The Ivy at Wellington

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA) Jessica Cho made an unnannounced visit for the purpose of initiating the complaint investigation into the above allegation. LPA met with Assistant Executive Director Melanie Sigar and explained the reason for the visit. At approximately 9:20am, LPA was greeted by Executive Director David Alvarado. During the course of the investigation, LPA inspected one unit and interviewed three staff, one witness, and made an interview attempt with one resident. LPA obtained copies of Resident/Staff Rosters, facility map, work orders, plumbing invoice, and photos. The investigation is as follows: Regarding the allegation, Faciltiy is in disrepair, it is alleged that there is a lingering odor in the closet by the front door of the unit for Resident #1 (R1) after a leak occurred from the 5th floor. LPA inspected the coat closet with Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). There was no odor present in the coat closet and in the unit. The carpet in the closet was removed by S2, however there were no signs of mold/mildew and signs of water damage. LPA smelled the carpet in the coat closet in several areas, and there was no odor present. Unfounded LPA inspected the bathroom and walk-in closet with Witness #1 (W1) and there were no odor present and signs of water damage. Based on interviews with three of three staff and one witness, the carpet was cleaned after the water leak. Based on the work order, the carpet was cleaned March 25, 2026. LPA attempted an interview with R1, however LPA was unable to qualify R1 due to their medical condition. LPA verified that per the facility map, R1 lives on the Independent Living (IL) side of the facility of Building A. Interviewed staff and witness also corroborated R1 resides in the IL. Building A is independent and is not under the purview of the Department's jurisdiction as the license only applies to Building B for the Assisted Living portion of the facility. Therefore, this agency has investigated the complaint and based on observation, interviews, and record review, the allegation: Facility is in disrepair is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Executive Director David Alvarado, and a copy of this report including the LIC811 were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 22-AS-20260706092549

Type of visit: Required - 1 Year

On July 9, 2026, Licensing Program Analyst (LPA) Taylor Simerly and Licensing Program Manager (LPM) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA and LPM met with David Alvarado Executive Director. LPA and LPM explained the purpose of today’s visit. The facility is licensed to serve (160) elderly adults ages 60 and above, of which (115) ambulatory, (174) can be non-ambulatory and (16) bedridden. Approved for delayed egress. The facility has an approved hospice waiver for (20). Currently the facility has (124) residents and (6) are currently on hospice. This is a five story facility with Assisted Living (AL) and Independent Living (IL). The facility also has a Conference Room, Fitness, Health Services, Beauty Salon, Card Room, Bistro, Staff Break Room, Arts/Crafts, Grand Parlor, bathrooms, locked swimming pool, and Club House. The Mail Room, Computer Room, Kitchen, Dining Room, and the Employee Office are located on the 4th floor. LPA Simerly, LPM Iniguez and the executive director toured the physical plant. There is a swimming pool on the Independent Living (IL) that is gated, however, the IL is not licensed by CCLD. LPA and LPM inspected residents’ bedrooms and bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 107.4°F to 115.7°F, and the room temperature ranged from 76°F to 79°F. During the visit, LPA Simerly and LPM Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there were sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire Drill was conducted on June 17, 2026 and the last evacuation drill was on June 24, 2026. A review of (7) residents' service files and (11) staff personnel files was conducted. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies. LPA and LPM reviewed the administrator’s certificate on file that is valid from January 6, 2026 to January 5, 2028. LPA and LPM observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was provided to LPA. Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time. There was a Technical Violation issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was emailed to David Alvarado, Executive Director.the state’s words, verbatim · CDSS document, Jul 9, 2026

Allegation investigated: Facility failed to meet resident's needs.

On March 24, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unnanounced visit for the purpose of continuing the investigation into the above allegation. LPA met with Assistant Executive Director (AED) Melanie Sigar and explained the reason for the visit. On November 20, 2023, the Department received the complaint initiated by LPA Jenifer Tirre on November 29, 2023. During the course of the investigation conducted by LPA Cho, LPA interviewed one staff/ witness and obtained copies of the following documentation for review: Resident/Staff Rosters, Residency Agreement, facility map, and written correspondence. It is alleged that Facility failed to meet the resident's needs concerning Resident #1 (R1). Based on record review, R1 resided in the Independent Living (IL) per the Residency and Service Agreement dated April 19, 2022. Page 7 of the agreement notes under section 9. "Not a Continuing Care or RCFE Contract," the agreement does not entitle resident to receive services in the Residential Care for the Elderly component of the community. Unfounded LPA verified per the facility map that R1 lived on the IL side of the facility in room 259 of Building A. Interviewed staff and witness also corroborated R1 resided in the IL portion of the facility. Building A are independent and not under the purview of the Department's requirements. The license only applies to Building B, the Assisted Living. Therefore, this agency has investigated the complaint and based on the interviews which were conducted and the records that were reviewed, the following allegation: Facility failed to meet resident's needs is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Assistant Executive Director Melanie Sigar, and a copy of this report including the LIC811 were provided at exit.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 22-AS-20231120131411

