The Gardens at Laguna Springs Memory Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection, LPA Valerio met with Director of Care Services Tiffany, and explained the purpose of the visit. LPA Valerio later met with Administrator Guadalupe Ramirez. LPA Valerio and Administrator Guadalupe Ramirez toured the facility to ensure compliance of Title 22 regulations. LPA Valerio observed 3 (three) resident bedrooms. The bedrooms were observed to be free from odors, fully furnished, and organized. Resident bathrooms located in the bedrooms were observed to sanitary. Common area bathrooms were observed to be clean, sanitary, and stocked with hygiene supplies. Common areas of the facility, which include the hallways, dinning area, lobby seating area, and activity room, were observed to free from hazardous items, fully furnished, and free from odors. LPA Valerio observed the facility to have an adequate food supply. The fire extinguishers around the facility were observed to be fully charge. The fire company was conducting their annual inspections during LPA's visit. The last emergency drill training was on November 05, 2025. Annual fee was received 10/01/2025. LPA Valerio reviewed four (4) resident files and four (4) staff files. Resident and staff files were observed to be up to date with required annual documentation. LPA Valerio obtained the following annual documentation. LIC 500, LIC 308, LIC 309 LIC 610, and copy of Liability insurance. Per California Code of Regulations - Title 22, no deficiencies were observed. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 23, 2025

Type of visit: Case Management - Other

On 10/21/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility to conduct a case management visit. LPA initially met with Jordan Reymundi and stated the purpose of the visit. The Executive Director/Administrator, Guadalupe Ramirez, was notified of the visit and arrived shortly after. During the visit, the LPA requested copies of documents related to a former resident (R1). This request included, but was not limited to, meal logs, records of urine and bowel output, and all communications with R1’s doctors and/or other medical professionals. The LPA requested that any available documents be sent by email no later than the end of the business day on 10/21/25. LPA requested any additional documents that are found later be submitted via email. Per interview with Reymundi and Ramirez, staff usually do not keep daily records of what residents eat unless a doctor gives an order or there is a change in the resident’s condition. Sometimes, staff might write in a resident’s chart if the person didn’t eat, but they don’t track meals in detail every day. When it comes to urine and bowel movements, staff also don’t record this information daily unless a doctor orders for it because of a health concern. If something seems unusual in their urine or bowel output, staff might make a note in the resident’s chart, but they don’t regularly monitor these outputs. For communication with R1's doctor, they would need to look through their records and will send any information they find. No deficiencies were cited on today's visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 21, 2025

Allegation investigated: Resident sustained multiple pressure injuries.

