The Lodge at Glen Cove

Allegation investigated: Staff mishandled residents medications

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a 10-day complaint investigation and deliver findings regarding the above allegation and met with Executive Director (ED), Richie Remigio. During the course of this investigation LPA conducted interviews, reviewed records, and made observations. Staff mishandled residents medications – Reporting Party (RP) alleges that facility staff did not administer resident (R1) medications as prescribed. Review of facility submitted Incident Report (IR) from 8/26/2026 indicated that R1 was prescribed antibiotics and staff were instructed to document and administer medication. Further review of IR indicated that medication was not documented and was placed into medication overflow, causing it to not be administered to R1 as prescribed. R1 was sent to the hospital and discharged into a Skilled Nursing Facility to receive further antibiotic treatment. Following this, staff received in-service training on receiving and recording medication. Based upon evidence gathered, there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid. Continue LIC9099C... Substantiated Continued from LIC9099... **A Civil Penalty in the total amount of $250.00 is being assessed for a repeat violation of Regulation 87465(c)(2) more than once in a 12-month period. Deficiency last cited on 07/10/2026. (See LIC421FC)** Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC809D. Exit interview conducted with Executive Director, whose signature on form confirms receipt. Continued from LIC9099C... Interview with five (5) of five (5) staff indicated that there have been no instances of staff being impaired on shift or leaving potentially hazardous materials in resident accessible areas. LPA toured interior and exterior of facility and did observe any impaired staff, any hazardous materials left accessible, or any smells indicating drug use. Staff are not meeting the residents showering needs – RP alleges that residents (R1, R2, R3) have not received regular showers due to a lack of encouragement from staff following refusals. Interviews with staff indicated that these residents do often refuse showers, however, staff will continue to attempt to convince them. LPA observed R3 refusing a shower from a care giver who called a medtech for assistance who, after multiple attempts, convinced R3 to shower. LPA did not observe there to be strong odors coming from residents’ rooms. Review of Shower Logs indicated that refusals are being properly documented. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Executive Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 4, 2026 · control 21-AS-20260827155033

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 5, 2026

87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement not met by Licensee as evidenced by: Based upon file review, R1 was not dispensed medication according to the physician's directions which poses/posed an immediate risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Sep 4, 2026

Plan of correction: Facility conducted retraining following incident. Deficiency cleared during visit.

Allegation investigated: Staff do not ensure resident's hygiene needs are met

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to continue an investigation into the above allegation. LPA was greeted by concierge. LPA met with Gina Lapid, Memory Care DIrector (MCD). Executive Director Richie Remigio was also present. Complaint alleges facility does not ensure resident's hygiene needs are met. During investigation, LPA reviewed shower log for resident (R1). Review of facility 'Shower Skin Sheet' form indicates that upon a resident refusing a shower, the form shall be signed by a caregiver, a LVN/medtech, and identify a date to which the shower was moved. Form indicates that “shower must be moved to the next day if there is a refusal." Review of shower refusals for R1 indicate approximately thirteen (13) instances of showers being refused over the course of approximately three (3) months. However, "date shower moved to" on each shower refusal is blank, indicating showers were not rescheduled. Based on LPA record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Substantiated Continued from 9099A... allegation is UNSUBSTANTIATED. Complaint alleges that staff does not ensure resident (R1) has clean bed linen and that staff do not ensure R1's room is maintained clean. During investigation, LPA reviewed R1's Admission Agreement which states that housekeeping services, including laundry, will be offered one time per week. During investigation, LPA conducted interviews. Staff indicate that housekeeping duties in Memory Care (MC) are performed twice a week. MC caregivers do the laundry for MC. Laundry is done on the overnight shift (NOC) and then AM shift puts it away. If there are incontinence issues then the soiled items are taken care of immediately, including bed linens if they are soiled as a result. During investigation, LPA received photographic evidence of the condition of R1's room. Review of photographic evidence shows R1's room as clean, neat, and tidy, with bed made and room free of clutter and garbage. During course of investigation, LPA visited facility three (3) times. Each time, LPA toured R1's room and found it to be clean, neat, and tidy, with bed made and bed linens to be clean, not soiled. LPA observed carpet to be clean overall and was not soiled. So, 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 with ED and MCD and a copy of this report given.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 21-AS-20260714081515

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Sep 1, 2026

87464(f)(4) Personal assistance and care as needed by the resident... with those activities of daily living such as dressing, eating, bathing... This requirement not met by Licensee as evidenced by: Based upon record review, R1 refusal showers were not rescheduled as required by facility policy, which poses a potential risk to the Health, Safety and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: Licensee shall submit proof of in-service training for caregivers regarding showering and documentation by Plan of Correction due date.

Allegation investigated: Staff confined a resident to indoor facility areas Staff did not ensure resident was bathed Staff did not assist resident after a fall Staff repeatedly tried to charge resident for services they did not need Staff did not provide adequate supervision to residents