Allegation investigated: Staff did not provide safet transportation to residents. Resident sustained an injury due to staff neglect.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegations. LPA spoke with Jerry Vadnais, Executive Director, and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, resident file review and interviews conducted. It is alleged staff did not provide safe transportation to residents and resident sustained an injury due to staff neglect, specifically to driver not securing resident walkers and walkers hitting resident (R1) on the head. Interview with staff stated that it was reported by R1 of the incident once they returned to the facility. Staff Continued on LIC9099-C Substantiated verified the validity of the incident. Staff were informed that there were two walkers that were not secured by the driver, when driving and driver made a turn the walkers moved and hit R1 on the head on their temple. Staff stated the policy is that items need to be secure in the van prior to departure. Interview with R1 stated that they were out in the community via facility van transportation when the driver was driving at a higher speed, made a sharp turn which caused the walkers to move from where they were and hit R1 in the head on their temple. During the course of the investigation, there was sufficient evidence to substantiate the allegations. The preponderance of evidence standard has been met; therefore, the above allegations are SUBSTANTIATED. See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director and a copy of this LIC9099 and LIC9099-D, along with a copy of the appeal rights was left at the facility. for further evaluation. Interview with R1 stated that staff provided medical attention, but they did not want to get further evaluation because they wanted to take a nap and did not want to go to hospital at that moment. Staff insisted and R1 until the following day decided to go to hospital for further evaluation. Therefore, the Department has determined the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 22-AS-20260108125813

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 17, 2026

Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Staff interviews that were conducted verified that resident had been injured while in the facility van. Therefore staff neglected the resident’s care. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Executive Director will provide in-services training in on the regulation cited and provide proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87312 · Plan of correction due date: Mar 17, 2026

Motor Vehicles Used in Transporting Residents Only drivers licensed for the type of vehicle operated shall be permitted to transport residents. The rated seating capacity of the vehicles shall not be exceeded. Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition. This requirement is not met as evidence by: staff interviews conducted veriied walkers in the facility van were not safely secured causing injury to residens in care. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Executive Director will provide in-services training in on the regulation cited and provide proof to LPA by POC due date.

Allegation investigated: Facility did not ensure resident was not accorded reasonable accommodations.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Gerry Vadnais, Executive Director and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, and interviews conducted. It is alleged that facility did not ensure resident was not accorded reasonable accommodations, specifically to resident (R1) sunroom being painted. LPA conducted a facility visit on October 29, 2025, and toured the facility and R1’s apartment. It was observed that R1’s sunroom had not been painted, or Continued on LIC9099-C Unsubstantiated painting hadn’t begun yet. Interview with staff stated that a notice was sent out to R1 on October 9, 2025, advising them that on October 13, 2025, the patio sunroom would be painted. Due to R1’s responsible party having concerns with the paint being used facility had not painted the sunroom. Staff stated that R1’s responsible party was concerned about the toxins the painting may have and what effects it would have on R1’s health since the sunroom was connected to apartment and it is an enclosed sunroom. Staff stated that R1 was given options to accommodate like moving apartments temporarily until painting was finished and dried completely. However staff and R1’s responsible party had not come to an agreement and project was put on hold until staff obtained the V.O.C. (volatile organic compounds) levels report as R1’s responsible party requested. Interview with resident indicated that painting to the sunroom had not begun and was unsure when it would begin since their daughter had a few concerns. Interview with R1’s responsible party stated that they had concerns with V.O.C. levels of the paint. However at the time of visit LPA obtained the report and provided a copy for R1 and their responsible party. Responsible party for R1 stated that they were satisfied with the report given had no concerns to report. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 22-AS-20251024160735

Allegation investigated: Staff did not allow resident's medication to be delivered.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA spoke with Gerry Vadnais, Executive Director and explained the purpose of the visit. During the course of the investigation, interview was conducted with staff, a review of facility records was completed and copy of pertinent documents obtained. It is alleged that staff did not allow resident's (R1) medication to be delivered. Based on the information on file for facility R1 resides in the independent living side in building A. Building A census is independent residents and it is not covered under CCLD licensure for the facility. Licensure for the facility only covers building B. Therefore, the Department has determined the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint. A copy of this report is being reviewed with Executive Director and a copy of this LIC9099 was furnished to the facility. Unfoundedthe state’s words, verbatim · CDSS document, Nov 17, 2025 · control 22-AS-20251010153151

Allegation investigated: Facility did not safeguard medications Facility staff are not trained in medication administration