On 5/6/2025, Licensing Program Analyst Arvin Villanueva arrived at this facility unannounced to conduct a follow-up complaint visit and deliver findings regarding the allegation noted above. LPA was met with Administrator Guadalupe Ramirez and stated the purpose of the visit. The investigation into this allegation consisted of interviews and record reviews. Interview with a witness (W1 ), revealed that upon Resident 1 (R1) hospitalization, R1 was found to have multiple pressure injuries. W1 stated that a physician informed W1 the injuries were the result of R1’s briefs not being changed and that the wounds would not heal. W1 also confirmed that R1 did not have any pressure wounds prior to their admission to the facility. {1 of 2} Substantiated Hospital Physician corroborated this information by explaining that the pressure injuries could have developed over the course of a few days, but not in a single day. This suggests that the injuries likely developed during R1’s residency at Gardens at Laguna Springs. The Executive Director of the facility, Guadalupe Ramirez (S1), reported that R1 wore briefs that were changed after every meal or accident, and staff reportedly checked briefs every two hours. However, there was no documentation or staff reporting of any pressure injuries. Staff member (S3) stated that R1 wore pull-ups as a preventive measure, that R1 was sometimes incontinent, and that pull-ups were changed approximately three times per day. A review of R1’s medical records obtained from the hospital confirmed the presence of multiple pressure injuries which were described as "community acquired," with moisture components noted on the sacrum, bilateral buttocks, scrotum, penis, and coccyx. Based on the information gathered, the allegation that resident R1 sustained multiple pressure injuries while under the care of Gardens at Laguna Springs Memory Care is SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit. Exit interview was conducted with Guadalupe Ramirez and a copy of this report and appeal rights were provided. {2 of 2} Interview with S1 stated that R1 had been eating less in the days leading up to the incident and this was discussed with W1, who agreed that R1 typically ate small portions. Staff were instructed to assist and hand-feed R1 when needed. Interview with S2 reported that R1 was offered meals three times daily along with snacks. S2 stated that R1 sometimes required encouragement or hand feeding, especially when tired. However, R1 never completely refused meals and always had access to food and snacks. On 07/15/2024, staff reported that R1 was lethargic and did not eat throughout the day because R1remained asleep. Upon finding R1 being nonresponsive, staff checked R1’s blood sugar and found it to be low. 911 was called immediately, and R1 was transported to the hospital. Review of medical documentation from Emergency Medical Services (EMS) confirmed that R1 was hypoglycemic prior to hospital transport. Medical records from hospital listed acute respiratory failure as the primary diagnosis upon admission. Physician stated that low blood sugar could have contributed to R1's altered mental status and may have predisposed R1 to respiratory complications such as pneumonia. Additionally, per record reviews and interviews, there was no physician order in place at the facility for routine blood sugar monitoring for R1, despite a history of diabetes. Based on the gathered information, there is insufficient evidence to support the allegation that staff neglect resulted in R1’s hospitalization. Staff documentation and interviews consistently indicate that R1 was being monitored regularly, provided food, and offered assistance with eating. While R1 did experience a medical emergency due to low blood sugar, there is no clear indication that facility staff failed to meet R1’s basic care. Therefore, the above allegation was UNSUBSTANTIATED. {2 of 6} Allegation - Staff did not meet the residents bathing needs The investigation into this allegation consisted of review of facility records, interviews with staff and review of documentation related to R1’s bathing schedule and care. Review of the Resident Assessment dated 07/16/2024, R1 requires assistance with bathing twice a week. The assessment specifies that R1 needs hands-on help with bathing, utilizing a shower chair, and staff assistance for scrubbing hard-to-reach areas. Review of the shower body audits for 07/10/2024, 07/14/2024 AM, and 07/14/2024 PM reveal that on the dates R1 was scheduled for a shower, R1 refused to take a shower but accepted sponge baths instead. The audits also indicate that staff observed R1’s body during the sponge baths and did not note any wounds, bruises, burns, excoriations, or rashes. Review of staff statement, S1 documented a statement about R1's bathing needs, mentioning that R1's responsible party (RP) had accused the facility of failing to provide a shower on a specific date. However, Guadalupe clarified that the facility had provided sponge baths during the AM and PM shifts on that day, as R1 had refused the shower. Review of another staff statement, S2 confirmed that R1's shower schedule was set for two days a week (Tuesday and Saturday). On days when R1 did not have the energy for a shower, R1's responsible party agreed that staff could provide a bed bath. S2 also stated that when residents refused showers, staff attempted different techniques to encourage bathing, but residents could not be forced to bathe. When a shower or bed bath was provided, staff performed a skin assessment and documented any findings. Staff interviews confirmed that R1 had refused showers on occasion, it was explained that R1's physician’s report did not provide specific instructions for bathing or shower needs. Additionally, staff interviews confirmed that R1 was offered showers twice a week and provided with sponge baths as an alternative. Based on the gathered information, there is insufficient evidence to support the allegation that staff did not meet R1’s bathing needs. Therefore, this allegation was UNSUBSTANTIATED. {3 of 6} Allegation - Staff did not ensure a resident was properly fed The investigation into this allegation consisted of review of facility records, interviews with staff and review of documentation related to R1’s bathing schedule and care. Review of the Resident Assessment dated 07/16/2024 indicates that R1’s care plan for meals was labeled as "minimal," with the requirement for assistance with cutting food, encouragement for hydration, and supervision due to R1’s special dietary needs. These included a mechanical soft meal, avoidance of sugary desserts, and the need for thin liquids due to R1’s diabetes and lactose intolerance. R1’s care plan specifically outlined these requirements, and it was the responsibility of the facility staff to ensure the care plan is followed. Interview with W1 claimed that on 07/14/2024, staff reported that R1 had not eaten breakfast