The Ivy at Blue Oaks

Type of visit: Case Management - Incident

On 9/11/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Administrator, Chad Rogers. On 9/5/26, the department received an incident report of R1 mistakenly receiving R2's medication. It was reported that on 8/29/26, during the PM med pass by S1, S1 mistakenly gave R1 medications prescribed for R2. Both residents share an apartment and were in close proximity to one another at the time. S1 immediately recognized their error, notified PCP by FAX and phone, notified poison control and contacted the Health Services Director (HSD). R1 was unharmed in the incident and was monitored for any ill effects. Records review of medication orders and medication administration records for the 2 residents found that at the med time of the incident, R1 was prescribed 4 medications- 2 to treat dementia, 1 calcium supplement and 1 for heartburn. R1 received R2's medications- 1 blood thinner before S1 caught their error. Medical providers consulted advised R1 be given their regularly prescribed medication. During the medication review, it was also found that R2's medications prescribed for 8/29/26 at 8 PM were not signed off as given. Medication, Clonazepam, prescribed on 8/28/26 still has not been received by the facility so has not been administered. In addition to records reviewed, LPA requested record of S1's hands on (shadowing/ being shadowed) training records. report cont. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Sep 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 11, 2026

Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on interviews and records review which found R1 given medications not prescribed and R2 not receiving a medication prescribed but not filled. This posed and immediate risk to residents.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: Licensee agrees to submit a plan for review and audit of medication systems with specific attention to: thorough investigation of S1's actions on 8/29 and remediate R2's med fill. Retraining and plan to monitor S1's compitency for all med pass procedures. The plan is stating intention to review and plan response. By 9/18, the actual plan and steps to be taken will be submitted. The plan for review will be subitted POCdue by 9/12/26.

Allegation investigated: Staff do not serve residents food of good quality.. Staff do not assist residents with care in a timely manner. Staff do not adequately communicate with responsible party regarding residents care.

On 6/18/26, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with executive Director (ED), Chad Rgers. The department received an anonymous complaint which failed to provide specific actionable information (names of those effected, names of staff involved, time line of the allegations or a time period of the alleged events). The reporting party did not provide contact information with which LPA could seek clarifying information. LPA requested documents establishing them as the new ED be submitted to update the facility file. LPA discussed the allegations with the ED and business manager. Neither could identify a resident issue brought to their attention that relates to the allegations. As a result of this investigation, LPA finds allegation to be (US)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 with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 18, 2026 · control 59-AS-20260611102742

Type of visit: Case Management - Other

On 5/20/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with the Executive Director. The department received incident reports regarding falls for R1. LPA discussed the care of R1 before and after the falls that occurred on 5/12/26 and 5/14/26. Based on identified care needs at admission, R1 was receiving care for identified needs. Since the falls, care and supervision has been increased with corresponding changes to their care plan. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, May 20, 2026

Allegation investigated: Facility has insufficient staff to meet resident care needs. Facility staff did not meet resident incontinence care needs.