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on January 29, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Gerry Vadnais. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility did not safeguard medications. Regarding the allegation the following was revealed: During the course of the interviews with individuals nine of nine individuals interviewed denied the allegations. During the initial visit on February 8, 2024, and subsequent visits on October 29, 2025, and November 14, 2025, LPA tour the facility and observed that the medications were locked inside the Medication Room. LPA also observed that the Medication Technicians (MTs) need a key to open the Medication carts. During the course of the interviews with residents, Resident 2 (R2) reported that the facility staff safeguard the medications properly. Per R3, she manages her own medications and stated that the medications get stored and locked in the Medication room. CONTINUED ON LIC9099-C... Unfounded R4 stated that staff secure the medications properly. Per R5, staff manage her medications and reported that staff safeguard the medications properly. During the course of the interviews with staff, Staff 1 (S1) reported that staff properly safeguard the Medications in the Medication carts and stated that only the MTs have a key to lock the Medication cart. S2 stated that staff properly safeguard the residents' Medications. Per S3, staff always safeguard the Medications in the Medication room. Regarding the allegation that facility staff are not trained in medication administration, the following was revealed: During the course of the investigation LPA reviewed documents including the Medication Technician Training Records dated April 13, 2023, for staff S1-S5. Per Medication Technician Training Record, S1-S5 completed 24 hours of initial training. Per Medication Technician Training Records S1-S5 completed 16 hours of hands-on shadowing training and eight hours of instructions/online training. During the course of the interviews with residents, R1 reported that staff are trained in medication administration. Per R2, staff are properly trained in medication administration. R4 stated that staff have completed all their trainings and reported that he is very happy with all staff. Per R5, staff are trained in Medication administration. During the course of the interviews with staff, S1 reported that the MTs have completed their trainings on administering Medications. Per S3, the MTs are trained in administering Medications and stated that the MTs do monthly Relias trainings and do monthly in-service trainings as needed. During the course of the interviews ED reported that staff are trained on Medication administration and stated that staff complete their trainings online or in-service trainings as needed. Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or are without a reasonable basis. LPA Ramirez conducted an exit interview with ED and a copy of this report was provided to the facility. Per S2, staff have never performed injections on the residents. S3 stated that staff have never performed injections on the residents. During the course of the interviews ED reported that staff are not allowed to perform injections since this is an Assisted Living. Per ED, the facility does not have the proper staff to perform injections. Regarding the allegation that facility staff falsified documents, the following was revealed: During the course of the interviews with individuals eight of nine individuals interviewed denied the allegations. During the course of the interviews with residents, R1 reported that she doubts that staff have falsified documents and stated that she has no complaints. Per R2, staff do not falsify documents. R3 stated that she does not have knowledge about staff falsifying the residents records. Per R4, he does not know if staff have falsified documents. R5 reported that staff do not falsify documents. During the course of the interviews with staff, S1 reported that staff have never falsified facility records and stated that she has never witness staff being forced to falsify documents. Per S2, she heard that staff sign for missing Medications. S3 stated that staff have never falsified facility or resident records. Per S3, she has never forced staff to falsify the Medications documentation. During the course of the interviews ED reported that if staff falsify documents, staff would be written up or terminated. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Vadnais, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 22-AS-20240129065431

Allegation investigated: Faciltiy did not safeguard resident's personal items.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted at the and granted entry. LPA spoke with Gerry Vadnais, Executive Director and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, and interviews conducted. It is alleged that facility did not safeguard resident’s personal items, specifically to items in an assigned residents (R1) locker. Interview with staff stated that when the license and the building were under the Continued on LIC9099-C Unsubstantiated previous license, they had issued lockers. Staff found a list of assigned lockers and to what residents it was assigned to. There was not an inventory list along with it and it is unsure if there was any since the previous licensee had control of the lockers. Each locker has a locker number and the corresponding residents name on it. In order to go into the locker area a resident need to make an appointment to gain access to their locker. Staff accompany residents to their locker; residents provide their own lock and therefore are the only ones who have a key to the lock. Staff do not obtain a copy of the key. Staff were made aware by the resident and accompanied R1 to their assigned locker. Locker was observed to not have a lock but had items in it that did not belong to R1. Interview with R1 stated that they originally had the locker 4 years ago and place items in the locker that they did not inform the management/staff about and did not give them an inventory list. R1 stated that they had not accessed or checked on locker since they placed items in there 4 years ago. R1 does not have anything to show what was in the locker and was the only one to have a key to the lock. LPA conducted a facility visit and toured the locker area and locker assigned to R1. It was observed to have paperwork, storage boxes and two paintings. LPA was informed that R1 indicated those paintings were not the ones they were missing. The locker was observed to have a number but without a lock or resident’s name. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 22-AS-20251006154342