or lunch, and that staff had forgotten R1 was diabetic, leaving R1 without food until the W1 intervened. However, interviews with facility staff, including staff members S2 and S3, provided additional information. Statement from S2 revealed that R1 was offered food three times a day, with snacks, and that when R1 was tired or uninterested in eating, staff would either try to hand-feed R1 or leave food nearby for R1 to eat independently. S2 confirmed that R1 always had access to food, and there was never a failure to offer meals. S3’s statement further supported this, detailing how R1 had been sleeping throughout the day on 07/15/2024, and that R1’s family had requested staff not to disturb R1 during these periods of deep sleep. S3 confirmed that snacks and ice water were provided, in case R1 woke up hungry. Review of the facility’s documentation and progress notes indicated that R1 had been monitored for vital signs, though there was a noted discrepancy regarding blood sugar monitoring. However, no direct evidence was found in the records to suggest that R1 was not offered food or hydration. Based on these findings, there is no sufficient evidence that staff did not provide adequate meals or assistance with feeding to R1. While there may have been lapses in documentation and monitoring, these do not directly support the allegation of neglecting R1’s basic nutritional needs. Therefore, the allegation is UNSUBSTANTIATED. {4 of 6} Allegation - Staff left a resident unattended The investigation into this allegation consisted of interviews with facility staff and other relevant parties. Interview with W1 revealed that R1 reported being left alone for five hours without staff checking in and that R1 felt thirsty but was unable to get up. Interviews with multiple facility staff consistently indicated that staff were attentive and followed regular check-in procedures. Staff reported that they generally checked on residents every hour, and more frequently if necessary, depending on the resident’s individual needs and mobility. Interview with staff member S1 confirmed that most residents, including R1, spent much of the day in the common area under staff supervision. Residents who chose to stay in their rooms were checked on after every meal and monitored by motion detectors that alerted staff if residents moved. S1 further stated that staff would often check on residents anytime they passed by their rooms, in addition to the standard hourly checks. Interview with S2 similarly indicated that staff were in frequent contact with residents, aiming to check on them hourly and monitoring for signs of medical concerns, such as pressure injuries. S2 also explained that residents like R1 wore briefs, which staff checked and changed every two hours or sooner if needed. S3 added that residents were generally checked on every 30 to 45 minutes when in their rooms, with the assistance of motion detectors to alert staff of movement. Additional interviews with staff members (S4, S5, S6) consistently confirmed that hourly rounds were conducted, residents were checked on regularly, and those with mobility issues, like R1, received assistance as needed. S6 further explained that R1 was a fall risk, used a walker, and was regularly monitored through both direct staff supervision and motion detectors. Given the consistent staff reports regarding the frequency of resident checks, the use of motion detectors, and the regular visual supervision of residents in common areas, there is insufficient evidence to support the allegation that R1 was left unattended for an extended period. Therefore, the allegation is UNSUBSTANTIATED. {5 of 6} Allegation - Staff did not ensure a resident consumed an appropriate amount of liquid The investigation into this allegation consisted of interviews and record reviews. According to review of R1’s Resident Assessment dated 07/16/2024, R1’s care plan indicated a "minimal" need for meal support, including assistance with cutting food and encouragement to stay hydrated. R1 was also prescribed a special diabetic diet with mechanical soft foods, thin liquids, and no sugary desserts, which the staff was aware of and worked to accommodate. Interview with staff S3 revealed that staff routinely left snacks and ice water within R1’s reach and continued to provide meals even when R1 appeared to have decreased appetite. S3 reported that although R1 sometimes ate only a few bites, staff never observed R1 outright refusing food, and meals were still provided regardless of R1’s intake. S3 also stated that on 07/15/2024, R1 was sleeping throughout the day per family instructions not to disturb, but meals, snacks, and water were still left nearby to ensure that R1 could access food and hydration if he woke up. Interview with W1 indicated expressed concerns that R1 had not eaten breakfast or lunch on 07/14/2024 and required assistance to eat, interviews with staff indicated that R1 was consistently provided food and water and that staff followed facility procedures to encourage consumption. Staff S1 confirmed that the facility did not formally document the amount of food and liquid consumed; however, all staff was to ensure residents had access to food and water throughout the day. Although the facility lacked documentation tracking R1’s food and fluid intake, there is no sufficient evidence demonstrating that staff did to offer or encourage proper hydration. Therefore, the allegation that staff did not ensure R1 consumed an appropriate amount of liquid is UNSUBSTANTIATED. Note that an unsubstantiated finding 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 this report and appeal rights were provided. {6 of 6} Further review of the MAR showed that the facility accurately documented the administration of medications and that the MAR orders matched the Medication Orders signed by R1’s Primary Care Provider on 07/03/2024. While LPA Valerio was unable to review physical medication bottles or packets due to the resident no longer being at the facility the documentation on file supports that staff followed the physician’s written instructions. Additionally, a review of R1’s progress notes revealed that while blood sugar monitoring was not documented—due to not having a physician order for glucose testing—other vitals such as temperature, pulse, blood pressure, respiratory rate, and oxygen saturation were recorded. Based on the information gathered throughout this investigation, here is no evidence to support that staff mishandled R1’s medication administration. Staff administered medications according to the documented physician orders, and no direct errors in medication handling by the facility were identified. Therefore, the allegation is UNFOUNDED. A finding of unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Guadalupe Ramirez and a copy of this report was provided. {2 of 2}the state’s words, verbatim · CDSS document, May 6, 2025 · control 27-AS-20241210134242

