The Oaks at Nipomo

Type of visit: POC

Licensing Program Analyst (LPA) Rankin conducted an unannounced Plan of Correction (POC) visit to the facility above. LPA met with Megan Drap, Executive Director, and explained the purpose of the visit. On 8/26/26 LPA, during a Case Management – Deficiencies visit cited the facility for Title 22 Regulation 87555 (b)(28)All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. During today’s visit LPA toured full kitchen area to ensure areas noted in the prior visit were cleaned, and food storage procedures were being addressed and complied with. LPA observed the following in the kitchen food preparation areas, areas were clean, although it was during breakfast so there was active preparation and plating being done. Bread and food items in this area were covered and closed as required. Fruits and vegetables such as bananas, pineapples, and onions were noted to be fresh, no concerns of any insects. LPA observed the following in the dry storage area, all packages were either sealed or placed in Ziplock bags, all items in containers or Ziplock bags were dated with current dates. No ripped or open boxes or packages were observed. No expired items were observed, flooring with prior stains had been addressed and stains had been removed. Floor beneath the shelves was clear or spills and debris. LPA observed the following in the walk-in refrigerator/freezer area, all items appeared fresh, no expired items found, all packages and/ or containers had tight fitted saran wrap or lids, flooring was free of debris, a few spills were noted under the ice-cream tub in the freezer, but all other food found before was removed. LPA requested better cleaning on and around the freezer door which was done during LPA’s visit. Deficiency Citations Cleared, copy of report was discussed, signed and will be emailed to the facility.the state’s words, verbatim · CDSS document, Sep 17, 2026

Allegation investigated: Staff do not ensure the facility is clean and sanitary

Licensing Program Analyst (LPA) Melisa Rankin conducted an initial 10-day complaint visit to the facility above. LPA met with Designee signer Theresa Egurrola, and explained the purpose of the visit. During the visit LPA toured the kitchen, bistro, and dining area. Took images of all areas observed and collected relevant documents. LPA also re-toured the kitchen area with the designee and the Culinary Director to provide notes regarding areas of concern. Allegation: Staff do not ensure the facility is clean and sanitary It was alleged that the kitchen is not being cleaned, that items of food and food debris were on the floor of the freezer and walk-in refrigerator, as well as the dining room carpet is heavily soiled and stained and food articles are under the dining room tables. Continue on 9099-C Substantiated On 8/18/26 LPA was provided images of areas of concern which show a package of closed Hawaiian Rolls, blackened bananas and food particle crumbs on the freezer floor, as well as liquid spills and a yogurt container on the floor of the dry storage area, and food items on a carpeted area that appears to be under a dining table. On 8/26/26 at approximately 8:15 a.m. LPA entered the kitchen, stopped in the prepping area where there is a sink, counter space, and shelves. On the bottom shelf were 2 plastic bins with onions. Upon inspection, LPA found 18 yellow onions with approximately 8 of them starting to rot, they were splitting open, mushy, and when moved, 2 small insects flew out from the bin. The second bin of purple onions appeared to be fine. Images of the onions and video of the flies were taken. LPA then went into the walk-in refrigerator and freezer area at approximately 8:26 a.m. and found the following: In the freezer area, under the shelves in the far-left corner there was still the package of Hawaiian Rolls, and behind that the black bananas, proof that they had been there since the original images from 8/18/26. On the floor was spilled ice cream about 6 inches in diameter below 4 tubs of ice cream. Also noted were the freezer door and hinges, observed from the refrigerator section that leads into the walk-in freezer was uncleaned, areas of white and black particles were observed. LPA observed the dining room at 1:55 p.m. and found many areas, some spotted, some larger in diameter where prior spills had occurred and a stain had remained. A few areas had crumbs, but it was also following lunch and the kitchen staff were cleaning, no unreasonable amount of debris were on the dining room floor during time of visit. Continue to 9099-C On 7/10/26 during the annual visit LPA cited the facility for the cleanliness of the kitchen, as well as the observation of a insects when food had not been properly disposed of. Other areas of concern regarding food storage management is being addressed on a Case Management. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). A civil penalty for a repeat violation for $250 is being assessed. Based on observation, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Copy of report and appeal rights printed and provided to facility. Note the pre-populated information on this form have a prior administrator's name from the Community Care Licensing Software system in error and cannot be updated during this visit.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 29-AS-20260821134127

