The Meadows Senior Living

Allegation investigated: Staff did not ensure that resident was received oxygen as prescribed.

On 9-1-2026, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to continue the complaint investigation regarding the allegation noted above. LPA met with Administrator Alyssa Sellers and explained the purpose of the visit. Based on intervies with staff and documents reviewed R1 may have removed the oxygen herself. Therefore the above allegation is UNSUBSTANTIATED. A finding of means 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, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 1, 2026 · control 27-AS-20260604132846

Allegation investigated: Staff did not provide adequate supervision to a resident Staff did not administer medications to resident

On 7-2-2026 at 2:59pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegations noted above. LPA met with Administrator Alyssa Sellers and explained the purpose of the visit. During this investigation, LPA conducted interviews with five staff members and reviewed facility file documentation including progress notes regarding resident1 (R1), medication log sheets regarding R2, census report, pull cord and pendent log reports, physician’s reports for R1 and R2, appraisals for R1 and R2, needs and service plan for R2, and video recording. Allegation: Staff did not provide adequate supervision for a resident. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that on 2-10-2026 R1 was noted on the floor by staff with wheelchair over her and thighs under the legs of the wheelchair. R1 was examined by a hospice nurse which did not reveal injuries or complaints of pain. A review of pendent log revealed that on 2-10-2026 at 5:52pm R1 pushed pendant to request assistance {Cont. on 9099C} Substantiated Report does not indicate location where R1 was at the time. The report further revealed that pendant of R1 was responded to by staff at 6:41pm indicating a wait time of 48 minutes and 52 seconds. Based on review of video recording it was revealed that R1 fell out of her wheelchair near her bed at 6:35pm during an attempted self transfer with wheelchair appearing to be partially on top of R1. A second video revealed a caregiver entering the room at 6:43pm to begin assessing R1 after noticing R1 on the ground. Interviews conducted further confirmed a wait time of approximately 48 minutes. A review of R1’s physician’s report and appraisal form indicated R1 experienced disorientation and required assistance for activities of daily living including incontinence care and was under hospice care at the time of the above incident. Based on the above evidence reviewed, it is determined that staff did not provide adequate supervision for R1 on 2-10-2026. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Allegation: Staff did not administer medications to a resident. LPA conducted interviews and record reviews as noted above. Record reviews revealed a self-medication management acknowledgement was signed by R2’s responsible person and Administrator to indicate R2 can manage own medication. A physician’s report for R2 dated 1-23-2026 stated R2 is unable to manage own medication and required assistance. A census report indicated R2 was in a hospital setting and not at the facility from the dates of 1-9-2026 to 1-29-2026. Based on review of medication log sheet for January 2026 it was indicated that R2 did not receive four medications as ordered between the dates of 1-30-2026 and 1-31-2026. Interviews conducted further confirmed the information revealed in the log sheets. No additional evidence existed which proved R2 ever received these medications. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citations are issued under Title 22, Division 6, and Health and Safety Code, Chapter 3.2, and noted on LIC 9099D. An exit interview was conducted with Administrator, and a copy of this report was provided. LIC 811 and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 27-AS-20260325122154

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Jul 3, 2026

H&S Code Section 1569.312(e) Basic Services Requirements. (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by: Based on interviews and record reviews, licensee did not ensure the proper and timely monitoring and supervision of R1. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Licensee will ensure completed staff training on proper and timely response to call buttons. Training date to be submitted to LPA by POC due date. Proof of completed training to be sent to LPA by 7/16/2026. Licensee will submit a plan outlining procedures for proper and timely answering of call buttons and other requests for resident assistance. Plan to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 3, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interview and record review, Licensee did not ensure the assistance of four self-administered medications for R2. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Licensee will ensure completed staff training on medication handling and procedures. Training date to be submitted to LPA by POC due date. Proof of completed training to be sent to LPA by 7-16-2026.

Allegation investigated: Unlawful eviction Staff do not provide residents with medication as prescribed Staff did not provide resident's responsible party with requested records/logs Staff did not safeguard resident’s belongings Staff did not accord resident with privacy Facility is in disrepair Facility has pests

On 7-2-2026 at 2:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with Administrator Alyssa Sellers and explained the purpose of the visit. During this investigation, LPA conducted interviews with six staff members and one resident in care. Additionally, LPA reviewed facility file documentation including appraisal forms, physician’s report, needs and service plan, admissions agreement, email communications, care notes, theft and loss policies, medication orders and log sheet, eviction letters, and pest control records. LPA also conducted a facility observation as part of this investigation. Allegation: Unlawful Eviction. LPA conducted interviews and record reviews as noted above. Based on these reviews and interviews, it was revealed that resident1 (R1) received an eviction notice dated 2-20-2026 which was sent to the Department for review on 2-20-2026. {Cont. on 9099C} Unsubstantiated Upon review of the eviction notice, it was determined that additional information was required to bring notice into compliance. As a result, facility rescinded the notice and re-issued a revised notice on 4-21-2026 which met regulatory requirements. Based on additional review, there was no evidence of any additional attempts to evict resident in an unlawful manner. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation: Staff do not provide residents with medication as prescribed. LPA conducted interviews and record reviews as noted above. Medication logs from January to March 2026 were reviewed. Based on these reviews and interviews, it was revealed that R1 has been receiving medication as indicated in the medication logs and accompanying orders. A specific medication order for Parkinson’s disease was noted to be given at the specific times of 8am, 12pm, 4pm, 8pm, and 10pm (bedtime). Medication log sheets indicate these times noted and medication dispensed at these times. Investigation did not reveal any additional evidence of staff not providing residents with medication as prescribed. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation: Staff did not provide resident’s responsible party with requested records/logs. LPA conducted interviews and record reviews as noted above. Based on these reviews and interviews, it was revealed that Administrator and staff6 (S6) received information of the records request on 4-1-2026. Investigation also revealed that on 4-2-2026, an email was sent to the individual requesting records to inquire as to which specific records were requested, however, a response was not received by facility. Interviews conducted did not reveal additional specific dates of requested records. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation: Staff did not safeguard resident’s belongings. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews it was revealed that a video recording device was placed in the room of R1 without staff knowledge. Interviews further revealed that when discovered, the device was unplugged due to lack of proper signage informing others of a camera in use. Additionally, it was further revealed that the device remained in the room. Inventory sheet reviewed did not indicate any belongings of this sort inventoried. No additional evidence revealed that the device was not safeguarded properly. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. {Cont. on 9099C} Allegation: Staff did not accord resident with privacy. LPA conducted interviews and record reviews as noted above. Interviews and various email communications reviewed revealed that a pre-arranged doctor appointment for R1 took place on 2-3-2026. Emails revealed this appointment required an “escort” and responsible party to be present. Interviews and care notes revealed transportation was arranged for R1 who was accompanied by staff2 (S2). S2 arrived with R1 at the doctor’s office and stated R1’s cognitive concerns and the need for an updated physician’s report. The doctor declined to conduct the assessment until R1’s responsible person arrived. R1’s responsible person arrived shortly thereafter, S2 left the room. The driver remained in the transportation vehicle during this event based on interviews conducted. As result, there is not a preponderance of evidence to conclude that facility did not accord resident with privacy, therefore, this allegation is UNSUBSTANTIATED. Allegation: Facility is in disrepair. LPA conducted interviews and facility observation as noted above. Based on interviews conducted, there have been no recent reports of disrepair items or requests for repairs. Observation did not reveal any evidence of disrepair items within facility common areas, kitchen area, outside of facility, or resident rooms. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation: Facility has pests. LPA conducted interviews, record reviews, and observation as noted above. An observation conducted by LPA on 4-1-2026 revealed evidence of pests, however, record reviews and interviews revealed that facility has been consistently utilizing a pest control service since 10/2/2025 to current with specific target rooms of 201, 204, and other various areas within the facility. Based on review of pest control information, pests may appear during stages of treatment as a normal process. Observation conducted on 6-10-2026 did not reveal any evidence of pests within the facility. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights and LIC 811 provided.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 27-AS-20260323173150

Allegation investigated: Staff did not ensure that the resident’s specialized care needs were met at the facility.