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Executive Director Richie Remigio. During the course of this investigation LPA conducted interviews, reviewed records, and made observations. Staff confined a resident to indoor facility areas – Reporting Party (RP) alleges that resident (R1) was not allowed outside of the facility for walks. Review of R1 Physician Report indicated that R1 is at “Risk if allowed to leave the community unsupervised”. Interview with management indicated that the facility holds two (2) scheduled walks a day for residents, one (1) in the morning and one (1) in the evening. Further interviews with management indicated that if a resident misses these walks or prefers a different time or individual walks they can request a walk with a staff member, however, when these walks are requested, the timeframe will depend on staff availability. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Staff did not assist resident after a fall and Staff did not provide adequate supervision to residents – RP alleges that R1 suffered a fall and was refused assistance from staff. Interview with Executive Director (ED) indicated that R1 suffered an injury to their thumb that resulted in a hospital visit after having a fall. Further interviews with ED indicated that R1 was assisted by staff after stating they were in pain but initially refused to go to the hospital and only consented after pain worsened. Interview with Health Services Director (HSD) indicated that R1 presented with pain due to a fall and emergency services were activated. Further interview with HSD indicated staff ensured R1’s comfort while waiting for paramedic services and resident returned from the hospital same day. Review of internal report indicated that staff activated emergency services after being made aware of R1’s pain. Review of discharge paperwork indicated that R1 was taken to the hospital the same day staff were made aware of injury. Review of Incident Reports (IRs) indicated that facility did not submit an IR to Community Care Licensing regarding R1’s hospitalization. Interviews with six (6) of six (6) staff indicated that assistance is always provided to residents who request it. Over the course of five (5) facility visits, LPA observed staff checking on residents and providing assistance when requested. Staff repeatedly tried to charge resident for services they did not need and Staff did not ensure resident was bathed – RP alleges that facility repeatedly tried to sign R1 up for a variety of different care plans with no medical documentation by a doctor or medical professional and staff were refusing to assist R1 with bathing. Interviews with management indicated that R1 was requesting higher care needs including more frequent bathing and higher levels of supervision which resulted in various care plans being drafted and R1’s responsible party being consulted. Further interviews with management indicated that bathing frequency higher than basic services would require a new care plan and new charges. Review of resident task notes did not indicate that resident was not being refused assistance with bathing. Review of communication between facility and responsible party indicated care plans were not implemented until reviewed and signed by responsible party. Further review indicated that care plans from 2023 to 2025 did not have any changes aside from a new diagnosis from a physician. Care plans are not required to be from a medical professional and can be a result of facility observation or resident requests. Interviews with six (6) of six (6) staff indicated that staff will always assist residents with bathing as per their care plan. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated No deficiencies cited. Exit interview conducted with Executive Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 21-AS-20260518143950

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a case management - other visit and met with Executive Director Richie Remigio. The purpose of this visit was to cite deficiencies discovered during investigation of complaint 21-AS-20260518143950 that were unrelated to complaint. Interviews indicated that resident (R1) suffered a fall that resulted in an injured finger and R1 was sent to the hospital via emergency services. LPA reviewed facility submitted Incident Reports (IRs) and observed that facility did not submit an IR to Community Care Licensing (CCL) regarding this incident. LPA also followed up on a change in facility management, Richie Remigio will be taking over as Administrator, facility will submit the following documents to CCL in order to update Administrator: Copy of active and current Administrator Certificate Copy of Board of Directors Resolution Meeting Minutes Signed Administrator Resume LIC500 - Personnel Report LIC501 - Personnel Record LIC308 - Designation of Facility Responsibility Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC809D. Exit interview conducted with Executive Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 25, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 25, 2026

87211 (a)(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 specified in (A) through (D) below... This requirement not met by licensee as evidenced by: During interviews and file review LPA observed that resident (R1) suffered a fall and hospilization that was not reported to Community Care Licensing which poses/posed a potential risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: Licensee shall submit proof of training regarding reporting requirements by Plan of Correction due date of 9/25/2026 by 5:00pm.

Allegation investigated: Staff are not providing adequate laundry service. Staff do not ensure that resident's room is clean. Staff are not meeting resident's hygiene needs.

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Administrator Candice Moses. Staff are not providing adequate laundry service and Staff do not ensure that resident's room is clean – Reporting Party (RP) alleges that staff will leave resident (R1) in dirty clothing and will not change/launder bedsheets for up to two (2) weeks and that dirty clothing is being hung in R1’s closet without being laundered. Over the course of this investigation LPA conducted interviews, made observations, and reviewed records. Interview with management indicated that housekeeping services are provided once a week through dedicated housekeeping staff and caregiving staff will clean what is left. Interview with staff indicated that they will try to make the beds and take out the trash when not done by housekeeping services. Continued LIC9099C... Substantiated Continued from LIC9099... Over six (6) visits LPA observed Memory Care hallways and public areas to be clean, however, during tour of R1’s room LPA observed bed to be made over dirty clothing and used tissues. Interviews with RP indicated at least six (6) documented instances over the course of two months of R1’s bedding not being laundered, despite being soiled, and dirty clothes being reused without laundering. Staff are not meeting resident's hygiene needs – RP alleges that facility staff are not bathing R1 regularly resulting in multiple instances of R1 going one (1) or more weeks without bathing. Interviews with staff indicated that residents will not often refuse bathing, but mood changes may cause them to refuse. Further interviews indicated that if R1 is not bathed on time they will refuse bathing for the rest of the day. Review of facility Shower Refusal form indicated that upon a resident refusing a shower, the form shall be signed by a caregiver, an LVN/medtech, and a date shower moved to, and that “shower must be moved to the next day if there is a refusal”. Review of Shower Refusals for R1 indicated approximately seventeen (17) instances of showers being refused over the course of approximately five (5) months. Further review of Shower Refusals indicated four (4) of seventeen (17) were signed off by an LVN/medtech, and zero (0) of seventeen (17) had a date moved to. Review of resident care notes indicated showers were documented, however, when compared to Shower Refusals R1 is not being documented as being showered the day following a refusal and will not be showered at least until their next scheduled shower day without further refusal forms. Further review of R1 care notes indicated R1 has gone twenty (20) or more days without being showered. Interview with RP indicated multiple instances of R1 not receiving scheduled showers despite requesting them. Based upon evidence gathered, there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... Over the course of six (6) visits LPA observed staffing levels to be sufficient to provide care and supervision to residents. LPA observed staff assisting residents when required as well as hosting multiple large group activities in both Memory Care and Assisted Living. Staff are not properly trained – RP alleges that staff who provide direct care and supervision are untrained. Spot review of staff training logs indicated that sixteen (16) of eighteen (18) staff met or exceeded Title 22 regulations regarding twenty (20) hours a year of training. Interviews with management indicated that the two (2) of fifteen (15) staff who did not have full training hours were new hires still undergoing training and were not yet providing unsupervised care. Further interviews with management indicated that staff complete regular in-service training on top of online training on requested topics or in response to something new. Staff are not providing resident with toiletries – RP alleges resident (R1) is not being provided toiletries such as toilet paper and soap/shampoo. Interview with RP indicated they do not believe R1 is being given toiletries due to visits in Memory Care where toilet paper was out and soap/shampoo was not seen in R1’s bathroom. Interview with management indicated that basic toiletries such as soap and toilet paper are provided by the facility, however, if residents wish to use specific products those products shall be provided by family/responsible party. Further interviews with management indicated that most Memory Care rooms share a joint shower that is locked from inside to prevent residents from accessing potentially harmful personal care items and wandering into other resident rooms. Soap/shampoo and other personal care items are locked in these shower rooms and will be used when staff assist residents with bathing. LPA toured joint shower room and observed it to be clean, organized, and stocked with personal care items in separate plastic cabinets assigned to each resident. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jul 10, 2026 · control 21-AS-20260417164246

