The Oaks at Inglewood Assisted Living

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced visit on this date. LPA met with Yanet The purpose of the visit today is follow-up on plan of correction visit from the annual inspection completed on 1/28/2026. The facility submitted required documents including an update to the plan of operations to included a dementia component. The facility will need a new fire clearance. The fire clearance will address delayed egress and other items identified from the inspection by the Fire Marshal. The department has requested that the completed and most recent Fire Marshal report be sent to the LPA by the close of business on 2/26/2026. During the visit LPA toured the facility and observed expired five year sticker and the annual sticker on the fire hydraulic system/ fire riser. The facility stated that work was completed by a local vendor but they did not provide the compliance stickers. Because there are additional repairs needed. An exit interview was conducted, and a report was left with the facility with appeal rights.the state’s words, verbatim · CDSS document, Feb 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Feb 26, 2026

87203 Fire Safety-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by observation. The facility has an expired five year sticker and the annual sticker on the fire hydraulic system/ fire riser. This is an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: The facility will provide the department with a plan to complete the needed repairs and have the annual and five year stickers update to be in compliance with the State Fire Marshal. The plan will be sent to the department by 2/26/2026.

Allegation investigated: Staff do not provided adequate food service

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for the above allegation. Allegation: Staff do not provided adequate food service. Based on records reviewed and observation on 10/09/25, 10/31/25, 11/14/25, and 12/15/25. LPA also reviewed facility’s menu. Based on record review, and observation, it was determined that facility is serving food consistent with published menu. Additionally, interviews conducted did not reveal corroborated statements of inadequate food service. As a result, there is not a preponderance of evidence to conclude that staff are not providing adequate food service to residents, therefore, this allegation is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 28, 2026 · control 27-AS-20251030115830

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection. The facility is a two story structure located in North Stockton with a capacity to serve 86 resident and a current census of 70. The grounds were observed to be maintained and clear of obstruction and debris. There is pond on the premises that was observed to be gated, locked and in compliance with Title 22 regulations. There is sufficient outdoor furniture for the residents to participate in outdoor activities and pergolas for shade. LPA and Staff inspected the physical plant at to ensure the health and safety of the clients in care. LPA inspected the facility with Staff including but not limited to the kitchen area, resident rooms, bathrooms, dining room, and storage areas. The facility had the required carbon monoxide detectors. LPA observed the facility to be free of odor and clean. LPA observed sufficient lighting throughout the facility. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA reviewed fifteen (10) client files and ten (8) staff files, including criminal record clearances. continued. During the resident file review LPA observed 3 of 10 residents with a diagnosis of Dementia. The facility is not operating in accordance with the terms specified in the plan of operation approved by the department. The facility does not have an approved plan to care for Dementia diagnosed residents. LPA observed centrally stored medications locked in then medication room. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, and interviewed both. During the inspection LPA observed unlocked toxin in the activities room under the sink accessible to the residents. All staff were cleared and associated to the facility. First aid kit was checked and is complete. Citations given. Exit interview conducted. A copy of this report was left with the Staff.the state’s words, verbatim · CDSS document, Jan 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jan 29, 2026

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: based on observation the licensee failed to secure toxins. A cabinet under the sink in the resident's activity room was left unlocked and it contained toxins. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Staff was able to remove the items during the visit. The facility will have an in-service to address the need to secure toxins and send a copy of the sign-in sheet to the department by the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87208(a)(5)(6) · Plan of correction due date: Jan 29, 2026

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (5) Staffing plan, qualifications and duties. (6) Plan for training staff, as required by Health and Safety Code sections 1569.625, 1569.626, and 1569.69 and as specified in Section 87411, Personnel Requirements–General and Section 87705, Care of Persons with Dementia.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: The facility will update the plan of operations to include care and supervison of resident with Dementia. This plan will be submitted to the department for approval. If additional time is need the facility will request additional time to complete the POC.

