The Inn on Villa Lane

Type of visit: Required - 1 Year

At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Amber Cavagnaro, Designated Responsible Party (DRP). Facility Administrator is away on vacation. Today's inspection will be conducted with DRP. Facility is a Residential Care Facility for the Elderly (RCFE) with seventy-eight (78) residents in care. Facility has both assisted living and memory care residents, with a Hospice waiver for 16 and approval for 10 bedridden residents. Facility has a delayed egress system in place and the assisted living residents utilize pendants which they wear. At approximately 11:30 AM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a two story building, with emergency evacuation chairs in place at the top of each stairwell. Facility was a comfortable temperature, and passageways were free from obstructions. LPA observed egress devices activated and staff responded timely. Facility has the required postings in the main common areas which are accessible to the public. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. LPA observed one housekeeping closet containing cleaning supplies unlocked. DRP locked it immediately and agreed to schedule a training with staff to ensure compliance with regulation moving forward. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are outdoor shaded seating areas for activities. Continued on LIC809C... Continued from LIC809C... LPA observed residents engaged in activities in common areas. Facility has internet service and an internet access device designated for resident use. Facility's last fire inspection was conducted 10/2025. Fire extinguishers were observed fully charged and were last inspected 08/2025. Emergency Disaster Plan was reviewed and updated 04/2026. Facility conducts monthly disaster drills with the most recent drill conducted 06/2026. Facility has a back up generator for emergency preparedness. Facility has emergency lighting and first aid kits were inspected and observed to contain the required items. At approximately 1:00 PM, LPA conducted file review of eight (8) staff files. All staff files reviewed contained all of the required documents and proof of current First Aid and CPR certifications. LPA observed 2 out 8 staff files missing proof of some of the required annual medication training hours which DRP states they believe the training has been completed but that DRP is unable to locate the transcripts at this time. DRP agreed to obtain the records from the Administrator upon their return and provide to LPA at the follow up visit. Facility assists with coordinating medical and dental appointments as well as transportation to and from appointments when residents have the need. Facility does not handle P&I. LPA will return at a later date to review resident files, medications, and medication records. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500 - Personnel Roster (updated) Exit interview conducted with DRP whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 14, 2026

Allegation investigated: Staff does not administer resident’s medication in a timely manner. Staff does not keep an accurate medication log.

On 03/19/2026, at approximately 10:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct an additional interview and deliver complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20251219144634, which was received by Community Care Licensing (CCL) on 12/19/2025. Reporting Party (RP) alleges that staff does not administer resident’s medication in a timely manner and staff does not keep an accurate medication log. LPA met with Dorla Licausi, Administrator. On 12/19/2025, LPA conducted an interview, obtained douments, and requested statements from Staff 1 (S1) and Staff 2 (S2) and additional documents which were received via email on 12/21/2025. Based on interviews conducted, written statements obtained from S1 and S2 and recieved via email on 12/21/2025, review of the facility's controlled substance log, and the medication administratrion record (MAR) for Resident 1 (R1), it was revealed that S1 gave R1 their medication on time. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Additionally, based on review of R1's centrally stored medication record (CSMR), MAR, and the facility's controlled substance log for the month on 12/2025, LPA did not find any evidence to show that the facility staff are not keeping an accurate medication log. Based on interviews conducted, observations made, and records reviewed, the allegations that staff does not administer resident’s medication in a timely manner and staff does not keep an accurate medication log are UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that 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, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 21-AS-20251219144634

Allegation investigated: Staff are mismanaging resident medication

On 02/04/2026, at approximately 1:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to initiate a 10-day complaint investigation and deliver complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20260130150310, which was received by Community Care Licensing (CCL) on 01/30/2026. Reporting Party (RP) alleges that staff are mismanaging resident medication. LPA met with Dorla Licausi, Administrator. During visit, LPA obtained documents and conducted interviews. Per Incident Report (IR) dated 02/04/2026, Centrally Stored Medication Destruction Records (CSMDRs) and Medication Administration Records (MARs) for both Resident 1 (R1) and Resident 2 (R2), Controlled Drug Record for R1, Narcotic Count Sheet for R2, and interviews with both Staff 1 (S1) and the facility Administrator, it was revealed that S1 made a medication error on 01/28/2026 by giving R1 a dose of medication from R2's medication container. Continued on LIC9099C... Substantiated Continued from LIC9099... They were the same medication but different doses. No harm to either resident was reported. Per Administrator and IR, S1 will undergo retraining and coaching for the incident. Based on documents obtained and interviews conducted, the allegation that staff are mismanaging resident medication is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Administrator.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 21-AS-20260130150310