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Sep 18, 2026

87555 General Food Service Requirements (b) (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when they failed to clean the freezer remove food items that attracted insects, left food items on the freezer floor for 8 plus days, not regularly clean and wipe down areas inside of walk-in refrigerated areas, which poses a potential health and safety risk violation to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: Facility will clean all surfaces, especially in walk-in refrigerator/freezers. LPA will return to view kitchen area to clear citation. LPA will give the facility 7 days from today before conducting the citation clearance visit specific to the culinary department.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced Case Management Deficiency visit in conjunction with complaint visit ( # 29-AS-20260821134127). LPA met with facility Designee, Theresa Egurrola. The purpose of this report is to issue a citation for deficiencies observed during the complaint investigation which were not related to the complaint allegations. On 8/26/26 at approximately 8:15 a.m. LPA entered the kitchen, stopped in the prepping area where there is a sink, counter space, and shelves. On the bottom shelf were 2 plastic bins with onions. Upon inspection, LPA found 18 yellow onions with approximately 8 of them starting to rot, they were splitting open, mushy, and when moved, 2 small bugs flew out from the bin. The second bin of purple onions appeared to be fine. Images of the onions and flies were taken. The observation noted above is also on the complaint report, but relevant to this case management visit. LPA then went into the walk-in refrigerator and freezer area at approximately 8:26 a.m. and found the following: In the refrigerator there was thawed shrimp in a metal container with saran wrap over it, the date stated “7-30”, when tipped there was a foggy grey liquid in the bottom of the container. A broken plastic container dated “7-30” with black bean humus, unknown how long the container has been broken and food item has been exposed. Green leaf items, believed to be cilantro were in a sealed bag, but the produce has started to turn brown and yellow in some areas. In the freezer area, LPA also observed 3 open/unsealed/uncovered packages, the items were breaded chicken strips, what appeared to be spring rolls, and breaded mozzarella sticks. Continue on 809-C At approximately 8:40 a.m. LPA walked into the kitchen area near the drink dispenser and where packages of bread is stored. LPA found unsealed/open packages of hot dog and hamburger buns. The last time these items would have been an option for the menu would have been during the dinner meal on 8/25/26. It is probable that the items have been open for at minimum 12 hours based on mealtimes from the evening before and the morning time they were observed. At approximately 8:42 a.m. LPA went into the dry storage and found another package of hot dog buns opened, and by touch through the packaging, there were buns that were starting to stiffen. LPA also found a box of rice, and penne pasta, opened and unsealed. On 11/25/26 a complaint regarding expired and opened packages was completed and the facility was cited, similar issue, but different regulation was cited on 7/10/26 during the annual review. Based on the Repeat Violation from the 11/25/26 citation and the concern of contamination of spoiled onions, and expired shrimp this civil penalty for a repeat violation for $250 is assessed. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). A copy of the report and appeal rights was printed and left for the facility. Note the pre-populated information on this form have a prior administrator's name from the Community Care Licensing Software system in error and cannot be updated during this visit.the state’s words, verbatim · CDSS document, Aug 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(28) · Plan of correction due date: Sep 18, 2026

