The Chateau at River's Edge

Allegation investigated: Facility did unlawful eviction. Facility refused to refund resident after unlawful eviction. Facility did not respond to call light in a timely fashion. Facility not providing incontinent care as needed.

On 07/22/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the results of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator /Executive Director (ED). LPA met with Designee, Karla Trujillo and a brief interview followed. LPA conducted a search of Community Care Licensing's Eviction Log and could find no evidence that Chateau at River's Edge presented R1 or R1's POA with an eviction letter. LPA requested a copy of the eviction letter from the reporting party and received a blank form titled "30 Days Notice of Intent to Vacate." The POA received this form as an attachment from Marianne Richardson, the Executive Director (ED) at the time. In her email dated 10/21/25 at 1:11 PM, it stated that they never wanted R1 to move out, but due to R1's medical condition, per the California Code of Regulations, R1 would have to continue to recover at a skilled nursing facility until they were reassessed and cleared to return to the community. ED Richardson had a history of discussing potential evictions with their LPA and submitting drafts of eviction Unsubstantiated letters to Community Care Licensing (CCL) for review to ensure that they contained all of the elements to be legal. No such draft was submitted to CCL. This LPA also interviewed the Regional Nurse Manager (RN) who was present when the Director of Assisted Living (DOAL) contacted the POA with regard to R1's medical condition. According to the RN, the DOAL stated that, "R1 would benefit from treatment at a skilled nursing facility as at the moment, R1's needs required a higher level of care than the facility could provide." Many residents require temporary care at a skilled nursing facility prior to returning home to their assisted living communities after their medical condition has been stabilized. The RN stated that the word eviction was never used because they was no intent to evict R1. As the POA terminated the admission agreement and moved all of R1's belongings out without offering 30 days' notice, the Executive Director attached the form to be completed by the POA. The standard for the preponderance of evidence was not met and the Department found this allegation to be UNSUBSTANTIATED, meaning that the allegation may have happened or is valid, but there was not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility refused to refund resident after unlawful eviction As the eviction was not substantiated, no refund was due. The Department found this allegation to be UNSUBSTANTIATED, meaning that the allegation may have happened or is valid, but there was not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility did not respond to call light in a timely fashion. LPA reviewed 112 pages of pendant call logs. Out of 42 instances staff responded in less than 20 minutes with the majority or the response times being less than 10 minutes. There was an anomaly on 09/09/25 when it took staff 34 minutes and 54 seconds. The preponderance of evidence seen in this report was that the staff were responsive to R1's needs as R1 consistently pressed their pendant for assistance roughly every 2 hours on some days. The Department found the above allegation to be UNSUBSTANTIATED. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility not providing incontinent care as needed. During the course of this investigation, this LPA conducted 7 staff interviews and reviewed staff schedules for the time period of this complaint. This LPA learned from S1, S2 and S5 that although at times there were call outs, staff would accommodate by working split shifts or picking up extra hours to ensure coverage. This LPA also learned that R1 developed a new behavior during this time period. R1 previously accepted incontinent care from S4, but then R1 began refusing to allow this staff person to assist them. This would cause a delay in care as S4 would have to find another care giver available. Based on the above interviews, the review of schedules and the response time for R1's call log, the standard for the preponderance of evidence was not met and the Department found the allegation above UNSUBSTANTIATED. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with the Designee, Trujillo.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 27-AS-20251020154520

Allegation investigated: Facility elevator is in disrepair

On 2/25/26, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to open and complete a complaint investigation for the allegation noted above. LPA met with Executive Director, Justine Ortiz (S1) and explained the purpose of the visit. LPA requested a copy of facility's elevator repair invoices, service agreement, elevator permit. LPA also interviewed S1 and S2. On 2/18/26, the Department received an incident report from Executive Director, Justine Ortiz (S2), reporting the elevator is down as of 2/13/26 and a plan is in place until the elevator is up and running again. On 2/24/26, S1 contacted the Department to report the elevator parts have been ordered. On this day, S1 stated an emergency technician came out on 2/14/26 and the elevator repair has been requested and is pending maintence once the parts that need replacment are recieved by "TK Elevator" company. CONTINUED ON 809-C Substantiated There building is three stories. There is one elevator in assisted living. Regional Maintenance, Jeff, confirmed the parts ordered are the elevator motor and pump. Maintenance Director, Tom Lowers (S4), stated elevator maintenance work is checked on a quarterly basis or as needed. On 2/25/26, LPA reviewed the copy of permit in elevator to see if it’s current and set to expire 5/15/26. LPA reviewed elevator maintenance record in which the last inspection date was 12/4/25, 11/3/25, and 9/17/25. LPA observed 'evac chairs' in each stairwell in which staff is trained to use and new staff will be training on. LPA observed the elevator is taped off and sigs informing the elevator is out of order are posted. The plan in place states there is signs posted informing the elevator is “Out of Order” signs has been placed on the elevators, a notice has been sent to all residents regarding the outage, meals are being offered in residents’ rooms for those who prefer not to go to the dining room, and care staff and Alpha One are assisting residents to and from the first floor as needed. On 2/25/26, LVN director of Assisted Living, Brittany Smith (S3), stated there are no non-ambulatory or bedridden residents residing on second floor and third floor.S1 and S2 stated programs and activities have been arranged on each floor to ensure continued engagement. Based on documents reviewed regarding elevator maintenance and LPA observation on The allegation "Facility elevator is in disrepair" is substantiated. The facility has ensured timely reporting, regular elevator maintenance, and there is a plan in place to ensure resident accommodation as repairs are undertaken. There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with S1. LIC 9102TV and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 27-AS-20260218141723

Type of visit: Required - 1 Year

On 10/16/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct the annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director (ED). LPA met with Marianne Richardson and a brief interview followed. LPA observed 9 residents eating breakfast in the dining room being attended to by 2 servers. LPA and ED continued on into the kitchen which was inaccessible to residents in care. LPA observed that kitchen staff were wearing appropriate clothing, gloves, and long hair was secured appropriately at the time of the inspection. LPA inspected inventory of food and found it to be sufficient for 7-day perishable and 2-day non-perishable. LPA reviewed storage and dating procedures with the chef. LPA also observed the fire extinguishers were last inspected on 10/30/24 by Johnson Controls. The ED and LPA proceeded to visit 2 resident rooms in assisted living. All had the required furniture, furnishings and lighting to be in compliance at the time of this inspection. LPA inspected the bathrooms and observed hand soap, towels and trash cans along with grab bars and non-slip/skid surfaces in the showers. LPA measure the hot water in room 131 to ensure it was between the required 105 - 120 degrees Fahrenheit. The hot water measured 109.6 degrees and was in compliance at the time of this inspection. LPA activated the call alert/pendant in room 131. Staff responded in 2 minutes and 13 seconds. LPA and ED inspected the Medication Room. LPA reviewed the administration, storage and destruction procedures and compared the physical pill package for one of the resident's medications to ensure it matched what was logged in the electronic medication recording system. LPA also inspected the first aid kit to ensure it had all the required elements. While touring the facility, LPA observed 6 residents in assisted living participating in a morning fitness class in an activity room led by a staff member. Later in the tour this LPA observed 7 residents present for the morning exercise class in memory care being led by the fitness instructor and supervised by 2 memory care staff and the Assisted Living Director. The following materials were posted in the facility: "If You See Something, Say Something" and Ombudsman contact information posters, Resident Rights, grievance policy, calendar of activities, facility menu, and facility license. The ED and the LPA then inspected the exterior of the facility. All screens and gutters were in good repair at the time of this inspection. There was a fenced in garden area in memory care with shade and furniture for residents to enjoy. The front of the facility had a shaded area with furniture for residents in the assisted living area to enjoy. A file review was then conducted by the LPA. The staff roster was reviewed to ensure that all 84 employees had the required background clearances. All were in compliance at the time of this inspection. Files were then reviewed for 3 staff and 2 residents. LPA provided technical assistance regarding training requirements for CPR and First Aid. LPA reviewed that servers in the dining room under 18 years of age must be supervised by someone with caregiver and/or medication technician training in case of emergency. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Marianne Richardson.the state’s words, verbatim · CDSS document, Oct 16, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not prevent resident from developing multiple pressure injuries