Allegation investigated: Staff did not ensure the facility fire alarm was not in disrepair

Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to deliver findings for the above listed allegation. After reviewing records and conducting inspections, we found that the facility promptly addressed the issue with the alarm system. The necessary repairs were completed, and after a thorough inspection, the system was cleared as safe for residents. As part of the service request, the facility was required to temporarily disable the smoke detector located in the main hall on the second floor. During this period, a safe alternative was provided to ensure continued protection for all residents until the replacement detector was installed. Unsubstantiated Documentation, including service records and invoices, confirmed that the alarm system was not in disrepair at any point. The system is maintained annually, and the most recent inspection panel displayed current fire clearance tags. As a result, there is not a preponderance of evidence to conclude that Staff did not ensure the facility fire alarm was not in disrepair, therefore this allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 27-AS-20250908122642

Type of visit: Case Management - Incident

Licensing Program Analyst Albert Johnson conducted an unannounced Case Management visit to follow up on an AWOL incident, which occurred on 09/30/25. LPA explained purpose of visit to staff. On 09/30/25 Resident 1 (R1) AWOL'd from the facility, and was observed by a staff person on lunch at the bank in the parking lot roaming, Staff escorted R1 back to the facility. No other incidents followed. R1's primary physician was notified by the facility of the AWOL. LPA reviewed R1'S file and LIC 602 (Physician's report) and R1 is not able to leave the facility unassisted. The facility did a reassessment for R1 and will be meeting with the family to decided what will be the best course of action for R1. Deficiencies were observed and cited from the California Code of Regulations, Title 22. Exit interview conducted. Appeal rights giventhe state’s words, verbatim · CDSS document, Oct 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 10, 2025

87411(a)- Personnel Requirements - General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.-This requirement is not met by interviews conducted and records review R-1 AWOL'd from the facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: The facility shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Administrator shall send the in-service training materials, plan on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended. The Administrator will email the date of the in-service training to LPA by 10/10/2025 to meet the 24 hour POC requirement.

Allegation investigated: Facility staff are billing for services not rendered.

Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to deliver findings for the above listed allegation. Based on records reviewed and interviews with the facility staff, the facility did not reassess R1 before requiring R1 to stop self administration of their medication and requiring R1 to receive medication assistance for antibiotics and other existing medications. R1 was discharged on 8/3/2025 and returned to the facility with new orders. The facility did not receive information in the discharge papers that would have changed the doctor's support of R1 taking and/or controlling their medication. The facility followed the wishes of a family member; this family member had Power of Attorney over financial not medical and therefore did not have the right to change or request to change the way medications are given or not given. SUBSTANTIATED California Code of regulations, Title 22 are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report was given Substantiatedthe state’s words, verbatim · CDSS document, Sep 30, 2025 · control 27-AS-20250825154337

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 14, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by the facility not following the doctor's orders to allow R1 to take and control the medications as identified on the physician's report and forcing R1 to surrender the medications at the wishes of family without the appropriate/required Powers of Attorney.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: The facility agrees to conduct an in-service for all staff involved in assessments to review discharge papers from all ER/hospital visits and to review the POA terms for families before honoring request. The agenda and those attending should be sent to the department by POC date 10/14/25.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct a case management visit. LPA met with and explained the purpose of the visit. The purpose of the visit was to deliver invite for an informal meeting schedule for August 14, 2025 at 10:30 am. The informal meeting will be held via Teams platform. The attendance is mandatory and additional information is provide in the letter provided today during the visit. A Health and Safety check was conducted which included overall safety of the facility including food supply, physical plant and staffing. No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conductedthe state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: POC

LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the licensing visit conducted on 5/08/2025. Deficiency cited under Title 22 Regulations has not been cleared. The facility submitted a request to appeal the citation given on 5/8/25. The appeal letter was submitted on 5/30/2025. The department didn't have a record of this appeal noted in FAS. The letter was sent by United States mail and by email to the Regional Manager of the South Sacramento ASP (Adult and Senior Program) unit. The POC visit will not be completed on this date. The department will review the situation and determine the next steps to remedy this matter. Exit interview.the state’s words, verbatim · CDSS document, Jul 8, 2025

Allegation investigated: Staff are charging resident for a higher level of care than what is received

Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to open a complaint investigation into the above listed allegation and deliver findings. Based on records reviewed and interviews conducted the facility is not following their approved plan of operation. The facility's plan of operation submitted to the department has been amended to include a new level of care description and fees. The facility has implemented this new level of care descriptions and fees without submitting to the licensing agency for approval prior to implementation. Based on records reviewed and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The facility has been cited for this violation on 5/08/2025 control number 27-AS-20250508090354. Therefore a 9099D pages will not be included in this report. The facility will include this finding into the plan of correction for the complaint dated 5/8/2025. Exit interview conducted and a copy of this report was given with appeal rights. Substantiatedthe state’s words, verbatim · CDSS document, May 15, 2025 · control 27-AS-20250513191306

