The Lodge at Piner Road

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

Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegation and met with facility Executive Director Eric Perry. During the course of the investigation LPA conducted a facility visit, conducted interviews, collected and reviewed documents. Documents included Resident R1’s medical assessment, resident R1s Medication Administration Records (MARS) and Doctor’s Prescription orders. Additionally, LPA reviewed a Temporary Restraining Order dated 12/4/2026, Order on Request to Continue Hearing/Restraining Order dated 12/19/2026 and an Elder or Dependent Adult Abuse Restraining Order After Hearing dated 1/14/2026 which is currently in effect. Continued on 9099-C... Unfounded ...Continued from 809 Complaint alleges that staff do not distribute residents’ medications as prescribed. LPA reviewed resident R1’s MARs for the months of 10/2025 through 4/19/2026. LPA observed no instances of medication not being distributed according to doctor’s orders. Witness W1 provided pictures of various pill bottles taken prior to 12/19/2026. The pictures provide no evidence of the facility staff not distributing R1’s medications as prescribed. Additionally, the same allegation involving resident R1 was previously investigated by LPA Dina Alviso in complaint 21-AS-20251218115655. On 1/12/2026 LPA Alviso found the allegation of the staff not giving the resident the medications as prescribed to be Unsubstantiated. As both the current and previous investigation found no evidence that the staff do not distribute residents’ medications as prescribed, we have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Perry. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 21-AS-20260415085648

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso conducted Required - 1 Year inspection, on 5/5/2026 at approximately 9:45am, and met with ED/Administrator Eric Perry. LPA toured the facility, assisted living, including the memory care unit, with Administrator Eric Perry, Memory Care Director Monica Hernandez, and Maintenance Director, Abraham Bautista.. Facility has an approved dementia plan of operation. There is an approved hospice waiver for twenty (20) residents. Fire clearance is approved for ninety-two (92) non-ambulatory, of which twenty (20) may be bedridden. The facility has an emergency disaster plan as required. The facility has an infection control plan as required. Facility has emergency food, water, and other emergency supplies to meet the seventy-two (72) hour shelter in place requirements. All stairwells had the required evacuation chair, and the posted instructions on use of the chair were visible to all. The food supply was observed to be sufficient in perishable and nonperishable food items. All exits were observed to be free and clear of obstruction. Facility was observed to be at a comfortable temperature. Facility had sufficient lighting in common areas, visitor/resident restrooms, hallways, and the observed resident units. Fire extinguishers were serviced and tagged. Medications were locked up and inaccessible to residents in care, in both memory care and assisted living areas of the facility. Cleaners/disinfectants were locked up and inaccessible to residents in care. LPA is requesting the following documents be updated and submitted by 6/5/26: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working Continued on LIC809C-dated 5/5/26.... Continued from LIC809 dated -5/5/26... LIC610E-Emergency Disaster Plan , review & if changes submit a copy-if no changes, copy of last page Infection Control Plan, review & if changes submit a copy -if no changes, copy of last page Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all licensees. Copy of current Administrator Certificate Copy of current Liability Insurance. The LPA will continue this annual inspection at a later date. No deficiencies cited during today's annual inspection. Exit interview with the Administrator Eric Perry.the state’s words, verbatim · CDSS document, May 5, 2026

Allegation investigated: Staff are not giving resident medications as prescribed Violation of resident's personal rights

Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 9:45am on 1/12/26, and met with Eric Perry, Administrator, and Dori Elder, Resident Care Coordinator. Reporting party (RP) alleges that "staff are not giving resident medications as prescribed, and violation of resident's personal rights." LPA reviewed resident R1's records, including admission records, medical assessment, care plan, medication mars/medication log, Kaiser Dr's Orders, legal power of attorney (POA) paperwork, and legal court ordered "temporary restraining order" currently in effect. Interviews were conducted with staff, S1, S2, and S3, and interviews with other related parties. The investigation revealed that medications for resident, R1, are being provided as prescribed by the Physician; Medications are prescribed for specific health diagnosis of R1, and are being provided to them as ordered, per review of medication records. Continued on LIC9099C.. Unsubstantiated Per review of records, staff have provided medications for R1 to have while away from the facility. Per review of records, there is a legal representative, POA, power of attorney for R1, which is still in effect. There are no new court orders and/or approvals on change of current POA. The POA ensured resident had prescribed medications ordered and obtained, when the medications didn't return back with the resident, upon R1's return to them. R1's medications are filled by Kaiser Pharmacy regularly for resident R1. Per review of records, and conducted interviews, there was no information obtained in the investigation to support that a violation had occurred. The resident/R1 has visitors that come to the facility to visit, including some family members who visit, and take resident out of the community as well. Per interviews with staff, and other related parties, visitation is not being withheld from R1, and resident is not being isolated from others. Per staff interviews, and interviews with other parties, there is a legal temporary restraining court order in effect at this time. Per review of records, there is a temporary restraining order, In summary it states, individual, (I1), is restricted to one (1) supervised visit a week with R1, for a period of one (1) hour. The supervised visit must take place at the facility, Ivy Park At Piner, and must be pre-scheduled with Cheryl Fox, RN. This is in effect until the "end of the court date of 1/14/26". Per interview with facility staff, S1, the facility is following the legal court restraining order, and will contact parties as required/needed, including local police department if needed at any time, regarding the temporary restraining order. Per review of records, and conducted interviews, there was no information obtained in the investigation to support that a violation had occurred. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations of "staff are not giving resident medications as prescribed, and violation of resident's personal rights" are Unsubstantiated, meaning that 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. No deficiencies cited. Exit interview was conducted with Eric Perry, Administrator. Complaint Report LIC9099 was provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 12, 2026 · control 21-AS-20251218115655

Allegation investigated: Facility staff did not ensure resident needs were being met Facility staff did not ensure resident was provided access to call button

Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 10:45am on 12/8/2025, and met with Eric Perry, Administrator, and Dori Elder, Resident Care Coordinator. Reporting party (RP) alleges that "facility staff did not ensure resident needs were being met" and "facility staff did not ensure resident was provided access to call button." LPA reviewed resident R1's records, including admission records, medical assessment, care plan, and medications/Dr's Orders. LPA toured the facility. LPA requested copies of records; LPA was provided the requested copies during the inspection. LPA conducted interviews with staff, and other related parties. The investigation revealed that R1 had been declining slowly, and was being seen on 10/4/25 in the hospital for a rash; R1 returned to the facility on 10/4/25 with no discharge paperwork. Facility was unaware on 10/4/25 that while hospitalized, R1 had been accepted for hospice care by Providence Campusses. Hospice agency nurse came out to see R1 on10/5/25, but there was no hospice care plan left and/or faxed to the facility Administrator and/or other administration staff of the facility. Continued on LIC9099C... Unsubstantiated . The facility had their care plan in place only during this time for R1's care. Facility became aware of hospice care for R1 on 10/5/25. The facility had been requesting a copy of the hospice care plan from the agency, since it was not provided the day of R1's acceptance on 10/4/25 and/or on 10/5/25 when R1 was seen by hospice agency Nurse at the facility. The care plan was received by the facility late pm, approximately 8pm, on 10/6/25. On 10/7/25, Administrator and Resident Care Coordinator were reviewing care plan, instituting care plan for R1, and discussing with hospice staff R1's medications due to R1's not having the ability to take some of their medications. Per interviews, R1 was receiving food, drinks/liquids, and care upon the return of R1 to the facility. Per LPA's tour of R1's room the resident had a call button in their room, it is unknown if there was a call button previously. Per staff interviews, R1 was refusing care assistance, and was very agitated upon their return; R1 was monitored by staff, and provided needed services as resident allowed/and let care staff provide at the time. On 10/8/25 the hospice agency had agreed to ensure R1 would receive their medication as needed/required for their care, coming out to provide certain medication to R1 while on hospice services. Administrator stated that the hospice agency did come in to provide R1's needed medication until their passing. There was no information obtained that supported a violation occurred regarding the allegation. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations of "facility staff did not ensure resident needs were being met" and "facility staff did not ensure resident was provided access to call button." are Unsubstantiated, meaning that 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. No deficiencies cited. Exit interview was conducted with Eric Perry, Administrator.the state’s words, verbatim · CDSS document, Dec 8, 2025 · control 21-AS-20251007150201