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Chateau at River’s Edge RCFE on 4/3/25 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Administrator, Marianne Richardson and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, the department was unable to corroborate the allegations. The department conducted interviews with four (4) facility staff members and four (4) residents. Department also conducted interview with home health personnel HH1 and HH2 (see confidential names list, LIC 811) The department also obtained records for alleged victim, (R1) including physician’s report for R1, R1’s needs and services plan and documented care notes from facility staff and home health personnel. Unsubstantiated Facility staff interviews demonstrated staff were aware of resident’s wounds on thighs and had communicated with home health agency on 8/4/23 that was already providing wound care for R1 for preexisting wounds. As all community care licensed facilities are non-medical, facility staff were not trained to provide wound care and provided documented outreach to home health agencies responsible for wound care. Home health did not diagnose the injuries to R1’s thighs as pressure injuries but as “trauma skin injury”. Facility and home health records indicate Home health visits for wound care occurred on 8/7/23, 8/9/23, 8/14/23, 8/15/23 and 8/18/23. Prior to R1 being sent to the hospital for treatment on 8/21/23 the facility provided multiple attempts at reaching R1’s home health agency for wound care as documentation in facility records indicate the staff members did not believe the wounds observed were healing and were deteriorating per facility notes for R1. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 27-AS-20230822112418

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Chateau at River’s Edge RCFE on 4/3/25 at 9:00am to conduct a case management deficiencies inspection to address deficiencies observed in the process of conducting a complaint investigation regarding R1 (see confidential names list, LIC 811 dated 4/3/25). In the course of the department’s investigation, the department identified the facility did not meet title 22 regulations for providing timely medical assistance for R1 as their bilateral injuries to both thighs were not in a state of healing and were in fact worsening. The facility documented concerns regarding R1’s wounds on 8/9/23. On 8/12/23 and 8/13/23, facility staff attempted to reach Home Health nurse responsible for wound care and on both dates there was no response from home health and no visits conducted to address worsening wounds. On 8/17/23 facility nurse notes identified wounds continuing to deteriorate. R1 was not transported to be evaluated at the hospital until 8/21/23 at the advice of R1’s physical therapist who observed a foul odor emanating from R1’s wounds. Additionally, the home health and wound care order in place for R1 when they returned from skilled nursing on 7/24/23 was for a surgical wound on the hand/wrist. On 8/1/23 Home health was initiated, and no pressure injuries are noted. On 8/7/23 R1’s physical therapist observed two (2) “large wounds on buttocks” and R1 should have been re-evaluated for a change in condition. The facility did not have R1 re-evaluated. The department has also concluded the facility did not put in place any interventions to prevent worsening of wounds on R1’s thighs from prolonged sitting on the toilet seat such as a padded toilet seat or timed toileting to prevent R1 from prolonged sitting as well as sitting for extended periods of time in their wheelchair. The department has also concluded the facility not mot meet the requirements for basic services provided to R1. The department obtained evaluations and needs and services plans dated 7/22/23 that R1 requires “extensive” assistance for toileting. Multiple Home Health agency staff observed R1 on the toilet with no staff members present or aiding R1 who demonstrated sitting on the toilet for prolonged periods of time without intervention or assistance from staff members. Statements obtained from the administrator at the time of the incident described the resident as mostly independent. Per R1’s appraisal on 7/22/23 R1 was documented as needing standby assistance from staff members while toileting. Per California code of regulations, Title 22, the following deficiencies are cited during today's inspection. Due the violation resulting in an injury to the resident, an immediate civil penalty is issued and the department will evaluate the deficiency for additional civil penalties. Exit interview conducted and a copy of this report and appeal rights are left at the facility.the state’s words, verbatim · CDSS document, Apr 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a)(1) · Plan of correction due date: Apr 4, 2025

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by department review of facility records, home health care and physical therapy notes and hospital records that that facility did not seek timely medical attention for resident’s degenerating wounds on both legs as the facility continually reached out for wound care to make unscheduled visits to address wounds when staff members documented increased deterioration of resident’s wounds which posed an immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Facility will provide a written plan of correction indicating the steps facility will take in regards to wound care and when to have the resident sent to the hospital for additional treatments interventions that may not have been successful in the assisted living environment.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(f) · Plan of correction due date: Apr 4, 2025

Reappraisals: The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation, if any, of the appropriate licensed medical professional, and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident’s record. This requirement was not met as evidenced by review of resident’s needs and services plan upon return from skilled nursing, staff interviews and documentation in resident’s file. Per the needs and services plan, R1 was identified as only needing a standby assistance for toileting. Statements and documentation obtained indicate that R1 would frequently sit on the toilet for extended periods of time and staff were not always present to ensure resident did not sit on the toilet for extended periods of time and as a result developed the injuries to both legs. Home health documented that R1 is a max 2 personal assist for toileting which was not documented or integrated into R1’s care plan which poses and immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Facility will conduct training for all caregivers on wound care and skin breakdown and the facility plan for communicating changes in conditions as it relates to wound care and skin issues that may occur in an assisted living environment. The training materials used in the training and written documentation of the communication plan to be provided to the department.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(g) · Plan of correction due date: Apr 4, 2025

Reappraisals: The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. This requirement was not met as evidenced by R1’s medical records, home health and physical therapy care notes and statements obtained by the department. the facility did not ensure corresponding changes to the care and supervision for R1 as R1 was not re-evaluated for changes in condition and no changes to R1’s care plan were made despite developing and worsening wounds on R1’s legs and no intervention in care and supervision were provided to the resident to prevent wounds from developing and worsening including but not limited to timed bathroom breaks and padded toilet seats. As a result, R1 incurred serious bodily injuries which poses an immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: A written plan of correction indicating the specific timelines for reappraisals once it is documented/observed by facility staff that a resident has had a change in condition to wounds or skin breakdown.