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 10, 2026

87468.1(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement not met by Licensee as evidence by: Based upon observations and interviews, R1 was not ensured clean and comfortable accomodations which poses/posed a potential risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Licensee shall submit plan on ensuring resident accomodations are clean and laundered by Plan of Correction due date of 8/10/2026 by 5:00PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 10, 2026

87464(f)(4) Personal assistance and care as needed by the resident... with those activities of daily living such as dressing, eating, bathing... This requirement not met by Licensee as evidenced by: Based upon file review and interviews, R1 was not bathed as required by care plan which poses/posed a potential risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Licensee shall submit proof of training regarding showering and documentation by Plan of Correction due date of 8/10/2026 by 5:00PM.

Allegation investigated: Staff do not distribute resident's medication as prescribed

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Administrator Candice Moses. Staff do not distribute resident's medication as prescribed – Reporting Party (RP) alleges that resident (R1) did not receive medication as prescribed for multiple days. During the course of this investigation LPA conducted interviews and reviewed records. Review of R1 Medication Administrator Record (MAR) indicated one hundred (100) or more instances of medications not being distributed. Review of Exceptions note indicated the most consistent reason for medication not being distributed is due to “medication not available”. Interviews with management indicated that R1’s medication is not delivered to the facility and is instead delivered to POA. Further interviews with management indicated that the facility will contact POA to bring R1’s medication but this will often take many days. Continued LIC9099C... Substantiated Continued from LIC9099... Further review of R1’s MAR indicated numerous inconsistencies with medication marked “not available” for multiple days in a row followed by one (1) to four (4) days of medication being administered, and then multiple more days of medication “not available”. MAR indicates this cycle continuously repeats. Interviews with management could not explain these inconsistencies. Interview with RP indicated that medication inconsistencies had been caught early on and attempts to rectify them yielded no results. Review of communication with R1’s hospital indicated numerous instances of physicians/pharmacists not being informed of medication running out. Further review of communication between facility management and hospital indicated the incorrect physician was often being informed of the need for refills, leading to medication not being refilled on time. Based upon evidence gathered, there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... Further review of R1’s file indicated that documentation is being properly kept and stored, including Title 22 required forms. Inconsistencies with documentation of medication distribution has been included on allegation “Staff do not distribute resident's medication as prescribed”. 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. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jul 10, 2026 · control 21-AS-20260625120926

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jul 13, 2026

87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement not met by Licensee as evidenced by: Based upon file review and interviews, R1 was not dispensed medication according to the physician's directions which poses/posed an immediate risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Licensee shall submit a plan on how they will ensure medication is filled and dispensed as prescribed by Plan of Correction due date of 7/13/2026 by 5:00PM.

Allegation investigated: Staff are allowing unwanted visitors to visit with resident

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Administrator Candice Moses. Staff are allowing unwanted visitors to visit with resident – Reporting Party (RP) alleges that facility staff are allowing resident (R1) to receive visitation from unwanted parties. During the course of this investigation LPA conducted interviews and reviewed records. Interviews with management indicated facility policy is to allow residents to receive visitation from whomever they would like as long as there is consent from the resident in question. Interviews with staff indicated that R1 does not refuse visitation from indicated party and regularly states they enjoy the visits. Further interviews with staff indicated that R1 will be asked if they want to receive a visitor beforehand and if they consent the visitor will be allowed to see R1. Interview with Witness (W1) indicated that R1 was not refusing to see indicated party. Interview with R1 indicated they would "absolutely want" to receive visitation from party indicated by RP. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Review of R1 chart notes indicated visitation is being logged. Further review of R1 files indicated that R1 does have a Durable Power of Attorney, however, there is not a court order against visitation. 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. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jul 10, 2026 · control 21-AS-20260630120609

Allegation investigated: Staff are not providing adequate food service for residents

At approximately 12:30PM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Adminsitrator Candice Moses. Staff are not providing adequate food service for residents – Reporting Party (RP) alleges that meals are often not enough or dishes are missing parts. During the course of this investigation, LPA made observations and conducted interviews. Interviews with eight (8) of eight (8) residents indicated that facility meals are of adequate size and facility has not run out of food. Further interviews indicated that six (6) of eight (8) residents often are not able to finish their entire meals. Two (2) of eight (8) residents indicated a desire for more food variety. Interviews with three (3) of three (3) staff indicated that they have not witnessed facility food levels running low and, upon resident request, will bring more food out until residents are full. Interviews with management indicated that if there is ever a missed shipment of food from supplier, staff will go to nearby grocery stores and purchase the supplies needed. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Further interviews with management indicated that facility follows a dietician created food plan and menu in order to meet the needs of all residents. LPA observed residents eating snacks between meals times as well as being served full meals outside of mealtimes upon request. LPA toured facility kitchen and observed fresh and frozen food levels to meet requirements. LPA also observed facility holds informational seminars held by a registered dietician to inform residents of healthy food choices. 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 No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jun 18, 2026 · control 21-AS-20260417124451

