The Kensington at Walnut Creek

Type of visit: Annual/Random

On 08/28/2026 at 9:00 AM, Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, Joyce Aquino and explained the purpose of the visit. The facility’s fire clearance was approved for capacity 200 non-ambulatory residents. Hospice waiver approved for twenty (20) residents. LPAs toured the facility with Joyce and Raymundo Rosales (Maintenance Director) including but not limited to six (6) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperatures was maintained at 74, 75 and 76 degrees F. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 114.1, 117.5, 107 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LIC809-C Continued... LIC809-C (Page 2) LPA reviewed eight (8) residents records. LPA reviewed seven (7) staff records and 7 of 7 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/04/2026: Updated LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization - Reviewed Updated LIC 500 Personnel Report LIC 610E Emergency Disaster Plan - Reviewed Copy Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 28, 2026

Type of visit: Case Management - Incident

On 07/08/2026 at 11:15 AM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident reported to Community Care Licensing Division (CCLD). LPA met with Executive Director Joyce Aquino and explained the purpose of the visit. The Unusual Incident Report (UIR) indicated that on 06/05/2026, Resident 1 (R1) was found by local law enforcement on Geary Road at approximately 11:50 PM after leaving the facility without staff knowledge. During today's visit, LPA obtained and reviewed the following documents: Resident Roster, Staff Roster (LIC 500), R1's LIC 602A Physician's Reports (dated 05/09/2024 and 05/21/2026), Emergency Information/Face Sheet, and R1's Care Plans dated 04/18/2026, 05/22/2026, 06/06/2026, and 06/30/2026. LPA's review of the records determined that R1's physician's report and care plans document that R1 is unable to leave the facility unassisted and requires staff supervision when outside of the community. Despite these identified care needs, R1 exited the facility without staff awareness and was later located by local law enforcement. Immediate civil penalty Immediate civil penalty $500.00 assessed today. Deficiencies were observed during today's visit and cited on the attached LIC 809D in accordance with California Code of Regulations, Title 22. Failure to correct the cited deficiencies may result in civil penalties. An exit interview was conducted with Executive Director Joyce Aquino. A copy of this report, LIC421IM form and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 23, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on record review and interview the licensee did not comply with section above by not ensuring care and supervision when R1 eloped during the night and later found by local police which poses an immediate Health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Administrator agreed to conduct an In-Service training with community care leadership on ensuring that residents' care plans (appraisals) are updated as appropriate with change of conditions and staff training on supervision and elopement prevention, and any additional safeguards implemented to prevent future incidents. Sign-in sheet and lesson plan to be submitted to CCLD by POC due date. Immediate $500 civil penalty assessed.

Allegation investigated: Staff mishandled the residents medication Staff did not safeguard the residents medication

On 4/13/2026 at 9:15 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator Joyce Aquino and Executive Director Specialist Kelly Reynolds. On the allegation: Staff mishandled the residents’ medication Based on interviews, the facility has experienced ongoing issues related to the mishandling of residents’ medications. The facility is currently working with Licensing to address these concerns and has been doing so for some time. Staff interviewed were unable to provide specific or new examples but stated that Licensing is already aware of the situation and actively involved. continued on LIC 9099C... Unsubstantiated Continued from LIC 9099 On the allegation: Staff did not safeguard the residents’ medication During investigation, LPA interviewed staff who stated that they have not had medications go missing or lost from either memory care or assisted living. Staff explained the process when a resident refuses medications, that they will make up to three attempts to give it to a resident then they will document the missed dosage reason and properly dispose of that dosage in the locked medications disposal. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 13, 2026 · control 15-AS-20260106111236

Type of visit: Case Management - Incident

On 02/17/2026 at 10:15 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit regarding incident reports received by the Community Care Licensing Division (CCLD) on 01/07/2026. LPA met with Assistant Executive Director Deborah Bradley and Executive Director Specialist Kelly Reynolds and explained the purpose of the visit. LPA received an Unusual Incident Report (UIR) regarding an incident that occurred on 01/03/2026 indicating that Staff (S1) administered a narcotic medication dose to Resident (R1) at approximately 7:49 AM and administered another dose of the same narcotic medication at 8:36 AM. LPA reviewed R1’s physician’s orders, Medication Administration Record (MAR) for January 2026, and narcotic log. Documentation indicates the medication hydrocodone/APAP 5/325 mg tablet was ordered to be administered as one tablet twice daily, every four hours. The UIR indicated R1 refused the evening dose. The UIR further documented that on 01/04/2026, Staff (S2) notified Staff (S3) that R1 had been administered two doses of the medication that morning. Administrative review identified duplicate medication orders within the facility’s QMAR system. LIC809-C Continued... LIC809-C (Page 2) LPA obtained copies of R1’s physician’s report, care plan dated 12/01/2025, MARs for January through February 2026, Resident Roster, Staff Roster (LIC 500), Med Tech roster, and Med Tech training transcripts for fourteen (14) Med Tech staff and Med Tech schedules (Dec '25 thru Feb '26). Based on record review, deficiencies were observed and cited in accordance with the California Code of Regulations, Title 22 (see LIC 809D). Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted, and a copy of this report and appeal rights were provided to facility representatives.the state’s words, verbatim · CDSS document, Feb 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 24, 2026