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 6, 2026

Incidental Medical and Dental Care 87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure that R1 received their medications as prescribed. This poses a potential Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: Licensee to submit proof of coaching and retraining with S1 to CCLD by POC due date of 03/06/2026.

Allegation investigated: Staff do not keep the facility clean and sanitary

On 02/04/2026, at approximately 10:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to initiate a 10-day complaint investigation and deliver complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20260130150310, which was received by Community Care Licensing (CCL) on 01/30/2026. Reporting Party (RP) alleges that staff do not keep the facility clean and sanitary. LPA met with Dorla Licausi, Administrator. During inspection, LPA completed a walk through of the facility with Administrator and made observations. LPA found the facility to be clean and sanitary and witnessed housekeeping cleaning resident rooms. Based on an interview conducted with Administrator, residents' rooms are cleaned weekly. At minimum, this includes: vacuuming, mopping, dusting, beds are stripped and sheets and towels are washed. Kitchen's and bathrooms are cleaned weekly as well. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Additionally, residents' trash is checked on each shift (three times per day) and is dumped if needed. Residents' personal laundry is washed by the care staff once per week. The hallways are cleaned on the days when housekeeping is scheduled to clean the rooms in that wing and more frequently if needed. If anything needs to be addressed and cleaned, it is dealt with immediately. The other common areas and public restrooms are cleaned daily. LPA obtained cleaning schedules for the month of February 2026 which confirm the cleaning schedule reported by Administrator. These schedules reflect that the facility has three full-time housekeeping staff: one focuses on the memory care unit and the other two focus on the remainder of the facility. Based on interviews conducted, observations made, and records obtained, the allegations that staff do not keep the facility clean and sanitary is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that 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, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 21-AS-20260130150310

Type of visit: Case Management - Incident

On 10/28/2025, at approximately 9:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident visit and met with Dorla Licausi, Administrator. LPA is conducting a case management visit to obtain more information regarding an incident report received by the Department on 08/28/2025 for an incident that occurred on 08/27/2025, involving Resident 1 (R1), a memory care resident, who eloped from the facility after attending a community event. Today, LPA conducted an interview with Staff 1 (S1) and obtained additional documents. Facility is being cited for not providing the services necessary to meet resident needs as evidenced by a lack of supervision while outside the memory care unit which led to R1's elopement from the community (see LIC809-D). The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and appeal of rights provided. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 29, 2025

87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record review, self-report, and interview conducted with S1, R1 eloped from the community without staff knowledge and staff did not prevent R1 from wandering away from the facility which poses an immediate Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee to submit proof of training conducted with staff to ensure future elopements do not occur to CCLD by POC due date of 10/29/2025.

Allegation investigated: Staff does not ensure medications are dispensed as prescribed to residents.

On 10/14/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250821122246 investigation findings regarding the above allegations and met with Dorla Licausi, Administrator. Reporting Party (RP) alleges that Staff 1 (S1) does not ensure medications are dispensed as prescribed to residents. Prior to receiving this complaint, LPA Florio received an incident report on 07/30/2025, stating S1 made a medication error on 07/20/2025 with Resident 1 (R1), which did not result in harm to the resident. The report states S1 was coached and medication administration and record keeping were reviewed. LPA Florio conducted 10-day complaint investigation visit on 08/22/2025 and obtained documents, made observations, and conducted interviews. Continued on LIC9099C... Substantiated Continued from LIC9099... During this visit, an interview with Staff 3 (S3) further revealed that S1 made the medication error. On 08/27/2025, LPA received another incident report for another medication error made by S1 with Resident 2 (R2). No harm to resident was reported. An interview conducted today with Staff 2 (S2) revealed that as a result of these two medication errors, S1 has been terminated as reflected on Performance Improvement Action Plan/Termination Letter dated 08/26/2025. Based on observations made, interviews conducted and records obtained, the allegation that staff does not ensure medications are dispensed as prescribed to residents is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Administrator.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 21-AS-20250821122246

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 15, 2025

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observations made, records reviewed, and interviews conducted, Licensee did not ensure that R1 and R2 both received their medications as prescribed. This poses a potential Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Licensee already performed coaching and retraining with S1 on 08/01/2025 and subsequently terminated S1 on 08/26/2025.