On 07/02/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open an investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director. LPA met with Alyssa Sellers and a brief interview followed. The following documents were requested for resident (R1): Admission Agreement LIC 602 Appraisal/Reappraisal and Care Plan Incident report for 911 call Staff names and phone numbers for 6/27/26 Call lights/pendant logs for 6/26/26 through 06/27/26 Review of Medication Record for June 2026 Unsubstantiated Caregiver assignment sheet for R1 During this visit, this LPA interviewed the resident (R1) and 3 staff (S1, S2 and S3). This LPA also reviewed the records requested above. Based on a review of records, in the resident's (R1's) service plan, R1 was independent and did not need assistance with their special medical needs. Due to R1's complicated medical condition, an event occurred which resulted in R1 activating their personal call alert pendant. Staff (S2) responded within 4 minutes and S1 arrived shortly after. R1 was on the phone with emergency services when S2 arrived. S1, a medication aide, had received a call from emergency services alerting them to the fact that a resident had called for transport due to shortness of breath. When S1 arrived in the R1's room, they observed that R1's medical equipment had detached from their body and as The Meadows is not a skilled nursing facility, by regulations, they were not allowed, trained, or qualified, to assist the resident with re-establishing the connection. It was appropriate for the resident to call 911. If the resident had not called, S1 or S2 would have been required to do so as their Wellness Director, an. LVN, was not on duty that weekend. R1's service plan stated that they (and their special medical equipment) would receive checks 3 times daily. LPA reviewed the log which was completed for all of the required checks. In an interview with R1, R1 stated that they were at fault for waiting too long to call for assistance which caused the event that required emergency services to intervene. The standard for the preponderance of evidence has been met, the Department found the allegation, "Staff did not ensure that the resident’s specialized care needs were met at the facility," UNSUBSTANTIATED. A finding of unsubstantiated does not mean the event did not happen or was untrue, it means that there was not enough evidence to substantiate the allegation. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS, and an exit interview was conducted with Sellers.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 27-AS-20260630084535

Allegation investigated: Staff are not meeting resident's hygiene needs. Staff does not ensure that resident receives shower services.

On 1/30/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a follow-up complaint investigation and to deliver findings regarding the allegations noted above. LPA met with the Executive Director/Administrator, Alyssa Sellers (AD), and stated the purpose of the visit. Allegation 1: Staff are not meeting residents’ hygiene needs The investigation into this allegation consisted of review of facility records, interviews, and on-site observations. The LPA reviewed staff in-service training records. Training dated 12/9/25 included topics such as completing care needs, documenting refusals, and staff responsibility for all residents. Training dated 12/6/25 covered showers, toileting, handwashing, and face washing. {1 of 3} Unsubstantiated Training dated 2/20/25 included general policies and procedures, grooming assistance, proper storage of hygiene supplies, hydration, meal times, shower and spa room use, and protected health information. These records showed staff received training related to resident hygiene care. Per review of R1’s Physician’s Report dated 10/3/2025, R1 was assessed to be at risks if allowed direct access to personal grooming and hygiene items. R1 was also diagnosed with Alzheimer's dementia. LPA interviewed Resident (R1). R1 confirmed they receive assistance with activities of daily living, including hygiene care. R1 stated not having any issues with staff meeting their hygiene needs at this time. Three additional residents were interviewed and did not report concerns regarding staff not assisting with hygiene care. Staff on duty, (S1) and (S2), were interviewed and denied the allegation. Both staff stated residents receive assistance with hygiene as needed and as scheduled. During a facility visit on 12/10/2025, LPA observed grooming carts containing residents’ hygiene items labeled with residents’ names. Baskets with resident-specific hygiene supplies and additional facility-provided items were also observed. LPA observed resident bedrooms and noted hand soap available for resident use. Based on record review, interviews, and observations, there was insufficient evidence to support the allegation that staff are not meeting residents’ hygiene needs. Therefore, this allegation is unsubstantiated. --------------------------------------------------------------------------------------------------------------- Allegation 2: Staff do not ensure that residents receive shower services The investigation into this allegation included record review, interviews, and direct observation. The LPA reviewed Resident 1’s (R1) shower schedule and shower tracking sheets for October, November, and December 2025. Records showed R1 was scheduled to receive showers at least twice per week on Sundays and Thursdays. {2 of 3} Staff initials were documented on scheduled days, indicating showers were provided. Records also showed R1 requires assistance with parts of the bathing process, including getting in and out of the shower or tub. Per review of R1’s Physician’s Report dated 10/3/2025, R1 was assessed to be at risks if allowed direct access to personal grooming and hygiene items. R1 was also diagnosed with Alzheimer's dementia. R1 was interviewed and stated staff assist them with showers at least two times per week. R1 did not report any concerns about missing showers. Three additional residents were interviewed and did not report concerns about not receiving showers. Staff on duty, (S1) and (S2), denied the allegation and stated staff ensure residents receive scheduled showers. During a facility visit on 12/10/2025, LPA observed the common shower room in the Memory Care area, which included two shower stalls and a walk-in bathtub for non-ambulatory residents. The LPA noted a resident in the Memory Care area being assisted by staff during a shower. The LPA also observed a room where shower schedules were kept. Based on record reviews, interviews, and observations, there was insufficient evidence to support the allegation that staff do not ensure residents receive shower services. Therefore, this allegation is unsubstantiated. Note that an unsubstantiated finding means that although the allegation may have happened or valid, the preponderance of evidence standard is not met. No deficiencies were cited as a result of this visit. An exit interview was conducted with AD and a copy of this report and appeal rights were provided. {3 of 3}the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 27-AS-20251202152416

Allegation investigated: Illegal Eviction

On 1/21/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced to conduct a follow-up complaint investigation and deliver findings regarding the allegation noted above. LPA met with Business Manager, Kaushik Sharma (S1), and stated the purpose of the visit. This visit was conducted concurrently with their annual inspection visit. The Executive Director/Administrator, Alyssa Sellers (AD), was notified and unable to be present at the facility. The investigation into the allegation of illegal eviction centered around resident R1. The investigation consisted of interviews and record reviews. {1 of 2} Unsubstantiated LPA reviewed R1’s records and interviewed staff and the administrator. R1 moved into the facility on February 10, 2025. At first, R1 did not have behavioral problems. Over time, R1’s condition changed. Starting in March 2025, R1 began showing signs of aggression. By June and July 2025, R1 had several incidents where R1 yelled at or pushed other residents and staff. The facility held care meetings with R1’s responsible party on July 2 and August 6 2025 to talk about R1’s behavior and possible next steps. Hospice was added to help manage R1’s care. On August 12, 2025, R1 had a serious incident where R1 refused medication and attacked staff. Police and EMS were called, and R1 was taken to the hospital. The next day, August 13, R1’s responsible party removed all R1’s belongings from R1’s apartment. The administrator said the facility had not officially refused R1’s return yet, but during the August 6 meeting, they agreed R1 could not come back if R1’s behavior continued. After R1 moved out of the facility, the facility sent a letter titled “3-Day Eviction.” The administrator admitted this was a mistake because the resident had already moved out. The letter was sent only for documentation purposes and not to force R1 to leave. The admission agreement says the facility must give 30 days’ notice for termination unless DSS approves a 3-day eviction for emergencies. In this case, DSS approval was not requested because the resident had already left. The administrator said they will fix their process and use the correct type of letter in the future. Based on the information gathered, the allegation that the facility illegally evicted R1 is unsubstantiated. The evidence shows the R1’s responsible party decided to move R1 after care meetings and hospital transport. The “3-Day Eviction’’ letter was sent after the move and did not cause the eviction. Administrator admitted that the title was incorrect. An unsubstantiated finding means that although the allegation may have happened or valid, the preponderance of evidence standard is not met. No deficiencies were cited as a result of this visit. An exit interview was conducted with S1 and AD and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 27-AS-20250813205515

Allegation investigated: Staff did not ensure resident received sufficient beverages, resulting in dehydration. Licensee did not adhere to resident's admission agreement. Staff did not follow resident's diet order. Unlawful eviction.