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing... facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not administering medication for R1 ordered by the physician and given according to the physician's directions. R1 was administered the same dose of narcotic medication in the morning which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: Administrator agreed to conduct training with med techs to assist the residents with self-administration of narcotics including but not limited to documenting and will send staff sign-in sheet and any training documents to CCLD by POC due date. Civil Penalty assessed for repeat violation $250.00

Type of visit: Case Management - Incident

On 12/18/2025 at 9:55 a.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit regarding medication related incident reports received by the Community Care Licensing Division (CCLD) on 12/09/2025, 11/20/2025, 10/20/2025 and 07/03/2025. LPA met with Interim Executive Director (ED) Ricardo Romero, Sr and explained the purpose of the visit. The case management visit was conducted due to multiple Unusual Incident Reports (UIRs) submitted by the facility over several months involving medication administration errors. CCLD received a UIR regarding an incident that occurred on 12/07/2025, which indicated that Resident (R1) requested a PRN medication for agitation; however, Staff (S1) administered an anti-diarrheal medication instead to R1. CCLD also received a UIR for an incident that occurred on 11/19/2025 at approximately 5:00 p.m., which indicated that R2 was inadvertently administered the wrong medication during the evening medication pass by S4 and S5. During interviews with S2 and S3, it was stated that the medication error occurred while S5 was training S4. LIC809-C Continued... LIC809-C (Page 2) Additionally, CCLD received UIRs documenting two medication related incidents that occurred on 10/07/2025 and 10/12/2025. The report for 10/07/2025 indicated that R3 was not administered a prescribed medication patch; however, it was documented and signed by S7 as having been given. The report for 10/12/2025 indicated that S7 administered a medication to R4 by sprinkling it on food. S7 stepped away after providing the food to R4. Subsequently, a guest consumed the food containing the medication. During interviews with S8, it was stated that when S7 stepped away, R4 offered the food containing the medication to the guest, who was seated at the dining table with another resident. During interviews conducted on 08/27/2025, S2 and S3 stated they were not aware of any documented follow-up notes or Plan of Correction addressing the medication errors. Both staff reported that the Medication Technician, S7, responsible for administering the incorrect medication was no longer employed at the facility. CCLD also reviewed a UIR regarding an incident that occurred on 07/03/2025, which indicated that R5, all memory care residents, missed their morning medications due to staffing issues after S9 tested positive for COVID-19 and left the facility. The report further stated that S10 from another community arrived to assist; however, the time window for the morning medication pass had elapsed. LPA obtained the following documents: R4's physician's report (LIC602-A), fax confirmation requesting an updated LIC602-A (dated 10/15/25), doctor's orders for crushed/sprinkled medications in foods/liquids and copy of S9's time card (dated 07/01/25 thru 07/10/25). As a result of the above findings, deficiencies were observed (see LIC 809D) and cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted, and a copy of this report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Dec 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jan 19, 2026

CCR 87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on record review and interviews, the licensee did not comply with section above by not administering medications to residents (i.e., R1, R2, R3, R4, R5) according to the physician's directions which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Administrator shall have all staff that administer medications to complete a 4hrs minimum Medication Training course with an approved CDSS vendor. Repeat Violation Civil Penalty $250.00 Course topics shall cover Medication Administration including but not limited to documentation procedures, narcotics, injections, enemas, suppositories, missed and medication errors. Completed certificates will be submitted to CCLD by POC due date.

Type of visit: Case Management - Incident

On 12/18/2025 at 2:00 p.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit regarding an incident report received by the Community Care Licensing Division (CCLD) on 12/16/2025. LPA met with Interim Executive Director (ED) Ricardo Romero, Sr., and explained the purpose of the visit. The Unusual Incident Report (UIR) indicated that on 12/13/2025 at approximately 10:41 p.m., Resident (R1) was found on the floor by Staff (S1). S1 contacted 911 and conducted an initial assessment, during which bruising was observed on R1’s forehead. R1 was transported to the hospital emergency room for further evaluation. The UIR reported that R1 returned to the facility with no ongoing concerns. During the visit, LPA interviewed S2, who stated that R1 frequently walks back and forth within the memory care unit and has demonstrated increased wandering behaviors. S2 stated that the facility has requested an updated physician’s report (LIC602-A) from R1’s primary care physician. S2 further stated that following R1’s return to the facility, the licensee implemented alert charting every shift and is currently completing a new assessment and updating the care plan for R1. LPA collected and reviewed the following documents: R1’s physician’s report (LIC602-A), care plan (dated 01/02/2025), Fax confirmation requesting an updated LIC 602A (dated 10/15/2025) and Care Tracking Log (dated 12/14/2025 through 12/18/2025). No deficiencies were issued during visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 18, 2025

Allegation investigated: Staff mismanaged residents’ medications. Staff falsified medication administration records. Licensee does not ensure staff administering medication to residents are appropriately trained.

