within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 09/2025. Smoke/Carbon Monoxide detectors are hardwired and located throughout the facility. Fire alarms are inspected by an outside vendor. Facility has a food menu that is rotated weekly. LPA observed an activities calendar for both assisted living and memory care. Facility modifies activities calendar for memory care residents. LPA is unable to finish annual inspection. Annual continuation inspection will be conducted at a later date. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director.the state’s words, verbatim · CDSS document, Jul 7, 2026

Type of visit: Case Management - Incident

04/28/2026; Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Melon Rivera and Business Manager, Karina Vazquez. The purpose of the visit was to follow up on a special incident report (SIR) that was self-submitted to Community Care Licensing (CCL). CCL received an SIR on 04/22/2026 stating at approximately 6:30PM on 04/15/2026, staff were alerted that resident (R1) was not in their designated area. At the time, two caregivers were actively assisting another resident with care needs, and a medication technician was on a scheduled break. Caregiver assigned to monitor the floor had temporarily stepped away to support care tasks, resulting in a brief lapse in direct supervision. Staff heard an alarm sounding and cleared it without verifying which resident had triggered it. Once R1s absence was identified, staff initiated a systematic search of the unit. When the resident was not located, a Code Silver was activated. During the search, staff received information by bystanders reporting that the resident had been seen past Novato Hamilton Station. Staff located the resident off site with two individuals who had assisted R1 to their vehicle. R1 was escorted back to the community. Per conversation with Business Manager, R1 was missing for approximately 30-45 minutes. R1 is a resident in memory care and a high-risk for elopement. In-service training for elopement was conducted for care staff on 04/21/2026. 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. Exit interview conducted. Copy of report, LIC809D, LIC811, and Appeal Rights provided to Business Manager.the state’s words, verbatim · CDSS document, Apr 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Apr 28, 2026

87705 Care of Persons with Dementia:(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, staff were not aware when R1 left the building and cleared the alarm without verifying which resident triggered it. This poses an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: In-service training on elopement was conducted on 04/21/2026. POC cleared at time of visit.

Type of visit: Case Management - Other

04/06/2026, LPA Loera arrived unannounced to conduct a case management visit and met with Director of Health Services, Allezmoy Bourque and Business Manager, Karina Vazquez. LPA conducted interviews regarding an SOC341 that was submitted to CCL on 11/12/2025 and followed up by the department on 11/18/2025. No Deficiencies Cited during visit. Exit interview conducted. Copy of report was discussed and provided.the state’s words, verbatim · CDSS document, Apr 6, 2026

Type of visit: Case Management - Other

03/19/2026, LPA Loera conducted an unannounced visit and met with Director of Health Services, Allezmoy Bourque and Business Manager, Karina Vazquez. The purpose of the visit was to follow up and conduct interviews for an SOC341 that was submitted to CCL on 11/12/2025 and followed up by the department on 11/18/2025. LPA was unable to interview staff (S1) and staff (S2) as LPA was notified they were not on shift at the time of visit. LPA made observations and obtained contact information. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided along with LIC811 (Confidential Names) to Business Manager.the state’s words, verbatim · CDSS document, Mar 19, 2026

Allegation investigated: Staff does not provide adequate food services to residents Staff does not provide adequate supervision to residents due to lack of staff

On 02/19/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Executive Director, Melon Rivera. During the course of the investigation, LPA reviewed records, conducted interviews, and made observations. Compliant alleges, staff does not provide adequate food services to residents and staff does not provide adequate supervision to residents due to lack of staff. Based upon department record review, observations, and interviews conducted the following determination has been made. Complainant alleged staff does not provide adequate food services to residents stating facility serves breakfast late; resulting in the time dinner is last served until breakfast is served being over 15 hours and staff are not taking the time to sit down with residents to feed them. Continued on LIC9099C Unsubstantiated Upon document review of facilities CFL Resident Handbook on page 18, under meals and dining, facility provides breakfast from 7:00am until 9:00am, lunch from 11:30am until 1:30pm, and dinner from 4:30pm until 6:00pm. Interviews conducted with staff show four out of four staff stating breakfast is usually served between 8:00am – 8:30am. Two of four staff stated dinner is usually served between 4:00pm – 5:00pm. Interview with Executive Director revealed there are currently 18 residents in memory care and out of those 18, 4 residents need full assistance with eating as one caregiver will be between two residents assisting them with feeding. Regulation 87555(b)(1) states “not more than fifteen (15) hours shall elapse between the third and first meal. Document review and interviews conducted reveal food services are being conducted within fifteen (15) hours between the third and first meal. Complaint alleges staff does not provide adequate supervision to residents due to lack of staff resulting in staff leaving residents alone in the common area on 12/07/2025 during the morning. Review of staff’s clock in sheet for 12/07/2025 shows there were five staff for the AM shift (6:30am - 2:30pm) and one additional staff from approximately 9:00am – 5:30pm. LPA reviewed 8 residents needs and service plan, none indicate they need one to one care. LPA was unable to gather enough evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 21-AS-20251222111145

Allegation investigated: Staff did not meet a resident's incontinence needs Staff allowed a resident to be soiled Staff did not meet a resident's laundry needs

On 02/19/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Executive Director, Melon Rivera. During the course of the investigation, LPA reviewed records, conducted interviews, and made observations. Compliant alleges, staff did not meet a resident's incontinence needs, staff allowed a resident to be soiled, and staff did not meet a resident's laundry needs. Based upon department record review, observations, and interviews conducted the following determination has been made. Complainant alleged staff did not meet a resident's incontinence needs. Complainant stated on 01/09/2026, resident (R1) was found saturated in urine. Review of R1s care summary, shows that R1 has incontinent bladder and requires assistance with frequent or unscheduled incontinence care. Interviews with two out of three staff revealed that R1 will try to use the bathroom on their own and once they have an accident, they will call for assistance. Interview with staff also reveal that since R1 has incontinence care, staff can check up on R1 and minutes later, R1 can have an accident. continued on LIC9099C Unsubstantiated Complainant alleged staff allowed a resident to be soiled on 01/09/2026. LPA was provided with documentation regarding the incident on 01/09/2026; showing that staff (S1) confirmed that incontinent care was provided to R1 twice during the shift with no concerns noted. Interview with witness revealed that they do not recall the incident happening on 01/09/2026 and R1 seems to do good with staff and has no concerns. Shift notes for AM shift (6:30AM - 2:30PM) 01/09/2026 show “good” for R1 with no additional notes provided. Complainant alleged staff did not meet a resident's laundry needs as R1s laundry was full and most of R1s clothes were unwearable or soiled on 01/09/2026. LPA observed R1s room and found it to be clean and odor free. R1s closet was found to have clean dry clothing; ready to be worn. Interview with witness revealed they have no concerns regarding laundry needs. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 21-AS-20260109122431