On 4/15/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke with Executive Director/ Administrator to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Title 22 personnell regulations require that staff be trained, competent and sufficent in number to meet the identified care needs of residents. One of the measures of sufficient staff numbers is in personnell records documentation of staff who actually worked per shift. This investigation was specifically reviewing staffing and care prior to January 1, 2026. Based on review of staff schedules provided the following was found: Staffing for the month of Nov. 2025: 5- AM shifts with 2 caregivers/ 1 med tech; 5- days with 3 caregivers/ 1 med tech AM; 17- days with 4 or more caregivers/ 1 med tech AM; 1- day with 3 caregivers/ 1 Med tech PM; 29- days with 4 or> caregivers/ 1 med tech PM; 2- days with 1 caregiver ON; 9- days with 2 caregivers ON; and 19- days with 3 or> caregivers ON. Substantiated Staffing for the month of Dec. 2025: 5- AM shifts with 2 caregivers/ 1 med tech; 5- days with 3 caregivers / 1 med tech AM; 21- days with 4 or> caregivers/ 1 med tech AM; 1- day with 3 caregivers / med tech PM; 30- days with 4 or> caregivers/ 1 med tech PM; 12- days with 2 caregivers ON; and 19 days with 3 or> caregivers ON. Staff interviews found that staff who worked during Nov. and Dec. 2025 experienced a number of staff leaving and new staff being hired. Staff stated that given the duties and acuity of residents in memory care such as 2 person assists, incontinent care, bathing, dressing, monitor wanderers, fall prevention plans, assist with eating , laundry, serving/ bus tables, cueing, transfer assists and unexpected occurrences, if there are too few staff, they were unable to provide care as outlined in individual plans. While staff responses varied regarding the ideal number of staff, they uniformly stated that 3 experienced staff on AM/PM made it likely that there could generally provide care as outlined in care plans with minimal occurrences of delays in care and that AM/PM shifts with only 2 caregivers made it impossible to attend to resident needs timely. LPA reviewed incident reports submitted by the program and conducted records review of seven residents for whom there had been reported incidents. Summary of the review: R1- dementia diagnosis, food restrictions, incontinence, wandering/ exit seeking, confusion and aggressive episodes. RO records found incident for 11/26/25. R2- dementia diagnosis, incontinence, transfer assistance and ADL assistance. Incident reported for 10/16/25. R3- dementia diagnosis with extensive history of behavioral episodes, full assist with ADLs and incontinence care, required close observation for behaviors and inedible objects in their mouth. Incidents of falls, behavioral disturbances and sleeplessness on ONs. R4- dementia diagnosis, vision impairment, incontinence, food preference. 8/30/25 incident. R5- dementia diagnosis, food restrictions; incontinence assist, walker use/ wheelchair, confusion, "sundowning" and stand by assist for ADLs. Incident on 8/5/25 hospital care.. R6- Parkinson’s diagnosis with dementia, having CHF, hemiplegia and a catheter. Incidents on 8/5/25, 9/6/25 and 9/6/25. R7- Records found that R7, had a reported incident on 9/9/25 and has moved to assisted living before this investigation. Interviews of staff and family regarding R1 found R1 to regularly wander within the memory care unit, trying to open doors and, at times, to enter other resident rooms. When resident care demands were high and staffing low, staff were not able to maintain awareness of R1’s status or location. R1’s service plan was for staff to “closely observe and guide wandering”. R1 would impulsively eat and had difficulty managing food. R1 was to be 1:1 staff assist while eating. R1 was twice hospitalized for aspirations, was observed by family, on one occasion following an aspiration hospitalization, with cheeks full of food. On one occasion, it was reported in interviews, R1 required another visitor to the facility to perform the Heimlich due to R1 choking (staff present at the time of the incident were not identified). Interviews of staff and family regarding R6 found that R6 was known to be a fall risk and to have cognitive impairment that effected their ability to effectively use a call pendant and limited their awareness of their ambulation limitations. Family estimated R6 required cues/ reminders every 20-30 minutes in order to be more successful with their fall prevention plan. Staff interviews found that R6 quickly forgot safety information provided. R6’s assessment found a high level of care need. R1, according to staff interviews, would regularly be found on their floor without injury and R6 would be unable to explain how it occurred. Interviews of staff and families also found R6 had a catheter and that catheter care of changing and flushing was done, in the community, by a family member who was not a licensed professional. This issue is addressed in an additional case management report. While records and statements found a large variability in staff scheduled per AM/PM shifts, from 2 caregiver and a med tech to 4 (or more) caregivers and a med tech, the vast majority had at least 3 caregivers. Staff statements that when there were 2 caregivers, for approximately 30 memory care residents, their main concern was safety. Resident ADL and incontinence care, schedules, monitoring could not be adhered to and posed potential risks to residents in care. Title 22 requirements are that a resident with incontinence either have a structured bowel and/or bladder retraining program to assist the resident in restoring a normal pattern of continence or a program of scheduled toileting at regular intervals. Incontinence garments may be used. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Administrator . Copy of this report and appeal rights provide. Staff interviewed stated awareness of the monitoring and that in providing care, efforts were made to view the wound site. Staff also stated that R1’s behavioral expressions around bathing, dressing and incontinence care, coupled with family insistence on doing showers presented challenges to care and effective monitoring of the wound. Staff insufficient care and supervision lead to residents choking on food incidents.- Interviews of staff and families found that there were incidents of residents choking on food or drink. However, LPA was unable to find a direct relationship between care and supervision and the occurrence of a particular incident. Resident was assigned a fee increase though care identified was not provided- Health and Safety Code 1569.657 the licensee may increase residents’ care cost, following an reappraisal that identifies the increased care needed and provided. R5’s appraisals documented increased care needs that prompted a increase in fees. The licensee must then notify the resident and/or representative within two days of the increase. Regulation requirements were followed and a meeting is available between the representative and facility staff to discuss the care and fees for R5. As a result of this investigation, LPA finds allegation to be (US)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 with administrator and report copy provided.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 59-AS-20251226110029

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 13, 2026

Personnel Requirements – General (a) , Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met based on records and statements. This posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Licensee is continually hiring and training staff to maintain numbers needed for the needs of residents. Licensee will submit the plan for covering staffing needs when there are unexpected absence of staff, including reflecting the staff adjustment in the staff schedule.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(a)(1)(BandC) · Plan of correction due date: May 13, 2026

Managed Incontinence (a)(1)(B and C) (B) A structured bowel and/or bladder retraining program to assist the resident in restoring a normal pattern of continence. (C) A program of scheduled toileting at regular intervals. This requirement was not met based on records and statements. This posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Licensee agrees to add to the plan above, how staffing will be responded to to specifically address the incontinence care plans for resident.