On 12/09/2025 at 10:00 AM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen conducted a subsequent visit and met with Executive Director (ED) Dolly Bindar to deliver the findings of above allegations. LPAs explained the purpose of the visit with ED. During investigation, the LPA obtained the following documents from the facility: Resident (R) and Staff (S) rosters, medication administrator records (QMARs electronic software system), Medication Technician (Med Tech) trainings, Resident's Face Sheets, Physician's Reports, Physician's Orders, MARs (Sept/Oct/Nov 2024), Progress Notes, Medication Tech Relias Transcripts (2024), narcotic records, care plans, assessments and communication faxes. LPA interviewed staff, residents and witnesses (W). LIC9099-C Continued... Substantiated LIC9099- C (Page 2) Allegation: Staff mismanaged residents’ medications. Finding: Substantiated On 11/09/2024, Licensing Program Analyst (LPA) L. Alexander conducted interviews and reviewed facility records. During the interview, Witness (W1) stated that Resident 1 (R1) has cancer and is prescribed morphine 15mg. W1 reported that staff document the medication as administered multiple times when it was never actually given. W1 stated that R1 is often in significant pain due to missed doses. W1 further alleged that staff select “Exception” within the QMAR system and note “on hand” even when the medication is unavailable. LPA reviewed R1’s physician’s orders, which indicated that morphine 15mg is to be administered one tablet by mouth three times daily (9:00 a.m., 12:00 p.m., and 6:00 p.m.). Review of R1’s October 2024 Medication Administration Record (MAR) revealed missing doses on 10/14/24, 10/15/24, 10/16/24, and 10/18/24. Staff 2’s (S2) chart note on 10/16/24 stated, “waiting on pharmacy to deliver not on hand.” The MAR reflects that on 10/14/24, morphine was administered at 6:00 a.m. and 2:00 p.m., and on 10/15/24, at 6:00 a.m. and 10:00 p.m., with the 2:00 p.m. dose omitted. Allegation: Staff falsified medication administration records. Finding: Substantiated LPA reviewed Resident 2’s (R2) physician’s orders, which included a narcotic to be administered one pill by mouth every eight (8) hours. LIC9099-C Continued... LIC9099- C (Page 3) The Medication Administration Record (MAR) dated 10/18/2024 shows that Staff 1 (S1) documented administering the narcotic at 6:00 a.m., and Staff 2 (S2) documented administration at 2:00 p.m. However, the Individual Resident Narcotic Record indicates that S1 administered the medication at 6:00 a.m., and S2 signed for administration of the same medication at 7:00 a.m. Allegation: Licensee does not ensure staff administering medication to residents are appropriately trained. Finding: Substantiated W1 stated that Med Techs are still administering insulin injection medications to residents. LPA reviewed R2’s physician’s reports, physician’s orders, care plan, MAR (Sept-Nov 24; Aug-Oct ’25) and it shows that R2 cannot administer their own injections. The MARs reveal that Med Techs were administering injections and checking blood glucose via finger stick. On 10/16/2025 LPAs L. Alexander and K. Nguyen interviewed R2 and S1. R2 stated that they are not on insulin and that the Med Techs do not inject them. R2 has a diagnosis of dementia and physician’s orders clearly states insulin injections and blood glucose checks. S1 stated that Med Techs are not doing the insulin injections, but they are setting the PEN up for R2 and that R2 is injecting themselves. LPA asked S1 if they are using the “hand or hand” method and S1 confirmed yes. LIC9099- C (Page 4) An exit interview was conducted with Executive Director, Dolly Bindar and the findings of this investigation were discussed. Copies of the LIC 9099, LIC 9099-D, and Appeal Rights were provided to the Licensee during the visit.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 15-AS-20241029121159

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jan 9, 2026

CCR 87465(a)(6) – Incidental Medical and Dental Care When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by: Based on record review and interviews, the licensee failed to ensure accurate medication administration documentation for R2. On 10/18/2024, the MAR reflected narcotic administration times of 6:00 a.m. and 2:00 p.m., while the Individual Resident Narcotic Record showed administration at 6:00 a.m. and 7:00 a.m. The discrepancy between the two documents demonstrates falsified or inaccurate medication administration documentation which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator agreed to review and audit all narcotic medication logs and MARs for accuracy. Administrator agreed to conduct medication documentation training for all Medication Technicians and submit proof of completion to CCL by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87629(b)(1) · Plan of correction due date: Jan 9, 2026

CCR 87629(b)(1) Injections Injections. Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidence by: Based on record review and staff interviews, the licensee did not comply with the section cited above by ensuring that injections are administered by an appropriately skilled professional. Records show that Medication Technicians (Med Techs), who are not appropriately skilled professionals, were administering insulin injections and performing blood glucose checks for R2. S1 confirmed that Med Techs “set up” insulin pens and used a “hand-over-hand” method during injection. This failure to ensure proper training and delegation in medication administration poses a potential health and safety risk to residents, including risk of injury, infection, or medication error.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator will conduct an audit on all residents that receiving dr's order for injections to determine if they can self inject or require assistance with skilled professional. Will send a confirmation that audit was completed by POC due date.

