The Forum at Rancho San Antonio

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Rosalie Zbasnik-Hulog and stated the purpose of today's visit. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility to include at random 5 resident rooms, common living areas, activity room, dining room, kitchen and storage. 5 Out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom sinks ranged from 116.0 - 116.2 degrees F. Fire extinguisher was observed and inspected on 05/06/2026. Facility smoke detectors were inspected by third party vendor. The last disaster drills were conducted on 06/12/2026 and 06/19/2026. LPA Rai observed a complete first aid kit at the facility. LPA Rai reviewed facility records for 6 staff and 6 residents. LPA Rai reviewed resident medications and central stored medication records. During today's visit, LPA Rai discussed an Incident Report the Department received regarding a resident(R1) to resident (R2) altercations occurring in the Memory Care unit. LPA Rai interviewed 5 residents and 6 staff. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. During today's visit, LPA Rai discussed a Death Report the Department received for resident (R3) wherein R3 had a change of condition and was taken to the hospital and passed away the same day at the hospital. No deficiencies were cited per California Code of Regulations, Title 22. Technical Violation was provided. This report was reviewed with Administrator, Rosalie Zbasnik-Hulog and a copy of the report was provided. LIC 858 and LIC 859 were provided.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit regarding an incident report, regarding a death report for a resident referred to as R1. LPA met with Administrator Rosalie B Zbasnik-Hulog and explained the purpose of the visit. On March 4, 2026, the Department received an incident report stating on March 3, 2026, stating resident R1 had passed away. The incident report stated on March 3, 2026 at 6:10pm, Wellness staff received a phone call from R1's family member, stating he/she has been calling R1, but no answer. Wellness staff went to the room and found R1 unresponsive. LPA requested R1's Identification and Emergency Information, house keeping schedule, physician's report, pre admission appraisal, medication list. LPA requested a copy of resident R1's death certificate once it becomes available. At this time, this case in under review and Department will conduct a follow visit , if warranted. No deficiencies cited during today's visit. This report was reviewed with Administrator Rosalie B Zbasnik-Hulog and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 5, 2026

Allegation investigated: Resident is not being assessed for injuries after fall. Facility staff left resident on the floor after calling 911.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Director of Health Services Rosalie Hulog (DHS). On 09/24/2025, the Department received a complaint with the above allegations. On 10/01/2025, an initial investigation visit was conducted. LPA interviewed DHS, 3 staff and resident R1. Incident report, physician report, and appraisal/Needs and service plan of R1 were obtained. Continue on LIC(099-C, Page 1 of 3. Unfounded Resident is not being assessed for injuries after fall: Facility staff left resident on the floor after calling 911: On 10/01/2025, LPA interviewed Director of Health Service (DHS) Rosalie Hulog and Memory Care Manager. Both stated the facility policy is that caregivers are not allowed to move residents when they find residents were on the floor. The caregivers need to call nurses first (if nurse is busy, caregivers need to call Med Tech to come). Both stated the nurses check/evaluate resident on the floor and call 911 immediately. Both stated nurses check resident visually only. Both stated nurses cannot move the residents on the floor until paramedics come on site to evaluate the residents. Both stated nurses check if resident on the floor painful, bleeding, and check the vital signs. Both stated the nurses need to prepare the resident's document and to answer the questions from paramedics to help residents to be sent to hospitals. Both stated the policy was instructed to staff during the staff training. ON 10/01/2025, LPA interviewed the facility staff LVN (S1). S1 stated on 9/22/2025, he/she was notified by a caregiver that memory care unit resident R1 was found on the floor in R1's bedroom. S1 stated he/she went on site of R1's bedroom. S1 stated he/she called 911, evaluated R1 and prepared R1's document to be sent to hospital. S1 stated the facility's policy is not to move residents who are found on the floor. S1 stated another caregiver S2 was with him/her on site to take care and monitor R1. LPA interviewed caregiver S2. S2 stated he/she was notified on the floor in R1's room by another caregiver. S2 stated when he/she was on site at R1's room, S1 already there. S2 stated he/she observed S1 assessed R1 and prepared R1's document for the emergency room. S2 stated R1 stated he/she was fine but legs were numbed. S2 stated the facility policy is not to move residents who are found on the floor. Based on the review of the incident report dated 9/2325, R1's vital signs were 120/57 for blood pressure, 98.2 for temperature, 80 for pulse, 18 for respiratory rate, and 98% for oxygen. Based on the review of the facility policy of fall, it specifies do not move or lift an individual off the ground until it's verbalized that there's no pain and able to get up with minimum support and able to bear weight and ambulate. Continue on LIC9099-C. Page 2 of 3. The Department has investigated the above allegation. Based on the interview and record reviewed, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citation noted today. Exit interview was conducted with DHS. The report was provided to DHS for signature. A copy of the report was provided to DHS. Page 3 of 3.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 26-AS-20250924132416