Type of visit: Case Management - Incident

02/11/2026 Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Allezmoy Bourque, Director of Health Services. The purpose of the visit was to follow up on a special incident report (SIR) that was self-submitted to Community Care Licensing (CCL). CCL received an SIR on 01/26/2026. Report stated that on 01/26/2026, during routine rounds, a staff member (S1) assisted resident (R1) with a transfer from R1s wheelchair to the toilet. During the transfer, the wheelchair moved out from under R1, and S1 was unable to maintain support long enough for R1 to be seated on the toilet. S1 safely assisted R1 to the floor and radioed for additional assistance. Upon arrival of additional staff, R1 was found of the floor, semi-wedged between the right side of the toilet and the wall. R1 was assessed and asked if they were experiencing pain to which R1 reported discomfort to their right shoulder. Staff attempted to assist R1 up on two occasions without any success. R1 requested that 911 be called for assistance. LPA obtained additional documentation and was informed R1 is receiving physical therapy. No Deficiencies Cited during visit. Exit interview conducted with Director of Health Services. Copy of report was provided along with LIC811 (Confidential Names).the state’s words, verbatim · CDSS document, Feb 11, 2026

Type of visit: Office

On 01/07/2026, an informal office meeting was conducted in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Kim Mota, Licensing Program Analyst, Anthony Loera, and Executive Director, Melon Rivera. The purpose of the informal office meeting was to discuss facilities compliance regarding sufficient staffing. Executive Director stated he has took over staff scheduling and has hired two new directors who will be overseeing assisted living and memory care. Copy of report was provided to Executive Director.the state’s words, verbatim · CDSS document, Jan 7, 2026

Allegation investigated: Staff are not able to answer call buttons in a timely manner

On 12/30/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegation. LPA arrived and met with Executive Director, Melon Rivera. During the investigation, LPA reviewed documents and made observations. Reporting Party (RP) stated on Friday 12/19/2025, resident (R1) had to wait over 2.5 hours for help to get out of bed. Document review of conversation show that a staff went to assist R1 within 12 minutes but left to grab another staff to assist and came back claiming no one was there to help and left again forgetting R1. Another staff member came to assist R1 at 6:46am. Document review of R1s alarm response report shows on 12/19/2025, R1 pressed their pendant at 3:55am and did not receive assistance out of bed until 6:46am, 2 hours and 50 minutes total. RP stated on Sunday morning 12/21/2025, resident (R2) pulled their room cord for assisance and didn't receive assistance. Document review of R2s alarm response report shows on the 12/21/2025 at 6:05am, R2 called for assistance and didn't receive help until 7:05am, a total of one hour. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given. *civil penatly in the amount of $250 is being assessed for a repeat violation in a 12 month period* Substantiatedthe state’s words, verbatim · CDSS document, Dec 30, 2025 · control 21-AS-20251222140731

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Jan 12, 2026

§1569.269 Enumerated rights... (a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs........ ....This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, R1s bell response time was 2 hours and 50 minutes and R2s bell response time was one hour, which poses a potentional risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: Licensee shall conduct training for all care staff on how residents pendant calls will be responded to in a timely manner and shall submit proof of completed training for all staff to Community Care Licensing (CCL) by 01/12/2026.

Allegation investigated: Licensee does not ensure the facility has enough staffing

On 12/30/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegation. LPA arrived and met with Business Manager, Karina Vasquez. During the investigation, LPA conducted interviews, reviewed documents and made observations. During the course of the investigation, LPA was provided with documentation for complaint 21-AS-20251119091655 that relates to the above allegation. A review of residents (R1) care notes state on October 20th, 2025, and November 1st, 2025, facility was “short staff”. On October 16th and November 22nd review of R1s care notes state that there was no med tech on shift, resulting in residents unable to be administered their medications if needed. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given. *civil penalty being assessed in the amount of $250.00 for repeat violation in a 12 month period* *report amended to relfect correct civil penalty amount* Substantiatedthe state’s words, verbatim · CDSS document, Dec 11, 2025 · control 21-AS-20251125121454

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 30, 2025

87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record review, the facility did not ensure they had a med tech on duty resulting in R1 missing their medication, which poses an potential health and safety risk to residents in care. *civil penalty being assessed in the amount of $250.00* *LIC9099D amended to reflect correct civil penalty amount*the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Licensee to submit plan of how facility will ensure facility has sufficient amount of staffing for all shifts to CCL by POC due date 12/29/2025.

Allegation investigated: Personal Rights

On 12/11/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegation. LPA arrived and met with Buisness Manager, Karina Vasquez. During the investigation, LPA conducted interviews, reviewed documents and made observations. During the course of the investigation, LPA was unable to gather information to support the allegation. Reporting Party (RP) stated a current employee at the facility has gone around showing their co workers a video of them abusing/sexually assaulting a resident from a different community. Interviews conducted reveal one out of six staff members to have seen the video, two out of six staff members said they have heard rumors about the video, and three out of six staff members said they have not seen or heard about the video. Although staff stated to have seen the video, no staff identified a resident of the facility in the video. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 11, 2025 · control 21-AS-20251125113603

Allegation investigated: Staff are mismanaging resident's medication Staff did not follow reporting requirements