Allegation investigated: Staff does not ensure records are properly maintained. Staff handles resident in a rough manner. Staff does not ensure residents are spoken to in an appropriate manner. Facility does not ensure staff is in good health to perform the duties of her position correctly. Staff do not ensure residents receive adequate care and supervision resulting in un-witnessed falls. Staff does not ensure reporting requirements are being followed.

On 10/14/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250821122246 investigation findings regarding the above allegations and met with Dorla Licausi, Administrator. Reporting Party (RP) alleges that Staff 1 (S1) does not ensure records are properly maintained; handles resident in a rough manner; and does not ensure residents are spoken to in an appropriate manner. RP further alleges that facility staff does not ensure staff is in good health to perform the duties of her position correctly; do not ensure residents receive adequate care and supervision resulting in un-witnessed falls; and does not ensure reporting requirements are being followed. LPA Florio conducted 10-day complaint investigation visit on 08/22/2025 and obtained documents, made observations, and conducted an interview. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Today, on 10/14/2025, LPA obtained additional documents, made observations, and conducted a further interview with Staff 2 (S2) which revealed that there is no documented proof that S1 did not ensure records were properly maintained and any errors made were corrected resulting in no harmed to any residents. Additionally, based on interviews with Staff 3 (S3) on 08/22/2025 and S2 today, progress notes from 05/29/2025 through 08/26/2025 and shower skin assessments from 07/31/2025 through 08/25/2025, and observations made of R1, each revealed no evidence of bruising or reports of R1 being handled in a rough manner. Rather, LPA did obtain Unusual Incident/Injury Reports for incidents dated 06/29/2025 and 08/18/2025 where R1 experienced falls. These interviews also revealed that there was no proof that S1 used foul language or spoke inappropriately to Resident 2 (R2). Per a Physician's Report dated 03/12/2025, R2 is in late stage dementia, is disoriented, and experiences hallucinations. Further, both interviews with S2 and S3 revealed that S1 was never been observed under the influence of any substances during work, and a health screening dated 06/14/2025 and TB test dated 06/16/2025 revealed that S1 was cleared and in good health. In regards to adequate care and supervision, per a facility personnel roster dated 06/10/2025 and facility staffing schedules dated 06/12/2025 and 10/05/2025 as well as an interview with S2, it was revealed that the facility is adequately staffed with at least 5-6 staff present from 6am-3pm in memory care, which currently has 20 residents; 2 caregivers and 1 medication technician present for the evening shift; and two staff on the night shift. Lastly, regarding reporting requirements, LPA was unable to find any evidence to support that the facility is not doing so. Based on observations made, interviews conducted, and records reviewed, the Department received conflicting information regarding the above allegations. Based on interviews conducted, observations made, and records obtained, the allegations that staff does not ensure records are properly maintained; handles resident in a rough manner; and does not ensure residents are spoken to in an appropriate manner. RP further alleges that facility staff does not ensure staff is in good health to perform the duties of her position correctly; do not ensure residents receive adequate care and supervision resulting in un-witnessed falls; and does not ensure reporting requirements are being followed are UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that 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, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 21-AS-20250821122246

Type of visit: Case Management - Incident

On 10/14/2025, at approximately 4:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident visit and met with Dorla Licausi, Administrator. LPA is conducting a case management visit to obtain more information regarding two incident reports received by the Department: (1) received on 07/30/2025 for an incident that occurred on 07/20/2025, involving Staff 1 (S1) and Resident 1 (R1); and (2) received on 08/27/2025 for an incident that occurred on 8/25/2025 involving S1 and Resident 2 (R2). Both of these incidents were followed up on today as a part of complaint investigation #21-AS-20250821122246 received by the Department on 08/21/2025. A citation was issued under the complaint investigation. Exit interview was conducted with Administrator, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 14, 2025

Allegation investigated: Medication - not dispensing medication as prescribed by physician. Medication - missing medication. Neglect/Lack of Supervision - resident not repositioned. Buildings and Grounds - staff not ensuring facility is safe sanitary and in good repair.