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Assistant Executive Director, Mark Nelson and Administrator, Rosalie Zbasnik/Hulog and stated the purpose of today's visit. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility to include at random 10 resident rooms. 10 Out of 10 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom sink ranged from 109.9 - 118.1 degrees F. Facility smoke detectors and sprinklers were in working condition and inspected by a third party vendor on 4/23/2024 and 5/8/2025. The last disaster drills were conducted on 7/4/2025 and 7/22/2025. LPA Rai reviewed facility records for 10 staff and 10 residents. LPA Rai reviewed resident medications and central stored medication records. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. During visit, LPA Rai discussed a 90-day Eviction Notice for resident (R1). Administrator, Rosalie stated the family has been issued the letter on 07/16/2025 and the family is working with the facility's social worker as R1 requires higher level of care. LPA Rai reviewed the 90-day Eviction Notice and the letter is compliant with CCR 87224 Eviction Procedures. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Assistant Executive Director, Mark Nelson and Administrator, Rosalie Zbasnik/Hulog and a copy of the report was provided. LIC 858 and LIC 859 were provided.the state’s words, verbatim · CDSS document, Jul 25, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA met with Administrator (ADM) Rosalie Zbasnik/Hulog and stated the purpose of today's visit. During visit, LPA Rai toured the inside and outside of the facility to include the assisted living unit and memory care unit. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. LPA Rai observed the temperature of the freezer at 0 degrees F and the temperature of the fridge at 37 degrees F. LPA Rai observed storage unit for emergency food supply and two back-up generators on the premise. LPA Rai randomly toured 10 resident bedrooms. 10 Out of 10 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathrooms had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 108.7 degrees F - 119.7 degrees F. Fire extinguisher was observed and inspected on 10/17/2023. Facility smoke detectors and sprinklers were in working condition and inspected by a third party vendor on 5/1/2024 and 7/19/2024. The last disaster drill was conducted on 03/18/2024 and 6/21/2024. LPA Rai reviewed facility records for 10 staff and 11 residents. LPA Rai observed 6 out of 11 Appraisal/Needs and Services Plan was not signed by resident and/or responsible party. LPA Rai observed the facility Individual Service Plan was not signed by resident and/or responsible party. LPA Rai reviewed at random 10 resident current and PRN medications and central stored medication records. Deficiencies were cited per California Code of Regulations, Title 22 and Technical Violation was provided. This report was reviewed with Administrator (ADM) Rosalie Zbasnik/Hulog and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jul 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b) · Plan of correction due date: Jul 30, 2024

87463 Reappraisals (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement was not met as evidenced by: Based on record review and interview, 6 out of 11 resident files did not contain Appraisal/Needs and Services Plan and Individual Service Plan signed by resident and/or responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure Appraisal/Needs and Services Plan is signed by resident and/or responsible party by POC due date. Administrator agreed and understood.

Allegation investigated: Facility abandoned resident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Executive Director, Nancy Kao and stated the purpose of today’s visit. On 2/22/2022, the Department received a complaint with the above allegation. On 2/24/2022, the Department conducted an initial investigation at the facility. On 2/14/2022, R1 was sent to the hospital due to not feeling well and R1’s child informed the facility about R1 staying in the hospital due to further tests. It was alleged that the facility refused to accept R1 back to the facility upon discharge from the hospital. Continuation of LIC 9099-C, Page 1 of 2. Unfounded Page 2 of 2. On 2/24/2023, the Department conducted an interview with Administrator (ADM) who was the Assisted Living Manager at the time of interview. ADM stated R1 needed to be reassessed during the initial discharge planning by the hospital. ADM stated R1 would be admitted back to the facility as soon as R1 was ready to be picked up from the hospital. On 10/5/2023, the Department conducted an interview with Administrator (ADM) who stated the hospital was ready to discharge resident back to assisted living facility but R1 needed to be reassessed and it was determined R1 required higher level of care and needed skilled nursing care. ADM stated R1 was going to be accepted back to the facility, but the level of care needed to be determined if R1 was appropriate for skilled nursing care or assisted living care. Based on hospital notes on 2/17/2022, hospital physician determined R1 needed post-hospital continuous nursing care and R1 would be admitted to skilled nursing facility. Based on review of facility’s Leave of Absence form, R1 was admitted to the hospital and away from the assisted living facility from 2/14/2022 through 3/19/2022. Based on hospital’s Skilled Nursing Facility orders on 2/18/2022, resident was discharged from hospital to skilled nursing facility on 2/18/2022. Based on review of the Progress Notes from 3/19/2022, R1 was readmitted to facility’s assisted living unit under hospice services. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the Department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited as per California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Nancy Kao and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 23, 2024 · control 26-AS-20220222101527