The Gardens

Type of visit: Required - 1 Year

Licensing Program Analyst Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Nurse Manager Jamie Scott, Administrator Brandy Strahl and Skylee Godfrey. This facility has a non-ambulatory fire clearance. This facility has a delayed egress system. This facility shares a campus with a skilled nursing facility and the backside of the property is The Courtyard 515000683. The parking lot has a wrought iron fence and gate that automatically opens. The common areas were toured and several rooms were toured. No health, safety, and personal rights issues were observed. Several resident files were reviewed staff training were reviewed. Several topics were discussed. No deficiencies cited.the state’s words, verbatim · CDSS document, Jul 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Nurse Manager Jamie Scott. Administrator Brandy Strahl, was present during this visit. This facility has a non-ambulatory fire clearance. This facility has a delayed egress system. This facility shares a campus with a skilled nursing facility and the backside of the property is The Courtyard 515000683. The parking lot has a wrought iron fence and gate that automatically opens. The common areas were toured and several rooms were toured. No health, safety, and personal rights issues were observed. Several resident files and staff training were reviewed during this visit. Several topics were discussed. No deficiencies cited.the state’s words, verbatim · CDSS document, Jun 12, 2025

Type of visit: Required - 1 Year

LPAs HIratsuka and Tryon, conducted this unannounced annual visit. LPA toured the facility with Nurse Manager Jamie Scott. Administrator Brandy Strahl, was present during this visit. This facility has a non-ambulatory fire clearance. This facility has a delayed egress system. This facility shares a campus with a skilled nursing facility and the backside of the property is The Courtyard 515000683. The parking lot has a wrought iron fence and gate that automatically opens. The common areas were toured and several rooms were toured. No health, safety, and personal rights issues were observed. Five resident files and staff training were reviewed during this visit. Several topics were discussed. No deficiencies cited.the state’s words, verbatim · CDSS document, Jun 25, 2024

Allegation investigated: • Staff physically abused resident in care. • Staff verbally abused resident in care.

On 10/19/2023 LPA Tryon visited the facility to complete the complaint. LPA met with Brandy Strahl, ED and Jamie Scott. During the investigation LPA has spoken with witnesses, staff, reviewed documentation and reviewed and obtained police report. Regarding the allegation that Staff physically abused resident in care and verbally abused resident in care, LPA has spoken with witnesses, staff, reviewed documents, and staff statements. LPA learned that on 01/20/2023 former staff S1 was seen pulling resident R1 forward by their arms repeatedly in their chair at a meal and telling R1 they needed to sit up or S1 would not feed them. This was witnessed by at least 2 other staff members. In addition, staff S1 was seen pulling resident R2 backwards in their wheelchair. Resident was stating “stop” and that they were being hurt. S1 was also seen transporting resident R3 in their wheelchair with a belt buckled around them. Due to R3’s disability, They are unable to unfasten the seatbelt independently. Staff also witnessed S1 pulling R3 by the arm to get into the dining room. Substantiated The facility subsequently did an internal investigation into the above, followed facility personnel procedures, and took appropriate action. Although the facility took actions against S1, it has been found that S1 was physically and verbally abusive towards residents while employed at the facility. Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. A finding of substantiated means that the preponderance of the evidence standard has been met. California Code of Regulations, Title 22, Division six and Chapter eight are being cited on the attached LIC 9099D. Regarding a resident physically assaulting another resident, staff reported observing a resident going towards another resident, however staff intervened, and no incident took place. There was talk of other residents being “assaulted” but LPA found no information about this, therefore cannot prove or disprove that any assaults actually occurred. Therefore, the allegation is unsubstantiated. Regarding staff not preventing residents from entering other residents’ rooms, LPA has spoken with staff, witnesses, etc. Based in interviews conducted, R1’s responsible party requested the R1’s bedroom door has the ability to be locked. It was reported that the door was unlocked the next day. It is not possible to say if the door was locked the previous night, who may have unlocked it, why, etc. The resident may have unlocked the door, which they certainly have the right to do. Staff are not able to constantly monitor the lock on one resident’s door to ascertain that it is always locked; and the resident has the right to lock or unlock their own door. The allegation is unsubstantiated. A finding that an allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 59-AS-20230530084440

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Oct 19, 2023

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Through interview of staff and review of documentation, LPA learned that staff S1 repeatedly pulled resident R1 by the arms at the dining table and told her to sit forward or she would not feed her. She also fastened a seatbelt around R2 in her wheelchair when R2 could not unbuckle the belt; and pulled R2 backwards down the hallway, while R2 said to stop, it was hurting; and pulled R3 by the arms down the hallway. This potentially caused an immediate health and safety hazard.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: The facility immediately followed up regarding these incidents and investigated the situation. S1 was appropriately dealt with by the faciity. The facility also conducted Resident Rights training on DATE with staff to avoid similar situations in the future. POC complete.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Oct 17, 2023

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Through interview of staff and review of documentation, LPA learned that staff S1 repeatedly pulled resident R1 by the arms at the dining table and told her to sit forward or she would not feed her. This potentially caused an immediate health and safety hazard.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: The facility immediately followed up regarding these incidents and investigated the situation, followed facility procedures and took appropriate action. The facility also conducted Resident Rights training with staff to avoid similar situations in the future. POC complete.