Allegation investigated: Staff are charging a resident for services not received

Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to amend the finding to unfounded. The Department reviewed documents received and information obtained through interviews. It was found that residents and their responsible parties were provided a 60-day notice of a price increase and there were no significant changes to the Plan of Operation that needed to be provided to the licensing agency for approval. Based on the above, the facilities' appeal has been granted, and the deficiency will be dismissed. Unfoundedthe state’s words, verbatim · CDSS document, May 8, 2025 · control 27-AS-20250508090354

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection. The facility is a two story structure located in North Stockton with a capacity to serve 86 resident and a current census of 74. The grounds were observed to be maintained and clear of obstruction and debris. There is pond on the premises that was observed to be gated, locked and in compliance with Title 22 regulations. There is sufficient outdoor furniture for the residents to participate in outdoor activities and pergolas for shade. LPA and Staff inspected the physical plant at to ensure the health and safety of the clients in care. LPA inspected the facility with Staff including but not limited to the kitchen area, resident rooms, bathrooms, dining room, and storage areas. The facility had the required carbon monoxide detectors. LPA observed the facility to be free of odor and clean. LPA observed sufficient lighting throughout the facility. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA reviewed fifteen (15) client files and ten (10) staff files, including criminal record clearances. LPA observed centrally stored medications locked in then medication room. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, and interviewed both. All staff were cleared and associated to the facility. First aid kit was checked and is complete. No citations given. Exit interview conducted. A copy of this report was left with the Staff.the state’s words, verbatim · CDSS document, Feb 26, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst, Albert Johnson arrived on 11/26/2024 for an unannounced case management to follow up on an incident report made by the facility. On January 19, 2024, the Department concluded an investigation related to a death report for resident 1 (R1). Per facility’s Unusual Incident/Injury Report, on April 20, 2020, at approximately 7:30 a.m., facility staff answered R1’s call. R1 reported they fell and hit their head. 911 was called. R1 was admitted to the hospital with an admission diagnosis of severe sepsis, acute kidney injury, metabolic acidosis, hyponatremia, and candidiasis. On April 22, 2020, at 10:30 p.m., R1 was pronounced dead at the hospital. The death certificate listed multi organ failure, septic shock, septicemia with Escherichia coli, complicated urinary tract infection due to infected urinary cyst as immediate causes of death with congestive heart failure and atrial fibrillation as other significant conditions contributing to death but not resulting in the underlying cause of death. The licensee was cited for California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, section 87466 Observation of the Resident. On August 8, 2024, a follow up visit was conducted due to the facility not arranging medical services for R1 when they reported being in pain on six separate occasions. The licensee was cited for California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, section 87465(a)(1) Incidental Medical and Dental Care Observation. At the time of the case management visits on January 19, 2024, and on August 8, 2024, immediate civil penalties totaling $1000 were issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in death based on Health and Safety Code Section § 1569.49(e). This is evidenced by information gathered through medical records that the facility failed to properly assess the resident’s needs and develop a plan of care to meet their needs; the facility failed to get timely medical attention for resident despite their long-standing complaints of pain; resident’s medications were not all available until after 5 days post admission to facility; resident’s medications that were not provided were crucial for cardiac, pain control, and post-procedure antibiotic; facility failed to recognize resident's complaints, symptoms, and change in condition that resulted in death. Today, 11/26/2024, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $1000 was previously issued on January 19, 2024, the amount of the civil penalty issued today will be $14,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Tha Chi and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Nov 26, 2024

Type of visit: POC

LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the licensing visit conducted on 9/24/2024. Deficiency cited under Title 22 Regulations have been cleared. Administrator/Licensee complied with the terms of the POC by POC due date. Facility was provided POC cleared letter.the state’s words, verbatim · CDSS document, Oct 10, 2024

Allegation investigated: Facility staff are not properly cleaning facility kitchen

Based on observation on 6/21/2024, 8/22/2024, and records reviewed the facility is not in compliance with the regulatory requirement to maintain a clean and sanitary kitchen with storage of food, expired food, unlabeled food, bread storage area not clean and open containers observed. Based on staffing for the kitchen the facility is required to have consultation services for food services. The facility is out of compliance with this requirement. The last quarterly visit was on 8/30/2023, during the visit on 8/30/2023 the consultant identified several action items, including repeat problems and sanitation hazardous. The facility is actively looking for a Dietitians to conduct the quarterly visits to assist the facility in coming back into compliance with this requirement. (Advisory Given) Substantiatedthe state’s words, verbatim · CDSS document, Sep 24, 2024 · control 27-AS-20240620163357

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Oct 10, 2024

b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by observation and records reviewed. observation on 6/21/2024, 8/22/2024, and records reviewed the facility is not in compliance with the regulatory requirement to maintain a clean and sanitary kitchen with storage of food, expired food, unlabeled food, bread storage area not clean and open containers.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: The facility will hire a Consultant to assisted the facility as it relates to compliance with food safety and maintenance of hazardous concerns identified in the report dated 8/30/2023. The consultant will be hired by POC date 10/10/24. An advisory was given for consultant's visits which should be happening quarterly.