Allegation investigated: Lack of supervision resulted in resident on resident sexual abuse. Facility is allowing resident to violate gun policy.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Jessica Cho for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Gerry Vadnais and explained the reason for today’s inspection. The investigation conducted by LPA Sean Haddad into the allegations that lack of supervision resulted in resident on resident sexual abuse and facility is allowing resident to violate gun policy revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed AD, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Admission Agreement, R1’s Physician’s Report dated November 17, 2021, R1’s Resident Appraisal dated March 17, 2022, R1’s Level of Care Assessment dated November 2, 2021, R1’s Mini-Mental State Examinations conducted on November 23, 2021, and March 17, 2022, R1’s Physician’s Report dated June 14, 2023, R1’s Medical Records, R1’s Care Notes, Resident #2’s (R2) Physician’s Report dated June 17, 2023, and R2’s Admission Agreement. Unfounded Regarding the allegation that lack of supervision resulted in resident on resident sexual abuse: it was alleged that in June 2023, R1 reported that their spouse R2 recently sexually abused them and that R2 has been sexually abusing them for years. Per R1’s Admission Agreement, R1 and R2 moved into the same room in the facility in November 2021. Review of R1’s Physician’s Report dated November 17, 2021, and R1’s Resident Appraisal dated March 17, 2022, revealed that R1 did not have any diagnoses, was ambulatory, had no functional impairments, and was able to communicate their needs. R1’s Level of Care Assessment dated November 2, 2021, indicates R1 had no care needs and R1’s Mini-Mental State Examinations conducted on November 23, 2021, and March 17, 2022, indicate R1 had no cognitive impairment. Per R1’s Physician’s Report dated June 14, 2023, R1’s health began to decline and R1 was diagnosed with hyperthyroidism, grave’s disease, anxiety, and depression, R1 was still ambulatory, R1 was not able to communicate their needs, R1 had functional impairments relating to self-care and medication management, and R1 had complications from their recent thyroid disorder diagnosis. LPA reviewed R1’s Medical Records which indicate that in June 2023, R1 was seen by medical providers often, had multiple hospitalizations, and had multiple medication changes as their medical condition changed. LPA reviewed R1’s Care Notes which document that in June 2023, R1 was checked on regularly by staff, had contact with their family, told staff they were doing well and reported no problems, but did report medical problems and received medical care when necessary. When interviewed, AD stated that R1 had never reported any issues of abuse, staff had never suspected any abuse involving R1 and R2, and that if any abuse had been suspected, the facility would have investigated it immediately. Interviews with eight facility staff revealed that staff did not see any indications of abuse and R1 never reported any issues. LPA reviewed R2’s Physician’s Report dated June 17, 2023, which indicates R2 had a right lower extremity amputation. Per AD, R2 had an amputated leg and needed a wheelchair to move around. Per AD, R1 moved out of the facility on June 27, 2023, and R2 moved out of the facility in February 2024. R1 was interviewed by local law enforcement, did not disclose that they were sexually abused by R2, and R1 passed away in September 2023. LPA interviewed R1’s family who stated that R1’s initial report of abuse in June 2023 was the only time R1 ever reported the issue, and that the facility had no reason to suspect abuse between R1 and R2. When interviewed, R2 denied sexually abusing R1. The information obtained regarding whether R1 was abused by R2 is conflicting and the information obtained did not corroborate that the facility did not provide proper care and supervision as R1 never reported any issues to the facility and facility staff had no reason to suspect abuse between R1 and R2. Regarding the allegation that the facility is allowing resident to violate gun policy: it was alleged that the facility is allowing R2 to store guns and ammunition at the facility in violation of the facility’s gun policy. LPA reviewed R2’s Admission Agreement, which incorporates the house rules which specifically state that weapons, including firearms, are not allowed in the facility. LPA interviewed AD who confirmed that guns are not allowed at the facility and stated the facility did not know R2 had guns and ammunition in their room. Per AD, the facility had received a concerning report regarding R2 and was notified by R2’s family that they had already removed some of R2’s guns, but AD was suspicious that there may be another gun, so AD had R2’s room searched and removed an additional gun and ammunition. When interviewed, R2 stated that the gun that was confiscated had been inadvertently brought to the facility when they moved in and that they had been intending to relocate it to store it outside of the facility. AD stated that the facility was unaware R2 had guns in their room, R1 who lived with R2 had never reported anything, and staff did not see the guns while cleaning R2’s room. While R2 did store guns and ammunition at the facility, the information obtained did not corroborate the allegation because the facility was unaware of the guns and enforced its gun policy as soon as it learned R2 was violating the policy. The Department has investigated the above allegations and found them to be Unfounded, meaning the allegations were false, could not have happened, or are without reasonable basis. An exit interview was conducted, and a copy of this report was discussed with and provided to Executive Director Gerry Vadnais.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 22-AS-20230831115602

Allegation investigated: -Staff tamper with resident's personal belongings -Staff are not following the monthly menu -Staff are serving a poor quality of food