Allegation investigated: Staff did not provide resident's medication as prescribed Staff mismanages resident's medications

Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 10:45am on 12/8/2025, and met with Eric Perry, Administrator, and Dori Elder, Resident Care Coordinator. Reporting party (RP) alleges that "staff did not provide resident's medication as prescribed" and "staff mismanages resident's medications." RP was not able to provide any specific information on medications/prescribed medications. LPA reviewed resident R1's records, including admission records, medical assessment, care plan, medications/Dr's Orders, and documentation on incidents/progress notes. LPA requested copies of records; LPA was provided the requested copies during the inspection. LPA conducted interviews with staff, and other related parties. The investigation revealed that staff are providing R1's medications as prescribed. Per interviews and record reviews, R1's medications are documented as required, and signed off by staff when provided to the resident. Per interviews conducted with other parties, there is question as to what medications are being provided by staff to R1, not that staff aren't providing medications as ordered. Per review, all resident R1's medications have Dr's Orders, and are provided to R1 per physician orders. There was no information obtained that supported a violation occurred regarding the allegation. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations of "staff did not provide resident's medication as prescribed" and "staff mismanages resident's medications." are Unsubstantiated, meaning that 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. Nothe state’s words, verbatim · CDSS document, Dec 8, 2025 · control 21-AS-20251204145622

Allegation investigated: Facility staff hit resident

Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 10:00am on 12/2/2025, and met with Dori Elder, Resident Care Coordinator, and Monica Hernandez, Memory Care Coordinator. Reporting party alleges that "facility staff hit resident." There were no staff names, of who hit the resident, able to be provided with the allegation reported. LPA reviewed resident R1's records, including admission records, medical assessment, care plan, appraisal, medications/Dr's Orders, and resident incidents. LPA requested copies of records; LPA was provided the requested copies during the inspection. LPA conducted interviews with staff, and other related parties. The investigation revealed that R1 has a current care plan in place, all care needs listed, and updated medications list. R1 is escorted to all meals and activities as needed per care plan. R1 does have a responsible party that is involved, and visits regularly with R1. Continued on LIC9099C... Unsubstantiated LPA reviewed documented incident progress notes regarding the resident, and incidents reported. Per the investigation there was no information obtained to support a violation had occurred. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation of "facility staff hit resident" is Unsubstantiated, meaning that 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. No deficiencies cited. Exit interview was conducted with Dori Elder, Resident Care Coordinatorthe state’s words, verbatim · CDSS document, Dec 2, 2025 · control 21-AS-20251125153312