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 7, 2025

Observation of the resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes...are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and record reviews, R1 developed multiple pressure sores while in care. This poses an immediate heath, safety and personal risks to resident in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Per discussion, the Administrator will submit a written statement of understanding of the regulation cited. Submit statement by POC due date. Per discussion, the Administrator will conduct staff training relating to observation of residents. Submit proof of completed staff training by 5/21/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA Valerio met with front desk staff, and explained the purpose of the visit. LPA was shortly met by Administrator Guadalupe Ramirez. LPA Valerio and Administrator toured the facility to ensure compliance of Title 22 regulations. LPA Valerio observed common areas, which included the lobby area, two lounge areas, an activity room, dinning hall, and hallways. All areas were observed to be clean, fully furnished, free from debris, and free from odors. Residents were observed walking in the hallways, sitting in common areas, or engaging with staff members. LPA Valerio checked one restroom located in the common area. The bathroom was observed to be sanitary, have hygiene supplies, and stocked with toilet paper and paper towels. Hot water in the bathrooms were measured and determined to provide hot water within the regulatory range of 105.0 - 120.0 degrees F. LPA Valerio toured multiple resident bedrooms. Bedrooms, which include a bathroom, were observed to be fully furnished, free from odors of incontinence, and clean. Toxins, sharps, and medications were observed to be locked and inaccessible to residents in care. Fire extinguishers were observed to be within compliance and fully charged. All emergency exits were free from obstructions. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises LPA Valerio reviewed four (4) resident files. Resident files were observed to be up to date with required annual documentation. LPA Valerio reviewed four (4) staff files. Staff files were observed to have required annual training. Continues on LIC 809 - C... Continued from LIC 809 LPA Valerio followed up on an incident report submitted to the Regional Office on 11/28/24. After discussion with Administrator Guadalupe Ramirez, there are no health or safety concerns regarding the incident. LPA Valerio obtained the following for the Regional Office Facility File: LIC 500 - Personnel Report, LIC 308, LIC 309 - Administrative Organization, LIC 610D, and copy of current Liability Insurance. Per California Code of Regulations (CCR) - Title 222, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 6, 2024

Allegation investigated: Staff does not ensure that resident's room is free from pests.