On 12/11/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegations. LPA arrived and met with Buisness Manager, Karina Vasquez. During the investigation, LPA conducted interviews, reviewed documents and made observations. Compliant alleges, Staff are mismanaging resident's medication and staff did not follow reporting requirements. During the course of the investigation, document review of residents (R1) MARs records for October 2025 show on October 16th, 2025, at 6:00am R1 did not receive their Morphine Sulf 20mg/ML solution due to no NOC med tech on shift to administer. On November 22nd, 2025, at 8:00am R1 did not receive their routine Morphine 20mg/ml due to no med tech on shift and staff noted “resident is in pain”. continued on LIC9099C Substantiated Community Care Licensing (CCL) received a Special Incident Report (SIR) on 12/01/2025 regarding R1 missing their scheduled Morphine Sulfate 2.5mg dose. The SIR states the date it occurred on was 11/24/2025, but in the description of the incident it states, “It is noted that on Friday, November 12th, the resident’s scheduled Morphine Sulfate 2.5mg PO does was missed”. It is unclear what date the medication was exactly missed on as November 24th was a Monday and November 12th was a Wednesday. The dates given in the SIR are inaccurate. On October 20th, 2025, it is unclear if R1 received their morphine dose at 8:00am as staff notes state “short staff was passing meds upstairs”. Documentation for November 1st, 2025, at 8:00am, 8:30am, and 12:00pm, it is unclear if R1 received their routine morphine and Refresh Tears Ophth 0.5% drops as staff notes state “short staff”. It should be noted per R1s medication list, R1 is to receive morphine every four hours for pain management. For the dates of October 16th and November 22nd where documentation states R1 missed their medication, CCL did not receive a Special Incident Report (SIR). Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 21-AS-20251119091655

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Dec 12, 2025

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on document review of MAR, R1 was not administered their prescription medication on October 16th and November 22nd which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Licensee to submit plan on how facility will ensure residents receive their prescription mediciation on time to CCL on POC due date 12/12/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 29, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence..... This requirement not met by licensee as evidenced by: Based on document review, facility did not send an incident report to CCL for missed medication for R1 on October 16th and November 22nd, which poses an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Facility to conduct training for all staff on reporting requirements and to send proof of completed training to CCL by POC due date 12/29/2025.

Allegation investigated: Staff did not ensure residents confidential information was maintained

On 11/24/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Executive Director, Melon Rivera. During the course of the investigation, LPA conducted interviews and made observations. Based upon department record review and interviews conducted, information provided was contradicting with a lack of corroborating evidence to support the allegation. Reporting Party (RP) states a discussion about a resident transitioning off hospice was held in a common area violating resident rights. RP also stated no name was overheard. Interviews conducted reveal three out of four residents have not heard staff speaking loudly, revealing residents’ confidential information. One out of four residents stated they had heard a conversation about a resident transitioning out of hospice but did not hear any resident name being mentioned. The department is unable to find enough evidence to support the allegation as statements given did not hear a name of a resident being mentioned during the alleged discussion. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 24, 2025 · control 21-AS-20251114115936

Allegation investigated: Staff is not following the personnel requirements

On 11/18/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Executive Director, Jose Acumabig. During the course of the investigation, LPA reviewed records, conducted interviews, and made observations. Complaint alleges, staff is not following the personal requirements. Reporting Party (RP) states on the night of 10/10/2025, the facilities NOC shift was understaffed as three caregivers were on shift for all residents in assisted living and memory care. Document review of facilities scheduled shifts vs. actual hours worked show on the night of 10/10/2025, four staff were scheduled to work 10:30pm – 6:30am, which consisted of three caregivers and one medication technician. Three caregivers were on shift as the medication technician did not show up for their scheduled shift. Two additional care staff, who were not scheduled to work, clocked in from approximately 3:30am to 7:00am. The remaining caregivers that were on shift do not have training to dispense medication. If a resident needed medication during the hours 10:30pm through 6:30am, none of the staff on shift have training to properly dispense medication. Substantiated Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 21-AS-20251013154933

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 9, 2025

87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record review, the facility did not ensure staff on duty had training to dispense medication and/or had a med tech on duty which poses an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Facility to submit self-certification to CCL stating they understand regulation 87411(a) and submit an updated NOC shift schedule to ensure staff on duty have medication training by POC due date 12/09/2025.

Allegation investigated: Staff is caring and supervising residents while intoxicated.

On 11/18/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegation. LPA arrived and met with Executive Director, Jose Acumabig. During the course of the investigation, LPA conducted interviews, reviewed documents, and made observations. Based upon interviews conducted, reviewed documents, and observations made, information provided was contradicting with a lack of corroborating evidence to support the allegation. Reporting Party (RP) stated a staff member (S1) was observed to be intoxicated with the smell of alcohol. According to interviews conducted, four out of five staff interviewed revealed that they did not know of any staff showing up intoxicated, while one of out five staff interviewed stated that they know of some staff showing up smelling like marijuana. During the course of the investigation, the Department was unable to find evidence that S1 was intoxicated and impaired causing an inability to provide adequate care and supervision. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 18, 2025 · control 21-AS-20251030114309

Allegation investigated: Licensee does not ensure the facility has enough staff to meet the residents needs

On 11/18/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Executive Director, Jose Acumabig. During the course of the investigation, LPA reviewed records, conducted interviews, and made observations. Compliant alleges, licensee does not ensure the facility has enough staff to meet resident needs. Based upon department record review, information provided was contradicting with a lack of corroborating evidence to support the allegation. It was alleged that licensee does not ensure the facility has enough staff to meet resident needs. Review of facilities Personnel Report (LIC500) shows 35 caregivers and 8 medication technicians. Staff schedules for the months of September and October show for Memory Care there are at least two medication technicians and six caregivers for AM shift (6:30am - 3:00pm), one medication technician and 5 - 6 caregivers for PM shift (2:30pm - 11:00 pm), and one medication technician and 2 - 3 caregivers for NOC shift (10:00 pm - 7:00 am). continued on LIC9099C Unsubstantiated For Assisted Living staff schedules for the months of September, October and through the end of November show one medication technician and three caregivers scheduled for AM shift, PM shift shows one medication technician and 2-3 caregivers, and NOC shift shows one medication technician and 1-2 caregivers. 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.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 21-AS-20250909154224

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Jose Acumabig. The purpose of the visit was to follow up on an SOC341 that was self-submitted to Community Care Licensing (CCL). CCL received an SOC341 on 11/12/2025. Report stated that on 11/10/2025, staff member (S1) told management they had concerns regarding staff (S2) and staff (S3). S1 witnessed S2 aggressively pull bed covers, physically restrain, and yell at a resident (R1). S1 told S3 about the incident and instructed S3 to report the incident. Facility confirmed there was no report related to the incident that was submitted by S3. S2 was suspended while facility conducted an internal investigation. Facility made all notifications per Title 22 Regulations. During visit, LPA was informed that S3 is no longer employed at the facility. LPA obtained additional documentation. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director.the state’s words, verbatim · CDSS document, Nov 18, 2025