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso conducted Required - 1 Year inspection, on 5/1/25 at approximately 9:20am, and met with Administrator Eric Perry. LPA toured the facility, assisted living, including the memory care unit, with Administrator Eric Perry, and Maintenance Director, Abraham Bautista.. Facility has an approved dementia plan of operation. There is an approved hospice waiver for twenty (20) residents. Fire clearance is approved for ninety-two (92) non-ambulatory, of which twenty (20) may be bedridden. The facility has an emergency disaster plan as required. The facility has an infection control plan as required. Facility has emergency food and other emergency supplies to meet the seventy-two (72) hour shelter in place requirements. Per emergency disaster drill records, last emergency disaster drill was conducted on 4/17/25, and 3/20/25. LPA reviewed ten (10) resident files. All files were complete. LPA reviewed ten (10) staff files. LPA reviewed staff training. All staff had criminal record clearance as required. The first floor is all assisted living, and the second floor is assisted living, which also houses a memory care unit. All stairwells, total of three (3), had the required evacuation chairs, and instructions posted on how to use the chair. All exits were observed to be free and clear of obstruction. The memory care unit, and assisted living areas were observed to be clean and orderly, The memory care has a keypad for entry into the memory unit, through a delayed egress door. There was sufficient lighting in the facility, in all hallways, common areas, and observed resident rooms and bathrooms for residents' use. Continued on LIC809C,,, The medication rooms have medications centrally stored, locked up, and inaccessible to residents in care, and inaccessible to staff that that are not trained to assist residents with medications; There were small refrigerators in the medication rooms, for medications that need to be refrigerated. LPA reviewed medication records and medication logs, for routine medications, narcotic medications, and PRN medications. Housekeeping carts observed in the facility were found to be locked, making cleaners/disinfectants inaccessible to residents in care. Bathrooms have grab bars, and non-slip flooring/mats for residents use. Hot water was measured at 116.4 and 118.2 degrees Fahrenheit, which is within regulation. Fire extinguishers that were checked were found to be serviced and tagged as required. Facility had sufficient paper products, cleaners/disinfectants, and personal protective equipment (PPE). There is an outside courtyard patio for resident use in the memory care, which includes patio furnishings. The assisted living area has outside patios for residents use. LPA observed some of the memory care residents participating in an activity, chair exercise game, being provided by the staff. LPA observed AL residents preparing to go out on an activity in the community. The facility has activities in the facility for all residents, and has various outings into the community for memory care residents, and assisted living residents, as part of the activity calendar. LPA is requesting the following documents be updated and submitted by 6/1/25. LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Infection Control Plan (ensure to review and update as needed/required) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all licensees. Copy of current Administrator Certificate Copy of current Liability Insurance. There were no deficiencies cited during today's inspection. Exit interview was conducted with the Administrator, Eric Perry.the state’s words, verbatim · CDSS document, May 1, 2025

Allegation investigated: Staff do not provide resident's medications as prescribed

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/14/25 at approximately 10:00am, and met with Administrator Eric Perry. Reporting party alleged that "staff do not provide resident's medications as prescribed". LPA reviewed resident R1 & R2's records, including medication records. LPA obtained copies of requested records, including medication lists, Dr's Orders/signed orders by the Physician, and documentation by staff. LPA interviewed staff, and other related parties. The investigation revealed that a list of a medication was provided on 10/15/24 by resident's (R1) visiting Nurse, regarding a medication R1 was to be assisted with; The list had no Physician's signature as required, and there was no order prior for this medication from the Physician, per file review. The facility staff stated they needed a Doctor's order, a Physician's signature on the medication list being provided by the Nurse. Facility contacted Kaiser three times and had decided to go to Kaiser and was able to obtain Physician's signature on 10/29/24, per interviews with S1 & S2;The resident had missed the medication for approximately two weeks, due to the facility not having no Dr's Order on file with Doctor's signature. Continued on LIC9099C... Substantiated Facility contacted Kaiser three times, decided instead to go to Kaiser, and was able to obtain Physician's signature on 10/29/24, per interviews with S1 & S2;The resident had missed the medication for approximately two weeks, due to the facility not having a Dr's Order on file with Doctor's signature. The investigation revealed that R2 moved into the facility approximately early evening 10/24/24. R2's medication assistance program started on 10/25/24, per record reviews, and staff interviews. R2's medication was ordered in a timely manner but not picked up in a timely manner. Per interviews the resident's refill medications were to be delivered by the R2's representative party. Per interviews, the Administrator picked up the medications from Kaiser, and paid the cost for the medication after being notified by staff the medication hadn't been provided to R2. Per record reviews the medication was missed from 11/7 through 11/14 due to the medication refill not having been picked up. Per facility Administrator, the admission agreement has a statement regarding medication emergencies "The care facility, as required by law, must obtain medications for the resident/patient timely. If I am unable to supply medications for the above resident I agree to pay Consonus Pharmacy Services for the cost of the medication plus an emergency service fee." Administrator stated that the facility Resident Care Coordinator should have used this, agreed to by signature of representative, to obtain the resident's medication so the medication could have been obtained sooner. There was sufficient information obtained to support that alleged violation had occurred. Medication was not provided to the resident as required and prescribed by the Physician; The resident's refill medication was not picked up in a timely manner, per investigation, record reviews, and interviews. The reported allegation of "staff do not provide resident's medications as prescribed" is substantiated. This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed, see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator Eric Perry. Appeal Rights provided.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 21-AS-20241105111834

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

87465(a)(4) Incidental Medical & Dental Care -The licensee shall assist residents with self-administered medications as needed, This requirement was not met as evidenced by: The resident's refill medication was not picked up in a timely manner, per investigation, record reviews, and interviews. This is a risk to resident's health & safety.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Licensee to ensure all resident medications are refilled and picked up and/or delivered in a timely manner for all residents in care. Hold an in-service training with all medication staff, including resident care coordinator, and memory care director regarding "assisting residents with medications, ordering refills as required, facility's medication policy/procedures". Submit proof of training by 1/27/25. Plan of correction due 1/15/25.