At approximatley 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facliity unannounced to complete an investigation into the above allegations. LPA met with Executive Director Dorla Licausi. Based on records reviewed and interviews conducted, LPA was not able to find evidence that facility was not dispensing medication as prescribed by physician. Resident, R1, was prescribed a Fentynal patch 12mcg every 3 days, then an increase to 25mcg was ordered. Facility did not have a written order, nor were the correct patches available at the time of a verbal order. Facility began applying the correct patch when the proper documentation and patches were received. Records reviewed indicate the placement and removal of each patch. LPA did not find detailed disposal records for each patch, other than the destruction record indicating the patches were disposed of. LPA discussed with Executive Director various methods of better destruction documentation going forward. LPA reviewed medication records and did not find evidence of missing medication. Documentation of applied and removed patches matched the perscription count. Based on records reviewed, R1 did not need assistance repositioning in bed and was able to reposition themselves. Based on interviews conducted, R1 did not like certain positions and would make their needs known to staff. Continued on LIC9099-C... Unsubstantiated During the course of this investigation, LPA toured the building and grounds and did not find occurrences of unsanitary areas or items that were in need of repair. LPA was informed that staff had left soiled garments on a counter top in a residents room. LPA reviewed photos and observed what appeared to be some folded, clean articles of clothing, 2 dirty dishware items in a sink and a clear plastic bag with a small, closed plastic bottle on the counter. There was no evidence of soiled garments or unsanitary conditions. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 21-AS-20250321090748

Type of visit: Required - 1 Year

At approximately 10:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Dorla Licausi, Executive Director. Facility is a Residential Care Facility for the Elderly (RCFE) with seventy-four (74) residents in care. Facility has both assisted living and memory care residents, with a Hospice waiver for 16 and approval for 10 bedridden residents. Facility has a delayed egress system in place and the assisted living residents utilize pendants which they wear. At approximately 11:15 AM, LPA initiated a tour of the facility with ED and observed the following: Facility is a two story building, with emergency evacuation chairs in place. Facility was a comfortable temperature, and passageways were free from obstructions. LPA observed egress devices activated and staff responded timely. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Closets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are outdoor shaded seating areas for activities. LPA observed residents engaged in activities in common areas. Facility has internet service and an internet access device designated for resident use. Continued on LIC809-C... Continued from LIC809C... Facility's last fire inspection was conducted 03/2025. Fire extinguishers were observed fully charged and were last inspected 08/2024. Emergency Disaster Plan was reviewed and updated 05/2024. Facility conducts monthly disaster drills with the most recent drill conducted 05/2025. Facility has a back up generator for emergency preparedness. At approximately 12:00 PM, LPA conducted file review of ten (10) staff and ten (10) resident files. All staff files reviewed contained all of the required documents, proof of training and proof of current First Aid and CPR certification. All resident files reviewed contained all the required documentation. Facility assists with coordinating medical and dental appointments as well as transportation to and from appointments when residents have the need. Medications and medication records were inspected and the logs were observed maintained in compliance with regulation. Facility does not handle P&I. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC610E - Emergency Disaster Plan (updated) Exit interview conducted with ED whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 10, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Julie Florio conducted a case management- incident inspection, on 6/10/25 at approximately 6:00 pm, and met with Dorla Licausi, Executive Director (ED). LPA is conducting a case management visit to obtain more information regarding an incident which occurred on 05/31/2025, involving Staff 1 (S1) and Resident 1 (R1), Resident 2 (R2), Resident 3 (R3,) Resident 4 (R4), Resident 5 (R5), Resident 6 (R6), and Resident 7 (R7) which was reported by ED via email on 05/31/2025 followed by an incident report and corresponding SOC341's received by the Department on 06/02/2025. During visit, LPA obtained records, made observations and conducted an interview. No deficiencies were cited during todays visit. Exit interview was conducted with ED, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Jun 10, 2025