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation and to deliver findings. LPA Valerio met with Administrator Guadalupe Ramirez, and explained the purpose of the visit. The investigation consisted of observations of the facility, records review of facility files, and interviews with the Reporting Party, residents, and staff. According to the RP, the RP visits regularly and states the facility has an ant issue. R1 has a cat and the ants are attracted to the cat food. The RP was visiting R1 one day and decided to go check on the room, which is when RP found ants all over the bed. RP reported that the facility attempted to address the issue; however, the RP is concerned that ants were on the bed and staff did not noticed. Continues on LIC 9099 - C... Unsubstantiated ...Continued from LIC 9099 On 08/23/2024, the Local Ombudsman conducted an announced visit to the facility. It was reported that when they visited, the room was spotless and free from pest. On 08/26/2024, LPA Valerio observed the facility and R1's bedroom. LPA inspected common areas, hallways, dining tables, and activity area. LPA inspected R1's bed, pillow, corners of the bedroom, around the cat food, and in the bathroom area. Pests were not observed during the visit. LPA took pictures for future reference. On 08/26/2024, LPA Valerio reviewed the video submitted to the Regional Office. The video captures a pillow on a Resident 1 (R1) bed. The pillow is covered with black ants, small to medium sized ants. There are some that are dead on the pillow and some that are crawling on the pillow along with a few on the bed sheets. LPA Valerio attempted to interview the resident in care. However, due to communication barriers, the interview was unsuccessful. Residents did not appear to be in distress and were being supervised by staff members. LPA Valerio interview Staff 1 (S1). S1 reported that "they do have ants; however, staff do a good job about cleaning up after the residents. This place is in the middle of a field, so I assume this was the ant's home before we got here… There is not a time where we do not try to address the issue." According to an interview with Staff 2 (S2), S2 stated that they have had pest control services come every month, but they have also increased their services within the last month. S2 provided invoices from June, July, August, and September. S2 stated that they comes and check all the rooms and outside of the facility. They put the sprays and everything. Staff do constant check of the rooms and when it is known there are pest, they say it on their walkie talkie. They assess to see if the resident has any on them, if they are in the room. They shower them, check for any food, and clean the room. According to Pest Control Invoices, the facility has a monthly pest service. On 05/29/24, 06/18/24, 08/09/24, pest control services provided normal service in addition to treats for the ant issue. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Sep 16, 2024 · control 27-AS-20240819163942

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Annual Inspection Visit. LPA met with Administrator and explained the purpose of the visit. Administrator assisted with today’s visit. The facility had a mitigation plan completed and approved on 6/17/2021. LPA toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. A review was conducted of the apartment sizes and different layouts. Each unit has mini-split air and heating unit. The medication room was toured. Kitchen pantry and walk-in freezer was toured for adequate food supplies and storage. LPA observed required furniture and lighting throughout the facility. The hot water temperature was measured at 113.4*F in resident apartment during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility measured at 73*F which was within the required range of 68-85*F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s) were last inspected on December 7, 2023. First aid kits were up to date. Smoke and carbon monoxide detector(s) in the facility were in good repair. Continued on 809-C Page 2 Continued from 809 - Page 2 LPA reviewed seven resident files and seven staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. LPA requested the following documents for facility file to be sent via email by December 20, 2023: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 610-E Emergency Disaster Plan, and Liability Insurance. ruth.wallace@dss.ca.gov Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held with administrator. A copy of report and LIC 811 (Confidential Names) left at facility.the state’s words, verbatim · CDSS document, Dec 14, 2023

Allegation investigated: Facility staff do not ensure pull cords are accessible to residents in care Facility staff are not properly addressing pest infestation in facility Facility staff prevent residents from accessing food Facility staff mismanage residents medication Facility staff are not properly supervising residents who are a fall risk Facility staff speak inappropriately to residents in care Facility staff are not trained appropriately to provide care to residents Facility staff not safe guarding residents’ belongings