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrive at facility was greeted and granted entry by staff. LPA spoke with Gerry Vadnais, Executive Director and explained the purpose of the visit. Findings are based upon this investigation which included facility file review, menus, room service menus, tour of the physical plant of the facility and interviews conducted. It is alleged that staff tamper with resident’s personal belongings. The interview with 2 of 2 staff stated that resident (R1) complained about an artificial plant in the exterior of their apartment in which the leaves were cut and/or removed. R1 never complained about a safe or missing batteries from it. Staff stated they weren’t Continued on LIC9099-C Unsubstantiated aware that R1 had a safe in their room and that residents are free to have their own property in their apartment. As to which residents don’t always inform the staff of purchases made to place in the inventory form LIC621 Resident personal property and valuables. LPA toured the physical plant of the facility and observed the artificial plant in question. LPA on the following dates: June 4, 2025, June 18, 2025, and on July 17, 2025, conducted a tour and observed that the artificial plant remained the same as it was observed on June 4, 2025. It is alleged that staff are not following the monthly menu, specifically to the room service to go menu. Interviews with 2 of 2 staff stated that the facility has several menus they use: the dining room menu, the to go menu for room service, and the alternative options menu. Facility recently improved the room service system to improve consistency and quality. As of May 21, 2025, room service orders are not done by telephone call but rather an ordering system for the specific meal period, the forms are slot units on the wall adjacent to the kitchen/in front of the facility elevators. There will be daily order forms on the table outside the kitchen and will be available in a weekly package as well that can be taken and completed in the residents leisure time. Staff stated the R1 orders a mainly from the room service option and crossed out the meal options and writes in a meal that is not offered on the menu, regardless of staff accommodating to R1 as best as they can based on what they are requesting. Interviews with 10 of 10 residents stated that they have never had an issue with the room service and have always received what they have ordered. If they want something not offered on the menu, they let staff know and staff always try to accommodate residents as best as they can. It is alleged that staff are serving a poor quality of food. LPA toured the facility kitchen, and it was observed that there was sufficient amount of quality and quantity of perishable and nonperishable food for residents. LPA observed food being prepped and staff preparing the food for the residents. In addition, LPA obtained a copy of the facility weekly menu for review with meal options and the room service menus for one week and observed the food service to be well balanced with a variety of choices. LPA conducted interviews with the Executive Chef and indicated that food service for residents have the choice to modify the menu to their liking as well as food being modified based on resident needs. Residents have the ability to choose from the variety of options offered out of the weekly menu. Interviews with 10 of 10 residents stated that they didn’t have an issue with the food served and they have always been able to modify the food to their liking or request for Continued on LIC9099-C something out of the menu. LPA toured the dining room and bistro and observed food being served, menu posted, and alternative menu posted. Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. This report was reviewed with the Executive Director and a copy was furnished to the facility.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 22-AS-20250603091336

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Melanie Sigar, Assistant Executive Director and LPA explained the nature of the visit. Facility is licensed for 115 ambulatory, 174 non-ambulatory residents, of which 16 may be bedridden. Facility has an approved hospice waiver for 20 residents. The facility currently has 7 residents are on hospice during today's visit. LPA Martinez along with Assistant Executive Director toured the inside and outside of the physical plant of the facility. LPA observed a bistro on the first floor where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus for both areas and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. Facility has apartment style bedroom for residents. LPA inspected apartments; all required components were observed in inspected apartments. Each apartment has their own bathroom, LPA inspected resident bathrooms. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Various resident bathrooms were Continued on LIC809-C tested for hot water temperature and water temperature measured between 117.6-120 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA observed the restrooms are equipped with a call button. Call button when pulled calls to caregiver pager as well as the front desk for response accuracy. LPA observe caregiver receive a call button notification and observed caregiver response to call. LPA observed several residents throughout the facility who appeared clean, and happy. LPA observed several courtyards with shaded seating areas for residents’ enjoyment. LPA observed a swimming pool with a fence around it. LPA observed the pool gate has five self-latching entry door which opens towards the pool. The fence has a key lock at the gate door for inaccessibility. LPA measured the pool fence which measured 6.08 ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPA observed the pool has five entry doors throughout the pool area. Toxic chemicals, cleaning solutions and disinfectants are stored locked in the housekeeping storage closet. Carbon monoxide detectors tested and noted to be operational. LPA observed fire extinguishers throughout the facility that are fully charged and had a service date of March 17, 2025. LPA verified fire drills are conducted and logs reflect the last fire drill conducted was May 19, 2025. Fire drills are conducted quarterly. Smoke detectors and sprinkler system are tested by an outside agency. LPA verified the last sprinkler inspection was conducted June 17, 2025 and they are done quarterly. Smoke detectors are inspected every 6 months and last inspection was June 10, 2025. LPA verified all systems passed inspection. Facility has ten stairwells and ten evacuation chairs in those stairwells. LPA began the review of records. LPA reviewed nine resident files, all resident files contained required documentation including updated physician reports and care plans. LPA reviewed five staff files. Staff files contained required documentation including health screens, first aid, and fingerprint clearance. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the facility representative and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 18, 2025

Allegation investigated: -Staff discarded residents' meals. -Staff disoensed medication to residents that was not prescribed.