Allegation investigated: Staff did not call emergency services for residents in care Staff did not prevent residents from smoking inside the facility Staff did not prevent residents from sleeping on the facility floor Staff did not prevent residents from entering other resident rooms Staff did not prevent resident from interfering with resident's care needs

At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Executive Director Dorla Licausi, reviewed records and interviewed staff. Based on records reviewed, LPA was not able to find evidence so support the allegations listed above. Records reviewed showed the facility contacted emergency services when residents are in need and basic first aid is provided when emergency services are not required. Based on interviews conducted and records reviewed, the facility has a strict no smoking indoor policy. Residents, however, are able to make decisions and not follow the policy. When smoking indoors is observed, staff remind residents of the risk and request they use the outdoor smoking areas. Based on records reviewed, residents have been found sleeping in areas other than their rooms. Records show when a resident is found sleeping in public areas, they are checked on and assisted back to their rooms. Based on records reviewed, residents are sometimes found in other resident rooms. Residents are checked on and assisted to their own rooms. Staff document the interaction and when needed, care plans are updated to increase monitoring of residents. LPA was not able to find evidence to show residents are interfering with other residents care needs. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 1, 2025 · control 21-AS-20241211154024

Allegation investigated: Staff did not prevent resident from distributing marijuana products to residents in care Residents have access to centrally stored medications Staff are not able to provide adequate supervision to residents in care

At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Executive Director Dorla Licausi, reviewed records and interviewed staff. Based on records reviewed, LPA was not able to find evidence so support the allegations listed above. Residents are allowed to leave the facility when they choose and to utilize recreational marijuana. LPA was not able to find evidence that residents were distributing marijuana products inside the facility. Based on records reviewed, there are many levels of care provided at the facility. Several residents are able to store and manage their own medications. Medications are secured in a locked drawer or when they leave their rooms by locking the door. LPA has made numerous visits to this facility and found the medication room to be secured when not occupied by staff. LPA conducted a review of staff schedules and found the facility is within regulation. When residents require additional assistance, staff are scheduled to assist. LPA did not find evidence that a resident who needed supervision did not receive it. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 1, 2025 · control 21-AS-20250123145755

Type of visit: Case Management - Incident

At approximately 11:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management in regards to an incident report submitted to the department on 08/26/2024. LPA met with Executive Director Dorla Licausi and reviewed records. On 08/17/2024, Resident, R1, received a wrong dose of medication. After R1 had already taken the pills, staff noticed it was the incorrect amount of medication. Physician was notified and informed staff to observe resident for changes. The amount of this medication has been changed several times in the past few months and the medication was not flagged when the dose changed the last time. Staff was retrained on facility medication practices to ensure an error does not occur in the future. ***This is a repeat violation of the same code section in a 12 month period. An immediate Civil penalty is being issued in the amount of $250.*** Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Dorla Licausi and Appeal rights were given.the state’s words, verbatim · CDSS document, Aug 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 28, 2024

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed Licensee did not ensure R1 received the correct amount of medication. This poses an immediate Health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Facility conducted retraining for responsible staff. POC cleared at time of visit.

Type of visit: Required - 1 Year

On 07/19/2024 at approximately 09:15am, Licensing Program Analyst (LPA) J. Macias arrived to conduct an unannounced required Annual Inspection and met with Administrator, Dorla Licausi. Facility contact information was reviewed. Fees are current at the time of visit. Facility is two stories with both assisted living and memory care. At approximately 10:00am, LPA and Administrator toured the facility & grounds, which included resident apartments, kitchens, food storage, dining rooms, and various common areas used by residents. Facility provides different types of activities which include painting, dominos, and various games. Facility was at a comfortable temperature and was found to be clean and in good repair. Resident rooms were furnished per regulation and had sufficient lighting, grab bars and non-skid bath mats for use by residents as needed. Water temperature in various restroom sinks accessible to residents in care were all within the range of 105 to 120 degrees F allowed per regulation. LPA observed all walkways and exits to be unobstructed. All stairwells had evacuation chairs as required. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality, stored per regulation. All toxins were locked up and inaccessible to residents as required. Medications are centrally stored in a secured room and inaccessible to residents. Medications were reviewed and found no deficiencies. At approximately 11:00 am, LPA reviewed five (5) resident files. All resident files were found to be complete with all required documentation. At approximately 12:00 pm, LPA reviewed six (6) staff records, which were all found to be well organized, thorough, and contained the required documentation. First Aid and CPR certification were current in staff files reviewed. All fire extinguishers were current and charged as of August 23, 2023. Facility has Fire alarm system that is serviced by an outside vendor that was last inspected on 04/18/2024. Last fire drill was conducted on 6/11/2024, per review of records. Administrator to submit updates of the following documents by 8/19/2024: LIC 500 Personnel Summary LIC308 Designation of Facility Responsibility Copy of Liability Insurance LIC 610 Emergency Disaster Plan (If changes) Infection Control Plan (If changes) Exit interview conducted with the Administrator.the state’s words, verbatim · CDSS document, Jul 19, 2024