Type of visit: Case Management - Other

On 12/10/24 at 3:45pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case management inspection to observed and photograph a resident bedroom. LPA met with administrator Marianne Richardson and together toured the facility and room. LPA obtained photographs of the former resident's bedroom identified as G10. Per California Code of Regulations, Title 22, there are no deficiencies cited during today's inspection. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 10, 2024

Type of visit: Required - 1 Year

On 11/06/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct an annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED), Marianne Richardson. The two met and a brief interview followed. The ED escorted the LPA through the building where the LPA observed the following: a housekeeper servicing rooms on the first floor. In assisted living, this LPA observed 9 residents outside the private dining room playing a trivia game led by a staff member. In memory care this LPA observed 4 residents participating in chair yoga exercises led by a staff member. During the tour this LPA checked to ensure that all fire extinguishers had been serviced, in this case by Johnson Controls, and were in compliance at the time of inspection. LPA inspected the medication cart and compared medications prescribed for R1 to the medications in the cart. All was in order and no errors were located. LPA also inspected the cart for expired medications and found none at the time of inspection. This LPA reviewed the policies and procedures for administering and destroying medications as well as the procedures for administering PRNs. Technical assistance was provided regarding information found in the California Department of Social Services Medications Guide. This LPA also reviewed the facility's first aid kit to ensure it contained the required components. All was in compliance at the present time. LPA inspected a sample of resident rooms. Each had the required furniture, furnishings, and lighting to be in compliance at the present time. Bathrooms also contained the required grab bars and non-skid surfaces in the showers. LPA measured the hot water in a resident bathroom to ensure it was between 105 and 120 degrees Fahrenheit. LPA conducted an external inspection of the facility. There were no external bodies of water present. All windows, window screens, gutters and patio areas were free of debris and in good repair. LPA then went on to conduct a review of 3 resident files. Resident files were complete at the time of inspection. LPA reviewed a sample of 3 staff files. LPA observed documentation for training through an online learning system. LPA provided additional technical assistance with regards to the types of training that the regulations require. LPA toured the dining room where she observed 18 residents having lunch. LPA inspected the kitchen where the following pantry items were found after their "best if used by" date: 3 cans of Crisco - 12/02/22, 5 containers of grits- (1) 05/21/24, (2) 08/13/24, (1) 07/01/24. LPA also found a half-full bottle of teriyaki sauce that was supposed to be refrigerated after opening. According to Title 22 of the California Code of Regulations, this deficiency was cited on the LIC 809D page. No additional deficiencies were cited during today's inspection. A copy of this report was provided along with a copy of APPEAL RIGHTS and an exit interview was conducted with Marianne Richardson.the state’s words, verbatim · CDSS document, Nov 6, 2024

The state marks this report as 12 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: - Staff does not ensure perishable food is properly stored at appropriate temperatures. - Staff does not ensure kitchen equipment is in good repair.

On 10/23/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with the Executive Director (ED) Marianne Richardson. Regarding: "Staff does not ensure that food is stored at proper temperatures." During the course of this investigation, this LPA conducted a review of records and interviews. Interviews with staff: (S1), (S3), and (S7) confirmed that the refrigerator had not been working properly at the time of the complaint and it did not maintain the required temperature of -45 degrees Fahrenheit (or below) to be in compliance. The new Executive Chef purchased a new one on 9/30/24. Prior to the Chef's arrival, the facility still used this refrigerator daily to store perishable food items. The standard for the preponderance of evidence has been met and the allegation, "Staff does not ensure that food is stored at proper temperatures," has been SUBSTANTIATED. This deficiency has been cited on the LIC9099D page. Substantiated Regarding: "Staff does not ensure kitchen equipment is in good repair." Based on interviews and a review of records, it was substantiated that the refrigerator at the facility was not functioning properly. This complaint was opened on 07/31/24 and the refrigerator was not replaced until 61 days later and cost $4,380.00. In addition to the malfunctioning refrigerator, a deli slicer was also sent out for repair. S1 stated that it would "jam up." This LPA learned by reviewing the repair invoice that the slicer had a bad knob and was missing feet (which aided in maintaining its stability during use.) The total repair cost $945.00. The standard for the preponderance of evidence has been met and the allegation, "Staff does not ensure kitchen equipment is in good repair," has been SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency has been cited on the LIC 9099D page. A copy of this report was provided, along with APPEAL RIGHTS and an exit interview was conducted with the Designated Facility Administrator. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding: "Staff does not ensure residents are spoken to in an appropriate manner." This LPA conducted interviews and 4 out of 4 of those interviewed stated that they had not seen or heard anything offensive. S6 stated that there was a server who said they liked to "treat the residents like family" and joke around with them. S6 went on to say that not everyone shares the same sense of humor and diners at other tables might not have appreciated how that server spoke to diners. S4, S6 and S7 all separately stated that the server wasn't offensive, just not very professional. The server was coached and counseled on best practices when communicating with residents in the dining room. The occurrence did not rise to the level of a Title 22 violation. The standard for the preponderance of evidence was not met, and the Department found the allegation was UNSUBSTANTIATED. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding: "Staff does not ensure personal hygiene and food services sanitation practices are followed." LPA Arvin Villanueva inspected the kitchen on 07/31/24 and this LPA made observations on 10/01/24, 10/02/24, 10/16/24 and 10/23/24. On each occasion, this LPA found staff to be complying with personal hygiene and proper food sanitation practices. All required staff had their hair secured and was wearing gloves when handling food. LPA reviewed documentation of Safe-Serve sanitation training for kitchen staff. LPA also conducted interviews and 6 out of 6 of those interviewed stated that sanitation practices were followed. The standard for the preponderance of evidence was not met, and the Department found the allegation was UNSUBSTANTIATED. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding: Staff do not ensure infection control guidelines are being followed. During the course of this investigation, this LPA reviewed the following documents: the facility's infection control plan, dated 06/20/22, the email correspondence and direction provided by Sacramento County Public Health, the email sent out to all of the residents' responsible parties, and the newsletter that went out to the residents in care. This LPA also conducted interviews and 5 out of 6 staff interviewed stated that the infection control plan was followed. During the course of these interviews, this LPA learned that separate dining tables were set up at the end of the hallway on the second and third floors so that Covid positive residents could leave their rooms and have a different environment during their meals. This LPA also learned that most of the time, the Covid positive residents ate their meals in their rooms. The Designated Facility Administrator, Marianne Richardson, provided this LPA with a record of the meal delivery slips for all of the residents during this time period. Public Health provided the following recommendations in an email to Marianne Richardson dated 5/28/24: "1.Stay home if you have Covid 19 symptoms, until you have not had a fever for 24 hours without using fever reducing medications AND other Covid 19 symptoms are mild and improving. If you do not have symptoms, you should follow the recommendations below to reduce exposure to others. 2. Mask when you are around other people for 10 days after you become sick or test positive (if no symptoms). You may remove your mask sooner if you have 2 sequential negative tests at least 1 day apart. Day 0 is symptom onset date or positive test date. 3. Avoid contact with people at higher-risk for severe COVID-19 for 10 days. Higher risk individuals include the elderly, those who live in congregate care facilities, those who have immunocompromising conditions, and that put them at higher risk for serious illness. 4. Seek treatment if you have symptoms, particularly if you are at higher risk for severe Covid 19." There were additional details provided in these emails, and this LPA reviewed them in their entirety. Based on a record review and the information obtained from interviews, the standard for the preponderance of evidence was not met and the Department found this allegation to be UNSUBSTANTIATED. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. According to The California Code of Regulations, Title 22, no deficiencies were observed or cited during this visit. A copy of this report was provided along with APPEAL RIGHTS. Exit interview.the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 27-AS-20240725145033