On 1/21/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced to conduct a follow-up compaint investigation and deliver findings regarding the allegations noted above. LPA met with Kaushik Sharma, Business Manager (S1) and stated the purpose of the visit. This visit was conducted concurrently with their annual inspection. The Executive Director/Administrator, Alyssa Sellers (AD) was notified and unable to be present during this visit. Throughout the investigation, LPA conducted observations of the facility, interviews with staff and residents in care and record reviews relevant to this complaint. {1 of 5} Unsubstantiated Allegation - Staff did not ensure residents received sufficient beverages, resulting in dehydration. The investigation into this allegation consisted of interviews, record reviews and observations. Through interview, witness (W1) believes the facility did not give resident (R1) enough to drink at meals and medication times. W1 said staff once saw R1 “guzzling” ice water and took that as a sign of dehydration. Interviews with staff revealed that water is offered at each meal, often during activities and whenever residents ask. Staff stated that they do not track or log daily fluid intake unless residents show a change in condition and placed on alert; R1 was not on dehydration alert. Dietary and care staff described hydration stations in common areas, water pitchers on dining tables, drinks in the dining-room fridge/freezer, and a mobile cart that offers water, juice, popsicles, and fruit, especially on hot days. Through interviews with current residents in care, they did not report any problems with food or hydration issues. One resident stated that there are places in the facility to get water. Records review showed R1 was not on dehydration alert. Review of facility’s newsletter for July 2025 that provides residents with information and reminders to hydrate, especially during summertime, and the importance of avoiding dehydration, UTI’s, heat stroke and other heat related conditions. During this LPA’s observations on 7/1/25 and 12/26/25, LPA observed hydration stations with water, coffee, and tea near the lobby. At lunchtime, LPA observed a glass of water at each dining table place setting, and many residents also had juice, coffee, or tea. Menu items were posted and easy to see. Staff did not report signs of dehydration for R1 before the hospital transfer, and R1 was not put on a dehydration alert. While W1’s concerns are noted, there is not enough evidence to show that staff did not provide sufficient beverages to R1. Based on the information gathered, the allegation that staff did not ensure the resident received sufficient beverages, resulting in dehydration, is unsubstantiated. {2 of 5} Allegation - Licensee did not adhere to resident's admission agreement: The investigation into this allegation focuses mainly around R1’s situation. The investigation included interviews with staff, review of the admission agreement signed on January 22, 2025, R1’s payer ledger, and related correspondence. Based on interviews, R1 was not denied return to the community following hospitalization. The administrator explained that R1 was sent to the emergency room on March 18, 2025, due to stroke symptoms. After hospitalization, the facility’s Director of Health and Wellness typically assesses residents before readmission to ensure care plans remain accurate and regulatory requirements are met. In R1’s case, there was a change in care needs under review. During this time, R1’s Power of Attorney (POA), decided to seek alternative placement that could accommodate these changes and was more financially feasible. Through interviews and record reviews, the POA provided a written 30-day notice via text message on April 2, 2025, which was confirmed by a screenshot and a written message dated April 30, 2025. Review of the admission agreement shows that residents may terminate the agreement at any time by giving a 30-day written notice, and they are responsible for paying all rent and fees during that notice period, even if they do not occupy the apartment. Review of R1’s payer ledger confirms that R1 was billed through April 30, 2025, consistent with the agreement terms. Staff interviews also confirmed that level-of-care charges stop when a resident physically leaves the facility, but rent obligations continue through the notice period, per admission agreement. R1’s last billing stopped on April 30, 2025. Based on the evidence, the allegation that the licensee did not adhere to R1’s admission agreement is unsubstantiated. The facility followed the signed agreement by requiring payment through the 30-day notice period and did not deny R1’s return. {3 of 5} Allegation - Staff did not follow resident's diet order: Investigation included interviews with staff, residents in care, and other individuals involved with the care of R1, review of R1’s care plan, diet order, admission agreement, and facility observations. Interview with witness (W1) stated that R1 was diabetic and was supposed to receive a carb-controlled diet after switching from insulin to oral medication. W1 stated that R1 ate the same meals as other residents and that this caused R1’s blood sugar to rise. W1 also reported that blood sugar checks were not done regularly. During interviews, staff explained that diet orders are reviewed during admission and any changes are communicated to the kitchen. Staff also stated that menus are planned by a dietitian and that special diets are documented in a binder accessible to kitchen staff. Interviews with current residents in care did not report issues with food services and did not report staff not following their diet, food allergies or food preferences. Through record reviews, R1 had a diabetic diet. Review of the diet order form signed by the health practitioner on January 16, 2025, indicated R1 was to have a consistent carbohydrate diet, meaning a consistent amount of carbohydrates at meals and snacks. Foods with high sugar were allowed when planned into the total carbohydrate allowance for the meal. Additionally, review of training records showed staff were trained on diet and texture modifications. During observations, LPA observed menus posted and water provided at tables, and interview with kitchen staff confirmed that alternative meals are available upon request. Based on the information gathered, there is not enough evidence to prove that staff did not follow R1’s diet order. Therefore, the allegation is unsubstantiated. {4 of 5} Allegation – Unlawful eviction: The investigation into this allegation focuses mainly around R1’s situation. The investigation included interviews, review of R1’s admission agreement, termination clause, and facility records. According to the complaint, R1 was hospitalized on March 18, 2025, and was later informed that the facility would not allow R1 to return. The facility did not provide an eviction notice and that POA learned of the eviction indirectly through hospital staff. Review of R1’s admission agreement and termination clause shows that the facility may terminate the agreement with a 30-day written notice for reasons such as nonpayment, failure to comply with laws or facility policies, or if the resident’s needs can no longer be met. The agreement also states that a 3-day notice may be given with prior approval from the Department of Social Services if the resident poses a health or safety risk. CCR Title 22, Section 87224, requires proper written notice and DSS approval for certain evictions. Records show that R1’s POA submitted a written 30-day notice, via text, on April 2, 2025, to move R1 out of the facility. Staff interviews confirmed that the facility did not issue an eviction notice and did not deny R1’s return; instead, the POA chose an alternative placement that could meet R1’s changing care needs. Based on the information reviewed, there is insufficient evidence that the facility unlawfully evicted R1. The move-out was initiated by the POA, and the facility followed the admission agreement signed by R1 and/or R1’s POA. Therefore, the allegation is unsubstantiated. An unsubstantiated finding means that although the allegation may have happened or valid, the preponderance of evidence standard is not met. No deficiencies were cited as a result of this visit. An exit interview was conducted with S1 and AD, and a copy of this report and appeal rights were provided. {5 of 5}the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 27-AS-20250625155709

Type of visit: Required - 1 Year

On 1/21/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct their annual inspection visit. LPA met with Business Manager, Kaushik Sharma (S1), and stated the purpose of the visit. The Executive Director/ Administrator, Alyssa Sellers (AD) was notified and unable to be present during this annual visit. Overview: Facility is a two-story building. Facility is licensed to serve up to 160 elderly residents, up to 154 residents may be non-ambulatory and up to 24 may be bedridden. Bedrooms and non-ambulatory rooms are interchangeable. Facility has a hospice waiver granted for 15 residents. Physical Inspection: Areas inspected include, but not limited to, the kitchen, dining, resident units/bedrooms, resident bathrooms, common areas and outdoor areas. Tour of the facility was conducted with Facility Maintenance, Johnna Weaver. LPA inspected 4 resident units, 2 in the Memory Care (MC) area and 2 in the Assisted Living (AL) area. Hot water temperature ranged from 105 - 117 degrees Fahrenheit. The 4 resident units were observed to be in good repair at this time. Pull cords were tested in the residents’ bathrooms and were found to be in good working condition. Each resident room have its own heating/cooling and can be controlled by residents. Hallway temperature was between 68 – 74 degrees Fahrenheit. Fire extinguishers were observed throughout the hallways. One sample was last inspected on 2/11/2025. Smoke and carbon monoxide detectors were observed throughout. LPA observed centrally stored medications, toxins, sharp objects and other dangerous items were kept locked and inaccessible to residents in care. In the kitchen area, LPA observed at least seven-day non-perishable and two-day perishable food supplies. Pantry was observed to be fully stocked with non-perishable food items. {1 of 2} Facility has one walk in refrigerator and freezer. LPA observed dried blood on the floor inside the refrigerator. LPA observed meat that had been thawed in the refrigerator without label/date opened. Advisory was provided to kitchen staff to properly label opened food items, including date it was opened. Advisory was provided to kitchen staff to ensure refrigerator floor is cleaned. Kitchen refrigerator and freezer were maintained at regulatory temperature at 40 degrees Fahrenheit and 0 degrees Fahrenheit. Menus and activity calendar were posted. LPA met with the Activity Director in the activity room at the second floor. They were preparing for the next activity scheduled. Facility has a courtyard. LPA observed shaded area and outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. Fence and gate were in good repair. Record Reviews: LPA reviewed 8 staff files, 4 care staff, 2 med techs, and 2 kitchen staff. LPA reviewed 8 resident files, 4 AL residents and 4 MC residents. Review of 8 resident files, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. LPA did not review resident medications during this visit. Records indicate that some residents utilize Omnicare Pharmacy. Medication audit was conducted by Omnicare on 11/21/2025. Review staff files included, but not limited, background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. No issues were noted at this time. Review of fire drill/disaster drill records: facility conducts monthly drills and last drill was conducted on 12/29/25. Fire inspection report dated 5/8/25 was conducted by Consumnes Fire Department. Per inspection report, facility passed. LPA did not conduct interviews during this visit due to time constraint. Documents Requested: LPA requested a copy of current Liability Insurance Certificate, LIC500, LIC308 to be emailed to arvin.villanueva@dss.ca.gov. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited. Advisories were provided. Exit interview was conducted. A copy of the report was provided upon exit. {2 of 2}the state’s words, verbatim · CDSS document, Jan 21, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

LPA Hayes returned to the facility to correct the facility visit type from a complaint visit on 11/20/25 (27-AS-202511131209410) from 1:15pm-05:15pm. The report was amended in the Sacramento South Regional Office on 11/24/25 to reflect the original visit was at this facility and not in the Regional Office. LPA Hayes retrieved the original report and replaced it with an updated 9099 and given to Sharma. Report was signed by Sharma with permission from Alyssa Sellers, Administrator.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Licensee is retaining a resident that requires a higher level of care.