Allegation investigated: Staff are not ensuring that facility is maintained in a sanitary condition Staff are not ensuring that resident's hygiene needs are being met while in care

On 11/04/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegations. LPA arrived and met with Executive Director, Jose Acumabig. During the investigation, LPA conducted interviews, reviewed documents and made observations. Compliant alleges, staff are not ensuring that facility is maintained in a sanitary condition and staff are not ensuring that resident's hygiene needs are being met while in care. Based upon LPAs observations, LPA conducted a walk through of facility, including two elevators, common areas, chairs and four floors, including memory care that is located on floor one and two. LPA did not observe any feces or foul odors that would indicate the facility is not in sanitary condition and resident's hygiene needs are not being met. Facility was found to be clean and odor free as well as resident rooms. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 4, 2025 · control 21-AS-20251006090647

Allegation investigated: Staff are not able to answer call buttons in a timely manner

On 11/04/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegation. LPA arrived and met with Executive Director, Jose Acumabig. During the investigation, LPA conducted interviews, reviewed documents and made observations. During the course of the investigation, Document review of R1s alarm response report shows on 06/30/2025, R1 called for assistance at 4:24AM and didn’t get answered until 4:43AM, a total of 19 minutes. On 08/26/2025, R1 called for assistance at 5:05AM and didn’t receive assistance until 5:44AM, a total of 39 minutes. On 09/16/2025, R1 called for assistance at 5:27AM and didn’t receive assistance until 6:20AM, a total of 53 minutes. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given. Substantiatedthe state’s words, verbatim · CDSS document, Nov 4, 2025 · control 21-AS-20250909154224

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Nov 11, 2025

§1569.269 Enumerated rights... (a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, R1 bell response time was 19 minutes, 39 minutes, and 53 minutes which poses a potentional risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Licensee shall conduct all staff training on how residents pendant calls will be responded to in a timely manner and shall submit proof of completed training for all staff to Community Care Licensing (CCL) by 11/11/2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Karina Vasquez, Business Manager and Jose Acumabig, Executive Director. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 09/09/2025 Incident Report states on 09/03/2025 at approximately 1:55PM, a code silver was initiated for resident (R1) after R1 was found to be missing from both the common area and their assigned room within memory care section of the community. A coordinated response was launched involving approximately 12-18 staff members who assembled in the lobby and divided into search teams. Staff conducted a thorough search of all floors within the community and extended their efforts to surrounding outdoor areas, including the amphitheater and seashore landing - locations where R1 is known to frequent visit with their daughter. Search teams utilized various methods, including traveling on foot, in personal vehicles, and via the community transport bus. R1 was located approximately 0.5 miles from the community by two care staff members. Upon approach, R1 displayed resistance and agitation, continuing to walk with staff following closely behind for an additional 0.5 miles. Staff were eventually able to redirect R1s attention and safely escort R1 back to the community. Upon return, R1 was offered an antianxiety medication, which R1 accepted and tolerated well with 120 ml of water. No difficulty swallowing was observed. R1 denied any pain or discomfort, and no abnormalities in gait were noted during assessment. (Deficiency Cited) Per conversation with Business Manager and Health Care Director, they believe R1 got out from one of the back doors in memory care. R1 was gone for approximately one hour without supervision. The door alarm was activated when R1 left the facility. The alarm alerted staff, who went to go check the door and didn't observe any residents near so staff closed the door and reset the alarm. Facility conducted an in service training regarding elopement on 09/04/2025 and 09/09/2025. Per R1s physician's report (LIC602) R1 is diagnosed with dementia and is unable to leave facility unassisted. See LIC809-D for Deficiency. Exit interview conducted with Administrator and a copy of this report along with LIC811 (Confidential Names) was provided.the state’s words, verbatim · CDSS document, Sep 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87705(d) · Plan of correction due date: Sep 10, 2025

87705 Care of Persons with Dementia:(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure staff were aware when R1 left the building without assistance. This poses an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2025

Plan of correction: In-service training was conducted on 09/04/2025 and 09/09/2025. POC cleared at time of visit.

Allegation investigated: Reporting Requirements

Licensing Program Analyst (LPA) Loera arrived unannounced and met with Karina Vasquez, Business Manager and Sean Bannister, Memory Care Director to deliver findings of a complaint investigation. During the course of this investigation, documents were reviewed, observations made, and interviews conducted. Complaint alleges reporting requirements. Allegation, reporting requirements,that the facility did not report a fall to the POA (Power of Attorney)/responsible party. Record review show that R1 had a fall in the bathroom on 07/16/2025 and was sent out to kaiser to be evaluated. The fall was reported to R1s spouse who is also R1s responsible party. R1s spouse contacted R1s POA to notify them of the incident. Interviews conducted reveal the facility contacted the POA/responsible party on 07/16/2025. continued on LIC9099-C Unsubstantiated Based on record review, interviews conducted, and observations made, the allegations listed above are UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 21-AS-20250707082501

Allegation investigated: Staff do not ensure resident's incontinence needs are being met Staff do not ensure that resident has clean bedding

Licensing Program Analyst (LPA) Loera arrived unannounced and met with Karina Vasquez, Business Manager and Sean Bannister, Memory Care Director to deliver findings of a complaint investigation. During the course of this investigation, documents were reviewed, observations made, and interviews conducted. Complaint alleges staff do not ensure resident's incontinence needs are being met and staff do not ensure that resident has clean bedding. Allegation, staff do not ensure resident’s incontinence needs are being met. During the investigation, documentation, statements were reviewed, interviews conducted, and observations made. Review of residents (R1) Needs and Service Plan dated 01/21/2025 show R1 has incontinence episodes, wears briefs, needs total assistance with help on the toilet, and assistance with brief changes. R1s care notes show R1 spends most of their day with their spouse on the assisted living side of the facility. continued on LIC9099-C Substantiated Two out of four staff interviews conducted revealed that when R1 is with their spouse in assisted living and R1 has an incontinence episode, assisted living staff will call memory care staff and tell them they need to assist R1 with incontinence care. Per R1s Needs and Service plan under care notes, assisted living staff are to provide care during the day as needed to R1. Under Bladder Incontinence in R1s Needs and Service Plan, states resident will receive assistance with incontinence care as needed and staff will provide physical assistance to changed soiled brief and clothing. During the investigation LPA was provided with additional evidence that R1 pressed their pendant button for assistance around midnight on 08/24/2025 with no answer. Document review of R1s alarm response report shows R1 called for assistance at 11:40PM on 08/24/2025 and didn’t receive assistance until 12:28AM on 08/25/2025, a total of 47 minutes. Allegation, staff do not ensure that resident has clean bedding, based on interviews that were conducted with facility staff and outside parties, and records reviewed, it was determined R1s previous mattress was found to be saturated in urine. Interviews conducted with outside party revealed they have observed R1s mattress to be saturated in urine multiple times. Interviews conducted with 2 of 5 staff revealed R1s mattress was saturated in urine along with a urine smell before getting discarded. Record review show R1 received a new mattress on 07/07/2025. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 21-AS-20250707082501