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(21) · Plan of correction due date: Oct 23, 2024

General Food Service Requirements: (b) The following food service requirements shall apply: (21)...(-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C)... The facility did not comply with the above regulation as evidenced by: Based on interviews S1, S3 and S7 stated the refrigerator was not working properly and the new Executive Chef replaced it on 9/30/24. This poses/posed a potential health and safety risks to resident in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: As this appliance has already been replaced, this replace and a new plan for monitoring kitchen equipment is part an additional POC, this POC has been cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 30, 2024

Maintenance and Operations 87303(a) (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The facility did not comply with the above regulation as evidenced by: Based upon a record review and interviews, the facility continued to use a broken deli slicer and a malfunctioning refrigerator. This poses/posed a potential health and safety risks to resident in carethe state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: The Administrator will submit a letter to Community Care Licensing at Kimberly.viarella@dss.ca.gov. by 10/30/24 that will address monitoring schedule kitchen equipment for repair on a regular basis.

Allegation investigated: Licensee does not ensure facility is in good repair. Staff do not respond to resident requests for assistance in a timely manner.

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Marianne Richardson, and explained the purpose of the visit. The following has been determined in regards to the aforementioned allegations. The investigation consisted of review of facility maintenance logs, records review of resident files, observations of the facility physical plant, interviews with facility staff, and interviews with residents in care. Continues on LIC 9099 - C Unsubstantiated Continued from LIC 9099 According to an interview with the reporting party (RP), the facility elevator has broken down 12 times. Recently, the two times the elevator broke down, it was down for 10 days. For the individuals on the second and third floors of the building, they were not able to go down to the first floor. The facility would bring up the food to the residents. By the time, the resident received the food, it was cold. If a resident were to call for assistance with Activity of Daily Living (ADL), the resident had to wait 45 minutes to respond too the call. The RP expressed concern of if there was a fire, all residents on the second and third floor would end up dead. RP stated there is not enough man power or time to get residents out safely. In December of 2023, the roof leaked and fell down while the RP and resident was eating lunch. The RP provided pictures of the roof being in disrepair. On 04/03/2024, LPA Kimberly Viarella observed the facility. LPA observed the main dining room in Assisted Living (AL) was closed as the ceiling is being repaired and other updates were in the process of being completed. According to an interview with the Dining Room Manager, the elevator was repaired on 03/29/24 after being out of order for 8 days. It went down at 3:00 PM on 03/20/24, and came back into operation at 3:20 PM 03/28/24. LPA Viarella learned that Alpha One Ambulance Medical Services keeps an office at the Chateau at River's Edge, in the Independent Living (IL) portion of the facility. They were on call to assist with transporting residents up and down the stairs as requested. During that time, staff received stair chair training so that they were also able to assist residents in moving between floors while the elevator was out of order. On 04/15/2024, LPA Victoria Brown conducted a complaint investigation for a separate complaint (27-AS-20240411120832) regarding an allegation of staff does not prevent facility roof from leaking. LPA Brown learned the facility secured a contract with Sonray Construction to fix the roof in November of 2023. Due to weather conditions, the construction was delayed. To ensure safety, dining for residents were moved to another area. Resident rooms were not affected. Finding was determined unfounded. On 05/23/2024, LPA Valerio observed the facility. LPA Valerio observed the dining room and kitchen to be closed off from residents as it was under construction. LPA Valerio also observed the elevator to be in working condition. Continues on LIC 9099 - C, page 3 Continued from Page 2, LIC 9099- C On 07/09/2024, LPA Valerio observed the facility. LPA Valerio observed the construction to be completed in the dining room and kitchen. The elevator was observed to be in working condition. The elevator has an active permit issued by the Department of Industrial Relations - Division of Occupation Safety & Health. The inspection was on 02/13/24 and the permit expires 02/13/2025. LPA Valerio reviewed elevator log records. Elevator records show the elevator had a trouble call to TK Elevator 14 times throughout February 2023 to November 2023. The TK Elevator Repair, Test, and Callback Log showed entry dates for 02/13/24, 02/27/24, 02/29/24, 03/08/24, and 03/28/2024. During their hydraulic maintenance task log, it was completed during February 2024. LPA Valerio interviewed Administrator Marianne, which corroborated statements discussed with LPA Brown and LPA Viarella. Administrator Marianne started as the administrator in January of 2024. When the elevator went down in March, the facility used TK Maintenance, which was the maintenance company used prior to Administrator being brought in. Due to the last occurrence, another elevator company was sought out to service and provide maintenance to the facility elevator. Administrator stated they had round the clock staff and Alpha One to assist residents up and down the stairs. They have 3 chair lifts. Alpha One has a station right at the facility, so they are always here. When it first happened, they sent out two crews to assist us because it was during meal time. The chair operates with the help of two staff. Residents had the option to dine in their room, dine upstairs in the common area on the floor, or dine down stairs. The facility turned the activity room and another common area into dining areas. Meals could occur on the first, second, and third floor of the facility. Restaurant crew was bringing hot plates to room and carrying hot trays up and down all the stairs. They made sure socialization was still happening, people were getting fed, and people were getting what they needed. They also brought programming to each level so residents were not confined to their rooms. Administrator stated there was never a time where someone was stuck up there. Continues on LIC 9099 - C, Page 4... Continues from Page 3, LIC 9099 - C R1 recalled the incident of when the elevator went down. The staff would assist R1 by taking R1 to the back stairs. R1 stated it was 2 sometimes, maybe 3 staff that helped R1 down the stairs. R1 uses a walker. R1 would go down anytime R1 wanted to go there. It was mostly for meals. R1 said they offered bingo when the elevator was down. They offered to bring meals up to the room. R1 preferred going downstairs because the plates were hotter. When eaten upstairs, they were warm. They were not cold but not extremely hot. Staff would take about 10 - 15 minutes to get to R1's room. R1 stated R1 was never stuck upstairs. R2 has been a resident since December of 2023. In December, things were different compared to how they are now. In December, staff would take 45 minutes to an hour to respond to R2's call. Currently, staff take 10 - 15 minutes to respond to calls. R2 stated it was due to staff shortage. R2 recalls a time where a staff was shadowing one day and then the next day the staff was on their own. R2 believes that staff need additional training to care for residents, there needs to be better communication between management and residents, and staff/residents need to be trained on emergency evacuations. R2 stated there have been no fire drills since living at the facility. R2 stated the elevator breaks down on a regular basis. Staff brought everything to R2, meals and activities included. According to R2, staff made it work. R3 stated R3 was never stuck upstairs, is independent, and remembers staff bring meals to the room. R3 stated it took about 20 minutes for staff to respond. R5 stated on weekends, it takes staff longer to respond, possible due to being short staff. Staff take 30 minutes or longer to respond to calls on weekends compared to right away to 10 minutes on the week days. R5 stated the elevator has always worked, feels safe, and says staff treat them well. Continues on LIC 9099 - C, Page 5 Continued from Page 4, LIC 9099 LPA Valerio interviewed five (5) staff, Staff 1 (S1) - Staff 5 (S5). S1 works morning shift. S1 says it takes staff about 5 to 10 minutes to respond to resident call. If they are short, they work together to make sure they get to all the residents. S2 stated there is 5 - 6 staff on shift, sometimes 7 staff to directly care for the residents. S2 typically does immediately to help residents if S2 sees a call. If S2 is busy, S2 will use the walkie talkie to get someone else to respond to the call. S2 takes time with the resident and does not want to rush so they can get what they need. S2 does not recall a time when the elevator went down. S3 stated response time depends on how many staff are on shift and if the person is available. S3 stated it could take anywhere from one minute, five minutes, to fifteen minutes. S3 stated they use a Tablet aerial system for resident pendant calls to see who is calling and Carestream is used to document ADLs. S4 stated there are times where things are not working, but the facility gets them fixed. S4 feels there is enough staff on shift to care for the resident. S4 takes less than 5 minutes to answer the call lights. When the elevator broke down, staff brought everything upstairs, including meals. S5 stated training has been given for emergency evacuation, general orientation, and e-learning. S5 used the "special wheelchair" to get the residents down when the elevators were not working. S5 stated they needed two people to assist and it would not take long because they worked together. S5 answered call lights immediately. S5 stated we have to make sure we answer right away. Just in case they use the restroom or they want to get up, we do not want them to fall. When S5 is busy, S5 uses the radio to call for someone to help. S5 stated there is not a time where staff do not respond right away. Due to the above noted information, 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, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was held and a copy of report was given to Executive Director/Administrator Marianne Richardson.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 27-AS-20240327132006