On 10/2/2025, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct a follow up visit and deliver findings regarding the allegation noted above. LPA met with the Administrator/Executive Director, Alyssa Sellers (AD) and stated the purpose of the visit. The complaint alleged that the licensee was retaining a resident who required a higher level of care than the facility is licensed to provide. The investigation into this allegation consisted of interviews, and record reviews of available documentation. Through staff interviews, it was explained that residents are assessed prior to admission, then reassessed 30 days after admission, every six months, and when there is a change in condition or hospitalization. The assessments are completed by the Director of Health and Wellness (S1), who is a licensed vocational nurse (LVN) who receives ongoing training from the company’s regional nurse. {9099-1} Unsubstantiated The assessment tool helps determine whether a resident’s needs can be met by the facility or if a higher level of care, such as a Skilled Nursing Facility (SNF), is required. Interviews also revealed that S1 evaluates residents' ability to perform activities of daily living (ADLs) and provides recommendations to the Administrator, who then sends the final decision to the corporate team for review and approval. Other staff involved in assessments include the Residential Care Director and the Sales Director. A review of R1's records shows that assessments were conducted and documented. R1’s initial care assessment, completed on 8/16/22, showed that R1 required staff assistance with grooming, mobility (wheelchair use), showering, queueing with toileting, and medication management due to medical condition (M1). R1 was noted as alert and oriented, able to communicate needs, and independent in many areas of care. The medical assessment from 8/14/22 confirmed that R1 had no mental health conditions and required only minimal assistance with self-care. A later medical assessment, dated 1/16/25, continued to show that R1 did not have a cognitive impairment, remained alert, and required minimal assistance with daily activities. Though R1 was non-ambulatory, they were able to transfer independently and feed themselves. R1 also remained able to manage personal finances and medications. Progress notes showed that the facility coordinated with outside professionals, including hospital social workers, APS, and the Ombudsman, when R1’s condition changed. In January 2025, the hospital Social Worker informed the facility that R1 would be moved to a Skilled Nursing Facility. The facility, in turn, determined that R1’s condition had changed and that they could no longer meet R1's care needs, thus denying readmission. The facility also took steps by contacting APS and the Ombudsman in assisting R1 find proper placement. Based on the interviews and reviewed documentation, the preponderance of evidence is not met, therefore, the allegation is UNSUBSTANTIATED. An unsubstantiated finding means that although the allegation may have happened the preponderance of evidence does not prove it. No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report and appeal rights were provided. {9099-2}the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 27-AS-20250108170719

Allegation investigated: Staff do not prevent resident from developing multiple pressure injuries. Staff are retaining a resident who needs a higher level of care. Staff do not assist resident with obtaining medical care. Staff do not monitor resident for change in condition. Staff do not ensure that resident's incontinence needs are met. Staff do not assist resident with ambulation. Staff do not ensure that resident's showering needs are met. Staff do not ensure that resident's dietary needs are met.

On 8/22/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived at this facility to conduct a follow-up complaint visit and deliver findings regarding the allegations noted above. LPA met with Kaushik Sharma, Business Manager, and stated the purpose of the visit. Allegation: Staff do not prevent resident from developing multiple pressure injuries – The investigation into this allegation consisted of interviews and record reviews. Records show that staff were aware of R1’s risk for skin breakdown and made ongoing efforts to address it. R1’s care notes indicate that staff offered daily assistance to transfer R1 out of bed and reposition R1, but R1 frequently refused these interventions. When staff noticed an “open sore” on R1’s skin on 7/12/2024, they promptly contacted R1’s physician for further orders and notified R1’s family. Staff continued to monitor the “sore”, communicate with R1’s sibling about medical follow-up, and request home health services. {LIC9099-1} Unsubstantiated Documentation also shows that staff assessed R1’s mobility, encouraged transfers to a wheelchair, and educated R1 about the importance of repositioning to prevent further injury. Despite these efforts, R1 at times declined repositioning or participation in mobility activities. Hospice records from September 2024 confirm that nursing assessments found no pressure ulcers and that pressure injury prevention measures were reinforced. Interviews with facility staff and review of assessments demonstrate that staff followed R1’s care plan, provided incontinence care, and made timely notifications to family and healthcare providers regarding skin concerns. There is not preponderance of evidence that staff did not take reasonable steps to prevent pressure injuries; therefore, the allegation is UNSUBSTANTIATED. *************************************************************************************************************************** Allegation: Staff are retaining a resident who needs a higher level of care – The investigation into this allegation consisted of interviews and record reviews. A review of R1’s records shows that staff consistently monitored R1’s needs, communicated with family, and sought medical input when concerns arose. Care notes indicate that staff contacted R1’s physician and family regarding R1’s skin condition, offered daily assistance with transfers, and adjusted care plans in response to changes in R1’s condition. Documentation further shows that R1 was regularly assessed, including a semi-annual assessment on 8/27/24, which confirmed that R1’s care needs remained within the facility’s scope of services. When R1’s condition began to change, staff appropriately discussed the option of hospice and initiated a referral in coordination with R1, family, and the physician. Hospice services began providing additional support, and staff continued to assist R1 with meals, hygiene, repositioning, and supervision as needed. Interviews with facility staff confirmed that assessments are updated every six months or sooner if a change in condition occurs, and decisions about placement are made based on resident needs, physician input, and family involvement. Records also show that when family raised concerns about R1 needing a higher level of care, the facility offered options such as hospice and provided information on skilled nursing placement, while respecting R1’s wishes. Law enforcement also conducted a welfare check on R1 and found no concerns about neglect or improper care. Although R1’s health conditions require significant staff assistance, the evidence demonstrates that the facility continues to provide care within its licensed scope, with added support from hospice when appropriate. Therefore, the allegation is found to be UNSUBSTANTIATED. {LIC9099-2} Allegation: Staff do not assist resident with obtaining medical care – The investigation into this allegation consisted of interviews and record reviews. Records show that staff consistently monitored R1’s health condition and made multiple attempts to notify the physician and R1’s family about the “open sore” on R1’s skin. For example, on 7/12/24 staff faxed R1’s doctor requesting home health services, and on 7/13/24 staff contacted R1’s sibling after the doctor requested to examine the “sore”. Progress notes also show that staff followed up with the physician and R1’s family on several occasions throughout July and August 2024, asking R1’s sibling to schedule a doctor’s visit. On 8/28/24, the facility further assessed R1’s condition and contacted R1’s primary care provider to request a hospice referral. Hospice services were later initiated, and assessments by hospice staff confirmed that R1 was receiving appropriate care, including monitoring of skin, aspiration risk, and positioning. Interviews and assessment records also confirm that staff regularly encouraged R1 to get out of bed, reposition, and participate in activities, but R1 often refused. Staff nonetheless continued to offer assistance, followed physician orders, and communicated with R1’s responsible party and stepfather about medical needs. Documentation shows that police conducted a wellness check on 8/28/24, and R1 confirmed to officers that staff were caring for him appropriately. Therefore, while R1’s medical care was sometimes delayed due to the responsible party and family needing to coordinate doctor visits, the evidence demonstrates that facility staff made efforts to assist R1 with obtaining medical care. This complaint is determined to be UNSUBSTANTIATED. ****************************************************************************************************************** Allegation: Staff do not monitor resident for change in condition – The investigation into this allegation consisted of interviews and record reviews. A review of R1’s care notes shows that staff regularly documented R1’s health status and changes in condition. For example, on 7/12/24, staff noted an “open sore” and promptly faxed the doctor for home health orders. On multiple occasions afterward, staff followed up by contacting R1’s doctor and family members about the “sore” and documented their communications. Staff also continued to monitor and record R1’s condition, noting whether the “sore” was open, if R1 had complaints of pain, and when family had been informed. On 8/27/24 and 8/28/24, staff and supervisors assessed R1’s ability to transfer, feed themselves, and tolerate repositioning. When concerns were noted, the primary care physician was notified, and a hospice referral was requested. Documentation further shows that R1 was offered assistance with repositioning, but he sometimes refused. {LIC9099-3} Staff continued to monitor, reassess, and communicate changes to the family, physician, and administration. Additionally, hospice services were later initiated, and nursing notes confirm R1’s condition was being checked, and preventive care was reinforced. Interviews with the Administrator and Health and Wellness staff confirmed that residents are reassessed every six months and whenever there is a change of condition. Staff responsible for assessments are trained and licensed, and all assessments are reviewed by administration and corporate staff to ensure appropriate care. Records also show that police conducted a welfare check on R1 in August 2024, and R1 told officers that staff were taking care of them. Based on the review of care notes, medical records, staff interviews, and outside service documentation, there is no preponderance of evidence that staff do not monitor resident’s change in condition. Therefore, the allegation is UNSUBSTANTIATED. ********************************************************************************************************************** Allegation: Staff do not ensure that resident’s incontinence needs are met – The investigation into this allegation consisted of interviews and record reviews. Records show that staff regularly checked and changed R1, including documentation on 07/23/2024 noting that R1 was checked and changed with no complaints or pain observed. R1’s assessments and service plans also confirm that staff were responsible for providing full assistance with bowel and bladder care, including the use of a condom catheter and bed changes as needed. R1’s care notes further show that staff communicated with R1’s family and physician when concerns such as an open sore were observed, and staff requested medical follow-up and hospice evaluation to ensure R1’s health needs were addressed. Interviews with the administrator confirmed that staff consistently offered incontinence care, although R1 would at times refuse assistance. Additionally, hospice nurse notes dated September 2024 documented skin checks and reinforced pressure ulcer and incontinence care prevention, with no untreated pressure sores found. Based on the evidence gathered, there is no preponderance of evidence to support the claim that staff do not meet R1’s incontinence care needs. Therefore, the allegation is found to be UNSUBSTANTIATED. {LIC9099-4} Allegation: Staff do not assist resident with ambulation – The investigation into this allegation consisted of interviews and record reviews. Review of R1’s care notes shows that staff regularly offered assistance to R1, but R1 was often noted to refuse getting out of bed or into the wheelchair. Documentation reflects that staff monitored R1’s condition closely, communicated with R1’s family members, and sought medical support as needed when skin concerns were observed. R1’s care notes also indicate that staff attempted transfers with the assistance of two caregivers, in line with R1’s assessed needs, and that adjustments to the environment, such as bed placement, were discussed to better support safe ambulation and transfers. Facility records, including initial and semi-annual assessments, service agreements, and physician reports, consistently document that R1 required two-person assist for transfers and was non-ambulatory due to medical conditions, including paralysis from a stroke. Interviews with staff further confirmed that assistance was offered daily, though R1 sometimes declined. Per hospice care notes, hospice recommended wheelchair use during meals to prevent aspiration, reinforcing that staff were expected to support mobility to the extent possible. Based on the evidence gathered, there is no preponderance of evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED. ********************************************************************************************************************** Allegation: Staff do not ensure that resident’s showering needs are met – The investigation into this allegation consisted of interviews and record reviews. Records show that staff were responsible for assisting R1 with bathing, which included scheduled bed baths twice per week. R1’s assessments and service agreements documented that R1 required staff assistance with bathing and personal hygiene. R1’s progress notes also showed that staff regularly checked and changed R1, and offered assistance as needed. Although R1 was often noted to refuse getting out of bed or into the wheelchair, there is not enough evidence that staff did not provide care. Additionally, documentation shows staff continued to encourage R1, monitor R1’s condition, and communicate with R1’s responsible party and family members regarding R1’s health and care needs. Interviews further confirmed that staff were aware of R1’s care plan and provided assistance as outlined. Therefore, the allegation is UNSUBSTANTIATED. {LIC9099-5} Allegation: Staff do not ensure that resident’s dietary needs are met – The investigation into this allegation consisted of interviews and record reviews. A review of R1’s records, including the Physician’s Report dated 4/17/23, shows that R1 had a prescribed special diet of mechanical soft, high fiber. Facility assessments and service plans dated 8/31/22, 8/11/23, and 8/27/24 document that staff are responsible for setting up meals, providing adaptive equipment such as special plates and utensils, and assisting R1 as needed during mealtimes. R1’s care notes also show that R1 was able to feed themselves with adaptive devices but required supervision and occasional assistance when R1 became fatigued. Staff consistently offered meal assistance, and adjustments such as a blue plate that secures to the table and weighted utensils were made to support independence. Interviews and progress notes also confirmed that when R1 expressed difficulty with self-feeding, staff provided hands-on assistance to ensure R1 was able to eat safely. Additionally, hospice recommendations dated September 2024 further reinforced that R1 be positioned in the wheelchair during meals and be visually monitored to prevent aspiration. While R1 and family at times expressed concerns, the evidence shows that the facility staff provided meal support, supervision, and accommodations consistent with R1’s dietary needs and care plan. Based on information gathered, there is not enough evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED. Noted that an unsubstantiated finding means that although the allegation may have happened the preponderance of evidence does not prove it. No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report was provided. {LIC9099-6}the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 27-AS-20240828103826