Allegation investigated: Staff arranged for a resident to have another resident assist them while in care.

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. It has been alleged that facility staff made arrangements for Resident (R1) to assist another Resident(R2) by remaining in R2's room at night to remind R2 to call for assistance when needed. Through statements and document reviews, the following determinations are made: R1, R2, the Administrator and Nurse Consultant state that R1 volunteered to assist R2, who is a close friend, and that the facility staff have not requested or required R1 to provide any care or assistance to R2; There is no record indicating that the Physician for R2 has ordered night time supervision of R2 in excess of what is normally provided by staff for all residents in care. R1 and R2 state that the presence of R1 in R2's room at night is an informal arrangement which developed out of a friendship, was purely voluntary, and promulgated between themselves. Although the allegation may be true, based on statements and document reviews, there is not a preponderance of evidence to prove or disprove the allegation. Therefore, the allegation is UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 30, 2024 · control 21-AS-20240417163154

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived at this facility unannounced to conduct a case management visit in regards to incident reports. LPA met with Resident Services Coordinator Dylan Nunn. On 12/11/23 the department received an incident report along with SOC341 notifying CCL about resident (R1) and resident (R2). Per incident report, On 12/10/23 at approximate 5pm residents were having dinner when R1 approached some residents to attempt to grab R2's arms and kiss them, even when R2 replied "No", then staff intervene to redirect R1. Responsible parties were notified. On 12/11/23, R2 reported to staff that they were feeling some mild pain in their left upper arm, and refused to seek medical care when asked by staff. After the incident, R1 was closely monitored to ensure that this type of incidents do not happen again, so far no further incidents have happened. On 1/24/24 CCL received a self-incident report regarding resident (R3) who on 1/20/24 at approximate 10:20am staff alerted medication aide that R3 was experiencing a sharp pain in their lower back and was unable to move. Per incident report, R3 stated that they were brought to urgent care by their responsible party on 1/19/24, where they were diagnosed with a compression fracture to their lower back (T12). Staff called immediately 911 and R3 was transported to the hospital for further evaluation. During today's visit, LPA interviewed facility staff to obtain information about this incident, it was confirmed that R3 sustained a fracture without their knowledge. Based on records review, R3 had a diagnosis of wedge compression fracture of T11-T12 vertebra. Currently, R3 was admitted to skilled nursing for treatment. Continued on LIC809C... Continued from LIC809... Last incident reported that on 12/25/23 an allegedly medication error was observed in the medication book by facility staff. On 12/22/23 resident (R4) at approximately 5:34am supposedly received half of the prescribed dose of Oxycodone 5mg instead of one tablet by mouth every 6 hours as needed for pain as indicated by doctor's order. Based on records review, R3 was originally prescribed Oxycodone 5mg half tablet by mouth every 6 hours for pain, but the medication was adjusted as of 12/20/23 to one tablet by mouth every 6 hours as needed for severe pain. Per narcotic count sheet, R3 was assisted with one tablet starting on 12/22/23 after medication was filled by the pharmacy. The facility provided facsimile transmittal sheet dated 12/23/23 where R3's physician was reached out for medication adjustment and physician adjusted the medication. Based on interviews conducted, it was confirmed that R3 was assisted with their adequate medication dosage. No deficiencies cited during today's visit. Exit interview was conducted with Resident Services Coordinator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 30, 2024