Allegation investigated: Facility staff do not practice safe food handling

On 4/15/26, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with the Executive Director/ Administrator. LPA conducted records review, site visits and interviews. LPA is unable to find and or meet the preponderance, per policy. In the three visits conducted during the course of this investigation, LPA did not observe violations of food servive regulations. Facility staff and management presented facility policy training and quality assurance measures in place that meet or exceed Title 22 regulations. Resident interviews found general satisfaction with food quality and service and occasional reports of quality from particular servers but no specific regulation violation that could be verified by this investigation. As a result of this investigation, LPA finds allegation to be (US)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 with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 15, 2026 · control 59-AS-20260109161127

Type of visit: Case Management - Deficiencies

On 4/15/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Executive Director/ Administrator . During the investigation of complaint number 59-AS-20251226110029, LPA found, through records and statements, that R6 used a catheter and that the catheter changes and flushing were done by a family member who was not a licensed professional. Title 22 regulation 87623 Indwelling Urinary Catheter- (a)(1)(A)and (B) states: (A) Irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders. (B) A catheter shall only be inserted and removed by an appropriately skilled professional under physician's orders. R6 has since moved from the community. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Apr 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87623(a)(1)(A) · Plan of correction due date: Apr 20, 2026

Indwelling Urinary Catheter- (a)(1)(A)and (B) states: (A) Irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders. (B) A catheter shall only be inserted and removed by an appropriately skilled professional under physician's orders. This requirement was not met based on statements and records. This posed an immediate risk to R6.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: The resident is no in care. Licensee will submit the plan for review with directors to insure directors are reporting and properly addressing restricted health care needs.

Allegation investigated: Facility staff threaten resident in care.

On 12/22/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit and delivered the findings for the above allegations and met with the Administrator. LPA conducted extensive interviews. LPA is unable to find and or meet the preponderance, per policy. LPA interviewed R1, Administrator, S1 and S2. R1 stated to LPA that no staff have spoken to them in a threatening way. S1, who was a staff present at the alleged incident, denied S2 stated to R1 that S3 would harm R1. S2 stated that they had told R1 S3 could assist them if R1 wanted a different caregiver, and S2 denied threatening R1. As a result of this investigation, LPA finds allegation to be (US)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 with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 23, 2025 · control 59-AS-20251216113536

Type of visit: Case Management - Incident

On 12/22/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with the Administrator. The department received an incident report that reported R1 having left the facility unassisted on 12/14/25. Resident returned unharmed approximately 50 minutes after their wander- guard recorded their departure. R1 was accompanied back to the facility by an apparent employee from a nearby shopping center. Records review of R1's most recent physician's report lists: mild cognitive impairment, occasional disorientation, fall risk and unable to leave facility unassisted. Staff interviews found that R1 has not had recent history of attempts to leave unassisted. Interviews also found that R1 had had recent discussions of wanting to get a haircut with family or staff assistance that were unsuccessful. S1 was assigned to R1 at the time of R1's departure. S1 denies having been aware of a wander-guard alert of R1 exiting the building. S1 discovered R1 missing when S1 went to get R1 for a shower. S1 alerted others and searched the places R1 is known to go within the building. S2 was working at the front desk at the time of R1's departure. S2 reported that the front lobby was busy at the time of R1's departure. S2 did not see R1 leave. However, S2 recalled other residents and family having been in the lobby. S2 stated that when the front door alarm sounds, staff would need to physically clear the alarm at the front door. Report continued... S3 was present at the time of R1's departure and saw R1 return to the building accompanied by another person. S3 stated they were not aware of R1's departure. S4 was the med tech on shift but was on break at the time of the incident and only was aware of R1's return. A review of this incident found the following factors to have allowed R1 to leave undetected: Staff at the front desk having too many tasks at the time to fully attend to resident departures, staff not receiving alerts on pagers; and, communication between staff to confirm that a exit alarm is properly responded to and the resident has not left without assistance. Therefore, while there were sufficient number of staff, staff did not competently monitor R1 and respond to alerts of R1's exiting the facility. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Dec 23, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 24, 2025

Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met based on records and interviews. This posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: Licensee will submit the a summary of corrections put in place since this incident (to include front dest duties, wander guard alarm response procdure, equipment checks and staff communication for alarm responses). POC to be submitted by 12/23/25

Allegation investigated: Facility staff did not respond to resident call for assistance due to insufficient staffing. Facility staff did not provide identified care assistance to resident.