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Sep 5, 2025

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs... This requirement is not met by licensee as evidence by record review and interviews...... conducted, the licensee did not ensure R1 received assistance from staff on duty and/or receive assistance in a timely manner. This poses an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Facility shall submit plan to CCL to conduct training for all direct care staff on care and supervision by plan of correction due date 09/05/2025. Facility to submit proof of completed training to CCL by 09/15/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Sep 3, 2025

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontience. This...... requirement is not met by licensee as evidence by record review and interviews conducted, the licensee did not ensure R1 had clean bedding as R1s mattress was saturated in urine. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Facility provided proof to LPA of new mattress ordered on 07/07/2025. POC cleared at time of visit.

Allegation investigated: Due to lack of supervision, resident has had multiple falls

On 08/26/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegation. LPA arrived and met with Business Manager, Karina Vasquez. During the investigation, LPA conducted interviews, reviewed documents and made observations. Compliant alleges, Due to lack of supervision, resident has had multiple falls. Based upon review of resident’s (R1) Needs and Service Plan dated (02/03/2025), R1 is to use a walker/cane when ambulating, needs total assistance for ambulation, and walks independently with staff assisting R1 to meals and activities. R1 is encouraged to use their cane, per R1s Needs and Service Plan. Record reviews show R1 has had a total of 8 falls since the beginning of 2025; 01/09/2025, 04/03/2025, 06/18/2025, two on 07/01/2025, 07/11/2025, 07/12/2025, and 07/25/2025. continued on LIC9099-C Unsubstantiated Record review shows R1s Needs and Service Plan was updated on 06/09/2025 with the goal for R1 to avoid injury from falls by assisting R1 with appropriate shoes when ambulating, verbally remind R1 to ask for assistance with transfers, escort resident to meals and activities, report any changes in condition to physician, staff check in routinely 4 times per shift, remind R1 to use walker as needed (keep within reach), and upon status checks staff are to ask R1 if they need to use the restroom and standby assist if R1 needs to use to toilet. R1s Needs and Service plan was updated after R1 had a fall on 06/18/2025; for nursing staff to ensure R1 has on proper footwear. R1 needs and service plan were updated after R1 had a fall on 07/12/2025 and 07/25/2025 and R1 was placed on hospice on 07/26/2025. Document review of facilities narrative charting notes for R1 reveal the falls happened in their bedroom and/or bathroom. Also review of narrative charting notes show staff documenting R1s falls, change of conditions, check-ins, and reminding R1 to use their cane/walker. 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.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 21-AS-20250714113825

Type of visit: Required - 1 Year

07/02/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. There are currently 86 residents in care. Facility approved/cleared for 95 non-ambulatory which 14 may be bedridden. Facility has hospice waiver for 10. LPA toured the building and grounds with Executive Director and Business Manager. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated and freezer food was found to be stored in a safe manner being labeled and dated. Facility has four floors, the first and second being designed for Memory Care. The third and fourth floor are designed for Assisted Living. Facility has many common areas including offices, a gym, a salon and activity room. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured and found to be within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 09/2024. Smoke/Carbon Monoxide detectors are hardwired and located throughout the facility. Fire alarms are inspected by an outside vendor. Facilities last fire drill was conducted 06/30/2025. LPA observed a daily food menu served for break, lunch and dinner. Facility has a separate menu from their daily specials in the event a resident does not like what is being served that day. Facility has an activities calendar, one for assisted living and a separate one for memory care. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. continued on LIC809C LPA conducted a review of 8 resident records. All records had the required documentation. LPA conducted review of 8 staff records/training. Upon a review of staff records, LPA found all staff to have required training as well as current 1st Aid & CPR certification on file. No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/02/2025: LIC500- Personnel Report LIC308- Designation of Responsibility Updated Liability Insurance Exit interview conducted with Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident visit and met with Memory Care Director, Sean Bannister. The purpose of the visit was to follow up on self reported incident that was submitted to Community Care Licensing (CCL). Per conversation with Memory Care Director, there are no cameras in facility and no other staff or residents witnessed the incident. Facility has an ongoing internal investigation but not yet completed. Staff (S1) has been suspended while investigation is pending. Memory Care Director confirmed once they have completed their internal investigation they will send a copy to CCL, along with a copy of the Police Departments investigation findings once completed. LPA gathered documents. No deficiencies cited. Exit interview conducted with Memory Care Director. Copy of report and LIC811 (confidential names) was provided.the state’s words, verbatim · CDSS document, May 8, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident visit and met with Memory Care Director, Sean Bannister. The purpose of the visit was to follow up on self reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 05/07/2025, Report stated that on 05/07/2025 resident (R1) had asked staff (S1) on duty for a bowl of cereal. S1 gave it to R1 and R1 dropped it. R1 then stated that S1 yelled at them and snatched their glasses off their face and threw them. LPA gathered documents and confirmed facility is conducting an investigation that is still ongoing. R1 has a one on one caregiver from an outside agency. Facility is currently investigating if one on one caregiver was present during incident. No deficiencies cited. Exit interview conducted with Memory Care Director. Copy of report and LIC811 (confidential names) was provided.the state’s words, verbatim · CDSS document, May 8, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident visit and met with Memory Care Director, Sean Bannister. The purpose of the visit was to follow up on self reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 04/07/2025, followed by an SOC341 on 04/28/2025. Report stated that on 04/02/2025 resident (R1) had described an incident to an individual (I1) of an event from "the day before yesterday" during which a new male caregiver was abrasive with R1. R1 told I1 that their arms had been yanked and that the caregiver had placed the blankets over their head before leaving and slamming the door. The caregiver had reportedly "gotten in her face" and said "don't speak to me that way." I1 said that R1 cursed at him and then the caregiver left, slamming the door. LPA conducted interviews and gathered documents. No deficiencies cited. Exit interview conducted with Memory Care Director. Copy of report and LIC811 (confidential names) was provided.the state’s words, verbatim · CDSS document, May 6, 2025

Allegation investigated: Residents wandered away from the facility due to lack of supervision. Staff do not follow infection control practices.