Type of visit: POC

LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the licensing visit conducted on 6/17/2024. Deficiency cited under Title 22 Regulations have been cleared. Administrator/Licensee complied with the terms of the POC by POC due date. Facility was provided POC cleared letter. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 22, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Maja Jensen arrived on 8/8/24 for an unannounced case management to follow up on an incident report made by the facility. LPA Jensen met with Tha Chay and explained the purpose of today’s visit. Per facility’s Unusual Incident/Injury Report, on 04/20/2020, at approximately 7:30 am, facility staff answered Resident 1’s (R1’s) call. R1 reported she fell and hit her head. 911 was called. The Department conducted an investigation which consisted of a review of medical records and facility records. Records indicate that R1 was admitted to the facility on March 6, 2020. Between the dates of 3/11/2020 and 4/16/2020, facility notes document that R1 complained of pain 6 times on 5 different dates and facility did not seek medical attention for any of these 6 incidents. On 4/20/24 R1 was sent to the hospital due to a fall during which she hit her head, she was admitted to the hospital and diagnosed with severe sepsis, acute kidney injury, metabolic acidosis, hyponatremia and candidiasis. On 04/22/2020 R1 was pronounced dead at the hospital. The death certificate listed multi organ failure, septic shock, septicemia with Escherichia coli, complicated urinary tract infection due to infected urinary cyst as immediate causes of death with congestive heart failure and atrial fibrillation as other significant conditions contributing to death but not resulting in the underlying cause of death. Based on the review of the medical records, and other miscellaneous documents the investigation shows that despite R1’s repeated complaints of pain, the facility did not contact R1’s physician or seek medical treatment which lead to death from septic shock, septicemia with Escherichia coli, and an infected urinary cyst. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 8, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 9, 2024

Incidental Medical and Dental Care The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not as evidenced by: Based on review of facility records, R1 complained of pain on 6 separate occasions with no attempt by facility staff to obtain medical care appropriate to R1’s condition. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: The Administrator agrees to send an attestation declaring they have read, understood and will comply with CCR 87465 by 8/9/24.

Type of visit: Case Management - Incident

On 6/17/2024, Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management visit today at the facility. LPA was following -up on an incident dated 6/11/2024 for a fall with a fracture. During visit LPA Johnson reviewed records for R1, interviewed the Resident Services Coordinator about events related to R1's service needs. The records reviewed included transmittals to R1's primary care physician (PCP). The records indicated that R1 had an incident on 5/28/2024, R1 stated to staff that " I ran into a wall". R1 was complaining about left arm pain. R1 was given a PRN medication (Tramadol). R1's information was sent to the PCP on that same day 5/28/2024 and the PCP ordered the facility to get a X-ray of the left arm. On 6/4/2024, the facility received notification from the responsible party(RP) for the resident. The RP refused to follow PCP orders to have left arm X-rayed. (RP Stated "not necessary.") On 6/11/2024, R1 had a fall, called 911 themselves, R1 was complaining about left arm pain, R1 was taken by AMR to the ER and was treated for a fracture of the hip. Deficiencies were cited during this visit. The Department will review the information and will return at a later date if a civil penalty is warranted. Exit interview held.the state’s words, verbatim · CDSS document, Jun 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(6) · Plan of correction due date: Jun 18, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by The facility not following the doctors orders and not taking R1 to have a X-ray on the left arm at the request of the PCP.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee to ensure all staff are up to date and are knowledgeable of the latest PINs and regulations.