Allegation investigated: - Facility director made inappropriate decisions for a resident to be placed at a different facility where the staff member later became a director. - Staff coerced a dementia resident into signing documents. - Staff billed a resident for two rooms at the same time.

On 7/3/24 at 1:05pm Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a follow up investigation and deliver findings to the allegations noted above. LPA met with Marianne Richardson, Executive Director/Administrator, and explained the purpose of the visit. During this visit, LPA observed some residents were participating in a BINGO game being conducted in the activity area near the dining room. Some residents were observed to be dining at the dining room. LPA also conducted additional staff interviews. {Page 1/4} Unfounded Allegation: Facility director made inappropriate decisions for a resident to be placed at a different facility where the staff member later became a director. Throughout this investigation, LPA conducted interviews with facility staff, former staff and Power of Attorney (POA) representatives. Additionally, LPA conducted a review of resident files. According to interview with the POA representatives, the decision to relocate R1 was based on the need for a higher level of care which the assisted living could no longer provide. POA representatives further explained that R1 needed to be place in memory care based on current assessment of R1’s Behavior Therapist. The interviews further disclosed that while considering alternative placements at other facilities, the decision to move R1 to current facility was influenced by the recommendation of the former administrator, who had a positive relationship with R1. Additionally, it was clarified that the move was primarily driven by the need for memory care, which was not available at Chateau's at Rivers Edge at the time. Interview with current administrator confirmed that R1's relocation was necessary due to the requirement for memory care, which Chateau's did not offer at the time of the decision. Review of R1’s care notes revealed that on 12/19/23, R1’s behavior therapist had informed facility staff that R1 is not suitable for the community (Assisted Living) due to R1’s cognitive state. Based on that, further review revealed that on 12/20/23, POA representative for R1 contacted the facility informing them that POA will be putting in 30-day notice for R1. Based on all gathered information, the Department concluded that the allegation of inappropriate decision-making by the facility director regarding R1's relocation to a facility where they later became director is UNFOUNDED. The decision was justified by the resident's care needs and available placement needed at that time. {Page 2/4} Allegation: Staff coerced a dementia resident into signing documents. The investigation into the allegation that staff coerced a dementia resident (referred to as R1) into signing documents involved staff interviews and document reviews. According to an interview with staff, R1 demonstrated awareness of what they were signing at the time. Staff further noted the presence of a Notary Public during the signing of documents to assess R1's capacity to understand and consent to the content of the documents. Additionally, R1's accountant was present, providing further oversight. Review of Notary Public documents dated July 5, 2023, and October 4, 2023, confirmed R1 signed the documents in the Notary Public’s presence, verifying R1's identity and confirming that R1 executed the documents willingly and in their authorized capacity. Additionally, review of R1’s Physician Report (LIC 602A) dated January 23, 2023, indicated R1 was diagnosed with Mild Cognitive Impairment but retained the ability to follow instructions and communicate needs. Based on these findings, the Department concluded that the allegation of staff coercion of the dementia resident into signing documents was UNFOUNDED. The presence of a Notary Public, R1’s awareness during the signing process, and their ability to communicate needs supported the conclusion that the documents were executed voluntarily and in accordance with R1's capacity. {Page 3/4} Allegation: Staff billed a resident for two rooms at the same time. Throughout the investigation conducted by LPA, interviews and record reviews were conducted to address allegations concerning billing discrepancies for resident (R1). Review of R1's ledger from November 2019 to March 2024 revealed specific transactions. R1 was charged at the Independent Living unit for January 2023 on 12/21/22 and was credited partially for January 2023 on 1/23//23. Additionally, R1 was last charged at the Independent Living unit on 1/23/23, for the month of February 2023, but was credited the same amount immediately. Subsequently, on 1/23/23, charges appeared for R1 at the Assisted Living unit for the month of February 2023 and for part of January 2023. In an interview with the current Administrator, it was clarified that despite R1's belongings remaining in their Independent Living unit for nearly a year, R1 was not billed twice for occupancy. Based on the gathered information, the Department concluded that the allegation of staff billing resident for two rooms simultaneously was UNFOUNDED. The investigation confirmed that billing was handled appropriately, with no evidence supporting the claim of improper charges. Note that an unfounded finding means the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Marianne Richardson, Executive Director/Administrator, and a copy of this report was provided. {Page 4/4} This practice ensures that residents who require assistance are properly attended to during their mealtime and returned safely to their designated living area afterward. It was noted during interviews that Independent Living residents do not receive direct staff assistance as they are more independent, whereas Assisted Living residents receive necessary escorting. The investigation also referenced a documentation from R1’s Physician Report and Service Plan, which confirmed R1's need for extensive assistance and their inability to independently manage self-care due to cognitive impairment and physical limitations. Based on the gathered information, the Department concluded that the allegation that staff did not allow R1 to dine in the dining room of their choice was UNSUBSTANTIATED. The procedures in place, including escorting R1 and other residents when requested, were deemed appropriate given R1's care plan and safety needs. Note that an unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Marianne Richardson, Executive Director/Administrator, and a copy of this report was provided. {Page 2/2}the state’s words, verbatim · CDSS document, Jul 3, 2024 · control 27-AS-20240314135803