General Food Service Requirements 87555 (b)(28)All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when they failed to properly store, and dispose of food in the kitchen area, leaving packages opened, and rotting or expired items in refrigerated areas, which poses a potential health and safety risk violation to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: Facility will clean all surfaces, especially in walk-in refrigerator/freezers. LPA will return to view kitchen area to clear citation. LPA will give the facility 7 days from today before conducting the citation clearance visit specific to the culinary department.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced case management visit at 8:58 a.m. LPA was also conducting investigations for complaint numbers #29-AS-20260805124058 and #29-AS-20260801171938. The reason for the Case Management visit is to investigate a concern reported to the LPA during the complaint interviews as well as to follow up on a self-reported incident received on 08/03/2026. During this investigation LPA conducted file reviews, reviewed Medication Administration Records (MAR) and Centrally Stored Medication and Destruction Records (CSMDR), and obtained copies of these documents. LPA conducted interviews, and documents collected verified the events occurred. Interview with staff, and Memory Care Director were done on 8/6/26 during visit for the 2 complaints. Additional interviews were conducted during today’s visit. The self-report pertains to a medication error regarding Resident 1 (R1). The report was documented on a LIC 624 Unusual Incident/Injury Report form. Report stated that R1 was "given 10 daily doses out of 14 of Adelondrate 70mg weekly dose." Upon review of records, LPA discovered 7/14/26 to 7/25/26 R1 received the medication almost daily, the exception being 7/18/26 and 7/24/26. The medication is ordered to be given "1 TABLET BY MOUTH WEEKLY...". Interviews on 8/6/26 state that the medication error was a combination of the MAR not being properly approved in the system to prompt the medication to only show up 1 time a week, and the additional error was based on Medication Technicians not re-checking the label prior to giving the medication each day. Continue on 809-C The second report alleged that Resident 2 (R2) ran out of the medication Creon and did not receive a replacement refill for 6 days. During the 6 days Resident 3 (R3) allowed their medication to be used for R2 until the refill was obtained. Interviews were conducted, copies of the MAR and CSMDR were collected. The reports show the medication reported was started on 6/1/26 and was last given 6/18/26. It shows that the new prescription of Creon was started 6/25/26. The facility changed pharmacies, it was expected that the medication would arrive on cycle refill on 6/19/26, the facility was asked to provide documentation of when they reached out to the pharmacy when it did not arrive on cycle, the facility provided documentation of requests to obtain refills from the pharmacy starting on 6/22/26. LPA did a count of the days the medication should have covered for the resident, based on 200 pills, where 6 pills are used per day, the medication that was started 6/25/26 should have ran out on or around 7/28/26. It is unclear how the resident had enough pills to last through to 8/1/26. The resident ran out of Creon again on/or around the first part of August. Interview from R3 stated it was 8/3/26 and 8/4/26 where again R2 needed to use medication from R3’s supply. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit Interview conducted, copy of appeal rights and report were printed.the state’s words, verbatim · CDSS document, Aug 12, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 14, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical...care shall be developed by each facility. The plan shall encourage routine medical... 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 interview and record review, the licensee did not comply with the section cited above as Resident #1 (R1) received dosses of a medication ordered as 1 time weekly, but was given daily and Resident #2 (R2) was administered Resident 3’s (R3)’s medications for 6 plus days. This posed an immediate health and safety risk to people in care.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: Administrator, Residential Service and Memory Care Directors have addressed the issues with R1, write ups done following the discovery and training was completed. Pro-actively processes including obtaining refill approvals earlier have been started and a call with the pharmacy regarding the issue for R2's delay in medication is being disussed on 8/13/26 and a summary of the plan moving forward will be provided to the LPA by the moring of 8/14/26.

Allegation investigated: Facility has insufficient staff to meet the food service needs of the residents