Allegation investigated: Questionable death

On 8/22/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived unannounced at this facility to conduct a follow-up complaint visit regarding the allegation noted above. LPA met with Kaushik Sharma, Business Manager, and stated the purpose of the visit. The investigation into the above allegation consisted of record reviews. Through review of records, R2, a resident of this care facility, passed away on 8/13/2024 at approximately 0514 hours at a hospital Emergency Room. The death certificate lists coronary artery disease as the immediate cause of death, with hypertension as another significant condition. Other health conditions noted include urinary tract infection and sepsis, but none are indicated as the immediate cause of death. The certificate does not suggest any unusual circumstances contributing to R2’s passing. {LIC9099-1} Unfounded Through review of facility records, R2 had been at this facility for five days and had known diagnoses of acute kidney failure and hypertensive heart disease. R2’s POLST documents indicate Do Not Resuscitate (DNR) orders and a focus on comfort care. Further review of facility records from 8/8/2024 to 8/13/2024 shows that staff followed physician orders, appropriately managed medications, and provided care consistently with R2’s comfort-focused instructions. Based on the information gathered, there is no found evidence to indicate that R2’s death was the result of neglect, mismanagement, or any questionable circumstances. Therefore, the allegation is UNFOUNDED. Note that an unfounded finding means that the allegation is false, could not have happened, and/or is without a reasonable basis. Based on this investigation, no citations are issued. Exit interview was conducted and a copy of this report was provided. {LIC9099-2}the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 27-AS-20240904151144

Type of visit: Case Management - Other

On 7/1/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived at this facility unannounced to conduct a case management visit. LPA met with Executive Director/Administrator Alyssa Sellers and stated the purpose of the visit. The purpose of this visit is to follow up on the death of Resident_1(R1) occurred on 6/21/25. The Department an incident report and death report on 6/27/25. The investigation into R1’s death consisted of interviews and record reviews. Per review of the death report, the cause of death is unknown at this time. Additionally, R1 was receiving hospice care services due to Alzheimer's Disease. R1 was sent to the hospital on 6/21/25 due to shortness of breath and low oxygen saturation. According to an interview with the facility's Director of Health and Wellness (DHW), R1's family has not shared any updates about the cause of death. The DHW stated that R1 was removed from life support at the hospital, according to family member. ********************************************************************************************************************************** Also, in this visit, LPA conducted a physical walk through of common areas both in the Assisted Living side and Memory Care side for complaint # 27-AS-20250625155709. During the walk through of the Memory Care Living room, LPA observed a cleaning chemical spray bottle labeled POPCORN MACHINE CLEANER inside a cabinet, above the faucet to the left. The cabinet was observed to be unlocked and the cleaning supply was accessible to residents in care. However, the bottle was located at the very top of the shelf. Additionally, LPA observed a staff to be present providing supervision to the residents in the room. Based on this case management visit, deficiency is being cited. Exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Jul 8, 2025

(a) ...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, a cleaning sulutions was observed in an unlocked cabinet in the Memory Care Livingroom area which was made accessible to residents in care. This poses a potential health, safety and personal risks to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: Per discussion, the Executive Director/Administrator will conduct an in-service training relating to the cited regulation. Proof of training to be submitted to the Department by POC due date.

Allegation investigated: Staff are not ordering resident medications in a timely manner.