Type of visit: Case Management - Incident

On 12/9/2025 at 2:00 PM, Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander arrived unannounced to conduct a case management visit in regard to incident reports received to the Community Care Licensing Division (CCLD) on 11/15/2025. LPAs met with Executive Director, Dolly Bindar, and explained the purpose of the visit. LPAs received an Unusual Incident Report (UIR) on 11/15/2025 regarding an incident that occurred with Resident 1 (R1). LPAs interviewed Staff 1 (S1) regarding the incident and requested R1's files, including but not limited to the Physician report, any discharge summary, chart notes, care plan, hospice notes, and death certificate to be submitted by 12/30/25 to CCLD. No deficiencies were made during this visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 9, 2025

Type of visit: Case Management - Incident

On 12/09/2025 at 12:00 PM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a case management visit. LPAs met with Executive Director (ED) Dolly Bindar and explained the purpose of the visit. During a complaint investigation ( #15-AS-20241029121159) conducted on 10/16/2025, LPAs reviewed facility records and observed that Resident (R1) is prescribed an intravaginal medication. Facility documentation indicated that the medication was identified as self administered; however, LPAs observed that medication technicians were administering the medication to R1. R1’s Physician’s Report indicates that R1 is unable to self administer medications, including but not limited to suppositories. Despite this limitation, the facility allowed medication technicians to administer an intravaginal medication, which is not permitted to be administered by medication technicians under applicable regulations. The deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights, LIC and this report provided.the state’s words, verbatim · CDSS document, Dec 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87622(a)(2) · Plan of correction due date: Jan 9, 2026

Fecal Impaction Removal, Enemas, and/or Suppositories (a) The licensee shall be permitted to accept or retain a resident who requires manual fecal impaction removal, enemas, or use of suppositories under the following circumstances: (2) Manual fecal impaction removal, enemas, and/or suppositories shall be permitted if administered according to physician's orders by either the resident or an appropriately skilled professional. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not following dr's orders with R1 self-administering their intravaginal cream or appropriately skilled professional will administer the medication which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator will conduct an audit of all residents that require medication assistance including but not limited to suppositories and care plan will be updated and send to CCLD by POC due date.

Type of visit: Case Management - Incident

On 12/9/2025 at 3:00 PM, Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander arrived unannounced to conduct a case management visit in regard to incident reports received to the Community Care Licensing Division (CCLD) on 11/12/2025. LPAs met with Executive Director, Dolly Bindar, and explained the purpose of the visit. LPAs received an Unusual Incident Report (UIR) on 11/12/2025 regarding an incident that occurred with Resident 1 (R1). LPAs interviewed Staff 1 (S1) regarding the incident and requested R1's files, including but not limited to the Physician report, any discharge summary, chart notes, care plan, hospice notes, and death certificate to be submitted by 12/30/25 to CCLD. No deficiencies were made during this visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 9, 2025

Type of visit: Case Management - Incident

On 12/09/2025 at 2:00 PM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a case management visit. LPAs met with Executive Director (ED) Dolly Bindar and explained the purpose of the visit. During a complaint investigation (#15-AS-20241029121159) conducted on 10/16/2025, LPAs reviewed records and obtained witness statements related to an incident involving Resident (R1). On 10/13/2025, LPAs interviewed Witness (W2), who stated that on or about 07/01/2024, R1 attempted to sit in a chair, stumbled, and fell while Witness (W3) was on a FaceTime call with W2. W2 stated they received a call from W3 advising of the fall and drove to the facility. Upon entering R1’s apartment, W2 stated they observed R1 on the floor and assisted R1 back to a standing position. W2 reported remaining with R1 in the apartment while watching television. W2 stated that facility staff entered the apartment to assess R1; however, W2 advised staff that R1 was okay and stated that emergency services were not needed. W2 reported assisting R1 into bed and then leaving the facility. LIC809-C Continued... LIC809-C (Page 2) W2 further stated that on 07/02/2024, they returned to R1’s apartment in the morning and found R1 unresponsive. LPAs reviewed a Walnut Creek Police Department (WCPD) report, which indicated that on 07/02/2024, R1 was pronounced deceased at the facility. The report documented the presence of slight bruising to the right side of R1’s face and the right elbow. Facility records reviewed did not document that emergency medical services were contacted following the reported fall involving head impact, nor did records reflect ongoing monitoring or reassessment of R1’s condition following the incident. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Dec 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Jan 9, 2026

CCR 87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not activating 9-1-1 if an injury or other circumstance which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator agreed to conduct a In-Service training with all staff on emergency 911 response and will send participant sign-in sheet to CCLD by POC due date.

Type of visit: Case Management - Incident

On 12/9/2025 at 4:00 PM, Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander arrived unannounced to conduct a case management visit in regard to incident reports received by the Community Care Licensing Division (CCLD) on 11/21/2025. LPAs met with Executive Director, Dolly Bindar, and explained the purpose of the visit. LPAs received an Unusual Incident Report (UIR) on 11/21/2025 regarding an incident that occurred with Resident 1 (R1) and Resident 2 (R2). LPAs interviewed Staff 1 (S1) regarding the incident and requested a follow-up on R1's change in condition. S1 stated that this is the first time that R1 and R2 had an altercation. S1 stated that after the incident happened, the facility did an update assessment and met with R1's family regarding R1's behavior. R1 is now placed on a one-on-one after the incident to prevent further incidents. No deficiencies were made during this visit. No deficiencies were made during this visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 9, 2025

Allegation investigated: Staff does not ensure facility is free of pests.