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Ron Freeman Administrator and explained the purpose of the visit. During the initial visit on 04/07/26 LPA Rankin interviewed administrator, culinary director, residents, and reviewed and collected copies of records. During the investigation, LPA Rankin conducted interviews with residents and staff, reviewed and collected relevant documentation, including menus, and meeting minutes for resident council. LPA also attended a Resident Council meeting on 7/21/26. Continued 9099-C Substantiated On the allegation: Facility has insufficient staff to meet the food service needs of the residents It was alleged that the facility has residents reporting unacceptable wait times for service in the dining room, including 20–30 minutes to receive food after waiting 10 minutes or more before orders are taken. This concern had previously been reported to facility management during complaint #29-AS-20251119115422. It was also alleged that on 03/21/26 and 03/22/26 there was no designated dishwasher staff, resulting in dirty dishes stacking up and requiring the use of paper plates. On 7/8/26 during annual visit, LPA was made aware of a complete staff turnover. During the investigation, LPA reviewed resident council meeting minutes dated 2/18/25 through 6/17/26. Minutes consistently documented recurring concerns including wait times, temperature of food, service delays and times where there was only one server. Administrator responses to the council include the following: • On 8/19/25: “We are aware of this issue, and we are working on new solutions. Our prior work to address this issue has not been successful...” • On 10/21/25: “We are struggling getting orders taken and food out in a timely manner that meets our resident's expectations. This is not a new issue, and we are disappointed we have been unable to solve this issue at this time. …working on a multi-prong strategy to make improvements. We also have some changes coming to the culinary program that will probably make this even more of a challenge…So, we will continue to work on improving our service and our service times.” • On 1/22/26: stated concerns were being addressed through expectation clarification and training with culinary staff... Resident interviews and review of resident council minutes confirmed that residents used the facility’s grievance processes, which include using suggestion boxes, discussing concerns with team members (i.e. Culinary Director during “Food for Thought” meetings), discussing concerns with the Executive Director/Administrator, and raising concerns at resident council meetings. Process also notes the option to refer concerns to the state Ombudsman or the local state agency. Continued 9099-C Page 2 Evidence of change, improvement, or actionable responses was not observed. Residents have repeated similar concerns for at least the past year. The facility has a procedure for addressing resident grievances but these avenues have been unsuccessful. During Resident Council meeting on 7/21/26 LPA Rankin attended there were approximately 29 residents in attendance, the issue of staffing, items being out of stock, wait times, bistro are not being maintained were all re-discussed. During prior complaint #29-AS-20251119115422 dated 11/25/25, LPA observed similar concerns. During that investigation, Administrator and Culinary Director stated the facility was actively working to improve communication, refine procedures, and streamline meal service operations. Continued complaints documented in resident council minutes following the complaint and recent interviews demonstrate that these issues have persisted. During the annual inspection beginning 7/8/26, LPA learned that the Culinary Director resigned on 4/29/26 with a final day in community of 5/6/26 and a new Culinary Director began on 6/2/26, a cook was terminated on 6/15/26, and an additional 5 culinary staff resigned on 6/16/26. Following these separations the remaining 4 culinary staff resigned or were terminated over a period of 2-3 weeks, one due to personal reasons. The new Culinary Director then submitted resignation effective 7/16/26, but did not return to complete scheduled shifts. Staff schedules and interviews confirmed that this series of departures resulted in culinary leadership and key kitchen staff positions becoming vacant. As a result, non-culinary staff such as Directors, the Administrator, Care Staff, Med Technicians, and the Maintenance Director have been regularly covering kitchen duties, and the facility required temporary culinary support from other Licensee operated facilities. In addition to the long-standing concerns regarding meal service delays, the significant breakdown in culinary staffing over the span of approximately two months further supports the allegations of this complaint. During annual staff file review, LPA examined the records for the prior Culinary Director. A “Pathway to Success Plan” document dated 4/15/26 indicated the Culinary Director was going to be monitored due to performance concerns which noted areas regarding leadership, kitchen sanitation and cleanliness, food preparation, menus, resident satisfaction, and team member performance. LPA was informed that the Culinary Director resigned within weeks of this meeting. The cumulative impact of these staffing losses further affected the facility’s ability to meet Title 22 requirements. Continued 9099-C Page 3 Title 22, Section 87555(b)(18), requires facilities to employ, train, and schedule sufficient food service personnel to meet resident needs. The previous complaint findings documented the delays were related to training and process inefficiencies and advised reassessment of staffing patterns and operational processes. Current observations, interviews, and record review demonstrate that the facility did not implement adequate corrective action. The absence of dishwashing staff on 03/21/26 and 03/22/26 and the ultimate separation of 11 staff further demonstrate breakdowns in scheduling and staffing management. Based on interviews, observations, and record review, there is a preponderance of evidence that the facility has not employed, trained, or scheduled sufficient food service personnel to meet resident needs as required by Title 22. Therefore, the allegation is SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. Continued 9099-C Page 4 This issue was previously investigated under complaint #29-AS-20251119115422 in November 2025. During the prior complaint, LPA reviewed posted menus as well as revised “as served” menus, interviewed residents and staff, and discussed the facility’s menu planning system. The facility utilizes a software program called Grove, which is designed to ensure menus meet regulatory nutritional standards and provides structured guidance for menu planning and substitutions. During the current complaint, LPA interviewed residents on 4/7/26, and during annual visit on 7/8/26 who stated that there have been times when items are not replenished, such as bacon, certain fruits, etc. and that a recent holiday event was advertised to have a specialized menu, but ended up offering BLT sandwiches and one specialized item. Other than the holiday event menu, when asked about menu concerns and changes, those interviewed did not have issue with the changes and stated that it is occasional. LPA also reviewed resident council minutes from 2/18/25 to 6/16/26 there was new comments regarding requesting more variety in dinners and deserts and more replacement items being stocked in the bistro. During annual visit on 7/8/26, LPA was informed by residents and staff that the culinary department experienced significant staffing changes within the last two months, including the resignation of the Culinary Director, the hiring and subsequent resignation of a new Culinary Director, the termination of a cook, and the resignation of additional culinary staff. Through interviews and review of documentation, LPA found that Directors and the Administrator have been filling in for cooks and servers to assist with meal service. Title 22 regulations do not prohibit substitutions, provided menus are planned in advance, maintained on file, and overseen by qualified personnel. Menus posted and menus maintained on file met regulatory requirements. While residents reported occasional substitutions or uncertainty about meals until arriving in the dining room, the investigation found substitutions to be infrequent and within required nutritional standards. Based on review of records, resident interviews, menu documentation, and regulatory requirements, the facility is in compliance with Title 22 regulations regarding menu planning and nutritional offerings. Therefore, this allegation is UNSUBSTANTIATED at this time. Report discussed, and reports printed.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 29-AS-20260402125617