Allegation investigated: Staff neglect resulted in a resident being hospitalized Staff neglect resulted in a resident sustaining a fracture while in care

Licensing Program Analyst (LPA) Alviso conducted a complaint investigation, on 6/20/24 at approximately 12:50pm, and met with Administrator Eric Perry. The reporting party (RP) alleges that "staff neglect resulted in a resident being hospitalized, and staff neglect resulted in a resident sustaining a fracture while in care." LPA reviewed records on resident, R1, conducted interviews with staff, and other related parties. The investigation revealed that R1 has a care plan in place; Care services are provided for incontinent care, frequent checks on the resident, a minimum of four (4) times every shift. R1 had an unwitnessed fall on 1/30/24 in their bedroom; Staff assessed and contacted 911 for emergency assistance for R1. R1 was hospitalized due to sustaining a fracture, and neededing surgery. R1 was admitted into skilled nursing care on 2/1/24, and discharged back to the facility on 4/12/24. Facility updated care plan to meet R1's current needs. Unsubstantiated Continued from LIC9099... Per review of records, including facility and medical documentation, no information documented neglect/abuse regarding the incident of R1 on 1/30/24. R1 is not a one to one care resident, and at the time of the fall didn't need one to one care. Currently the resident has physical therapy, and a companion two to three times a week for a few hours to help with exercising. In review of allegations, information obtained, interviews with staff, and other related parties, there was no information obtained that supported that a violation had occurred, regarding the allegations. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations of "staff neglect resulted in a resident being hospitalized, and staff neglect resulted in a resident sustaining a fracture while in care." are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Eric Perrythe state’s words, verbatim · CDSS document, Jun 20, 2024 · control 21-AS-20240430151506

Allegation investigated: Facility staff did not provide a comfortable environment for a resident Facility staff handled a resident(s) in a rough manner Facility staff did not communicate with a resident, and their family, due to a language barrier Facility staff did not keep accurate records on a resident Facility staff mismanaged a resident's medications

Licensing Program Analyst (LPA) Alviso conducted a complaint investigation, on 6/20/24 at approximately 12:50pm, and met with Administrator Eric Perry. The reporting party (RP) alleges that "facility staff did not provide a comfortable environment for a resident, facility staff handled a resident (s) in a rough manner, facility staff did not communicate with a resident, and their family, due to a language barrier, facility staff did not keep accurate records on a resident, and facility staff mismanaged a resident's medications." LPA reviewed records on resident(s), R1 & R2, conducted interviews with staff, and other related parties. The LPA also conducted an interview with Hospice Agency Director of Patient Services, to review case notes on the care and observations by hospice nurses/staff that were coming into the facility regularly to see R2. In review of allegations, interviews, and information obtained, there were no identified/named staff, no exact dates and time able to be provided to the department regarding the allegations. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... The investigation revealed both residents, R1 & R2 were on hospice care. Record reviews and interviews regarding resident care services, medication assistance, incontinent care plan/assistance, including hospice services, had obtained different information than reported to the Department. There was no information obtained to support that violations had occurred regarding the allegations. There was differing information from parties interviewed, and per record review. The interviews conducted with various staff found that staff were able to communicate with the LPA, answer LPA's questions, and speak to the LPA in English; it is not known if before this complaint any staff were not able to communicate clearly. S1 stated that all staff are hired only if they can communicate with all residents, and English is required. Facility's record reviews and interviews obtained no information that staff had not provided a comfortable environment and/or that staff were rough with providing care to R2 or R1 while on hospice/ and in the facility. Records reviewed regarding care services, no information obtained that supported a violation occurred regarding record keeping and/or progress notes reviewed. The Hospice Agency Director of Patient Services, in summary, stated to the LPA that the hospice staff are very good about documenting notes regarding a resident, care services and/or concerns. In review of R2's case notes there are no concerns regarding care being provided to the resident, no medication concerns, R2 was getting their medications as needed, and there is no documented concerns of any neglect of the resident/R2. Hospice staff would report concerns/neglect of any kind as mandated reporters if observed/suspected. There was no information obtained during the investigation, and interview with hospice agency to support a violation had occurred regarding the allegations. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations of "facility staff did not provide a comfortable environment for a resident, facility staff handled a resident (s) in a rough manner, facility staff did not communicate with a resident, and their family, due to a language barrier, facility staff did not keep accurate records on a resident, and facility staff mismanaged a resident's medications" are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Eric Perrythe state’s words, verbatim · CDSS document, Jun 20, 2024 · control 21-AS-20240129113202