On 08/27/2025 at 10:15 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegation above. LPA met with Assistant Executive Director, Deborah Bradley and Interim Executive Director, Ricardo Romero and informed the reason for visit. During the course of investigation, LPA L. Alexander interviewed staff (S), obtained and reviewed copies of Western Exterminator Company service maintenance for 07/31/25, 08/16/25 and 08/22/25. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Allegation: Staff does not ensure facility is free of pests. Unsubstantiated. On 08/19/2025 LPA L. Alexander interviewed W1, that stated they received an email with video of a rat stuck to a glue board. On 08/27/2025 LPA Alexander interviewed S1 that confirmed the video location was in the dried foods pantry. S1 stated that the rodent was caught approximately one month ago on a glue board trap. S1 stated that they have a service contract with an exterminator company as well as they started service with Eco-Lab that are coming out to the facility weekly. LPA interviewed S2 that stated whenever there's any pests they will call an exterminator to come check. LPA toured the kitchen area, dried foods pantry and outside area where deliveries come in. LPA did not observe any pests during visit. LPA reviewed Summary of Service from Western Exterminator Company with service dates 07/31/25, 08/16/25 and 08/22/25 that showed traps and monitoring for pests is taking place. Although the 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 the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 15-AS-20250819105445

Allegation investigated: Unlawful eviction

On 08/27/2025 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegation above. LPA met with Assistant Executive Director, Deborah Bradley and Interim Executive Director, Ricardo Romero and informed the reason for visit. During the course of investigation, LPA L. Alexander interviewed witnesses (W), staff (S) and obtained copies of documented letters dated 11/22/24, 06/12/25, Kensington statements dated 06/01/25, 07/01/25, 08/01/25, payment ledger for R1's account, Contra Costa County Notice of Action letter dated 03/01/25, 30-Day Notice to Pay or Quit dated 07/21/25 and 07/24/25. Substantiated LIC9099-C (Page 2) Allegation: Unlawful eviction Substantiated. On 08/27/2025 LPA L. Alexander interviewed with W1, W2 and W3 that all stated that the eviction notice that was given to R1 on 07/24/2025 did not have the appropriate contact information for the local ombudsman. W1 and W2 stated that they never received notice that the eviction was rescinded. W1 and W2 stated that they understand that the eviction date would be 08/24/25 which would be 30 days. LPA reviewed the 30-Day Eviction Notice back on 08/15/25 and advised S1 that the contact information for the ombudsman was incorrect and to rescind the notice. S1 and S2 both stated that they did not rescind the notice but are working on a revision. S2 stated that as of 08/27/25 the statement of rescinding the 30-Day eviction notice was sent to R1's responsible party. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal rights and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 15-AS-20250822142027

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.683(a)(3) · Plan of correction due date: Sep 2, 2025

§1569.683 Eviction notices (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident...with specific facts to permit the notice to quit shall include all of the following: (3) Information about the resident's right to file a complaint...with the name, address, and telephone number of the nearest office of.. the State Ombudsman. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not sending the notice to evict with the correct contact information for the local Ombudsman to R1's responsible party which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: The Administrator will read the regulation and submit self-certification that it has been read, understood and they will comply going forward to CCLD by POC due date. In addition, the licensee shall rescind the eviction, notify resident's responsible party, and issue legal notice if that is still licensee’s plan.

Type of visit: Case Management - Incident

On 08/27/2025 at 2:30 PM, Licensing Program Analysts (LPA) L. Alexander arrived unannounced to conduct a case management visit in regards to incident reports received to Community Care Licensing Division (CCLD) on 01/02/2025. LPA met with Assistant Executive Director, Deborah Bradley and Interim Executive Director, Ricardo Romero and informed the reason for visit. CCLD received Unusual Incident Reports (UIR) with dated occurrences of 11/15/24, 11/27/24, 12/01/24, 12/04/24, 12/05/24, 12/13/24, 12/14/24, 12/15/24, 12/16/24 on 01/02/2025. The UIR were reporting different issues. However, the incident reports were reported late. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Aug 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 2, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events... This report shall include the resident's name... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not submitting a written report within 7 days of the occurences of any of the events for residents in care. Reports received to CCLD were dated 11/15/24, 11/12/24 and 12/1/24 as an example and were received on 01/02/25 which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Administrator will have a In-Service training with care leadership team staff to go over reporting requirements and will submit participant sign-in sheet to CCLD by POC due date.

Type of visit: Case Management - Incident

On 08/27/2025 at 3:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit in regards to incident reports received to Community Care Licensing Division (CCLD) on 06/23/2025. LPA met with Assistant Executive Director, Deborah Bradley and Interim Executive Director, Ricardo Romero and informed the reason for visit. On 06/23/2025 CCLD received two Unusual Incident Reports (UIR) that occurred on 06/16/25 and 06/18/25. The incident report indicated that resident (R) R1 left the community by themself through one of the backdoors. The report further indicated that the front desk reviewed the cameras and saw R1 crossing the street, on the sidewalk coming from the east side of building and also coming from the shopping center back to the community. The writer stated on the report that R1's Wander Guard did not go off. The UIR that occurred on 06/18/25 indicated that R1 left the community by themself through one of the backdoors again. The writer of this report stated that R1's Wander Guard went off. The report further stated that a RA was able to direct R1 back inside the community. On 08/27/2025 LPA L. Alexander interviewed S1 that stated they have been having conversations with R1's family regarding the elopements and suggested a 1:1 companion and memory care. S1 stated that the family started 1:1 companion on 06/18/2025 later that evening. LIC809-C Continued LIC809-C (Page 2) On 08/27/2025 LPA L. Alexander reviewed R1's physician's report (dated 03/21/23) that indicates R1 is not able to leave the facility unassisted and also has a diagnosis of dementia. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 3, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not reporting R1's elopement within the next day to Licensing which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Administrator stated that R1 has a 1:1 companion that started 06/18/25 and since then there has not been anymore elopements by R1. Deficiency cleared.