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(18) · Plan of correction due date: Aug 7, 2026

87555 (b)(18) General Food Service Requirements (b)The following food service requirements shall apply: (18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement is not met as evidenced by: Based on interviews, observations, and record review, the licensee did not comply with the section above when staff were unable to meet residents’ needs, as evidenced by staff interviews, resident council feedback, and two prior citations related to kitchen operations. Additionally, 11 culinary staff members either resigned or were terminated within a 60 day period. These conditions posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: Facility has hired a new Culinary Director as of 7/21/26, the Regional Culinary Director will provide training. Facility has filled 7 culinary positions as of today. They are in the process of filling the remaining cook, server, and dishwasher positions to cover scheduled shifts. Facility will provide LPA with Culinary Director Onboarding Outline and updated culinary staff roster by 8/7/26.

Allegation investigated: Illegal Eviction

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Ron Freeman, Administrator and explained the purpose of the visit. During the initial visit on 04/01/26 LPA Rankin interviewed administrator, staff, and reviewed and collected copies of records. During the investigation LPA Rankin interviewed and reviewed documents from LPA Haner Tomasko and interviewed relevant witnesses. On the allegation: Illegal Eviction It is alleged that the administrator told a family member they needed to pick up Resident 1 (R1) or the facility would call the police due to the resident’s behaviors, and that R1 could not return to the facility until the behaviors were addressed. Continued on 9099-C Substantiated Based on facility records, submitted incident reports, and interviews, on 2/20/26 at approximately 10:45 am R1 placed a belt around their neck, which staff believed created a serious concern for self-harm. Staff attempted to assist R1 to remove the belt but R1 “became aggressive and combative.” Staff called 911 but emergency medical services refused to transport R1. Interviews and incident report revealed R1 removed the belt from their neck on their own prior to emergency responders arriving. Based on facility documentation dated 2/20/26 at 4:52 pm; it was documented that R1’s family was informed they needed to pick up R1, and that R1 could come back “once [they are] properly medicated to manage [their] aggressive tendencies and any suicidal ideations.” In this same note was an update made by the administrator on 2/24/26 at 11:12 a.m. which states “…informed [family] that [they] needed to pick up [R1] and get [R1] to a physician…” and that “if [family] cannot get [R1] to a physician we would call the Sheriff for assistance…”. Facility records included a “Medication Release (For Home Visits, Outings, and Other Reasons)” dated and signed by a Medication Technician and the family on 2/20/26. The form listed R1’s medications and the quantities released, which appear to constitute a full medication release. The quantities documented were “30 caplets, 88 caplets, 44 caps, 59 caps.” On 2/23/26, prior to 4:00 p.m., Community Care Licensing (CCL) was informed about the facility’s statements that R1 could not return until certain conditions were met. At approximately 4:04 p.m., LPA Haner-Tomasko contacted the administrator, who confirmed the incidents described above and reported that 911 EMS was contacted but would not transport R1. During this call the administrator also confirmed to LPA Haner-Tomasko that they contacted R1’s family to take R1 to be seen by a physician due to a change in condition. It is against the facilities policy to transfer residents themselves for emergency services. LPA Haner-Tomasko documented that neither law enforcement nor the local crisis unit were contacted. The administrator was informed by CCL it was an illegal eviction to refuse to let R1 back into the facility. The administrator stated they would only let R1 return to the facility with 1:1 supervision. CCL explained increases in level of care could be discussed through the proper procedures, but the facility needed to allow R1 back into their home. Administrator indicated he understood. Continued on 9099-C pg 2 On 2/23/26 at 4:25pm note made by Memory Care Director “received a letter from resident neurologist…stating ‘[R1] has not expressed any suicidal ideations over the weekend…[their] cognitive status is baseline’.” Note goes on to further state the director contacted the family and “informed [family] that [R1] is able to return to community. We are requiring 1:1 24/7 companion…” Copy of the neurologist note dated 2/23/26 was provided to CCL. On 2/24/26, CCL, Long Term Care Ombudsman (LTCO), and the administrator discussed the incidents. CCL reminded the administrator of the eviction regulations and requested the resident be allowed to return. During this discussion, the administrator acknowledged that no unusual incident report had been submitted or called in, and no written eviction notice was provided to the family. CCL confirmed the administrator had not reached R1’s family to explain they could return to the facility without a 1:1, per the previous day’s conversation with CCL. Administrator stated they were hesitant for R1 to come back to the facility, citing safety concerns. However, CCL was informed R1’s family had obtained a physician’s note indicating R1 was not suicidal and did not pose a risk. CCL confirmed again that requiring R1’s family to pick them up at night with no notice was considered an illegal eviction, as was refusing to let R1 back into the facility. Administrator was again reminded after R1 was brought back to the facility, the facility was within their rights to obtain updated physician’s reports and conduct reappraisals