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrived at facility and was greeted at the door and granted entry receptionist. LPA spoke with Gerry Vadnais, Executive Director and explained the purpose of the visit. After further investigation into this complaint and information received LPA determined that this complaint was written under the wrong facility license number. We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Executive Director and a copy of this LIC9099 report was left at facility. Unfoundedthe state’s words, verbatim · CDSS document, Apr 8, 2025 · control 22-AS-20250324102341

Allegation investigated: Facility did not release resident records to responsible party

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above for the purpose of delivering findings. LPA met with Executive Director (ED) Gerry Vadnais and explained the purpose of the inspection. It is alleged facility did not release Resident 1’s (R1’s) records to responsible party. During initial complaint investigation conducted on February 26, 2025, LPA conducted a record review of R1’s file and observed all documentation in question to be present, including physician orders and resident progress notes. During today’s visit, LPA interviewed two of two staff responsible for the release of resident records to their responsible party. During their interview, Staff 1 (S1) stated that that they had not personally received any request for release of any residents’ records, including R1. Per S1, in order for any resident’s responsible party to obtain records all that is required is a verbal request. S1 denied personally denying or having any knowledge of any staff denying resident records to their responsible party. (Cont. LIC9099-C) Unsubstantiated During their interview, Staff 2 (S2) stated that in order for any resident’s responsible party to obtain records all that is required is a verbal request. S2 denied personally denying or having any knowledge of any staff denying resident records to their responsible party. S2 stated they were unsure of the exact dates, but stated R1’s responsible party had requested to review R1’s records on multiple occasion and was never denied access. S2 denied withholding any records from R1’s responsible party, including, physician orders and resident progress notes. After record review of R1's file and due to conflicting information received during interviews conducted, LPA is unable to determine if facility did not release resident records to responsible party. Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 22-AS-20250131085015

Type of visit: Case Management - Other

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver amended report. Due to technical difficulties LPA delivered findings to facility on 01/09/2025. LPA Mendivil discussed amended report with Maritese Meneses, Heath Services Director and Gerry Vadnais, Executive Director. An exit interview was conducted with facility staff and a copy of this report, and amended report of findings delivered on 01/09/2025 were provided at exit.the state’s words, verbatim · CDSS document, Jan 16, 2025

Allegation investigated: Facility administered unauthorized medications Facility staff did not provide medications as prescribed

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA Mendivil was greeted and granted entry into the facility by Executive Director Gerry Vadnais and explained the reason for the visit. The Department received a complaint on 01/02/2025 and the initial 10 day visit was conducted on 01/09/2025. During the visit LPA Mendivil interviewed staff and obtained copies of medication administration records from July 2023 to December 2024, physician reports, and doctors orders. Regarding the allegations facility administered unauthorized medications and facility did not provide medications as prescribed, the investigation revealed the following: It was alleged that Resident 1 (R1) was administered unauthorized medications. Substantiated Per review of R1's medical records the facility received a fax from R1's current physician requesting the medication of Oxybutynin to be tapered off and then discontinued, the fax was received on 07/19/2023. Per review of medication administration records (MAR) Oxybutynin was tapered off and eventually discontinued in August of 2023, review of December 2023 MAR the medication is refilled by R1's former physician and continued to be given to R1 until August 14th 2024. Based on interview with Health Services Director Marties Meneses she started at the community around August 2023. Health Services Director stated the order was followed but in December 2023, someone on her staff found the original order of Oxybutynin from R1's former physician dated 3/16/2023. Heath Services Director stated that once it was brought to her attention that an order was received on 07/19/2023 by R1's current physician then the MAR was updated. Health Services Director stated the order from 07/19/2023 was filed by previous Health Services Director and was not located until August 2024. Per interview with Health Services Director the issue was not reported to the Department. It was alleged on or around December 2023 R1's neurologist prescribed Sertraline. Per interview with Health Services Director it was confirmed the facility received a prescription for Sertraline on 12/29/2023. Per review of the MAR Sertraline was not given to R1 until 2/10/2024. Health Services Director was unable to provide information as to why the medication was not provided from 12/29/2023 to 02/09/2024 as she stated it was added to medication list by pharmacy. LPA Mendivil's review of MAR from December 2023 to February 2024 do not mention Sertraline or any brand name for Sertraline until 2/10/2024. Therefore based on the preponderance of evidence through records reviewed and interviews the allegations facility did not provide medications as prescribed and facility did not meet reporting requirements are determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 22-AS-20250102131745

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Jan 10, 2025

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication This requirement was not met as evidence by facility provided R1 with medication that was not authorized after being discontinued by current physician. This poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Health Services Director resolved issue with R1 by discontiuning medication based on current physician's orders. Health Services Director agreed to weekly audits of residents medications and MAR

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 10, 2025

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: 4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by resident was not given prescription medications from 12/29/2023 to 02/09/2024.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Health Services Director resolved issue with R1 by starting the medication as prescribed. Health Services Director has implemented an electronic system for prescription updates.