Type of visit: Case Management - Incident

On 08/27/2025 at 4:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit in regards to incident reports received to Community Care Licensing Division (CCLD) on 01/02/2025. LPA met with Assistant Executive Director, Deborah Bradley and Interim Executive Director, Ricardo Romero and informed the reason for visit. CCLD received on 01/02/25 an Unusual Incident Report (UIR) with an incident occuring on 12/01/24. The report indicated that on 12/01/24 at 8:33pm it was observed that R1 was assisted with the wrong medication by the Med Tech. The writer of the report further stated that R1's primary care physician was informed and advised. On 08/27/2025 LPA interviewed S1 and S2 both stated that they did not see any notes on the occurrences and what was the Plan of Correction for the med error. S1 and S2 stated that the Med Tech that administered the medication no longer works at the facility. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Aug 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 26, 2025

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing... facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not administering medication for R1 ordered by the physician and given according to the physician's directions which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Administrator agreed to conduct a refresher training with all Med Techs and will send certificates or transcript of completed training to CCLD by POC due date.

Type of visit: Required - 1 Year

On 8/14/2025 at 9:30 AM, Licensing Program Analysts (LPAs) L. Alexander and Y. Brown arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with, Care Specialist, Kelley Jeffries, and explained the purpose of the visit. Assistant Executive Director, Deborah Bradley and Interim Executive Director Ricardo Romero were in a meeting but joined after an hour. The facility’s fire clearance was approved for two-hundred (200) non-ambulatory. Hospice waiver approved for twenty (20). LPAs toured the facility with Deborah including but not limited to six (6) residents’ apartments, two (2) models, bathrooms, multiple activity rooms, kitchen, common area and outside courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 132, 135, 137 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Emergency fire drill was last conducted on 08/3/2025. Emergency disaster plan was last updated 08/01/2025. LIC809-C Continued.... LPAs reviewed eleven (11) residents records. LPAs reviewed seven (7) staff records and six (6) out of seven (7) have current first aid training and associated to the facility. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 11:33am unlocked prescription medications prescribed to R1's daughter: located in kitchen cabinet and refrigerator including but not limited to syringes, injection medications, Ibuprofen 200mg, and an expired medication (08/31/22). Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/21/2025: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed Current Administrator’s Certificate The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 14, 2025

The state marks this report as 13 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 11/19/2024 at 2:30pm, Licensing Program Analysts (LPAs), L. Alexander and L. Hall arrived unannounced to conduct a case management visit. LPAs met with Joseph Villanueva, Administrator and explained the reason for the visit. While LPAs were conducting a complaint investigation #15-AS-20241029121159 on 11/19/2024, LPAs observed during record review two (2) staff were not fingerprinted and associated to the facility. S2 stated she's interim and from the home office. S5 stated she has been employed with the facility for seven (7) years. LPA ran a guardian search to confirm. The deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights, LIC and this report provided.the state’s words, verbatim · CDSS document, Nov 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d) · Plan of correction due date: Nov 20, 2024

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidence by: Based on LPAs observation and record review the Licensee did not comply with the section cited above in having S2 and S5 fingerprinted and associated to facility, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Administrator agreed to have S2 and S5 fingerprinted and submit document to CCLD by POC date.

Type of visit: Case Management - Incident

On 11/06/2024 at 3:00 PM Licensing Program Analysts (LPAs) L. Alexander and D. Doidge conducted an unannounced Case Management visit regarding an Unusual Incident Report (UIR) that was reported to CCLD on 10/24/24. LPAs met with Executive Director (ED), Joseph Villanueva, and explained the purpose of the visit. The incident report indicated that R1 eloped Memory Care (MC) unit on 10/19/24 at around 2:00pm. LPAs interviewed S1 and S2 that observed R1 walking down the street. S1 and S2 stated that they were just arriving for their shift before 2pm and noticed someone that looked familiar. S2 stated that they recognized R1 walking across the street towards Sprouts Farmers Market and started running towards them to direct them back to the facility. S1 stated that they informed S3 that R1 had eloped down the street. LPAs interviewed S3 that stated that they got on their radio and informed MC of the eloped resident and the MC care staff came out to look for R1 and direct them back to the facility. LPAs interviewed S4 that stated that R1 walked out the egress door which is located on the east side of the building. S4 stated that the plate was stuck which is why the alarm and lights did not go off. S4 stated that they re-adjusted the Maglock and the door was fixed. LPAs obtained the following documents: physician's report, care plan, memory care staff schedule for 10/19/24 and maintenance work order for 10/18/24. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 22, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above in by not having egress doors working properly in Memory Care to prevent residents (R1) from eloping the facility which posed an immediate health and safety risk to persons in care. Repeat Violation assessed civil penalty $250.00the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Administrator agrees to have the egress doors checked by maintenance twice a day and documented. Administrator will train all associates to confirm egress is functional after walking through doors. Administrator will submit to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(k)(8) · Plan of correction due date: Nov 22, 2024

87705 Care of Persons with Dementia (k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: (8) Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above in by not having trained staff to meet the care and supervision needs for residents (R1) eloping from Memory Care which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Administrator agrees to conduct a re-training on elopement with all staff and will review staff schedules to ensure overlapping between shifts. Administrator will submit in-training sign-in sheet and updated staff schedules to CCLD by POC due date.