On 11/18/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Executive Director/ Administrator to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Records and statements by resident and staff found that on 8/28/25, R1 had an apparent medical emergency. Call button records for R1’s room recorded showed, on 8/28/25, bathroom pull station at 10:51, pendant alarm 11:00, bathroom pull station alarm cleared 11:05 and Pendant alarm cleared at 11:31. Bathroom pull station alarm cleared at 14 min 37 secs, pendant cleared at 30 min 25 secs. Staff working at that time were interviewed. Staff reported that a single caregiver was assigned to assisted living working with a single med tech. A second caregiver was scheduled but did not work. report continued... Substantiated Staff stated that when they became aware of the call for assistance to R1, staff had to complete assistance with another resident on the second floor. Some staff reported that pagers used by staff were unreliable- sometimes not working and sometimes delayed signal. Management denies hearing of such issues with pagers. Staff, responding to R1 on 8/28/25, were told by R1’s spouse that they had been calling for assistance for a half an hour. Additionally, it was reported that after waiting for call button response, R1’s spouse, reportedly, called to the front desk before assistance arrived. Therefore, it is found that personnel were not sufficient in numbers to meet the needs of residents. Records and statements found that on 6/28/25, R1 was hospitalized for an acute health condition. Following their return to the community, R1’s services plan was increased to include evening and overnight assistance for R1’s safety . Statements by staff and the Administrator found that the increased assistance was not consistently provided as agreed to R1 during this time. R1’s condition improved to no longer needing the increased assistance. The service was discontinued and R1 was reimbursed for the lapse in increased care. Therefore, personal assistance and care, as identified, was not provided to R1 and as indicated in R1’s service agreement. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 59-AS-20250919152445

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 12, 2025

Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met based on records and statements finding insufficient number of staff.This posed a potential risk to R1.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Licensee will submit the procedure of how the number of staff is determined per shift and how substitute staffing will be filled when scheduled staff do not work. This POC is due by 12/12/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Dec 12, 2025

Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated… This requirement was not met based on records and statements finding R1 returned with a change of condition and care needs identified were not provided. This posed a potential risk to R1.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Licensee will provide a copy of procedures for identifying changes to resident care and identified chain of command to implement updates to resident care to all care staff. ThisPOC is due by 12/12/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility announced on Oct.16, 2025 to conduct a Annual inspection utilizing the CARE tool. LPA met with the Executive Director and explained the purpose of the visit. LPA toured the interior and exterior of the facility and safety of residents in care. Areas toured include but are not limited to: common areas, kitchen, laundry room, outdoor areas- In the areas toured no immediate health, safety concerns observed an are clean and well maintained. LPA reviewed 6 resident files and 6 staff files. Files are complete and well organized. As a result of today's inspection, no deficiencies are cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Oct 16, 2025

Allegation investigated: Facility staff did not allow resident to attend activities of choice.

On 9/23/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Executive Director (ED), Michelle Swearingen, to deliver complaint findings for the above allegation. LPA reviewed resident records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Documents and interviews found that R1 moved into the facility, with their spouse, into assisted living. At the time of the admission, R1 was known to have a cognitive disorder diagnosis with behavioral disturbance. In February, R1, spouse was hospitalized. While spouse, who is the power of attorney for R1, was hospitalized, a decision was made with Administrator and another family member, to move R1 to memory care for safety and supervision of R1. Upon R1’s spouse return to the facility, R1 and spouse wished to interact within the facility and on outings. Report continued Substantiated R1 was restricted at times to join their spouse for meals in assisted living and to participate in outings provided by the facility. During the course of this investigation, R1 and their spouse have since been allowed to have increased freedom of movement and safety measures have been put in place. Though improved, at the time of the complaint, R1’s personal right to attend activities of their choice. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with ED . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 59-AS-20250716160452

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Oct 21, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) (6) To make choices concerning their daily lives in the facility. This requirement was not met. Based on records and statements, for a time, R1, was not allowed to make choices regarding their daily lives at the facility. This posed a potential violation of their rightsthe state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: During the course of this investigation a plan has been developed and adopted to reinstate R1's rights to move within and out of the facility under the supervision of others. POC cleared by visit

Allegation investigated: Licensee does not ensure that there are enough staff to meet resident's hygiene needs while in care. Staff member handled resident in care in a rough manner. Staff member yelled at resident in care. Licensee does not ensure that staff are adequately trained.