Allegation investigated: Facility did not follow elopement protocols

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Administrator Candice Moses. Facility did not follow elopement protocols – Responsible Party (RP) alleges that resident (R1) eloped from the facility to a busy intersection and was brought back by an individual who is not employed at the facility. During the course of this investigation LPA reviewed records, conducted interviews, and made observations. Review of Incident Report submitted by facility indicated that R1 eloped from the facility in the afternoon without staff knowledge. Review of LIC602 – Physician Report indicated that R1 is diagnosed with Dementia and is at risk if allowed to leave the community unsupervised. Six (6) of seven (7) staff interviewed indicated they were not fully aware of how R1 came back to facility, two (2) of seven (7) indicated they believed staff brought R1 back to the facility. Continued LIC9099C... Substantiated Continued from LIC9099... Interview with Administrator indicated that the resident was brought back by the family of a staff member, this individual was a not a staff member themselves, after seeing R1 along the side of a street and recognized them. Interviews with seven (7) of seven (7) staff indicated that in-service training on elopement has been given following incident. Based upon evidence gathered, there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... Staff did not provide responsible party with admissions agreement – RP alleges that an updated Admission Agreement was not provided upon Change of Ownership of facility. Review of facility information indicated that the facility has undergone a name change and has replaced management staff but has not completed a change of ownership. Following a Change of Ownership, facilities are not required to complete a new Admission Agreement for their residents and shall honor previous Admission Agreements upon resident requests. Staff did not provide resident or responsible party with reappraisal for alleged change of condition – RP alleges that facility did not provide an updated appraisal following facilities claim of a change of condition. Review of documents indicated that R1 eloped on 2/27/2026 and was taken out of the facility by family on 3/2/2026. Further review of documents indicated that an Elopement Risk Assessment, Mini-Mental State Examination, and Behavioral Expression Appraisal were conducted on 2/27/2026 with an updated Service Plan drafted on the same date. Interviews with management indicated that R1 moved out before the updated Service Plan was implemented and R1’s family did not sign off on the Service Plan. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, May 11, 2026 · control 21-AS-20260309111015

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 12, 2026

Personnel Requirements – General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Based on interviews and file review, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, May 11, 2026

Plan of correction: Licensee has conducted in-service retraining to staff on elopement protocols. Deficiency cleared at time of visit.

Type of visit: Case Management - Other

At approximately 1:15 PM Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a case management - other visit and met with Administrator Candice Moses and Memory Care Director Beatriz Cortez. The purpose of this visit was to follow-up on an SOC341 submitted by facility to Community Care Licensing (CCL) on 12/31/2025 regarding allegations of abuse towards Resident (R1). Facility is conducting internal investigation and has scheduled care conference to update care plan for R1. Staff schedules have been changed out of caution. LPA conducted interviews, made observations, and gathered documents. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jan 15, 2026

Type of visit: Case Management - Other

At approximately 1:30 PM Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a Case Management - Other visit and met with Executive Director Candice Moses. The purpose of this visit was to gather further information regarding an Incident Report and subsequent Death Report received by Community Care Licensing (CCL) on 6/26/2025 and 6/27/2025 respectively. LPA is following up due to potential discrepancies between Death Report and the Death Certificate that was later received by CCL. LPA is also following up on a reported change of Administrator from Samuel Deguzman to Candice Moses. LPA has requested the following documents be submitted by 1/12/2025: Copy of active and current Administrator Certificate Copy of Board of Directors Resolution Meeting Minutes Signed Administrator Resume LIC308 - Designation of Facility Responsibility LIC500 - Personnel Report LIC503 - Health Screening including proof of Negative or Inactive TB test results. No deficiencies cited. Exit interview conducted with Executive Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Dec 12, 2025

Type of visit: Required - 1 Year

At approximately 9:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Candice Moses and explained the purpose of the visit. Administrator certificate is current. Facility has a Hospice waiver for 25 residents. At approximately 9:45AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and court yards. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen equipment was clean and in good repair. Dishware appeared to be stored in a sanitary manner. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature. Facility has required supply of perishable and non-perishable food. Emergency water was present to ensure facility can be self-sufficient for 72 hours. Facility has a generator to supply power in an emergency. Evacuation chairs were located at each stairwell. Emergency lighting devices were present. First aid kit was present. No pools/bodies of water are on the premises. Facility has been conducting Emergency drills every 3 months. At approximately 10:45AM, LPA reviewed 14 of 130 resident files. All resident files contained the required documentation. 4 of 15 reappraisals were not conducted within the last 12 months. Documentation of a physician visit or declination form, within the last 12 months, was not present in 4 of 15 files. Medication records were organized and contained orders for each medication. Medications were secured in a locked medication room. Continued on LIC809-C… LPA will need to return at a later date to review staff records. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC610E- Disaster Plan Evidence of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Candice Moses and Appeal rights were given.the state’s words, verbatim · CDSS document, Nov 18, 2025

Allegation investigated: Staff did not dispose of residents records properly.