On 04/10/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of initiating a complaint investigation regarding the above complaint and delivering complaint findings. LPA arrived and met with Karina Vasquez, Business Director. During the investigation, LPA reviewed records, conducted interviews and made observations. Compliant alleges, Residents wandered away from the facility due to lack of supervision and staff do not follow infection control practices. Based upon department interviews with staff, information provided was contradicting with a lack of corroborating evidence to support the allegation. The allegation, residents wandered away from the facility due to lack of supervision. During the investigation LPA was provided with call service logs from the Novato Police Department and show no records of any communication between the facility and the police department relating to a missing resident. continued on LIC9099-C Unsubstantiated The allegation, staff do not follow infection control practices, LPA conducted interviews with staff and interviews showed no evidence that staff were using baby wipes to clean up feces. 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.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 21-AS-20250402083248

Allegation investigated: Staff do not respond to residents' call for assistance in a timely manner.

On 04/10/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of initiating a complaint investigation regarding the above complaint and delivering complaint findings. LPA arrived and met with Karina Vasquez, Business Director. During the investigation, LPA reviewed records and made observations. Compliant alleges, on 03/31/2025 residents pull alarm was going off for over an hour before staff were able to respond. Based on record review, staff did not respond to residents call in a timely manner. Review of alarm response records show it took staff 1 hour and 20 minutes to respond to residents call. Therefore, this allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. continued on LIC9099-C 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. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Business Director.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 21-AS-20250402083248

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 18, 2025

87411 Personnel Requirements - General (a) facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs......Based on record review of alarm response system, facility did not ensure that staff responded in a timely manner to..... ......call system to assist resident in care. Residents bell response time was 1 hour and 20 minutes, which poses a potentional risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Licensee shall conduct staff training on how call bells will be responded to and shall send proof of scheduled training to CCL by 04/18/25.

Allegation investigated: Staff are not adequately addressing resident's fall risk.

On 04/10/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of initiating a complaint investigation regarding the above complaint and delivering complaint findings. LPA arrived and met with Karina Vasquez, Business Director. During the investigation, LPA reviewed records, conducted interviews and made observations. Compliant alleges, Staff are not adequately addressing resident's fall risk. Based upon department interviews, information provided was contradicting with a lack of corroborating evidence to support the allegation. Per interviews conducted, facility has caregivers assiting with Resident's (R1) care as checking on R1 every hour and explored options for one-to-one care. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 10, 2025 · control 21-AS-20250407170351

Type of visit: Case Management - Incident

At approximately 1:00PM, Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Business Director, Karina Vasquez. The purpose of the visit was to follow up on self reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 02/21/2025. Report stated that on 02/14/2025, Resident (R1) who is ambulatory with and without a device, eloped from community around 11:00am. Memory Support alarmed doors notified staff that someone exited from Memory Support Unit but when checked it was found out to be a visitor exiting without the code. Med Tech did resident check per protocol and did not see R1. Staff began to search for missing resident. First responders notified community that resident was found safe off premises 0.8 miles away and HSA in response to code found R1 with first responders around 11:10am. R1 was returned to community after EMTs found no need for resident to be transported to the emergency room as R1 was in no need of medical attention and staff member was with R1 awaiting return to community. (Deficiency Cited) Per R1s physician's report (LIC602) R1 is diagnosed with dementia and is unable to leave facility unassisted. Based on conversation with Business Director, No one knew how R1 got out. Facility conducted an in-service training for memory staff for elopement the same day (02/14/2025) as the incident happened. Facility conducted an all staff elopement training on 02/19/2025. See LIC809-D for Deficiency. Exit interview conducted with Business Manager and a copy of this report along with LIC811 (Confidential Names) was provided.the state’s words, verbatim · CDSS document, Mar 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 13, 2025

87411(a) Personal Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility failed to provide supervision to R1 resulting in an elopement. The absense of supervision is an immediate risk to the Health, Safety and Rights of resident in care.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Cleared at time of visit. Facility conducted an in-service training about elopement procedures and has been completed for all memory care staff in the community.

Allegation investigated: Facility did not use proper Infection Control Protocols Licensee did not provide sufficient staffing

At approximately 09:45AM, Licensing Program Analyst (LPA) Loera arrived at this facility unannounced, to conduct an investigation into the above allegation (Facility did not use proper infection control protocols) and deliever findings. LPA met with Executive Director, Lisa Lomeli and Business Director, Karina Vasquez. LPA interviewed staff, requested, and reviewed documents. Complaint alleges staff did not use proper infection control protocols. Based on a review of facility’s infection control plan and public health guidelines, as well as Interviews with staff and living director, LPA was unable to find that facility staff did not follow proper protocol for care to COVID positive residents. LPA was unable to discover that facility did not use proper Infection Control Protocols per Title 22 Regulations. 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. continued on LIC9099C Unsubstantiated It is also alleged that facility has insufficient staffing. LPA conducted interviews, made observations, and reviewed facility documents. LPA was unable to discover that resident care needs were not being met per Title 22 Regulations. Although response times may be delayed, there is no evidence that care needs are not being met. There is differing information regarding insufficient staff after interviews and investigation to prove or disprove the allegation. 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 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. Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 21-AS-20240913164459

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468.1(a)(9) · Plan of correction due date: Dec 13, 2024

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: (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirment is not met as evidenced by: Based on document review and interviews conducted, facility did not ensure communication with R1’s representative was answered promptly and appropriately as required by regulation. This poses a potential health and saftey risk to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2024

Plan of correction: Administrator agrees to submit a plan to address how staff will ensure timely communication with residents responsible parties to CCL by POC 12/13/24.