Type of visit: Case Management - Deficiencies

On this day Licensing Program Analyst (LPA) made an unannounced visit for a case management in conjuction with complaint control 22-AS-20250102131745. It was alleged that Resident 1 (R1) was administered unauthorized medications. Per review of R1's medical records the facility received a fax from R1's current physician requesting the medication of Oxybutynin to be tapered off and then discontinued, the fax was received on 07/19/2023. Per review of medication administration records (MAR) Oxybutynin was tapered off and eventually discontinued in August of 2023, review of December 2023 MAR the medication is refilled by R1's former physician and continued to be given to R1 until August 14th 2024. Based on interview with Health Services Director Marties Meneses she started at the community around August 2023. Health Services Director stated the order was followed but in December 2023, someone on her staff found the original order of Oxybutynin from R1's former physician dated 3/16/2023. Heath Services Director stated that once it was brought to her attention that an order was received on 07/19/2023 by R1's current physician then the MAR was updated. Health Services Director stated the order from 07/19/2023 was filed by previous Health Services Director and was not located until August 2024. Per interview with Health Services Director the issue was not reported to the Department. Therefore based on interviews and records reviewed the following is being cited per Title 22. An exit interview was conducted and a copy was provided to facility representative.the state’s words, verbatim · CDSS document, Jan 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(D) · Plan of correction due date: Jan 15, 2025

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidence by facility did not report medication issue to the Department. This poses a potential safety risks to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Health Services Director to review regulation and provide proof to LPA by POC due date.

Allegation investigated: Resident sustained multiple unexplained bruises while in care.

This unannounced visit conducted by Licensing Program Analysts (LPA) Ruth Martinez is being conducted to conclude this agency’s investigation into the complaint allegation mentioned above. During the course of the investigation the following was conducted: interviews were conducted with staff, interviews were conducted with resident, a tour of the resident’s bedroom was conducted, a review of resident records was completed and copy of pertinent documents obtained. It is alleged resident sustained multiple unexplained bruises while in care. Interviews were conducted with staff which indicated that resident (R1) was being treated for Edema of the lower leg and for her ASCVD (Atherosclerotic cardiovascular disease) by a home health agency. R1 was sent to hospital on October Continued on LIC9099-C Unsubstantiated 30, 2024, due to general weakness and level of consciousness. Staff indicated that due to the Edema R1’s legs can get bruising as well R1 is on blood thinner medication that can play a big role in bruising easily. On November 13, 2024, LPA Martinez inspected R1’s apartment and observed R1 in their apartment in bed. LPA observed R1’s physical appearance and did not observe any bruising in R1’s arms, R1 in conversation showed LPA R1’s legs and LPA observe legs to have bandages due to R1’s Edema care but did not observe to have any bruising at the time of visit. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with Administrator and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Dec 4, 2024 · control 22-AS-20241104110548

Allegation investigated: Staff do not provide adequate care and supervision for a resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that staff do not provide adequate care and supervision for a resident, the investigation revealed the following: Resident 1 (R1) was hospitalized from 09/02/2024-09/09/2024 for weeping legs. Facility conducted an assessment upon return from the hospital with two changes from prior assessment dated 06/15/2024 which includes meal delivery and standby assistance with dressing until the resident recuperates. Resident's physician reports dated 04/23/2019 and 09/09/2024 are virtually the same indicating resident is able to leave the facility unassisted and receives medication management and assistance with bathing. Per interview with resident, resident is independent and able to manage ADL's except bathing assistance. Based on interviews conducted and record review, CONTINUED ON LIC 9099C DATED 10/01/2024 Unfounded the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 22-AS-20240904100619