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a 10-day complaint investigation and deliver findings regarding the above allegation and met with Tava Setareki, Business Office Director Specialist (BODS). Staff did not dispose of residents records properly – Reporting Party (RP) alleges that facility did not dispose of confidential resident documentation in a secured manner. During the course of this investigation LPA reviewed records, made observations, and conducted interviews. Review of photographs submitted by RP indicated that the confidential documents of multiple residents were disposed of in standard waste containers without maintaining resident confidentiality. Further review of photographs indicated that these waste containers were dumpsters. LPA located and observed that facility dumpsters are located outside of the facility in unlocked sheds. The dumpsters themselves were similarly unlocked. Continued LIC9099C... Substantiated Continued from LIC9099... Improper disposal of resident records may allow access by unauthorized viewers to private information, based upon this there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with BODS, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 21-AS-20251008092313

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Nov 14, 2025

Additional Personal Rights of Residents in Privately Operated Facilities 87468.2(a)(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement not met by licensee as evidenced by: Licensee did not dispose of confidential resident records in a secure manner which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: Licensee to conduct staff training on proper disposal of confidential material in order to protect residents personal rights. Licensee to submit proof of training to CCL by COB on Plan of Correction due date of 11/14/2025.

Allegation investigated: Staff did not assist resident in a timely manner. Facility is not sanitary and in good repair Staff did not keep facility free from pests.

At approximately 09:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this faciity unannounced to conduct an investigation into the above allegations. LPA met with Activity Director Tamia Lindsay, toured the building, interviewed staff and reviewed records. Based on interviews conducted, LPA was not able to find evidence that staff did not assist resident in a timely manner. The facility call system is designed to log each call with time of activation, location and response time, however the system is not fully operational and does not log any details. The call system alerts staff in the medication room, who then relay the location and resident to the caregivers by text. LPA was informed that when staff leave the medication room, the medication technicians take turns returning every five minutes to check the call system. This occurs on all shift. Facility is undergoing a leadership change and the call system is in the process of repair or replacement. During the course of this investigation, LPA toured the facility in search of items or areas that were unsanitary or in need of repair. LPA learned there were several laundry machines that were not operational, but facility purchased replacements. During the timeframe while they were down, facility staff would take resident laundry to a local laundry mat to ensure resident laundry was cleaned per their schedule. Based on Interviews conducted, there were no delays in laundry service during this time. Continued on LIC9099-C... Unsubstantiated The facility locks their front door after business hours to protect residents from people coming into the building without staff knowledge. To the side of the front door is a door bell with a sign informing visitor to press the button to announce their presence. A sign is posted on the front door with two telephone numbers for visitors to call if the door bell does not receive a response. LPA tested the door bell, which was operational, and observed it could be heard from the medication room hallway. Based on interviews conducted and visual observations, the facility is dealing with an ant problem. The facility has a contract with a pest exterminator company and is in communication with them regarding the increase in ants recently. LPA observed bait traps located throughout the facility. LPA was informed that when ants are observed in localized areas, the company will come and spray the areas to address the issue. LPA observed the facility is working to address the ant problem. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 21-AS-20250909084115

Allegation investigated: Staff are occupying residents room without authorization.

At approximately 12:30PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegation. LPA met with Care Coordinator Tamara Mason, interviewed staff and toured the building. Based on interviews conducted, a staff member was reported to have been caught sleeping in a resident room in May, 2025. Staff was reprimanded and later quit employment at the facility. Facility does not allow staff to use resident rooms for their breaks or getting extra sleep. Based on interviews conducted, facility has a beauty salon for resident use. Staff do not get their hair worked on while working at the facility. LPA was not able to find evidence to support the above allegation. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 11, 2025 · control 21-AS-20250729095017

Allegation investigated: Neglect/lack of care and supervision

At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to open an investigation into the above allegation. LPA met with Executive Director Jasmine Seiffert and reviewed records. Based on records reviewed and interviews conducted, Resident (R1) was issued an eviction notice on 06/19/2025 for refusing care and being aggressive. LPA reviewed R1's care plan and observed facility has been making updates as needed per regulation. Based on records reviewed, R1 has been refusing care and not allowing staff into their room. Facility has taken action to ensure the well-being of R1 by issuing a 30 day eviction. Facility staff have continued to attempt to provide care for R1 when they allow it. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 29, 2025 · control 21-AS-20250722102044

Type of visit: Case Management - Incident

At approximately 10:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an incident report submitted by the facility on 06/02/2025. LPA met with Assisted Living Care Coordinator Beatriz Cortez and reviewed records. Based on records reviewed, Resident (R1) contacted law enforcement and threatened to cause physical harm to another resident. Law Enforcement arrived at the facility and was not able to locate R1. According to staff, R1 had left the building. LPA reviewed records and observed R1 is able to leave unassisted, based on a physician report created by a physician who has treated R1 since 2014. R1 returned to the facility and was asked about the telephone call. R1 did not have recollection of making the call. LPA reviewed records and observed facility has been in constant contact with physician and responsible party and the care plan is being updated as needed. No citations issued during today's visit.the state’s words, verbatim · CDSS document, Jul 18, 2025

Allegation investigated: Residents room is not clean and sanitary

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Jasmine Seiffert. During this investigation LPA made observations, conducted interviews, and reviewed records. Residents room is not clean and sanitary – Complainant alleges that upon entry to Resident (R1) room “we were met with a smell or urine and other bodily fluids that smelt like they have been lingering for a while. On top of that there was trash all over the floor, no beds were made, there was trash and dirty dishes in the sink that looked like they have been there for a while”. During this investigation LPA made observations, conducted interviews, and reviewed records. R1 room was observed to be as described above with a strong smell of urine throughout. Interviews with staff indicate that R1 has continuously refused housekeeping services. Continued LIC9099C... Unsubstantiated During visit LPA observed that multiple staff were actively attempting to clean R1 room, but due to past threats and aggression were waiting for R1 to leave room. Interviews and record review also indicate that R1 is currently under a lawful 30-day eviction notice due to a refusal to clean room or allow staff to clean room. Based upon observations, record review, and interviews, we have found that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations/complaint is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted. Copy of report discussed and provided to the Administrator. The signature on the form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 21-AS-20250630103354

Allegation investigated: Staff did not provide adequate supervision to resident in care resulting in multiple falls