of R1 to determine if an increased level of care or 1:1 supervision was needed. Administrator was reminded that proper justifications for care increases are required per regulation, and no documentation had been provided. Administrator was reminded in the meantime; they are responsible to ensure proper care and supervision is provided to all residents. Administrator agreed to let R1 back in the facility without a 1:1 caregiver. At approximately 2:30 p.m. on 2/24/26, CCL confirmed R1 returned to the facility without 1:1 care in place. During interviews with LPA Rankin on 2/26/26 and 4/1/26, the administrator stated they told the family that R1 needed to go to a doctor and asked the family to pick R1 up, and that they would call the sheriff if the resident could not be calmed or appropriate assistance could not be obtained. The administrator stated this was not a threat, but rather an explanation of possible next steps. The administrator reported the goal was to obtain medical intervention to address R1’s extreme behaviors. Per administrator's understanding the sheriff's department is the local resource to assist with suicidal ideations. Continue 9099-C pg 3. Documentation and interviews confirm that the facility requested that a resident’s family pick up the resident and informed them the resident could not return until certain concerns were addressed. While the facility’s actions were improper, the issue of illegal eviction was addressed on the substantiated report. The reporting party also noted a prior eviction, stating it was an illegal eviction in early 2025, which CCL determined not to be an illegal eviction during a prior complaint investigation. The alleged improper fee increase was tied to the facility’s attempt to implement 1:1 care. This was discussed between the administrator and CCL on 2/23/26, and the Administrator was reminded that the facility cannot require 1:1 care without first completing a revised care plan and re-assessment. The facility was also reminded that it must accept the resident back and provide all required care and supervision pursuant to the needs identified through assessment. The admission agreement does reference the possibility of additional fees based on increased care needs; however, proper notification, assessment, and documentation must occur prior to charging additional fees. While the facility may ultimately implement and bill for 1:1 care if justified, the necessary procedural steps were not followed. The facility did follow CCL instructions and did not implement 1:1 care requirements or additional fees. CCL also reviewed the facility’s prior citation related to an inaccurate incident report regarding a resident elopement. This previous violation does indicate a need for improved administrative oversight and reporting accuracy. However, because it was previously cited under reporting requirements, it does not independently demonstrate a failure to meet administrative qualifications for the current allegation. The allegations further assert that the Administrator required at least three residents to wear Wanderguard devices despite their objections and despite the devices causing resident distress. CCL is aware of one confirmed case in which the facility relied on inconsistent information in the Physician’s Report (LIC 602A), despite repeated requests from the resident and their responsible party to have the device removed. Concerns regarding assessment accuracy and resident rights were discussed with the Administrator. Continued on 9099-C Page 2 of 9099-A-C LPA interviewed the Administrator regarding the delayed removal of the Wanderguard in the one confirmed case. The Administrator stated that if a resident has a diagnosis of Mild Cognitive Impairment (MCI), “they cannot leave unless the paperwork clears that from the doctor.” He explained that due to past incidents at other facilities where residents were injured after eloping, he is cautious and “follows the most restrictive order.” The Administrator further stated that the facility received a doctor’s note requesting removal of the device; however, they requested a new LIC 602A because “we now have two items that contradict the requirements.” He referenced a past court proceeding in which a judge asked, “why didn’t you go with the most restrictive?” Although concerns were raised regarding administrative practices and documentation, the investigation did not yield sufficient evidence showing that the Administrator acted outside the scope of administrative qualifications at the time of this report. The evidence does not meet the preponderance of evidence standard required to substantiate the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview done and copy of report printed for administrator. Page 3 of 9099-A-C A progress notes dated 2/20/26 at 4:34 p.m. indicate the facility was able to obtain a new medication order and an on-call number for R1’s physician. It is not documented why the facility did not keep the resident as they had new resources and medication to use. During the 4/1/26 visit, interviews with two directors corroborated the above-stated events. During record review, LPA observed documentation of the facility’s attempts to obtain physician guidance regarding increased agitation, behaviors, and exit-seeking. CCL received no written eviction notice for R1, and R1’s POA confirmed they did not receive any written eviction notice. While the facility made attempts to obtain medical support for R1, the facility did not comply with eviction procedures and did not permit R1 to return to the facility from the evening of 2/20/26 through the early afternoon of 2/24/26. Based on interviews and record review, no written eviction notice was provided to CCL or to R1’s representative. Therefore, the allegation of Illegal Eviction is SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. pg4the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 29-AS-20260323143217

