The Courtyard

Type of visit: Required - 1 Year

LPA Hiratsuka, conducted this unannounced annual visit. LPA toured with Administrator Brandy Strahl. This facility is on a campus surrounded by a wrought iron fence that has a gate for cars and an unlocked pedestrian gate. This campus also has a skilled nursing on it and behind this building is The Gardens 515001365. The buildings share common pedestrian areas and this building and the skilled nursing share the parking lot. This facility 54 resident rooms and all have full private bathrooms. There are two restrooms for staff and residents. There is a laundry room that is used mainly by staff but residents may use it if they wish. There are several small common areas, one large dining/activity room, and the front area has offices on the left and a small activity room on the right. Several topics were discussed. Several staff and resident files were reviewed. No deficiencies cited.the state’s words, verbatim · CDSS document, Dec 17, 2025

Allegation investigated: Facility staff did not provide adequate supervision to resident in care.

LPA Hiratsuka, conducted this unannounced complaint visit to deliver the findings into the allegation above. Title 22 regulations requires facilities to assess a resident to determine the level of care and supervision a resident requires and have a separate written plan of care of how the facility staff are going to meet the resident needs. Title 22 regulations do not require staff to be with a resident, in eye sight of a resident, or within hearing distance of a resident at all times. LPA reviewed facility and hospice medical records. LPA also interviewed staff and witnesses. Unsubstantiated The resident records show the caregivers checked on the resident at least every two hours. There was one incident where the resident had a lot of agitation during the late night and early morning hours of the following day. Facility notes show the resident was checked on, but did not show how many times the resident was actually checked because the notes that were written by the staff were summaries of the resident’s condition when it appeared they had time during their shift to do so. The written plan of care stated the resident required frequent checks but did not specify the amount of checks per shift were required. Due to the information gathered, LPA cannot determine Facility staff did not provide adequate supervision to resident in care. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 4, 2025 · control 59-AS-20250509094217

Allegation investigated: Staff mismanaged residents medication.

Licensing Program Analyst Kerry Hiratsuka conducted this unannounced complaint visit to deliver the results of the allegation above. LPA interviewed Administrator and staff. The med tech assigned to dispense medications was on vacation. Another med tech who normally passes medications at this facility's sister facility and is associated to this facility, came to assist this facility to assist with passing medications. There are two residents with the same first name and the substitute med tech accidentally got them mixed up and one resident received the medication for the other resident. The med tech immediatly reported the incident to managment and management immediately conducted an investigation into the incident, contacted the physician, responsible party, monitoring resident, and later reviewed medication proceedures with staff who are in charge of medications. Resident did not suffer any ill effects from the medication error. Substantiated Administrator stated there is going to be refresher training for staff who handle medications. Administrator stated she is also going to research ways to flag residents who share names. Based on the information gathered through interviews, LPA was able to determine that the allegation is substantiated. Therefore, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Please see 9099-D for the deficiency sited.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 59-AS-20250813093452

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 20, 2025

Incidental Medical and Dental Care. 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: The licensee shall assist residents with self-administered medications as needed. This requirement not met as evidence by the facility based on interviews there was a medication pass accidentally given to another resident which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: this is corrected during visit. Refresher training has already been done for the one med tech and is scheduled for the remaining med techs. And the administrator is researching ways to flag residents who share names to ensure the error doesn't occur again.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cassandra Mikkelson and Kerry Hiratsuka arrived unannounced to conduct an annual inspection. LPAs met with Administrator Brandy Strahl during today's inspection. LPAs conducted an inspection of the care facility to ensure compliance with Title 22 regulations. This facility is on a campus surrounded by an iron fence that has a gate for cars and an unlocked pedestrian gate. This campus also has a skilled nursing on it and behind this building is The Gardens 515001365. The buildings share common pedestrian areas and this building and the skilled nursing share the parking lot. This facility has 54 resident rooms and all have full private bathrooms. There are two restrooms for staff and residents. There is a laundry room that is used mainly by staff but residents may use it if they wish. There are several small common areas, one large dining/activity room, and the front area has offices on the left and a small activity room on the right. LPAs checked the kitchen area for the ability to prepare and store food. Facility has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are hard wired and operational in the care facility. Fire extinguishers are maintained and ready for emergency use. LPAs checked medication room and found medications to be locked away and inaccessible to the residents. LPAs reviewed five (5) resident files and four (4) staff files. As a result of this visit, no deficiencies were cited. Exit interview was conducted with Administrator. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 22, 2025

Type of visit: Case Management - Incident

LPA Hiratsuka conducted this unannounced case management visit. This is in response to the facility submitting a death report. LPA obtained a copy of some documents from the resident's file. No deficiencies cited.the state’s words, verbatim · CDSS document, Nov 14, 2024

Type of visit: Required - 1 Year

LPA Hiratsuka, conducted this unannounced annual visit. LPA toured with Administrator Brandy Strahl. This facility is on a campus surrounded by a wrought iron fence that has a gate for cars and an unlocked pedestrian gate. This campus also has a skilled nursing on it and behind this building is The Gardens 515001365. The buildings share common pedestrian areas and this building and the skilled nursing share the parking lot. This facility 54 resident rooms and all have full private bathrooms. There are two restrooms for staff and residents. There is a laundry room that is used mainly by staff but residents may use it if they wish. There are several small common areas, one large dining/activity room, and the front area has offices on the left and a small activity room on the right. Several topics were discussed. Several staff and resident files were reviewed. No deficiencies cited.the state’s words, verbatim · CDSS document, Jan 17, 2024