Licensing Program Analyst (LPA) Canela arrived unannounced for the purpose of getting additional information and delivering findings to the above allegation. LPA met with Jasmine Seiffert, Executive Director. In the course of the investigation LPA reviewed records, made observations and took statements. It was alleged facility staff did not provide adequate supervision to resident in care resulting in multiple falls. LPA reviewed resident R1s file and the following was noted. R1 moved in to the facility on 8/27/2024. R1s facility service plan with R1s husband, identified R1 requiring moderate assistance with bathing, dressing, grooming and no assistance with mobility, transfers to/from bed/chair, meals; full assistance with medication and although identified as independent for mobility, R1 required escort to meals and activities. It was noted on 8/30-8/31/2024 R1 was refusing to eat, agitated and aggressive towards staff, R1s husband went to facility and picked up R1 to stay at home and R1 was then returned to facility on 9/3/2024. Continue report see LIC9099-C Unsubstantiated After 9/5/2024, R1 was noted to be combative again, with aggressive behaviors and sustained un-witnessed falls, where they were sent to Emergency Department (ER) and returned the same day with a change in medications. Facility expressed that R1 was in the facility for a short period of time, the first week is always hard for new residents to adjust to their new home. R1 continued to be combative was sent to ER and the medication was adjusted, R1 was then more sleepy, and sustained falls in their room while walking and not when assistance or supervision was required by staff, based on their service plan. on 9/10/2024, R1 was placed on Hospice care with Anchor Health, who placed R1 on comfort meds ordered and increased medication. Facility was following R1s doctors and Hospice orders with medication and medication was keeping resident sleepy. Facility stated they had developed a fall prevention plan as R1s was often drowsy from the medication, and a meeting with R1s family and Physician was being planned, but R1 moved out on 9/18/2024. Staff interviewed expressed R1 was being supervised and did not require 1 to 1 care. Although the allegations may be true, based on the above information, and records reviewed, there is not a preponderance of evidence to prove or, disprove, the allegation did occur. Therefore, the allegation for staff did not provide adequate supervision to resident in care resulting in multiple falls is UNSUBSTANTIATED at this time. No citation issued.the state’s words, verbatim · CDSS document, Mar 10, 2025 · control 21-AS-20241029133104

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) A. Canela, arrived unannounced to conduct this required 1 year inspection and met with Jasmine Seiffert, Executive Director/Administrator. LPA toured the facility with Assisted Living care coordinator, Beatriz Cortez. This facility is located near the Glen Cove Marina and has a total of 141 apartments. There are two floors in the facility and a ground floor. The ground floor has a section that is used for memory care residents and has a locked perimeter that was approved by the fire department with 30 second delayed egress that was tested today and operational. Facility was at a comfortable temperature with all exits free from obstruction. Some resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/10/2024. The kitchen area was found clean with sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. All resident bedrooms have appropriate lighting and furniture with a supply of extra blankets and linens. There was a supply of hygiene products, paper products, PPE and emergency food and water. LPA conducted a sample review of resident files. Staff have current 1st Aid training and med techs have proof of CPR on file. Toxins are stored in locked maintenance closets and carts located throughout the facility. Continued onto LIC809-C LPA requested the following documents be sent to CCL by COB 2/23/2025: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility client’s/client’s Copy of Administrator Certificate(s) Copy of Liability Insurance No deficiencies cited during todays inspectionthe state’s words, verbatim · CDSS document, Jan 29, 2025

Allegation investigated: Staff do not respond to call bells in a timely manner Resident hygiene needs not being met

Licensing Program Analyst (LPA) Canela arrived unannounced for the purpose of gathering additional information and delivering findings to the above allegations and met with Jasmine Seiffert, Executive Director. In the course of the investigation LPA reviewed records, made observations and took statements. It was alleged staff do not respond to call bells in a timely manner in that it has been taking about one hour to respond when residents use their pull cord for assistance. Facility was not able to pull older call records because of their system but provided records for the week LPA requested for review. Pull cord records for resident R1 showed, 14 calls were answered under 2 minutes, 11 calls were answered under 5 minutes and 14 calls were answered under 10 minutes, for the one week review. LPA did observe the facility was also answering the majority of other resident calls under 10 minutes and only 3 calls were answered 15-17 minutes, but no documentation of calls answered upto an hour. COntinue report see LIC9099-C Unsubstantiated Residents and staff interviewed did not corroborate the allegation and stated that calls are answered ok, but the facility could use more staff, back in November of 2024. It was also alleged resident hygiene needs not being met for resident R1, in that staff are not available to assist with showers and the bathroom. Investigation revealed, resident was refusing showers. LPA reviewed documentation, for the month of October 2024 R1 received 10 showers and refused 3. Residents interviewed stated they get assistance but sometimes it takes a little longer; no information on how long and when. Although the allegations may be true, based on the above information, and records reviewed, there is not a preponderance of evidence to prove or, disprove, the allegation did occur. Therefore, both allegations are UNSUBSTANTIATED at this time. No citation issued.the state’s words, verbatim · CDSS document, Jan 17, 2025 · control 21-AS-20241003101824

Allegation investigated: Neglect/lack of supervision resulting in resident's care needs not being met Facility not kept clean and sanitary