On 10/25/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced facility visit to complete and deliver findings for a complaint investigation received on 7/10/23. LPA met with Director of Resident Services Barbara Rose and discussed the conclusion for complaint and the findings. Throughout the course of the investigation, LPA toured the facility, conducted staff and resident interviews and reviewed records. Based on observations, records review, and staff and resident interviews, there is not a preponderance of evidence to substantiate the allegations mentioned above. Regarding the allegation that staff do not ensure pull cords are accessible to residents in care, it was learned that resident (R1) pulls her cord off the wall daily. Staff stated that they check and fix the cord on a daily basis. LPA observed that the pull cord in R1’s room is accessible and in good repair. Continued on 9099-C Unsubstantiated Regarding the allegation that staff are not safeguarding residents’ belongings, it was determined that there is not a preponderance of evidence to substantiate the allegation. Based on statement obtained, it was learned that facility has encouraged families to lock resident’s valuable upon move-in. Based on staff interviews, staff stated that they will help locate misplaced items and redirect residents if they try to enter a room that is not theirs. 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. Exit interview was conducted and a copy of the report was provided upon exit. Regarding the allegation that staff are not properly addressing pest infestation in facility, it was learned that pest control services were being done monthly and additional days were added to address the pest infestation that was happening in Elk Grove. According to resident interviews, residents stated that they observed some ants in their rooms, but it was treated. LPA conducted a review of the resident rooms and did not observe any pests. Regarding the allegation that staff prevent residents from accessing food, it was learned that all staff and residents have access to snacks and a variety of food on a daily basis. It was learned that residents do not have access to the kitchen for safety reasons. Based on resident interviews, residents stated that staff will provide snacks and food if they ask. Regarding the allegation that staff mismanage residents’ medication, there is not a preponderance of evidence to substantiate the allegation. Based on statements obtained, it was learned that medications were provided to residents according to doctor’s order. LPA conducted a medication review and did not observe any discrepancies. Regarding the allegation that staff are not properly supervising residents who are a fall risk, LPA finds insufficient evidence to substantiate the allegation. Based on statements obtained, it was learned that residents who are at fall risk were closely monitored. Regarding the allegation that staff speak inappropriately to residents in care, LPA finds insufficient evidence to substantiate the allegation. Based on statements obtained, there was no supporting information found. LPA interviewed staff S1, S1 denied making any inappropriate comments about residents. Regarding the allegation that staff are not trained appropriately to provide care to residents, LPA reviewed staff files and verified staff training. LPA interviewed staff S2. S2 denied providing any care to residents. S2 stated that they were only redirecting resident while waiting for available caregivers to come and assist. Continued on 9099-Cthe state’s words, verbatim · CDSS document, Oct 30, 2023 · control 27-AS-20230710111426

Type of visit: Office

A Non-Compliance Conference (NCC) was conducted on this day, 10/26/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 9/30/2022. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, LPM Stephen Richardson, Licensing Program Analyst (LPA) Tung Truong, LPA Christina Valerio, facility Regional RCFE Stephen Sarine, VP of Operation Michelle Baker and facility staff Barb Rose and Kayleen August. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process as well. Since the last meeting on 9/30/2022, six new complaints have been filed against the facility and four Type A deficiencies have been cited. The facility was cited for the following issues: Personal Rights of Residents in All Facilities, Administrator Qualifications and Duties, Basic services care and supervision and Plan of Operation. The focus of the concerns at this time were as followed: - Designated Facility Administrator-Qualifications/Duties - Maintaining continued compliance - Oversight of facility staff for proper care and supervision - Facility staff roles, duties, and responsibilities - Plan of Operation regarding outside agency Continued on 809-C - Plan of Operation regarding resident with behaviors - Adhering to the Plan of Operation - Outside staff fingerprint clearance and facility association Licensee agreed to do the following in order to bring the facility into compliance: Please provide the following to LPA by 11/3/23. - Provide updated Plan of Operation regarding admitting resident with behaviors - Provide updated policies and procedures regarding using outside agency staff - All staff including administrator shall receive training on Resident Intervention and Redirecting - All staff and administrator shall receive in-service training on Reporting Requirements Exit Interview Licensee/Administrator signature on file.the state’s words, verbatim · CDSS document, Oct 26, 2023

Allegation investigated: Staff do not ensure residents take medications as prescribed. Staff do not serve food of the quality necessary to met residents needs.

On 10/20/23, Licensing Program Analyst (LPA) Tung Truong conducted unannounced facility visit to complete and delivery findings for a complaint investigation received on 7/3/23. LPA met with Administrator Guadalupe Ramirez and discussed the conclusion for complaint and the findings. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on record reviews, and staff and resident interviews, there is not a preponderance of evidence to substantiate the allegations mentioned above. Based on statement obtained, it was revealed that facility staff do ensure residents were taking their medication as prescribed. Regarding the allegation that staff do not serve food of the quality necessary to met residents' needs, based on LPA observations and staff and resident interviews, it was determined that food was provided of quality to meet the residents’ need. Continued on 9099-C Unsubstantiated 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. Exit interview was conducted and a copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 27-AS-20230703082703