On 6/20/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived at this facility unannounced to condut a follow up complaint visit and deliver findings related to the allegation noted above. LPA met with Kaushik Sharma, Business Manager, and stated the purpose of the visit. The Administrator, Alyssa Sellers is unable to attend this visit. The investigation into the above allegation consisted of staff interviews, including the Administrator (AD) and staff (S1, S3, S4, S5), and a review of facility practices and records. During the investigation, staff confirmed that medication ordering is their priority at the facility and is conducted in a proactive manner. The AD explained that when a resident’s medication supply is low, staff make efforts to notify the resident's doctor, the responsible party, or the resident themselves if they manage their own medications. {1 of 2} Unsubstantiated The facility collaborates with pharmacies, including Omnicare, which is offered to residents at no additional charge. Omnicare typically delivers medications on time, and if the resident opts not to use this service, staff coordinate with other pharmacies. For residents who use Kaiser as their pharmacy, the AD explained that while there are occasional delays, staff take extra steps to ensure the medication is obtained, even dispatching a driver to pick it up as a last resort. However, this is only done in emergencies, such as an evacuation situation, and is not a regular service offered by the facility. Staff S1 reported that when a resident is down to a seven-day supply of medication, staff make contact to the pharmacy for refills and, if necessary, contact the prescribing physician. Staff S3 and S4 provided similar accounts, confirming that medications are ordered well in advance—often when there are 7 to 10 days remaining in a resident's supply. Staff S4 emphasized that medications are ordered as early as possible to prevent shortages and that any delays are typically due to issues on the pharmacy's end, not from staff failing to place orders on time. In cases where a pharmacy does not have a medication in stock, staff take immediate action to contact the doctor and arrange for an alternative solution. S5 further confirmed that the facility has procedures in place to reorder medications well before supplies run out. She explained that when a medication supply reaches 7 days, staff confirm whether additional medication is available, and if not, an order is promptly placed. Additionally, Staff S5 outlined the steps taken when a medication is out of stock, including notifying the resident’s doctor, the responsible party, and coordinating with pharmacies to expedite the delivery. A review of the facility’s medication ordering forms also supports the finding that the facility follows appropriate procedures. The Omnicare Refill Order Form requires staff to place orders at least five days before medication runs out, or 10 business days for Schedule II Narcotics. The facility’s own Medication Refill/New Order Roster is used less frequently but also includes clear instructions for tracking orders and deliveries. While there have been occasional delays in receiving medications from certain pharmacies, the evidence gathered from interviews and records indicates that staff follow a structured and timely process for ordering medications. Therefore, the complaint alleging that staff are not ordering resident medications in a timely manner is UNSUBSTANTIATED. An unsubstantiated finding means 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 are being cited based on today's visit. Exit interview was conducted with Kaushik Sharma (in person) and Carley Taylor (via phone) to discuss the report. A copy of this report and appeal rights were provided. {2 of 2}the state’s words, verbatim · CDSS document, Jun 20, 2025 · control 27-AS-20241223153138

Allegation investigated: Staff did not administer medication as prescribed.

On 6/20/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived at this facility unannounced to conduct a follow up complaint visit regarding the allegation noted above. LPA met with Business Manager Kaushik Sharma (S1) and stated the purpose of the visit. The Administrator/Executive Director Alyssa Sellers (AD) is not available during this visit. The investigation into the above allegation consisted of document reviews of Resident (R1)’s records, including, but not limited to, Care Notes, Medication Administration Record (MAR) from 3/6/2024 to 9/6/2024, and Controlled Drug Record. {1 of 2} Substantiated A review of R1’s care notes indicates that R1 started an antibiotic on 3/6/24, which was prescribed to be taken twice a day for 10 days. However, a review of R’1 Medication Administration Record (MAR) revealed that this antibiotic was given correctly in the PM dose from 3/10/24 to 3/19/24, completing the 10-day course in the PM. But in the AM, the medication was only administered for 9 days, missing one dose. R1 should have finished the dose in the morning of 3/20/24. Review of R1's Controlled Drug Records confirms one missing dose in the morning of 3/10/24. Additionally, R1 began another antibiotic on 5/9/24, which was prescribed to be taken twice a day for 10 days. The care notes showed that this medication was properly administered both in the AM and PM, with no issues or missed doses noted. However, another antibiotic, Nitrofurantoin (Macrobid), prescribed for 5 days, was not given as prescribed. The MAR shows that R1 only received the medication for 4 days in the AM (from 6/29/24 to 7/2/24) and 3 days in the PM, instead of the full 5-day course as directed by the prescription. Review of R1's Controlled Drug Record shows that this medication was initially given to R1 on 6/29/24 in the morning and last given on 7/2/24 in the morning. These discrepancies indicate that staff did not administer medications exactly as prescribed. The first issue was the missing AM dose in March, and the second issue occurred when the 5-day course of Nitrofurantoin was not completed as prescribed in July. Therefore, this allegation was SUBSTANTIATED. The above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099-D during this visit. LPA discussed plan of correction with the Administrator over the phone. Exit interview was conducted with Kaushik Sharma (in person) and Carley Taylor (via phone) to discuss the report and plan of correction. A copy of this report and appeal rights were provided. {2 of 2}the state’s words, verbatim · CDSS document, Jun 20, 2025 · control 27-AS-20240904151144

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 21, 2025

Incidental Medical and Dental Care (a)...The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on document review, Resident (R1) did not received their antibiotic medication as per physician's orders. This poses an immediate health, safety and personal risk to R1.the state’s words, verbatim · CDSS document, Jun 20, 2025

Plan of correction: Per discussion, the Administrator agreed to submit a letter of understanding of the cited regulation to the Department by POC due date. Additionally, per Administrator, a refresher medication training will be conducted and copy of staff training will be submitted to the Department by 6/27/25.

Allegation investigated: Staff is not properly assessing residents in care.

On 4/3/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a follow up complaint visit regarding the allegations noted above. LPA met with Administrator Alyssa Sellers (AD) and stated the purpose of this visit. The investigation into the above allegation consisted of interviews and record reviews. Through record review, it was determined that the staff at the facility, including (S2) and (S1), are responsible for assessing residents in care and fulfilling their duties as required. S2, the Transition Specialist (TS), is responsible for guiding prospective residents through the move-in process and conducting assessments as part of their role. S2 is qualified with a current 1st aid/CPR certificate and plays a role in bridging the gap between new residents and the community. S2’s involvement in assessing residents is consistent with the position, and S2 ensures that proper care plans are in place before residents transition into the facility. {1 of 2} Unsubstantiated Similarly, S1, as the Health and Wellness Director, holds a significant role in assessing residents' health and wellbeing. With a background in nursing and a current nursing license, S1 supervises personal care staff and coordinates the services provided to residents. S1’s responsibilities include performing thorough health assessments of all new residents, monitoring the health status of current residents, and participating in care conferences to discuss the ongoing needs of residents. S1’s qualifications, including CPR certification and state nursing license, manage the health and wellness of residents. In addition, S1 works closely with other staff members, including the Residential Care Director and the Sales Director, to ensure that all assessments and care plans are reviewed thoroughly and adjusted as necessary. Through interview, the assessment process involves multiple levels. S1 discussed the process involved in assessing residents. S1's role includes making recommendations based on assessments of residents' activities of daily living (ADLs). These recommendations are passed on to the administrator (AD), who further reviews the information and ensures the resident’s needs are met appropriately by the facility. After the administrator’s assessment, the recommendations are sent to corporate overseers for final approval. This multi-step approach ensures that every aspect of a resident's needs is addressed and verified. Interview also indicated that along with other staff members such as the Residential Care Director, actively assist with residents' care when needed, especially during times of staff shortages. S1 and the Residential Care Director, occasionally provide hands-on care to residents if necessary. Furthermore, S1 is responsible for assessing situations that require medical attention, such as minor injuries, and providing appropriate care. If more specialized care, such as home health or hospice services, is required, those needs are handled by external agency staff, ensuring that the resident receives the best possible care for their specific circumstances and needs. Based on the gathered information, there is no preponderance of evidence that staff are not properly assessing residents. Therefore, this allegation is UNSUBSTANTIATED. An unsubstantiated finding means 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. Exit interview was conducted with Alyssa Sellers and Carley Taylor. A copy of this report and appeal rights were provided. {2 of 2}the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 27-AS-20241223153138

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility does not report incidents to the Department in a timely manner.