Type of visit: Case Management - Annual Continuation

10/03/2024 at approximately 9:20am, Licensing Program Analysts (LPA) Loera arrived unannounced to continue an Annual Required inspection that was initiated on 09/04/2024, and was greeted by Business Manager, Karina Vasquez. At approximately 10:15am, LPA and Business Manager toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated and freezer food was found to be stored in facilities kitchen walk-ins being labeled and dated. Facility has 4 floors with the first and second floor being designed for Memory Care and floor three and four being designed for Assisted Living. Facility has many common areas including offices, a gym, a salon and activity room. LPA observed an activities calendar for residents to participate. Water temperature in sinks accessible to residents in care were measured within the range of 113.1 and 114.9 which is within 105 to 120 degrees F. Fire extinguishers were last inspected September, 2024. Smoke/Carbon Monoxide detectors are hardwired and located throughout the facility. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. At approximately 11:20 am, LPA conducted review of 8 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. At approximately 12:45 am, LPA conducted a review of 7 resident records. All records had the required documentation. continued on LIC809-C During inspection LPA followed up on elopement that was self reported to community care licensing (CCL) on 08/16/2024 stating that on 08/11/2024, Resdient ! (R1) had eloped from the community around 7:05pm. Report states Memory Support alarmed doors notified staff that a resident had eloped from Memory Support Unit. Report states staff did a head count and began searching for missing resident and was found around 7:30pm walking outside of community grounds in a nearby neighborhood. Report states R1 was returned back to the community and was put under one on one supervision. (Deficiency Cited) See LIC809-D for Deficiency. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Emergency Disaster Plan (review) Infection Control Plan (review) Exit interview conducted with Business Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 3, 2024

Type of visit: Required - 1 Year

09/04/2024, Licensing Program Analysts (LPA) Loera and Felias conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and met with Business Office Manager, Karina Vasquez. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 69 residents in care. Facility approved/cleared for 95 non-ambulatory and 14 bedridden. LPAs arrived at approximately at 2:00pm and observed that the facility's fire alarm was active. LPAs observed facility following their emergency disaster plan appropriately. LPAs met with Business Manager, Karina Vasquez, at approximately 2:45PM who notified LPAs that it was a false fire alarm. LPAs requested for incident report. At approximately 3:15pm, LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs also requested for Administrator Paperwork to be submitted to Community Care Licensing (CCL) to process Lisa Lomeli as the new Executive Director/Administrator for the facility. LPAs received notice that Lisa Lomeli was to be the new Administrator on 08/08/2024. LPAs received copies of requested paperwork during visit. LPAs unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Business Manager. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 4, 2024

Allegation investigated: Facility failed to report incident(s) as required per regulation

Licensing Program Analyst Leibert arrived unannounced to deliver findings on this complaint. Complainant alleges R1 fell numerous times while in care and was sent out to emergency care on 4/22/2024 and that Responsible Person (RP) was not notified. The following determinations are based on documents reviewed and statements taken: Two incident report were obtained, dated 5/7 and 5/20/2024 indicating R1 fell and that the RP was notified; An E-mail chain was obtained, dated 5/14 and 5/17, 2024, between the RP and the prior Executive Director (ED); The E-mail chain documents the claim that R1 went out for emergency medical care on 4/22/204 and that the staff did not notify the Responsible Person; The prior ED apologized to the RP for the situation and indicated that additional training was given to the staff as a result. Based upon the documents reviewed, the preponderance of evidence standard has been met. Therefore, the complaint is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Report left. Substantiatedthe state’s words, verbatim · CDSS document, Sep 3, 2024 · control 21-AS-20240711152524

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a) · Plan of correction due date: Sep 12, 2024

87211(a) A written report shall be submitted to the Licensing agency and to the person responsible for the resident within 7 days of the occurrence......Based upon documents reviewed, this requirement has not been met as evidenced by: R1 was transported for medical emergency on 4/22/24 and the Responsible Person was not notified by the facility. This posed an immediate risk to the personal rights of R1the state’s words, verbatim · CDSS document, Sep 3, 2024

Plan of correction: Administration shall provide refresher training to staff on the requirements of 87211 and will provide proof of training to CCL by POC date in order to clear the deficiency.

Allegation investigated: Facility staff does not administer resident's medication as prescribed. Staff left residents in soiled clothing for an extended period of time. Facility staff are not ensuring that residents needs are met.

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 1:30PM to deliver findings regarding the above allegations. LPA and Regional Director of Sales and Operations, Lori Spencer discussed the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents. Complaint alleges that facility staff does not administer resident's medication as prescribed. Per document review, facility was notified by their pharmacy that they were unable to refill a medication as the facility had requested a refill 10 days early, evidencing that medication(s) were being administered more frequently than prescribed. Interviews conducted revealed that staff members have witnessed medications being administered not as prescribed. Substantiated Continued from LIC9099 Complaint alleges that staff left residents in soiled clothing for an extended period of time and that facility staff are not ensuring that residents needs are met. 4 of 6 staff interviews conducted revealed that they have witnessed residents being left in soiled clothing. Interviews conducted revealed that insufficient staffing contributes to residents needs not being met. Based on interviews conducted, documents reviewed, and record review, the preponderance of evidence standard has been met, therefore the above allegations were found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. **An immediate civil penalty in the total amount of $250 has been issued for a repeat violation of regulation 87465(a)(4). LIC421FC** Exit interview conducted. Copy of report, LIC-809D, LIC421FC (Civil Penalty Assessment), Plan of Corrections, and Appeal Rights discussed and provided to Regional Director of Sales and Operations. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 21-AS-20240521145945

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 17, 2024

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review and interviews conducted, the licensee did not comply with the section cited above by medications being administered not as prescribed.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Licensee to submit a self-certification stating they will do the following: conduct a weekly medication room audit which includes service plans. Self certification is due by POC due date of 7/17/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 30, 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 interviews conducted, facility has insufficient staffing to provide the services necessary to meet the needs of the residents.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Licensee to submit proof of in-service training reviewing incontinence care to meet the needs of residents. Licensee to have meeting with direct care staff to discuss where care staff need additional support. Licensee to provide additional staffing and any additional supports identified during meeting. Licensee to submit to LPA proof of both meetings indicating what topics were covered as well as names, dates, job titles, and signatures. Proof to be submitted for review and approval by POC due date of 07/30/2024.