Licensing Program Analyst (LPA) Canela arrived unannounced for the purpose of continuing investigation and delivering findings to the above allegations and met with Jasmine Seiffert, Executive Director. In the course of the investigation, LPA toured facility, some resident bedrooms; obtained documents, and took statements. It was alleged Neglect/lack of supervision resulting in resident's care needs not being met and facility not kept clean and sanitary. More specifically, it was reported that R1 was found with feces all over foot & shoe; bathroom and bedding was soaked in urine. On a previous visit LPA observed resident (R1) bedroom had a very strong urine odor, the carpet had several large stains and R1's bathroom wall had a tiny smear of feces. Continue report see LIC9099-C Substantiated Continued report from LIC9099 LPA received additional corroborating statements that R1 was found with soiled, soaked in urine clothing, feces on their body and dried feces on the carpet and on bathroom. LPA toured R1s room and R1 had moved out a little over a week and the room did not have any furniture, but the room had a very strong urine smell, the carpet was with larger stains and the bathroom toilet seat and rim had dried smeared feces. It was also corroborated that R1 was found soaked and dirty multiple times and R1s family would pick up clothing to wash. R1s family reported they moved resident out because of the lack of care. LPA was unable to get statements from R1 due to their Dementia diagnoses. Based on LPA observations and statement received, facility failed to ensure R1s was kept clean and dry and failed to meet R1's needs. Facility also failed to ensure R1s room was clean and sanitary. The preponderance of evidence standard has been met, therefore the allegations for Neglect/lack of supervision resulting in resident's care needs not being met and Facility not kept clean and sanitary are both found to be SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 21-AS-20240502095016

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Sep 30, 2024

87464(d) Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...This requirement is not met as evidenced by: Based on LPAs observations, interviews conducted and pictures received. Staff did not ensure resident R1 was clean and dry and did not meet their needs. This poses an immediate Health, Safety or Personal rights risk to residents.the state’s words, verbatim · CDSS document, Sep 27, 2024

Plan of correction: Facility agrees to send in written statement on how they will meet regulation and proof of staff training in Memory care unit. Written statement due 9/30/2024 and proof of staff training focusing on incontinent needs by 10/4/2024 Attention LPA Canela

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 11, 2024

87303(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 was not met as evidenced by: Facility failed to keep R1s bedroom clean, and odor free. This is a potential risk to resident in care.the state’s words, verbatim · CDSS document, Sep 27, 2024

Plan of correction: Facility to send in written plan on how they will stay in compliance and proof of staff training. POC due date 10/11/2024 attention LPA A Canela

Allegation investigated: Lack of care/supervision resulting in residents going AWOL Staff did not keep facility free of pests.

Licensing Program Analyst (LPA) Canela arrived unannounced for the purpose of delivering findings to the above allegations and met with Jasmine Seiffert, Executive Director. In the course of the investigation, LPA toured facility, kitchen, dining area, some resident bedrooms; obtained documents, and took statements. It was alleged that lack of care/supervision resulting in residents going AWOL. Investigation revealed the facility had placed several residents in Assisted Living (AL) bedrooms who due to their diagnoses of dementia, should have been placed in the facilities secured Memory Care unit area. Due to resident R2 and R3 not having the proper supervision or safety measures for individuals with Dementia in AL, residents R2 & R3 walked out of the facility with no supervision. It was also alleged the facility was not kept free of pests, in that mice were observed in a residents bedroom. Facility disclosed they did have an issue and as soon as they had information a mouse was observed, they called pest control for assistance. Continue report see LIC9099-C Substantiated Continued from LIC9099 Based on LPA’s record review and statements received, the preponderance of evidence standard has been met, therefore, allegations for, "Lack of care/supervision resulting in residents going AWOL" and Staff did not keep facility free of pests are both found to be SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 21-AS-20240129091633

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 31, 2024

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required... This requiement was not met as evidenced by: Based on staff interviews and records reviewed: Facility did not ensure supervision of R2 and R3, who AWOL'd from the facility without their knowledge. R2's & R3's Physician's Report(LIC 602) states diagnoses of Dementia & they may not leave the facility unassisted. This is an immediate risk to the health and afety of residents care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: Facility to send in written plan on how they will ensure that residents do not leave the facility unassisted. Facility to train all staff regarding Care and Supervision, AWOL procedures. Staff training to include date, time of day, duration, subject, names and signatures of staff who attended. Written Plan and staff training to be submitted to Community Care Licensing (CCL) by POC due date 07/30/2024 Civil Penalty for $500.00 was issued during today's visit for Zero Tolerance, Absence of Supervision.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 31, 2024

87303(a) 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 was not met. As evidenced by: Residents room had an issue with mice in their closet/room. no mice dropping were observed in the kitchen. This is a potential risk to the health & Safety of residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: Facility called pest control and took care of the pest issue. Facility provided copies of pest contract invoice, to clear deficiency.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to go over a recent incident that was reported by the facility and met, Jasmine Seiffert, Executive Director (ED). On July 5, 2024, LPA received an incident report from ED regarding staff (S1) who was inappropriate with their actions towards a Memory Care resident (R1) LPA spoke with R1, and took statements from staff who were working on the day of the incident and Memory Care Coordinator (S2) Although S2 stated they have done in service training with memory care staff, LPA requested facility to redo training and go more in depth. During LPAs interviews with S2 and other staff, it was clear they may need assistance with understanding residents personal rights and the responsibility of staff being mandated reporters and how to complete an SOC341 to report possible adult abuse. LPA received records that were requested, the ED did submit the required SOC341 regarding this incident along with a video of the incident. Staff S1 was terminated by the facility and did not return to work after the incident. LPA also went over several residents (5) who are occupying rooms in the Assisted living area and have a diagnoses of Dementia. LPA requested current medical assessment, service plans and plan on how facility will ensure the safety and supervision of residents with Dementia diagnoses living in assisted living. Plan and records to be sent to LPA by 8/5/2024. LPA went over Dementia regulations 87705 Care of Persons with Dementia and reminded facility the following: Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal LPA will review information, No citations issued at this time.the state’s words, verbatim · CDSS document, Jul 23, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Canela arrived unannounced and met with Jasmine Seiffert, Executive Director/Administrator. During the course of a complaint investigation, LPA discovered the facility Assisted Living Care Coordinator failed to report several incidents and a Death report for resident R1 to Community Care Licensing as required. Incident reports and death report not reported were in November 2023 and prior to this facilities new Executive Director. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, May 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: May 17, 2024