Type of visit: Case Management - Deficiencies

On 09/10/2024 Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management - Deficiency. LPA met with Executive Director (ED), Joseph Villanueva, and explained the purpose of the visit. LPAs L. Alexander and G. Luk conducted an Annual Inspection on 08/07/2024 and cited for CCR 87707(c)(5) and HSC 1569.625(b)(2). The Plan of Correction (POC) original due date was 08/30/2024. The POCs that were reviewed were incomplete. LPA L. Alexander emailed ED on 09/09/2024 to confirm status that the POCs submitted were complete. The POCs included copies of resident's medical assessments and staff annual training. ED stated that resident's responsible party will submit medical assessment. ED stated that the staff training needed to be uploaded in their system by Human Resources Team and downloading for the staff to complete for 2024. ED stated that they will have the staff complete all RCFE required training by the end of the year. Meanwhile, ED requested if they could have more time for staff to complete the required training. LPA L. Alexander recited the uncleared deficiencies and scheduled a new POC due date. Facility has the following deficiencies that was not cleared: CCR 87707(c)(5) HSC 1569.625(b)(2) The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87707(c)(5) · Plan of correction due date: Oct 11, 2024

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not having current medical assessments for R5 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: Executive Director (ED) has agreed to obtain current medical assessments for R5. ED will submit documentation to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.625(b)(2) · Plan of correction due date: Oct 11, 2024

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not having current annual training for S6 and S7 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: Executive Director has agreed to obtain current annual training for S6 and S7 and will submit completed training to CCLD by POC date.

Allegation investigated: . Staff mismanaged residents medication.

On 08/07/2024 at 10:30 AM, Licensing Program Analysts (LPAs) L. Alexander and G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPAs met with Executive Director, Joseph Villanueva. During the course of investigation, LPA L. Alexander interviewed complainant (RP), resident and staff. LPAs obtained and reviewed documents including physician's report, medication administration records (MAR), centrally stored medication (CSMDR) list, physician's mediciation orders, med tech staff schedules. LIC9099-C Continued... Substantiated Allegation: Staff mismanaged residents medication. Substantiated. On 01/17/2024 LPA spoke with RP that stated that a "pink pill' was pushed on R1. Interview with R1 revealed that on this particular day "a pink" pill was being administered to them and they asked S2 what was the pill. R1 stated that S2 said the pill was the same pill but there was a "different manufacturer". R1 stated that they did not refuse to take the pill. RP stated later R1 found out the "pink pill" was a thyroid medication. On 08/07/2024 LPA interviewed S4 that stated R1 was not on any type of thyroid pill and that R1 was on many different kinds of medications. LPA reviewed MAR for Sept 2023 and observed R1 was not given insulin Lispro injection for multiple days. There was no documentation explaining those dates R1 missed insulin Lispro injections. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. Allegation: Staff does not keep an accurate medication log. Unsubstantiated. LPA reviewed Centrally Stored Medication Log and observed that R1 has all medications documented with name of medication, prescription date, number of refills, etc. Although the 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 the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 7, 2024 · control 15-AS-20240109150122

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 26, 2024

(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...with those activities of daily living such ...assistance with taking prescribed medications. This requirement was not met as evidenced by: Based on investigation, licensee did not comply with the section cited above by not administering medication according to doctor's orders which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2024

Plan of correction: Executive Director has agreed to training for administering medication and submit staff sign in sheet to CCLD by POC date.

Type of visit: Required - 1 Year

On 8/7/2024 at 10:30AM, Licensing Program Analysts (LPAs) G. Luk and L. Alexander arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with Executive Director, Joseph Villanueva and explained the purpose of the visit. LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, dining area, activity rooms, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 1/25/2024. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food supplies 1-2 times a week. Freezer’s temperature was registered at 0 degree F while the refrigerator’s temperature was recorded at 40 degrees F. Hot water temperature was measured at 120 degrees F in a resident's bathroom sink. Grab bars and non-skid mats were observed. There were adequate lights in each room. Indoor and outdoor passages were free of obstruction. LPAs reviewed 8 residents and 9 staff files starting at 12:10PM. At 1:30PM, LPAs observed R4, R6, and R8 does not have current medical assessment on file. At 1:40PM, LPAs observed R4 does not have TB test on file. At 2:00PM, LPAs observed S6 and S7 does not have current annual training completed. At 2:10PM, LPAs observed S6 does not have health screening and TB test on file. (Continue on LIC809C...) At 3:00PM, LPAs observed facility did not complete disaster drills every quarter. Last disaster drill was conducted on 3/5/24. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 7, 2024

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 08/07/2024 at 6:00 PM Licensing Program Analysts (LPAs) L. Alexander and G. Luk conducted an unannounced Case Management inspection. LPAs met with Executive Director, Joseph Villanueva and explained the purpose of the visit. While LPAs were at the facility for a complaint investigation, the following deficiency were observed. It was noted in the MAR on 9/24/2023, S1 administered insulin to R1. S1 is not a skilled professional. R1's physician's report states that R1 is unable to administer own injections. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Aug 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87629(b)(1) · Plan of correction due date: Aug 26, 2024

Injections. Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidence by: Based on investigation, licensee did not comply with section cited above by having a staff inject insulin for R1 which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2024

Plan of correction: Executive Director has agreed to conduct training for staff on injection regulations and submit staff sign in sheet to CCLD by POC date.