On 8/21/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Executive Director. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. LPA interviewed a family member of resident alleged to not have had hygiene needs met. Family member stated that a family member is present for part of every day of resident's stay. Family member did not have concerns for care of R1. R1 was not able to recall such an incident occurring. For the allegation of staff being rough with a resident and yelling at a resident, the specific resident was not identified and the staff are no longer present at the facility. No additional evidence was available for this allegation. Regarding the allegation of insufficient staffing, this complaint was stating general staff shortages that were alleged to occur months prior. Specific incidents alleged were not substantiated. The staff alleged to not receiving training did not identify the training not provided under Title 22 requirements. As a result of this investigation, LPA finds allegation to be (US)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 with administrator and report copy provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 21, 2025 · control 59-AS-20250627153032

Type of visit: Case Management - Other

On 6/5/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit met with Executive Director (ED. On 5/30/25, the department received an eviction notice for R1. The reason for the eviction is a change of condition with aggressive behavioral expressions. LPA observed R1 visiting with friends. LPA and ED discussed the progression of R1's increased behaviors and efforts to date to mitigate the behaviors. Administrator will submit copies of reappraisals and strategies utilized to date that identify and attempted to address R1's behaviors. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Jun 5, 2025

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility announced on March 11, 2025 to conduct a Post-licensing inspection utilizing the CARE tool. LPA met with the Executive Director and explained the purpose of the visit. LPA toured the interior and exterior of the facility and safety of residents in care. Areas toured include but are not limited to: common areas, kitchen, laundry room, outdoor areas- In the areas toured no immediate health, safety concerns observed an are clean and well maintained. There are currently 71 residents present. LPA reviewed 3 resident files and 3 staff files. Files are complete and well organized. LPA and ED discussed updated regulations, effective 1/1/25, for resident documents and staff training. As a result of today's inspection, no deficiencies are cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Mar 11, 2025

Allegation investigated: Staff are not following refund conditions

On February 25, 2025, Licensing Program Analyst (LPA) Kevin Mknelly spoke with acting administrator , Cheryl Stevenson, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted interviews. LPA finds that the allegations cited above are substantiated. The complaint alleged that R1 paid a pre-admissions fee in July 2024, to reserve a room at the facility. R1 stated the licensee was not yet admitting residents at the time. R1 stated they changed their mind about moving in and went to the facility to let them know on October 7, 2024. R1 stated she spoke to the admissions coordinator. R1 stated they sent a letter on 10/24/24 stating they would not be moving in and requested a refund of fees paid to date. Report continued Substantiated LPA conducted an investigation visit on February 11, 2025. LPA spoke with Executive Director, Cheryl Stevenson, and the business manager. LPA reviewed records for R1’s agreement and attempts of the licensee to issue a refund. LPA found that the personnel with whom R1 interacted July to November 2024 no longer work at the facility as they were directing the opening of the facility. Furthermore, a refund check was written to and mailed to an incorrect person, in November 2024, with the same last name but different first name that R1. The mailing address for the check was also for a person other that R1. This showed that a clerical error occurred which resulted in R1 not receiving a refund within 15 days of R1’s notice to not enter the facility. LPA has verified that the issue was resolved with both the licensee and resident verifying that the amount due to R1 has now been repaid as of 2/14/25. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. in care. (B) This poses a potential personal rights violation, to R1. Report reviewed with Cheryl Stevenson . Copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 25, 2025 · control 59-AS-20250206153154

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(E) · Plan of correction due date: Feb 26, 2025

Admission Agreements (g) Admission agreements shall specify the following: (5)Refund conditions. (E) Preadmission fees shall be refunded according to the following conditions: A 100 percent refund of a preadmission fee shall be provided to an applicant or the applicant’s representative if: a. The applicant decides not to enter the facility prior to the facility completing a preadmission appraisal ... This requirement was not met based on records and statements. This posed a potential risk to R1's personal rights.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: LPA has verified that R1 has received their reimbursement during the course of this investigation. Therefore the plan of correction is cleared by this visit. No further action required at this time.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility announced on 11/20/24 to conduct a Pre-licensing referencing the CARE inspection tool. LPA met with the Executive Director and explained the purpose of the visit. LPA toured the interior and exterior of the facility and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, outdoor areas and The Gardens (memory Care) area, In the areas toured no immediate health, safety concerns observed. There are currently no residents or staff present. Component III review is waived as the applicant has other facilities. The facility is in significant compliance. License pending approval. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Nov 20, 2024