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Alviso conducted an annual continuation inspection, on 6/20/24 at approximately 12:50pm, and met with Administrator Eric Perry. Annual inspection started on 5/7/24. Facility has an approved dementia plan of operation. There is an approved hospice waiver for twenty (20) residents. Fire clearance is approved for ninety-two (92) non-ambulatory, of which twenty (20) may be bedridden. The facility has an emergency disaster plan as required. The facility has a required infection control plan. Facility has a supplies to meet the seventy-two (72) hour shelter in place requirements. Facility is conducting emergency/disaster drills as required. The LPA reviewed seven (7) resident files. All files were complete. The LPA reviewed seven (7) staff files. All staff had required criminal record clearance. All staff had required training. All medications were locked and inaccessible to residents in care. All cleaners/disinfectants were locked up and inaccessible to residents in care. Sufficient supply of Personal Protective Equipment (PPE). There were no deficiencies cited during today's inspection.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso conducted Required - 1 Year inspection, on 5/7/24 at approximately 12:00pm, and met with Administrator Eric Perry. LPA toured the facility, including the memory care unit. Facility has an approved dementia plan of operation. There is an approved hospice waiver for twenty (20) residents. Fire clearance is approved for ninety-two (92) non-ambulatory, of which twenty (20) may be bedridden. The facility has an emergency disaster plan as required. The facility has a required infection control plan. Facility has a supplies to meet the seventy-two (72) hour shelter in place requirements. Every stairwell, four (4), had a required evacuation chair, with posted instructions on use. All common areas, observed bathrooms, and resident units had sufficient lighting as required. LPA observed meal service throughout the inspection for resident scheduled mealtimes. The food supply was sufficient. The kitchen was observed to be clean and orderly. All medications were locked and inaccessible to residents in care. The facility had all observed exits unobstructed. All fire extinguishers, eighteen (18), were serviced and tagged, 1/25/24, as required. First aid kits were observed to have all required items. Hot water was checked at 112. degrees Fahrenheit and 113.4 degrees Fahrenheit. The Department will continue this annual inspection at a later date.the state’s words, verbatim · CDSS document, May 7, 2024