87211(a)(1)(A)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 specified in (A) through (D) below. This report shall include the resident name.............; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement was not met as evidenced by: The facility failed to report several incidents and the Death report in November 2023 for resident R1. This is a potential risk to the health & safety of residents in carethe state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Facility to submit missing incident reports. Death report was provided during todays visit. Facility to send in written plan on how facility will ensure care coordinator/facility staff will send in required reports timely. New administrator to provide proof all staff have been trained in reporting requirements. Written Plan of correction due 5/15/24 & staff training due 5/17/2024

Type of visit: Office

An informal meeting was conducted today in the Santa Rosa Regional Office via Microsoft Teams . Present in the meeting were Licensing Program Manager (LPM) Kimberley Mota, Licensing Program Analyst (LPA), Araceli Canela and Administrator of the Lodge at Glen Cove, Jasmine Seiffert. The purpose of the Informal meeting was to address concerns regarding a self reported incident by the facility on 2/9/2024 that involved staff S2, S3, S4 and resident R1. Administrator took action, and submitted the required reports, conducted internal investigation and Mandated Reporter retraining for all staff. Administrator agreed to submit proof of training to Community Care Licensing. No deficiencies cited during today’s informal meeting.the state’s words, verbatim · CDSS document, Apr 24, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a case management visit and gather information/records regarding a self reported incident by the facility on 2/9/2024 that involved staff S2, S3, S4 and resident R1. LPA met with Executive Director /Administrator, Jasmine Seiffert, took statement and requested records for Community Care Licensing to review incident. In addition LPA returned to issue citations that were observed on 2/2/2024 during a complaint investigation, but LPA was unable to issue citations due to time restraints. On 2/2/2024 LPA discovered staff S1 who had been working, was fingerprint cleared, but was not associated to this facility as required. In addition LPA found resident R1 and R2 who have a Dementia Diagnoses to have items such as a cup filled with some type of vitamins, a sharp knife, bottle of window cleaner and a hammer. R1 and R2 are not in memory care unit, but occupy a room in assisted living. On 2/2/2024, LPA along with staff S2 removed the items from the residents rooms and placed them inaccessible. LPA went over such items with Administrator during the visit. During today's visit LPA went into R1 and R2s bedroom and did not observe any vitamins or sharp items; a bottle of cleaning solution and the hammer where in the top shelf, inaccessible to R1. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Mar 4, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Mar 4, 2024

87705(f)(2)Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by: During the inspection of 2/2/2024 LPA found, cleaning solution, hammer, knife and cup of vitamins accessible to resident R1 and R2. This is an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Facility to send in written statement on how they will stay in compliance. POC due date 3/5/2024 to LPA A Canela

From the deficiency page — Deficiency type: Type B · Section cited: CCR87355(e)(b) · Plan of correction due date: Mar 5, 2024

87355(e)(b) Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met as evidenced by: during the inspection of 2/2/2024, LPA discovered staff S1 who was working, had been fingerprinted, but previous Administrator forgot to properly associate S1 to this facility. This is a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Facility immediately processed paperwork to associate S1. Facility to send in written statement on how they will stay in compliance and ensure all new staff and current staff are fingerprint cleared and properly associated to this facility prior to working or volunteering. POC due date 3/5/2024 to LPA A Canela

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced and met with Jasmine Seiffert, Executive Director /Administrator. During a complaint investigation LPA discovered staff S1 who was not associated to this facility as required. In addition LPA found resident R1 and R2 who have a Dementia Diagnoses to have items such as a cup filled with some type of vitamins, a sharp knife and a hammer. Due to time restraints, LPA will return to issue citations warranted and LPA along with staff S2 removed the items from the residents rooms and placed them inaccessible. LPA went over such items with Administrator. No citations issued at this time.the state’s words, verbatim · CDSS document, Feb 2, 2024

Allegation investigated: Staff did not seek medical attention for resident in a timely manner

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This investigation consisted of site visits to facility, taking statements from staff and witnesses, review of pertinent documents. The following determinations are made: Complainant alleges that R1 was exhibiting unusual behaviors on or about 10/23/2023 and that the POA for R1 and the facility staff refused to seek medical care for R1 and that R1 had a dangerously high blood pressure; Staff state that R1 refuted Complainant's claims and had a blood pressure reading that was average for R1; Blood pressure logs confirm staff statements; Chart notes indicates that R1 exhibited "confused" behavior that day which appears to be a pattern of behavior that is documented on other days in the chart; Paramedics were called and R1 was taken to medical facility and released the same day back to the facility; After visit summary report indicates R1 was evaluated for cognitive issues and makes no mention of high blood pressure. Although the allegation may be true, based on statements and documents, there is not a preponderance of evidence to prove or, disprove, the allegation. Therefore, it is UNSUBSTANTIATED. Report left. No citations issued today. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 18, 2024 · control 21-AS-20240108143927

Type of visit: Required - 1 Year

LPA Hiratsuka, conducted this unannounced annual visit. LPA toured with Assisted Living Care Coordinator Beatriz Cortez. This facility has three floors. This building has assisted living and a memory care unit that has a delayed egress. There is a mix of one bedroom, two bedroom, and studio apartments. The memory care unit apartments are studios. Some of the memory care apartments share a shower. The showers in the shared units are locked and cannot be accessed without a caregiver. There are several common areas throughout the building. There is an interior courtyard. LPA toured several apartments. Several staff and resident records were reviewed. The following shall be updated and submitted to CCLD by 02/10/2024: -LIC 500 facility personnel or staff schedule -LIC 308 designation of administrative responsibility -copy of current administrator certificate -liability insurance Multiple topics were discussed No deficiencies cited.the state’s words, verbatim · CDSS document, Jan 13, 2024