Allegation investigated: Staff are not following infection control requirements

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on complaint investigation into the above allegations. LPA explained the reason for the visit with Senior Executive Director Gerry Vadnais. During the course of the investigation LPA toured facility with Health Service Director, conducted interviews with staff and residents, made visual observations and requested pertinent documentation such as Resident Roster, staff roster, notification letter, incident reports and copy of essential precautions. During investigation LPA conducted interviews with staff and residents. Staff interviews revealed that facility has infection control precautions put into place for Covid 19 such as masks available at reception desk & Health Services room for residents, Caregiving staff, Dining room staff & maintenance staff are required to wear masks when coming into contact with residents. Staff interviews also revealed that staff are cleaning surfaces daily in common areas such as dining room, cafe, activitiy rooms, fitness center and restrooms. CONTINUED ON 9099C Unsubstantiated Health Services Director states they have been in contact with Department of Public Health, resident families and contacted Licensing regarding covid positives. Staff interviews revealed that facility sends notification letter to residents and responsible parties inside on site mailboxes. Resident interviews revealed that half of residents interviewed confirmed they receive letters inside mailboxes while other half state they could not recall if they receive letters regarding Covid 19 notifications. All residents interviewed confirmed that staff are helpful regarding resident concerns. During visit LPA observed facility has hand sanitizer stations in common areas such as lobby, dining room, activities area, fitness room, cafe area, inside elevators and restrooms on each floor. LPA observed caregiver, dining staff and maintenance staff wearing masks. LPA observed Personal Protective Equipment carts outside of Residents rooms and observed hand washing signs located inside common area restrooms. LPA observed cases of PPE supplies such as gloves, surgical masks, face shields, N-95 masks and sanitizer. LPA reviewed facility notification letter sent out to residents & responsible parties stating that facility is taking steps for residents protection such as offering more hand sanitizer, staff wearing masks, surfaces being cleaned daily, offering in room dining and protocols for residents who have tested positive. LPA reviewed Facility essential precautions which state that residents, staff or visitors will be tested if covid symptoms are observed, routine sanitation of high touch surfaces daily, all suspected cases of covid will be retested 24 hours if symptom's occur. LPA also reviewed reporting requirements which state facility will report outbreaks. LPA observed Incident Reports which were provided by facility reporting cases. Based on interviews conducted, observations made and records reviewed 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 following allegation staff are not following infection control requirements is deemed UNSUBSTANTIATED. An exit interview was conducted with Director and a copy of this report was reviewed and provided at the time of this visit.the state’s words, verbatim · CDSS document, Jun 25, 2024 · control 22-AS-20240618142643

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Gerry Vadnais, Senior Executive Director and LPA explained the nature of the visit. Facility is licensed for 115 ambulatory, 174 non-ambulatory residents, of which 16 may be bedridden. Facility has an approved hospice waiver for 20 residents. The facility currently has 103 residents and four residents are on hospice during today's visit. LPA Martinez along with Senior Executive Director toured the inside and outside of the physical plant of the facility. LPA observed a bistro on the first floor where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus for both areas and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. LPA reviewed eleven resident files, all resident files contained required documentation including updated physician reports and care plans. Facility has apartment style bedroom for residents. LPA inspected apartments; all required components were observed in inspected apartments. Each apartment has their own bathroom, LPA inspected resident bathrooms. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Resident bathrooms were tested for hot water temperature and water temperature measured between 118.2 -120.2 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies Continued on LIC809-C were adequately stocked. LPA observed the restrooms are equipped with a call button. Call button when pulled calls to caregiver pager as well as the front desk for response accuracy. LPA observe caregiver receive a call button notification and response time was immediate. LPA observed several residents throughout the facility who appeared clean, and happy. LPA observed several courtyards with shaded seating areas for residents’ enjoyment. LPA observed a swimming pool with a fence around it. LPA observed the pool gate has a self-latching entry door which opens towards the pool. The fence has a key lock at the gate door for inaccessibility. LPA measured the pool fence which measured 6.08ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPA observed the pool has five entry doors throughout the pool area. Toxic chemicals, cleaning solutions and disinfectants are stored locked in the housekeeping storage closet. Carbon monoxide detectors tested and noted to be operational. LPA observed fire extinguishers throughout the facility that are fully charged and had a service date of March 16, 2024. Smoke detectors and sprinkler system are tested yearly by an outside agency, and LPA was provided with testing documentation, last testing was done April 3-5, 2024. Emergency drills are being conducted monthly with a variation of shifts and the last drill conducted on May 14, 2024, which conducted a drill in the AM shift and PM shift. Facility has ten stairwells and ten evacuation chairs in those stairwells. LPA reviewed five staff files. Staff files contained required documentation including health screens, first aid, and fingerprint clearance. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Senior Executive Director and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 20, 2024

Allegation investigated: Staff do not answer residents' call buttons in a timely manner Staff do not ensure residents are bathed

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for the complaint received on 10/27/23 and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted by executive director (ED) Gerry Vadnais. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that the staff do not answer resident's call buttons in a timely manner. LPA toured random resident rooms and tested the call buttons. LPA observed that staff responded between thirteen to fifteen minutes. LPA conducted a total of 7 interviews that consisted of staff and residents. All 7 interviews did not corroborate with the allegation by stating that although there is an average of a fifteen to twenty minute response period, the staff still responds to the call button. Unsubstantiated It was also observed that each facility staff has a radio that is carried around to communicate amongst the other staff to update on a resident's whereabouts are. LPA reviewed the pendant tracking report for the month of October and observed that the average response time was between twelve to twenty three minutes. It was alleged that staff do not ensure that residents are bathed. LPA observed that the facility tracks a resident's bathing schedule through a bathing log. LPA conducted 3 staff interviews who stated that if a resident declines in wanting to be bathed, not only is it documented, but staff will inform the resident's family of refusal, and depending on the resident's admission agreement, the facility will offer a refund. The 4 interviews conducted with residents stated that there were no concerns regarding bathing because the caregivers do a "good job" at ensuring bathing needs are met. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with ED Vadnais . A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Nov 3, 2023 · control 22-AS-20231027144246