Allegation investigated: Staff mismanaged resident’s medication

Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 9:35am on 12/6/23, and met with Administrator Eric Perry. LPA reviewed resident records, including medication records, conducted interviews with staff, and other parties. The investigation revealed that resident(R3) didn't receive medications as prescribed by the Physician. Per record reviews, and staff (S1,S2) interviews, resident had a change in medication order on 8/1/23, but the medication continued to be provided to the resident three times a day (3xs a day) per the old order; The new Physician's order was to provide the medication at one pill a day to the resident. The medication ran out sooner then it should have. The facility purchased the medication and provided the medication to the resident per new order dosage instructions. The resident (R3) received their medication in error, one medication, from 8/1/23 through to 8/21/23. Continued on LIC9099C... Substantiated R1 had a catheter that theyhad issues with, and the Physician discontinued the need for R1 to have the catheter, per interviews with S1 & S2. R1 was receiving in-home health services at the time. It is unknown per investigation, if there was any other time resident had catheter issues. Meals were observed by the LPA to be served at scheduled meal/ food service times per facility plan during LPA inspections; It is unknown if there are other times that meals are not being provided timely to residents in care. There was differing information obtained regarding allegations from what was reported to the Department. No information obtained to support that the violations occurred. Based on the interviews with staff, and other related parties, record/document reviews, and information obtained during the investigation, the allegations, "Staff did not seek medical attention for the resident, Staff does not keep care records and/or medical records on resident(s), Staff are not providing incontinent care in a timely manner, and leaving residents in soiled diapers, Staff do not meet residents’ hygiene needs in a timely manner, Staff not providing residents with meal(s) in a timely manner " are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Eric Perry. Based on LPA interviews, review of records, and information LPA obtained, the investigation has revealed that the allegation of "staff mismanaged resident’s medication." has been substantiated. Due to the substantiation of the allegation, a citation, will be cited today, 87465(a)(4) Incidental Medical and Dental Care, the licensee shall assist residents with self-administered medications as needed, see LIC9099D. Second/repeat citation within twelve (12) months, a civil penalty (CP) is assessed in the amount of $250 today, see LIC421FC. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited: Exit interview conducted with the Administrator. Appeal rights provided.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 21-AS-20230828094126

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 7, 2023

87465(a)A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: LPAs investigation, review of records, and interviews with staff, and other related parties. The resident (R3) received their medication in error from 8/1/23 through to 8/21/23. R3's Order had changed on 8/1/23, but the resident received three pills a day instead of the new dosage of one pill a day. This is a risk to residents health and safety. Second/repeat citation within twelve (12) months, a civil penalty (CP) is assessed in the amount of $250 today, see LIC421FCthe state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: Submit plan of correction of policy and procedures, of medical records staff, and medication technicians, ensuring all medications are provided to residents as prescribed by the Physician. POC due 12/7/23.

Allegation investigated: Staff are not responding to resident's emergency pendant.

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, at approximately 2:00pm on 10/19/23, and met with Administrator Eric Perry. LPA reviewed resident records, facility call bell records, staff records, food service records, and inspected the food supply. LPA conducted interviews with staff, and other related parties. The investigation revealed that call bell report showed a pendant/call bell system event, R1's emergency alarm, that was set off showed elapsed time in response;This is a risk to the health and safety of a resident(s). This deficiency will be cited, 87303(i)(1)(2) - Maintenance and Operation. Facilities licensed for 16 or more... shall have a signal system which meets specified requirements, see LIC9099D. Based on record reviews, and interviews during this investigation, the allegation of "staff are not responding to resident's emergency pendant." is substantiated. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Appeal Rights Given to the Administrator Exit interview conducted with the Administrator. Substantiated LPA toured the kitchen and observed the food supply to be sufficient, with fresh vegetables, fruits, meats, and many other food items. LPA reviewed food service records, which shows food purchase records, and facility menus of meals.There was differing information obtained from what was reported to the Department. No information obtained to support that the violations occurred. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations, facility is not following resident's care plan, facility staff at not properly trained, facility is not providing food/meals that is of good quality and nutritious " are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Eric Perry.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 21-AS-20230809142110

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1)(2) · Plan of correction due date: Oct 20, 2023

87303 Maintenance and Operation. Facilities licensed for 16 or more... shall have a signal system which meets specified requirements.This requirement was not met as evidenced by: Based on investigation, file reviews, interviews, facility failed to ensure staff are responding to emergency call bell alarm(s) in a timely manner. LPA reviewed facilities emergency alarm pendant/call bell system event report, emergency alarm that was set off showed elapsed time in response which poses an immediate health & safety risk to resident(s) in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator to ensure all required facility staff are trained on the emergency pendant/call bell alarm system and are following facility's policy/procedures/staffing and ensuring a timely response in answering resident's emergency alarms to ensure that resident's needs, health & safety are being addressed appropriately and within regulations. Submit proof of training by 10/31/23, include topics, trainer, date/time spent, attendees. Submit plan of correction, scheduled date for training(s) by POC due date of 10/20/23.