Type of visit: Case Management - Incident

On 4/18/2024, Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident that occurred on 4/14/2024. LPA reviewed special incident report dated 4/14/2024 stating R1 had an unwitnessed fall and as a result sustained a head injury requiring two staples. R1 has a history of falls and the facility has taken precautions to minimize R1 from falling. R1 has a current service plan that addresses the fall risk with home health services to assist with balance and ambulation. R1 moved in with a walker and is legally blind. During today's visit, LPA reviewed R1's file, medical records related to the fall and service plans dated 2/28/2023, 3/15/2023, 8/30/2023 and 3/19/2024. The facility appears to be exercising best practices with R1's service needs as it pertains to the fall risk mitigation. The department has requested by the close of business on 4/19/2024, an updated LIC 500 with actual times that the Administrator is on-site. Exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 18, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection on today's date of 2/16/2024. The LPA met with Tha Chay The facility is a two story structure located in North Stockton with a capacity to serve 86 resident and a current census of 76. The grounds were observed to be maintained and clear of obstruction and debris. There is pond on the premises that was observed to be gated, locked and in compliance with Title 22 regulations. There is sufficient outdoor furniture for the residents to participate in outdoor activities and pergolas for shade. LPA and Staff inspected the physical plant at to ensure the health and safety of the clients in care. LPA inspected the facility with Staff including but not limited to the kitchen area, resident rooms, bathrooms, dining room, and storage areas. The facility had the required carbon monoxide detectors. LPA observed the facility to be free of odor and clean. LPA observed sufficient lighting throughout the facility. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA reviewed fifteen (15) client files and ten (10) staff files, including criminal record clearances. LPA observed centrally stored medications locked in then medication room. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, and interviewed both. All staff were cleared and associated to the facility. First aid kit was checked and is complete. No citations given. Exit interview conducted. A copy of this report was left with the Staff.the state’s words, verbatim · CDSS document, Feb 16, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Maja Jensen arrived on 1/19/24 for an unannounced case management to follow up on an incident report made by the facility. LPA Jensen met with Tha Chay and explained the purpose of today’s visit. Per facility’s Unusual Incident/Injury Report, on 04/20/2020, at approximately 7:30 am, facility staff answered Resident 1’s (R1’s) call. R1 reported she fell and hit her head. 911 was called. The Department conducted an investigation which consisted of a review of medical records and facility records. Records indicate that R1 was admitted to the facility on March 6, 2020. Facility notes document the following occurrences: -R1 had an appointment scheduled to remove a stent but this was postponed until May of 2020. -On 3/11/2020, R1 complained of pain in her back and no medical attention was sought. -On 3/14/2020, R1 complained of stomach pain and no medical attention was sought. -On 4/3/2020, R1 complained of stomach pain and no medical attention was sought. -On 4/4/2020, R1’s daughter was called. R1’s daughter stated she was aware of the stomach pains due to kidney stones. Staff suggested to increase fluids. -On 4/15/2020, R1 complained of stomach pain and no medical attention was sought. -On 4/16/2020 at 12pm and 6pm R1 complained of stomach pain and no medical attention was sought. -On 4/18/2020 Staff called daughter of R1 and informed her of the constant stomach pain. R1’s daughter stated she will try to schedule an appointment for Monday (4/20/2020). -On 4/20/20 R1 was admitted to the hospital with an admission diagnosis of severe sepsis, acute kidney injury, metabolic acidosis, hyponatremia and candidiasis. Continued on LIC 809C.... On 04/22/2020 10:30 pm R1 was pronounced dead at the hospital. The death certificate listed multi organ failure, septic shock, septicemia with Escherichia coli, complicated urinary tract infection due to infected urinary cyst as immediate causes of death with congestive heart failure and atrial fibrillation as other significant conditions contributing to death but not resulting in the underlying cause of death. Based on the review of the medical records, and other miscellaneous documents, the facility delayed medical assistance and that resulted in a hospitalization leading to death from septic shock, septicemia with Escherichia coli, complicated urinary tract infection due to infected urinary cyst. In addition, the facility did not recognize R1’s change in condition. Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. The Department is also reviewing additional civil penalties which may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted. A copy of this report, appeal rights and a confidential names list (LIC 811) was given to Tha Chay.the state’s words, verbatim · CDSS document, Jan 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jan 20, 2024

Incidental Medical and Dental Care The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement was not met as evidenced by the facility notes and medical records which show medical assistance as delayed to R1. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 19, 2024

Plan of correction: The Licensee or Administrator agrees to email facility policies for calling 9-1-1 and changes in condition to maja.jensen@dss.ca.gov within 24 hours. The Administrator further agrees to conduct in-service training on 1-25-24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87466 · Plan of correction due date: Jan 20, 2024

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes ...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician....This requirement was not met as evidenced by: A review of medical records and facility notes showing R1's complaints of pain were not brought to the attention of R1's physician or responsible party on multiple occasions. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 19, 2024

Plan of correction: The Licensee or Administrator agrees to email facility policies for calling 9-1-1 and changes in condition to maja.jensen@dss.ca.gov within 24 hours. The Administrator further agrees to conduct in-service training on 1-25-24.