Type of visit: Case Management - Incident

On 04/24/2024 at 11:40 AM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an Unusual Incident Report (UIR) that was reported to CCLD on 03/03/2024. LPA met with Executive Director (ED), Joseph Villanueva, and explained the purpose of the visit. The incident report indicated that S1 gave another resident's medication to R1 in error while in training. The UIR indicated that the care staff notified R1's physician and family and that R1 was placed on 72 hours monitoring. The UIR indicated that S1 was provided additional training on the same day. In-service Training to be provided to all Medication Technicians LPA L. Alexander reviewed the documents pertinent to the incident report: R1's Physician's Report (LIC602A) In-Service Training Attendance Roster for "Med Errors"; ED stated that the training took place on 02/29/2024. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Apr 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 25, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,...(4) To care, supervision, and services...competency to meet their needs.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: Administrator stated that additional training was provided and a In-Service Training was conducted to the Med Techs on 02/29/24. Deficiency cleared.

Type of visit: Case Management - Incident

On 04/24/2024 at 12:45 PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an incident of Suspected Elder Abuse (SOC342) that was cross reported to CCLD on 02/23/2024 from Adult Protective Services. LPA met with Executive Director, Joseph Villanueva, and explained the purpose of the visit. The incident report indicated that on 01/25/2024 care staff reported to "Direct" that a caregiver (S1) on 01/23/2024 was yelling at a resident (R1) who is in memory care. The report indicated that S1 yelled at R1 to "be quiet or she would give her a cold shower." The report further indicated that S1 "roughly" placed R1's walker in front of them and told them to "go." LPA interviewed S2 who confirmed the incident and that S1 was placed on paid administrative leave pending further investigation by Human Resources and their Regional Human Resources. S2 stated that during the investigation they substantiated the allegation with the corroboration statements from other caregivers and witnesses in the memory care unit. S2 stated that S1 was terminated on 02/02/2024. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2024

Type of visit: Case Management - Incident

On 04/24/2024 at 2:35 PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an Unusual Incident Report (UIR) that was reported to CCLD on 01/31/2024. LPA met with Executive Director, Joseph Villanueva, and explained the purpose of the visit. The incident report indicated that Resident (R1) who resides in memory care was seen entering the community through the front lobby at around 10:30 PM. The incident reported indicated that R1 was escorted back to memory care. The incident further reported that the care staff noted that the resident's bedroom window was open and the screen was off. LPA interviewed S1 that stated that the facility installed window stoppers on all windows in memory care and sensors that will register to the front desk staff that's there 24/7. LPA asked S1 where were the memory care staff and S1 stated that the memory care staff checks on the residents but at the particular time they may have been providing care to other residents. S1 stated that this was a 15 minute gap from the last check. LPA toured with S1 the outside perimeter of R1's bedroom window and walked from the location to the front entrance of the lobby. LPA observed that the walk outside was leading to the residential carport area, to the street traffic on Geary Rd. LPA asked S1 are the front door entrance locked which per the report it was around 10:30pm and S1 stated that there is always someone at the front desk. LIC809-C Continued... LIC809- C Continued... LPA observed and with interview that R1 was able to force open the window and remove the window screen from the window. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 24, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on observation and interview the licensee failed to secure the windows and window screens in memory care which posed an immediate Health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: Administrator secured the windows by installing a "stopper" and also installed sensors on each window in the memory care unit. Deficiency cleared.

Type of visit: Case Management - Incident

On 04/24/2024 at 2:35 PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an Unusual Incident Report (UIR) that was reported to CCLD on 01/27/2024. LPA met with Executive Director, Joseph Villanueva, and explained the purpose of the visit. LPA received an report of Suspected Elder Abuse that indicated allegations that the care staff witnessed one of the caregiver (S1) tell one of the residents (R1) "that if she fell that he would send her to the hospital and they will cut her leg off." S2 stated once they were notified by the care staff of the allegation that they started their own investigation. S2 stated that S1 was placed on paid administrative leave while pending investigation. S2 stated that S1 was terminated as a result of their investigation on 02/02/2024. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2024

Type of visit: Case Management - Incident

On 10/26/2023 at 2:25PM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit to follow-up on a death report received by Community Care licensing. LPA met with Joseph Villanueva (ED) and Deborah Bradley, Assistant Executive Director (AED) and explained the purpose of the visit. Executive Director had to continue a staff meeting. However, the Assistant Executive Director met with LPA to discuss the incident. R1 passed away on 10/12/2023 with an unknown cause of death. During today's visit LPA obtained additional information pertaining to R1's death: Death Report Physician's Report Dated 06/24/19 Needs and Services Plan Level of Care Notification/Care Plan 08/22/23 Care Plan Prescribed Medication Residence and Care Agreement Chart Notes LPA requested from facility a copy of R1's death certificate and also a copy of the police report. LIC 809 Continued.... LPA was informed by Assistant Executive Director that family will provide R1's death certificate, once available and will provide CCL a copy. No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 26, 2023