On 2/5/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct the initial complaint visit regarding the allegation noted above. LPA initially met with the Director of Health and Wellness, Ashley Melendez (DHW) and stated the purpose of the visit. The Adminsitrator, Alyssa Sellers (AD) was notified and arrived shortly after. The investigation into the above allegation consisted of record review of written incident reports and staff interviews. Record reviews of the incident reports submitted to (or received by) the Department over the past six months (from August 2024 to February 2025) reveals 13 instances where written reports were submitted later than the required seven-day reporting timeframe: {con't to LIC9099-C} Substantiated - Incident for Resident_1 (R1) on 7/20/24—reported on 8/2/24 - Incident for R2 on 7/22/24—reported on 8/2/24 - Incident for R3 on 7/22/24—reported on 8/2/24 - Incident for R4 on 7/22/24—reported on 8/2/24 - Incident for R5 on 8/26/24—reported on 9/4/24 - Incident for R6 on 9/2/24—reported on 9/10/24 - Incident for R7 on 10/22/24—reported on 10/30/24 - Incident for R8 on 10/6/24—reported on 10/16/24 - Incident for R9 on 10/7/24—reported on 10/16/24 - Incident for R7 on 10/17/24—reported on 10/25/24 - Incident for R10 on 11/4/24—reported on 11/12/24 - Incident for R11 on 11/12/24—reported on 11/20/24 - Incident for R12 on 1/5/25—reported on 1/13/25 Interview with the Director of Health and Wellness (DHW), Ashley Melendez, indicated that reportable incidents include hospitalizations, injuries, and death, and that the Administrator, Alyssa Sellers (AD), determines which incidents require reporting. However, the process of incident reporting, as explained by the staff, involves multiple steps of review and approval. For example, reports are written by the DHW, reviewed by the AD and sometimes forwarded to corporate for additional review before being submitted to the Department. Interview with AD confirmed that those are not assessed as non-serious incidents, are not reported to the licensing agency. These are documented internally but not submitted as written reports to the licensing agency unless the incident is deemed significant by clinical staff. Based on the information gathered, the allegation that the facility does not report incidents to the Department in a timely manner is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Note that failure to correct deficiencies may result in civil penalties. Exit interview was conducted with Alyssa Sellers, AD and Laura Willingham, COO and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 27-AS-20250131133323

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 12, 2025

Reporting Requirement: 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)...report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement as evidenced by: Based on record review of incident reports whinin the past 6 months, 13 incidents reports were submitted to the Department past the 7 days reporting period. This poses a potential health, safety, and personal risks to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2025

Plan of correction: Per discussion, the Administrator and clinical staff will review reporting requirements. Administrator will submit a written statement of acknowledgment of the regulation cited. Submit statement by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced Case Management - Annual Continuation visit today at this facility to continue with the annual inspection initiated on 12/10/2024. LPA met with Administrator/Executive Director, Alyssa Sellers, and stated the purpose of this visit. LPA continued with facility visit to ensure facility is in compliance with Title 22 Regulations. Review of 9 resident files (R1 - R9) which include review of Admission Agreement, Medical Assessment, Needs and Services Plan, and Ambulatory Status. LPA did not conduct medication review during this visit. Review of 9 staff files (S1 - S9) which include review of background clearance, First Aid and/or CPR, Health Screen, Initial and Ongoing Training. It was noted that some staff completed their 1st aid training from Relias. At this time, LPA need to verify the validity of the training and may have to return for a case management visit. Facility conducts quarterly disaster drill. Facility has a dementia and infection control plan. Advisory was provided to update their plan of operation, if necessary, to ensure compliance with the new dementia regulation. Administrator provided the following documents during this visit: current Liability Insurance Certificate, LIC 610E, LIC500 and LIC308 to the Department. No deficiencies are being cited at this time. Exit interview was conducted and a copy of this report were provided.the state’s words, verbatim · CDSS document, Jan 9, 2025

Allegation investigated: Facility staff caused injury to resident in care.

On 12/24/2024 at 2:50pm, Licensing Program Analyst (LPA) arrived unannounced to this facility to conduct a follow up complaint visit and deliver findings regarding the allegation noted above. LPA met with the designated staff, Ashley Melendez, Director of Health and Wellness, and stated the purpose of this visit. On October 31, 2024, the facility self-reported an incident involving Resident 1 (R1) and staff member (S1). The incident occurred when R1 attempted to take a walker from another resident’s room. S1 intervened, resulting in a physical altercation during which R1 fell and sustained injuries. The facility conducted an internal investigation, deemed the fall suspicious, and notified local law enforcement, the Ombudsman, and other relevant authorities. This investigation consisted of interviews with relevant parties, reviews of relevant documents and an analysis of surveillance footage capturing the incident. {1 of 2} Substantiated Surveillance footage from October 31, 2024, revealed that R1 entered another resident’s room and took a walker. At 7:11:49 PM, S1 intervened to retrieve the walker. The video showed a physical struggle between S1 and R1, during which S1 pushed R1, causing R1 to fall backward and hit the floor. The footage contradicted initial documentation in R1’s progress notes, which alleged that R1 exhibited aggression and struck S1 prior to falling. R1’s care notes from October 31, 2024, described the incident as escalating from aggressive behavior by R1. However, this account was inconsistent with the video evidence. Interviews revealed that the facility’s internal investigation identified discrepancies between the surveillance footage and the account recorded in R1’s care notes. It was confirmed, through interview, that the video showed no evidence of R1 striking S1 and that the fall resulted from S1’s physical intervention. It was stated that S1 was terminated following the incident and that additional staff training was conducted. S1’s training records from 2023 to 2024 showed S1 received education in dementia care, de-escalation techniques, and resident safety. Training covered include managing challenging behaviors and minimizing resident-to-resident conflicts. Despite this training, S1’s actions during the incident were inappropriate and directly contributed to R1’s fall and subsequent injuries. The allegation that facility staff caused injury to a resident in care is SUBSTANTIATED. While the licensee provided adequate training to staff, S1 failed to apply the principles of de-escalation and resident safety, resulting in a preventable injury to R1. The video evidence clearly shows that S1’s physical intervention directly led to R1’s fall and injuries. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Immediate civil penalties were also assessed today in the amount of $500.00. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Exit interview was conducted and a copy of this report was provided along with appeal rights were provided. {2 of 2}the state’s words, verbatim · CDSS document, Dec 24, 2024 · control 27-AS-20241113165119

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 26, 2024

Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations. This requirement is not met as evidenced by: Based on interviews, record reviews, and analysis of video footage, staff (S1) pushed resident (R1) causing the resident to fall back and sustained injuries. This poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 24, 2024

Plan of correction: Prior to this complaint, staff member was immediately removed from the facility. Additionally, the Administrator conducted an in-service training for all staff following the incident, which included guidance on managing behaviors associated with dementia. Per discussion, the licensee will conduc ant in-service regarding elder abuse and proof of the in-service will be submitted to the Department once it is completed. Date of the proposed in-service training to be submitted by the specified POC due date.

Type of visit: Required - 1 Year

On 12/10/2024, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct their required annual visit. LPA met with Executive Director/Administrator Alyssa Sellers (ADM) and stated the purpose of the visit. This facility currently approved to retain/accept 10 hospice residents and fire cleared to retain/accept 24 bedridden residents. Note that bedrooms and non-ambulatory bedrooms are interchangeable. The LPA and ADM toured the facility to verify compliance with Title 22 regulations. The facility is a two-story building, with memory care located on the first floor. It has a capacity of 160 residents, serving both assisted living and memory care. The LPA inspected the first and second floors, activity rooms, dining room, cinema room, elevator, and resident apartments/units. Each floor is equipped with a medication room, and medications were found to be securely stored, locked, and inaccessible to residents. The resident apartments/units are spacious enough to accommodate personal furnishings, and all 4 observed units were clean, sanitary, and free of obstructions. Each observed bedroom had a smoke and carbon monoxide detector, and the memory care rooms were equipped with electronic monitoring systems installed on the ceiling to detect falls and notify staff. Memory care also has delayed egress doors. The LPA observed the kitchen area to be clean and sanitary. The facility maintains a minimum of two days’ worth of perishable food and seven days’ worth of non-perishable food. The LPA reviewed the menu and activity calendar, and the Administrator confirmed that each resident is provided with a copy of both. During the visit, kitchen staff were preparing dinner. The LPA noted a shaded area in the yard with tables and chairs, and the outdoor activity area is secure for dementia residents. The outdoor passageways, walkways, driveways, and steps were free from obstructions and hazards. The facility does not have any bodies of water. Water temperatures in 4 selected bathrooms (within resident apartments/units) were recorded between 113°F and 114°F. Room temperatures in the 4 observed resident apartments/units ranged from 69°F to 78°F. Due to time constraints, this annual visit will require a continuation visit. An exit interview was conducted with the Alyssa Sellers and , and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