Allegation investigated: Staff does not prevent facility roof from leaking.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above mentioned allegation on 4/15/24 at 9:45a. LPA met with Marianne Richardson, Executive Director and stated the purpose of the visit. LPA observed several trucks at the facility and workers on the roof. Both Sonray and Paragon construction crew were working on the roof during this visit. LPA inquired how long they have been working on the roof and one representative (name unknown) stated they have been working on the roof since last week (Friday). LPA inquired with Marianne Richardson, Executive Director who stated since November there has been a contract in place and no resident rooms affected and the crew has been working for the last 4 weeks. This concerns the dining room and kitchen area. Dining for the residents has been moved to another area of the facility for safety reasons. The facility has 2 kitchens on the premisis. The company Sonray Construction could not work on the roof due to the weather conditions until now which will be completed today. Marianne Richardson, Executive Director provided the contract dated 11/20/2023 and other documentation of the conversations between Sonray Construction and the facility on fixing the roof. Unfounded Sonray Construction began the roofing work, however, Paragon Construction is completing the additional scope of work required by the Engineer for the permit. A copy of the Paragon Construction contract dated 3/28/24 which was initiated 3/26/24 was provided. The inside areas of the dining room such as the carpet, mold inspection, painting will be completed within the next 2 weeks. An incident report was submitted to Community Care Licensing (CCL) as well. A report of completion shall also be submitted to CCL. Based on interviews and a review of documentation the allegation is deemed Unfounded. "The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint." Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 27-AS-20240411120832

Type of visit: Case Management - Deficiencies

On 3/5/2024 at 2:30PM Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit. LPA met with Marianne Richardson, current Executive Director (ED) and explained the purpose of this visit. During the course of the investigation into complaint control number 27-AS-20231121160532, deficiencies were identified which are being addressed by this case management. During the course of the investigation for the above listed complaint, facility observations, record reviews and interviews were conducted. During the course of the investigation, it was revealed through interview of S1 and R1’s responsible party (RP) that R1 was not served meals since the day R1 moved in on 11/18/23. Interview with the RP revealed that R1 had access to Glucerna which it appears R1 consumed based on empty bottles that were observed when one of R1’s family member visited R1 unannounced on 11/21/23 at 12:28pm. Review of facility’s meal logs from 11/19/23 to 11/21/23 (breakfast) revealed no record of R1 being served breakfast, lunch, and/or dinner. Review of facility’s meal logs from 11/22/23 to 11/30/23 revealed R1 being served at least 3 meals per day. As a result of this case management, a deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiency may also result in civil penalties. An exit interview was conducted with Marianne Richardson and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 5, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(1) · Plan of correction due date: Mar 6, 2024

87555 General Food Service Requirements: (b) (1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day...Not more than fifteen (15) hours shall elapse between the third and first meal. This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not ensure R1 received at least three meals per day from 11/19/23 to 11/21/23 at breakfast.the state’s words, verbatim · CDSS document, Mar 5, 2024

Plan of correction: Licensee to submit a statement of understanding regarding CCR 87555 to the Department by the POC due date.

Allegation investigated: - Staff left resident soiled for an extended period. - Staff did not ensure resident’s care needs were met in a timely manner. - Staff did not ensure resident’s room was cleaned adequately. - Staff did not maintain a comfortable room temperature for resident.

On 1/25/2024 at 10:30am Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to continue conducting a complaint investigation and to deliver findings for the allegations noted above. LPA Villanueva met with Marianne Richardson, current Executive Director (ED) and explained the purpose of the visit. Throughout this investigation, the LPA conducted facility observation, interviews, facility record review, staff record review, and resident record review. During the course of the investigation, the Needs and Services Plan, LIC 602 and Admissions Agreement were reviewed for resident_1(R1). Staff_1 (S1) was interviewed as well as the interim Administrator and RP. During the investigation S1 was interviewed and it was disclosed and confirmed to LPA that the above allegations occurred to R1. Per S1, when there is a new resident, S1 would be in communication with family members of that resident and the facility staff including involved management. A face sheet would be created of the new resident that includes a photo of the resident, apartment number of that resident, the resident's diet/food preferences, move-in date and other facts about that resident. {Con't to LIC9099-C} Substantiated {Con't from LIC9099} The face sheet would then get distributed to staff including the management, care staff, med techs, and kitchen staff and would be posted in the medication room and the kitchen for staff to be aware of the new move in and residents needs. S1 further explained that they would post welcome signage at the new resident's apartment door before that resident moved in. S1 confirmed that R1 moved into the facility on a day that S1 was off, therefore the process explained above was not completed. S1 confirmed that staff were unaware that the resident was present at the facility. S1 confirmed that R1 was left unattended for a period of about 2-3 days. S1 confirmed the allegations occurred. Therefore, the above allegations are SUBSTANTIATED in which the preponderance of evidence standard has been met. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An immediate civil penalty in the amount of $500 is assessed in addition to the citations issued. Additional An immediate civil penalty in the amount of $250 is assessed in addition to the citations issued due to a repeat violation. These incidents are currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. An exit interview was conducted with Marianne Richardson (ED) and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 25, 2024 · control 27-AS-20231121160532

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 26, 2024

87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) (f) and Health and Safety Code section 1569.2(i). This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not ensure care and supervision needs were provided in a timely manner to R1 which resulted in absence of care and supervision longer than one day. This poses/posed an immediate health and safety risks to resident in carethe state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: Licensee to submit a written care plan on how the facility will provide adequate care and supervision for new move in residents. The facility shall submit the care plan to Licensing by POC due date of 1/26/2024. Licensee to provide staff training on the procedure of the care plan for new move in residents. Licensee to submit the date of the training by POC due date. Licensee to submit proof of staff training once completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(1) · Plan of correction due date: Feb 1, 2024

87303 Maintenance and Operation: (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement is not met as evidenced by: Based on interviews and document review, the licensee did not ensure R1’s apartment unit was maintained at a comfortable room temperature at a minimum of 68 degrees F which poses/posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: Licensee to include in the staff training on the subject of maintaining comfortable temparature for residents per regulation. Licensee to submit the date of the training by POC due date. Licensee to submit proof of staff training once completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 1, 2024

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not me as evidenced by: Based on record review and interview, R1 was left unattended for an extended period of time. As a resulted the licensee did not ensure R1’s apartment unit was cleaned adequately which poses/posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: Licensee to include in the staff training on the subject of keeping facility clean, safe, sanitary, and in good repair per regulation. Licensee to submit the date of the training by POC due date. Licensee to submit proof of staff training once completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Feb 1, 2024

87625(b)(3) ... the licensee shall be responsible for ... Ensuring that incontinent residents are kept clean and dry and ... the facility remains free of odors from incontinence. This requirement is not met as evidenced by Based on interviews and record review, R1 was left unattended for an extended period of time. As a resulted, the licensee did not ensure R1 was provided incontinent care which left R1 being soiled for an extended time. This poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: Licensee to include in the staff training on the subject of incontinence care for residents per regulation. Licensee to submit the date of the training by POC due date. Licensee to submit proof of staff training once completed.

Allegation investigated: - Staff are not addressing vermin in the facility. - Staff are not keeping the facility free from odors from incontinence.