Type of visit: Case Management - Incident

At approximately 1:35PM Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced to conduct a case management inspection on an Incident Report that occurred on 2/22/2024 and was received by CCL on 02/27/2024. LPAs met with Executive Director (ED), Jessica Graham, and discussed the purpose of the visit. Incident Report states that Resident 1 (R1) drank Resident 2 (R2s) liquid medication (citalopram 10mls). R1 did not have an order for the medication that was consumed. Medication Technician on duty informed R1s primary care provider and R1s spouse. PCP stated that there would be no adverse affects. Per conversation with Executive Director, the medication technician placed the medication on the counter and turned around leaving the medication accessible to other residents when R1 drank the medication. **An immediate civil penalty in the total amount of $250.00 has been issued for a repeat violation of regulation 87465(a)(4). LIC421FC** Exit interview conducted. Copy of report, LIC-809D, LIC421FC (Civil Penalty Assessment), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 5, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 6, 2024

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 5, 2024

Plan of correction: Facility conducted an in service medication training through an outside vendor which outlined proper medication procedures. Facility has since onboarded a nurse who will be assisting with medications. Deficiency cleared during visit.

Type of visit: Case Management - Incident

At approximately 2:30PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection on an Incident Report that occurred on 12/15/2023 and was received by CCL on 12/21/2023. LPA met with Executive Director (ED), Jessica Graham, and discussed the purpose of the visit. Incident Report states that Resident 1s (R1s) order for routine Quetiapine was entered into the EMAR (Electronic Medication Administration Record) incorrectly by the pharmacy. The order was intended to be given as a routine medication and was entered as a PRN medication and not dispensed to resident since 11/20/2023. Per conversation with ED, the facility has a procedure for catching any errors by the pharmacy which was not followed, resulting in the medication error. ED discussed with LPA that the medication technicians could not have prevented this error as they do not have the capability of altering medication orders in the EMAR. **An immediate civil penalty in the total amount of $250.00 has been issued for a repeat violation of regulation 87465(a)(4). LIC421FC** Exit interview conducted. Copy of report, LIC-809D, LIC421FC (Civil Penalty Assessment), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 11, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 12, 2024

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Facility agrees to provide documentation outlining medication procedures when a new medication comes in from the pharmacy. Documentation to include their previous processes as well as an updated process to avoid medication errors in the future. Documentation to be provided to LPA by POC due date of 01/12/2024.

Type of visit: Case Management - Other

At approximately 2:20PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection. LPA met with Executive Director (ED), Jessica Graham, and discussed the purpose of the visit. LPA returned to the facility for the purpose of amending a document from a visit dated 10/17/2023. This document requires amending due to the use of the improper civil penalty form. LPA is also requesting additional documentation from an incident that occurred 10/14/2023 and was received by CCL on 10/16/2023. LPA previously followed up on this incident in report dated 10/17/2023. ED updated LPA on the SOC341 (Suspected Dependent Adult/ Elder Abuse) that was received by CCL on 10/16/2023 and was previously discussed on original report on 10/17/2023. LPA and ED discussed the incident and confirmed that there were not any witnesses to the incident. ED has not yet received the police report despite making multiple attempts to contact them. Per conversation with ED, outside caregiver returned to facility the day following the incident but was promptly removed from the facility grounds and has not returned to facility since. LPA received documentation on residents care manager, chart notes following the incident, and The Bluffs Requirements for Private Duty Attendants (outside caregiver did not complete required portion of form). ED was unable to locate at time of meeting the internal investigation documentation but confirmed that LPA will receive them via email by the end of the week (between 11/27-12/01). No deficiencies cited during visit. LPA is requesting the following documents by 12/01/2023 Any internal investigation documents on outside agency caregiver Files on outside caregiverthe state’s words, verbatim · CDSS document, Nov 22, 2023

Type of visit: Case Management - Incident

***Amended*** Licensing Program Analysts (LPAs) Rummonds and Felias arrived unannounced and met with Executive Director/ Administrator, Jessica Graham, and Connections for Living Director, Nathan Howland to conduct a Case Management - Incident visit. LPAs followed up on an Incident Report that occurred on 9/09/2023 and was received by Community Care Licensing (CCL) on 09/18/2023, which does not meet the regulation that requires facility to report incidents to CCL within 7 days. In addition, CCL received an SOC 341 (Suspected Dependent Adult/ Elder Abuse) that occurred on 10/14/2023 and was received by CCL on 10/16/2023. Incident report dated 09/18/2023, Resident 1 (R1) did not receive a scheduled dose of morning medications. It was reported that the medication technician on duty was unaware that the resident had moved into a new apartment. Medication retraining is scheduled to be conducted this week (deficiencies cited, see LIC809D, regulations 87211(a)(1)(D) and 87465(a)(4)). SOC 341 dated 10/16/2023, Resident 2 (R2) had a physical altercation with an outside agency caregiver. R2 reportedly was slapped across the face by their caregiver and showed signs of redness on their right cheek. Caregiver denied making physical contact with R2 and stated they had a verbal disagreement. Novato Police Department was called and arrived at facility at approximately 3PM to conduct interviews with staff and R2. R2 has a dementia diagnosis and was unable to provide details summarizing the incident to Novato PD. Facility has since suspended the Caregiver from involvement with the facility. R2's care manager and responsible party were informed of the incident. **An immediate civil penalty in the total amount of $250.00 has been issued for repeat violations of regulations 87211(a)(1)(D) and 87465(a)(4). LIC421FC** Exit interview conducted. Copy of report, LIC-809D, LIC421FC (Civil Penalty Assessment), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 17, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 18, 2023

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Facility to provide documentation showing that staff will be retrained. In service training to be conducted. Documentation to include: date of training, topics included, staff names, their job role, and signatures. Documentation to be submitted to CCL by POC due date of 10/18/2023 ***Civil Penalty assessed for a repeat violation of the same regulation within a 12 month period***

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Oct 27, 2023

87211 Reporting Requirements (a)...licensee shall furnish to the licensing agency..., including...:(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of ...events specified in (A) through (D)...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by: Based on Incident report, the licensee did not comply with the section cited above by not reporting timely which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Facility provided documentation showing that staff have been retrained. Deficiency cleared during visit. ***Civil Penalty assessed for a repeat violation of the same regulation within a 12 month period***