Type of visit: Case Management - Incident

On 11/12/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit regarding an incident occurred on 10/31/24. LPA met with the facility's Director of Health and Wellness (DHW), Ashley Melendez, and stated the purpose of the visit. Per incident, Resident (R1) attempted to take walker from another resident's space. Staff (S1) attempted redirection, then S1 and R1 got into a "scuffle" over the walker which resulted in R1 falling. R1 was taken to the hospital and was diagnosed with the following: D1, D2, D3, and D4. Further review of the incident indicated that facility investigated the incident and found that the fall was deemed to be suspicious and that local law enforcement and Local Long-Term Care Ombudsman were notified. During an interview with DHW, it was confirmed that they reviewed the surveillance footage of the incident and determined that R1 did not hit anyone, which contradicted the information recorded in R1's Progress Notes on 10/31/24. DHW explained that R1 had taken a walker from another resident's room and walked out. S1 then took the walker from R1, leading to a "scuffle" between S1 and R1, which caused R1 to fall. Following their internal investigation, DHW reported that S1 was terminated as a result. During this visit, LPA conducted a review of the surveillance footage of the incident on 10/31/24. LPA also conducted a review of R1's physician's report and Progress Notes dated 10/31/24 to 11/1/24. During today's visit, LPA obtained relevant documents related to R1 and S1 for further review. LPA also obtained copy of the following facility file including a personnel report, the staff schedule for the week of 10/26/24 to 11/1/24, and staff contact information. Additionally, LPA recorded part of the surveillance footage from 10/31/24. Based on today's visit, further investigation is needed. Exit interview was conducted with Ashley Melendez and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 12, 2024

Type of visit: Case Management - Incident

On 8/13/24, at 2:38pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit regarding an incident report received by the Department on 6/26/24. LPA met with Alyssa Sellers, Executive Director (ED), and stated the purpose of the visit. Incident Description: On 6/20/24, a resident in care (R1) reported to the care staff that they were being abused by their friend. R1 claimed that their friend was drugging them and attempting to kill them. R1 requested assistance to call 911 and to be transported to the hospital. Actions Taken: R1 was promptly transported to the hospital for evaluation and treatment. The police were notified and conducted a visit to the facility. Adult Protective Services (APS) and the Ombudsman were also informed and initiated their investigations. Hospital Findings: A drug test conducted at the hospital indicated the presence of opiates and fentanyl. These substances were consistent with R1’s current medications prescribed per hospice orders. Follow-Up Actions: On 6/21/24, a hospice nurse conducted a follow-up visit to adjust R1’s medications. Review of R1’s medication list from 8/25/23, confirmed the use of a fentanyl patch. R1’s Needs and Services Plan dated 4/9/24, confirmed that R1 was under hospice care due to a malignant condition. Progress and Final Outcome: Progress notes from 6/21/24, to 7/26/2024, documented ongoing hospice care and medication adjustments. R1 experienced increasing confusion due to the progression of their illness. R1 passed away on 726/24, during a hospice nurse visit. {1 of 2} Summary: The incident involving R1's report of abuse was thoroughly investigated by different agencies, and subsequent medical and administrative reviews confirmed that R1's medication use was appropriate as per hospice guidelines. The progression of R1’s condition and their eventual passing were consistent with the expected outcomes of their terminal illness and hospice care. Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection. An exit interview was conducted with ED and Caryl Ridgeway, Management Company representive and a copy of this report was provided. {2 of 2}the state’s words, verbatim · CDSS document, Aug 13, 2024

Type of visit: Post Licensing

On 5/6/24, at 10:46am, Licensing Program Analyst (LPA) Arvin Villanueva, arrived to this facility unannounced to conduct their post-licensing visit. LPA met with Alyssa Sellers, current Executive Director (ED), and explained the purpose of the visit. The facility currently has an approval to retain/accept 10 hospice residents and fire cleared to retain/accept 24 bedridden residents. LPA and ED toured the facility to ensure compliance of Title 22 regulation. LPA observed the first floor, second floor, the activity room, dining room, cinema room, elevator, and random resident apartments/units. Facility has a 160-resident capacity for both assisted living and memory care residents. Currently, there are 90 residents in care, including the 17 residents living in the memory care area. Facility is a two-story building. Memory care is located on the first floor. Each floor has medication room and medications were observed to be properly stored, locked and inaccessible to residents in care. The resident apartments/units are spacious enough to accommodate the residents' furnishings. 4 of 4 resident apartments/units were observed to be clean, sanitary and free of obstruction. Each bedroom in the memory care was observed to have an electronic monitoring system installed at the ceiling to monitor resident falls. Per interview with ED, the system detects when a resident falls and notify the care staff. Memory care has delayed egress doors. LPA observed a shaded area in the yard with tables and chairs. Additionally the outdoor area for activities is secure for dementia residents. Outdoor passageways, walkways, driveways, and steps are free from obstructions and hazards. The facility does not have bodies of water. Water temperature in 2 randomly selected bathroom (in a resident apartment/units) were measured at between 105 and 120 degrees F. Room temperature in 4 random resident apartments/units were observed between 70 and 75 degrees F. During the visit, the facility staff conducted a fire drill and the alarms were found to be operable. Con't to LIC809-C LPA conducted file review of 10 resident files and 10 staff files. During resident file review, it was determined that 4 of the 10 residents were diagnosed with dementia. Further review indicated that of the 4 residents with dementia, 3 of which did not have updated physician report and needs and services plan. Per interview with ED confirmed that these required documents were not updated annually as per regulation for the care of persons with dementia. 10 of 10 staff files reviewed were in compliance with Title 22 regulation. LPA obtained a copy of their current resident roster, staff roster and staff schedule. The following deficiency was observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Failure to correct the deficiency may result in civil penalties. An exit interview was conducted with Alyssa Sellers, ED, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 6, 2024

Type of visit: Prelicensing

On 1/9/2024, at 10:30am, Licensing Program Analyst (LPA), Arvin Villanueva arrived to conduct an announced inspection to the above facility for purpose of a pre-licensing evaluation. This pre-licensing is for Change of Ownership (CHOW). LPA met with the Administrator on record, Alyssa Sellers, and explained the purpose of the visit. LPA and the facility administrator toured the facility to ensure compliance of Title 22 regulation. LPA observed the first floor, second floor, the activity room, dining room, cinema room, elevator, and 10 random resident apartments/units. Facility has a 160-resident capacity for both assisted living and memory care residents. Currently, there are 89 residents in care, including the 13 residents living in the memory care area. Facility is a two-story building. Memory care is located on the first floor. Each floor has medication room. The resident apartments/units are spacious and will easily accommodate the client's furnishings. There is a shaded area in the yard with tables and chairs. Outdoor passageways, walkways, driveways, and steps are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Currently, LPA observe facility is undergoing cosmetic renovation inside, including new paints. Although renovation is occurring, there are no obstructions of emergency exits and no sharps and toxic material laying around and being left unattended. Bedrooms Residents: LPA inspected ten (10) resident apartments/units randomly, two (2) are from the memory care area. Facility is fire cleared for 6 ambulatory residents, 130 non-ambulatory residents, and 24 for bedridden residents. It is noted in the fire safety inspection that bedridden and non-ambulatory rooms are interchangeable in this facility. The selected apartments/units inspected were observed to be furnished with adequate storage for resident belongings. {Con't to LIC809-C} {Con't from LIC809} Bathroom: Each apartment/units contain private bathroom. All bathrooms inspected have working toilets, wash basins and full baths have showers. There are grab rails next to both the toilets and the showers as well as nonskid mats in showers. LPA observed adequate lighting in hallway leading to bathrooms via nightlights. Toxins: Toxins are stored and locked at all times. Water temperature: Water temperature in a randomly selected bathroom (in a resident apartment/unit) was measured at 119 degrees F. Food Service and Kitchen: Kitchen area and dining area were inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in locked and inaccessible to residents. Food supply was adequate and stored in kitchen refrigerator and walk-in pantry and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items. Stove burners and oven observed to be in good repair. Smoke Detectors: Each of the 10 residents’ apartment/unit were observed to have a smoke detector and carbon monoxide detectors. Smoke detectors are hardwired and interconnected, and they are fully operational. Medications, First-Aid Kit & Book: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet, available for staff use but inaccessible to clients. Clients & Staff Files: Applicant will not be handling cash resources of residents. Records of staff and residents are stored in a locked room and accessible to staff. {Con't to LIC809-C} {Con't from LIC809-C} Activities: Facility employs an activity director. LPA observed a living room on the first floor with a fireplace being installed. LPA observed residents doing activities in the activity area on the second floor. Outside activity area is properly enclosed with self-closing latches and all doors have auditory devices to monitor exits. Pool/Jacuzzi & Pets: LPA did not observe bodies of water at the facility. LPA observed some residents have pets. Component III: Conducted at the Pre-Licensing visit, on 1/9/2024 at The Meadows Senior Living, information provided about how to operate the facility within substantial compliance. LPA requested copies of the following documents: LIC 308, current liability insurance, current resident roster, and current staff roster. An exit interview was conducted with Alyssa Sellers, and a copy of this report was provided. Accordingly, LPA Villanueva will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Jan 9, 2024