On 1/25/2024 at 1pm Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to continue conducting a complaint investigation and to deliver findings for the allegations noted above. LPA Villanueva met with Marianne Richardson, Executive Director (ED) and explained the purpose of the visit. Throughout this investigation, the LPA conducted facility observation, staff interview, and facility record review. Allegation: Staff are not addressing vermin in the facility. On 12/13/23, LPA conducted facility observation in the following apartments: #312 and #316. Per interview with interim Administrator, these rooms are being used as storage. LPA observed apartments to be locked and not accessible to residents living in the building. Once inside, LPA observed evidence of vermin droppings in these apartments. The administrator has provided LPA with documentation proving that any pest control issues that may arise are being addressed proactively. Administrator able to furnish proof of on-going pest control contracted services invoices dated 1/4/23. {Con't to LIC9099-C} Unsubstantiated {Con't from LIC9099} Per review of the contract, the scope and nature of the work includes roaches, common ants, rats and mice. Further review indicated that the frequency of the service is once a month for a period of one year. During facility observation of the outside perimeter of the facility, LPA noted rodent bait stations placed around the building. Based on observation, interviews and record review, there is not a preponderance of evidence to conclude that the facility staff are not addressing vermin in the facility. Therefore, this allegation is UNSUBSTANTIATED. Allegation: Staff are not keeping the facility free from odors from incontinence. This investigation consists of observations. This LPA conducted facility observations during the following visits on 11/30/23 and 12/13/23. During these visits, LPA did not notice odors from incontinence. This facility was also visited by other LPAs on 12/14/23, 11/20/23. 10/02/23 and 9/28/23. During these visits, LPAs did not note in their reports of any odors from incontinence. Based on information obtained, there is not a preponderance of evidence to conclude that the facility staff are not keeping the facility free from odors from incontinence. Therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with ______ and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 25, 2024 · control 27-AS-20231206120154

Type of visit: Case Management - Deficiencies

On 1/25/2024 at 2:30PM Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit. LPA met with Marianne Richardson, current Executive Director (ED) and explained the purpose of this visit. During the course of the investigation into complaint control number 27-AS-20231206120154, a deficiency was identified which is being addressed by this case management. During the course of the investigation for the above listed complaint, facility observations, record reviews and interviews were conducted. During an unannounced visit on 12/13/23, this LPA and another LPA inspected the following apartments, #312, #314 and #316. The interim administrator informed LPAs that these 3 apartments are currently being used as storage. LPAs observed these apartments to be locked and not accessible to residents living in the building. Once inside, LPA observed evidence of vermin droppings in apartments #312 and #316 (photos taken). Per interim administrator, these apartments have not been used in years but unable to determine how long these droppings have been in these apartments. Although the licensee has addressed vermin issues in the facility and the interim administrator has provided proof of on-going pest control contracted services dated 1/4/2023 to address rats and mice and that these apartments are kept locked and inaccessible to residents in the building, the licensee did not ensure these apartments were cleaned and free of vermin droppings which can still pose potential health and safety risks to residents and staff in the building. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An immediate civil penalty in the amount of $250 is assessed in addition to the citations issued due to repeat violation.This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. An exit interview was conducted with Marianne Richardson and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 1, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not ensure the facility is clean, safe and sanitary as evidenced of vermin droppings in two apartments. This poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: Licensee to ensure facility is clean, safe, sanitary and in good repair at all times even in areas that are not being used by residents. Licensee to clean the apartment units #312, 314, and 316. Licensee to submit a decleration of understading of the CCR 87303 Maintenance and Operation to the Department by POC due date of 2/1/2024.

Allegation investigated: The facility elevator is in disrepair. Facility staff do not provide adequate food service to residents in care.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to investigate this complaint. LPA Moleski met with memory care director Xochitl Vuittonet and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski used the facility elevator during visits on 11/20/23 and 12/14/23. The elevator worked during these visits. During an interview, a former facility administrator said that the facility elevator started having issues on the morning of November 11, 2023. The administrator said that an elevator technician was called on Saturday, but parts for the elevator were not available over the holiday weekend. The administrator said that the elevator buttons did not immediately work, and needed to be pressed multiple times. [continued on 9099-C] Unsubstantiated The administrator said the elevator was not used over the weekend to prevent anyone from getting stuck inside. The administrator said the elevator was available for use for emergencies, if needed. The administrator said the elevator was repaired on November 13, 2023. The administrator said that meals were delivered to any residents who did not want to come downstairs. LPA Moleski reviewed an email sent by the former facility administrator to the Community Care Licensing Division on November 12, 2023. In the email, the administrator said the elevator was having “technical issues,” and that “we are able to use it” but “we made an executive decision to not use it until it can get fully repaired on Monday [November 13, 2023]”. LPA Moleski reviewed a work report from an elevator maintenance company. The report details service through the period of November 11, 2023 and November 15, 2023. According to the report, the elevator buttons were lighting up but would then turn off as of November 11, 2023. The report describes service being performed on November 13, 2023. The elevator had returned to service as of November 15, 2023, according to the report. LPA Moleski interviewed four staff members (S1-S4). In an interview, the facility maintenance director (S1) said S1 was first aware of the elevator issues as of November 10, 2023. At that time, the elevator’s button lights would turn off after being pressed, but would work if pressed repeatedly. According to S1, an elevator maintenance company was called on November 11, 2023. S1 said the elevator was fully operational as of the morning of November 14, 2023. LPA Moleski interviewed four residents (R1-R4). In an interview, R1 said food was delivered while the elevator was not being used. R1 said staff were “very good” about delivering food. R1 said R1 had no concerns regarding the food service while the elevator was not being used. LPA Moleski reviewed food service sheets dated between November 11, 2023 and November 13, 2023. According to the sheets, R1 was not served any meals during this time. In an interview, R1 said R1 had some food delivered, and said R1 had plenty of food in R1’s room. LPA Moleski reviewed R1’s LIC 602. R1 is ambulatory, according to the LIC 602. [continued on 9099-C] In an interview, the facility’s dining room manager (S2) said that R1 often refuses meal service, and that R1 prefers R1’s own food. S2 said there were no issues with food deliveries during the time the elevator was not being used. In an interview, S3 said there were no issues getting meals delivered to residents on November 12, 2023. S4 did not recall any issues with food service on November 13, 2023. In interviews, R2-R4 did not share any concerns regarding food service during the time the elevator was not being used. R3 said R3 was helped downstairs by a friend, and said that the elevator was available for use for emergencies. R3 said R3 used the elevator while it was not in general operation. R4 said R4 was carried upstairs in a wheelchair by paramedics while the elevator was not being used. The department has determined the following as it relates to the allegations that the facility elevator is in disrepair and that facility staff do not provide adequate food service to residents in care: Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Vuittonet.the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 27-AS-20231114075826

Allegation investigated: The facility is in disrepair.

On 12/13/23 at 10:00am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to open and investigate the complaint allegations noted above. LPAs met with the facility's Interim Administrator, Grace Hartnett, and explained the purpose of the visit. During this visit, LPAs Bilger and Villanueva conducted facility observation and staff interviews. Additionally, LPAs conducted facility file reviews. LPAs requested copies of the following documents for review: pest control agreement, facility admission policy and processes, resident move-in coordination documents, medication administration record (MAR) for November and December 2023, list of new adminssions for November and December 2023, and menu for November and December 2023. {Con't on LIC9099-C} Substantiated {Con't from LIC9099} For the allegation, facility is in disrepair, during a facility observation in the first floor of the facility, LPAs observed a door that is in disrepair located near the laundry room and memory care entrance. Grace Hartnett, the interim administrator, confirmed the door in question to be a fire door. The upper part of the door was peeled off and the inside of the door is exposed. Additionally, when LPAs tried to release the door from its magnet, the door would get stuck to the carpet and was observed the door to not function or close properly as intended. At 3:30pm, LPAs observed facility staff conduct fire alarm test. LPAs observed that the damaged door did not released from its magnet, therefore, the door did not closed as intended for fire safety. Based on observation and interviews conducted, the allegation that the facility is in disrepair is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. An exit interview was held with the interim administrator, Grace Hartnett, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 13, 2023 · control 27-AS-20231206120154

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Dec 12, 2023

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation and interview, a fire door located near the memory care of the facility was observed to be not functioning and not closing properly when released from its magnet, which poses an immediate health, safety and personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 13, 2023

Plan of correction: Licensee to repair or replace a new fire door to function property for safety protocol. A written plan to repair or replace to be submitted to the Department by the POC due date. LPA will conduct a POC visit at a late date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 20, 2023

87303 Maintenance and Operation: (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation and interview, a fire door located near the memory care area of the facility was observed to be in disrepair which poses a potential health, safety and personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 13, 2023

Plan of correction: Licensee to repair or replace a new fire door. A written plan to repair or replace to be submitted to the Department by the POC due date. LPA will conduct a POC visit at a late date.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility failed to repair broken elevator Facility staff failed to serve meals in a timely manner

On 10/18/23, Licensing Program Analyst (LPA) Tung Truong conducted unannounced facility visit to complete and delivery findings for a complaint investigation received on 9/11/23. LPA met Interim Administrator Elena Cuevas and discussed the conclusion for complaint and the findings. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on LPA observations of facility, record reviews, and staff and resident interviews, there is not a preponderance of evidence to substantiate the allegations mentioned above. Regarding the allegation that the facility failed to repair a broken elevator, it was learned that the elevator was inoperable from September 7 to 15 due to a bad circuit board. Continued on 9099-C Unsubstantiated On 9/12/23, elevator repair company informed the facility that all circuits boards would need to be replace due to older boards no longer being supported and not capable of communicating with newer boards. There was a delay in repair due to waiting for the boards to arrive. Based on records reviews, the facility contacted elevator repair immediately upon being aware of the issue. LPA observed that the facility had done everything to remedy the problem. Moreover, it was learned that the same elevator was out of service for four days in May 2023. LPA Gould unsubstantiated the allegation of elevator is in disrepair on 8/10/2023 by Complaint Control Number: 27-AS-20230501114110. Regarding the allegation that facility staff failed to serve meals in a timely manner, LPA reviewed records and conducted interview with 7 residents and 4 staff members. Based on staff interviews, staff stated that when the elevator was out of service, it does take a bit more time for food to be delivered. However, staff informed that all residents were receiving meals in a timely manner. Staff denied having knowledge of any resident who was provided meals late. Based on resident interviews, 5 out of 7 residents stated that meals were provided timely. LPA interviewed resident (R1), R1 stated that she receives all her meals in a reasonable time. As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 18, 2023 · control 27-AS-20230911131252

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual continuation inspection on 10/02/2023 at 8:00 AM. LPA Martinez met with Elena Cuevas and stated the purpose of today’s visit. LPA Martinez inspected the physical plant of the facility to ensure compliance with Title 22 regulations. The facility is licensed for 26 ambulatory residents and 116 non-ambulatory residents, which 10 may be bedridden. In addition, the facility has an approved hospice waiver for 15. There are currently 86 residents who reside at this facility. LPA Martinez toured the facility with Elena Cuevas on 10/01/2023 at 9:30 AM. During today's visit, LPA Martinez toured the memory care unit, and the memory care unit census is 9. LPA Martinez reviewed the fire inspection report with Elena Cuevas. Elena Cuevas and LPA Martinez toured the exterior of building and fire sprinkler system. During the tour, LPA Martinez and Elena Cuevas visited the pond area. Elena Cuevas reported the pond was three feet deep. During 09/28/2023 initial annual visit, LPA Martinez reviewed medication administration records, staff files, resident files, toured the facility, inspected the kitchen, and inspected fire extinguisher tags. 09/28/2023 deficiencies can be found on the annual 09/28/2023 809 report. In addition, LPA Martinez reviewed administrator change request documentation. The Department will continue to follow up with process of Elena's administrator certificate renewal request. As result of today's visit, there were no deficiencies cited. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 2, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 09/28/2023 at 8:30 AM. LPA Martinez met with Chelsea Xiong and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. Administrator holds current certificate. The facility is licensed for 26 ambulatory residents and 116 non-ambulatory residents, which 10 may be bedridden. In addition, the facility has an approved hospice waiver for 15. There are currently 86 residents who reside at this facility. LPA Martinez toured the facility with Karla Rocha on 09/28/2023 at 2:30 PM. Due to insufficient time, the annual will require a continuation visit. The Department will return at a later date to complete the annual inspection. However, at today's 09/28/2023 annual inspection the following deficiencies were observed: Nine out ten employees were missing first aid certificates. Kitchen freezer measured at 10 degrees. Kitchen refrigerator measured at 47 degrees. Resident 1 (R1) is on a special diet (Gluten Free) However, facility kitchen staff was unaware of special diet and facility staff reported resident 2 (R2) is also on a glutin free diet. The facility has not implemented a glutin free plan. Pond/large body of water procedures are being reviewed by LPA Martinez. As a result of this annual inspection, the following deficiencies can be found on the 9099 D page. In addition, the Department will return at a later date to complete the continuation of this annual visit. An exit interview was conducted, and copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 28, 2023

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Oct 10, 2023

87411(c)(1) Personnel Requirements - General: All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidence by: Based on file review, The Licensee did not ensure 9 out of 10 employees had first aid annual training. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Oct 10, 2023

87555(b)(21)General Food Service Requirements: The following food service requirements shall apply: Freezers of adequate size shall be maintained at a temperature of 0 degrees... and refrigerators of adequate... maximum temperature of 40 degrees F (4 degrees C)... This requirement was not met as evidence by: Based on inspection, the Licensee did not ensure temperature measures at 0 and 40 degrees. Freezer measured at 10 degrees and refrigerator measured at 47 degrees. This posed a potential health & safety risk to residents.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: POC to be cleared by visit.

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Oct 10, 2023

87464(d) Basic services facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...This requirement was not met as evidence by: Based on record review R1 and R2 are on glutin free diets, which kitchen staff reported having no knowledge of glutin free diets and do not have a service plan to meet the needs of R1 and R2. This posed a potential health and safety risk to R1 and R2.the state’s words, verbatim · CDSS document, Sep 28, 2023