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Jul 31, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily...evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents. For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.the state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited when they refused to allow Resident 1 (R1) to return to the facility for approximately 4 days, which posed an immediate health and safety risk to residents in care. As R1 no longer resides in the facility, administrator agreed to review regulations 87468.2 (a)(20) regarding involuntary transfers, discharges, and evictions and 87224 Eviction Procedures with the directors of the residential care units and provide statement of understanding to CCL by 7/31/26.

Allegation investigated: Staff sleeping while on duty

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Ron Freeman and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 7/9/26 where LPA conducted an interview with a director. Allegation: Staff sleeping while on duty It was alleged that overnight staff were sleeping while on duty and that a supervisor was aware of the issue. On 7/10/26, during the annual review, the LPA requested and reviewed thirteen (13) staff files, ten (10) of them were overnight staff, or staff noted to have covered recent overnight shifts. No records regarding staff sleeping were found. The LPA interviewed three Directors. All initially reported that they were not aware of current concerns regarding staff sleeping. Each stated that when such issues are brought to their attention, they take immediate corrective action due to resident safety concerns. Continue on 9099-C Substantiated Later in the afternoon on 7/10/26, a director revealed that after a brief inquiry it was found that Staff 1 (S1) was observed sleeping during the overnight shift of 7/9/26 and had announced this during the morning huddle. The Director reported that S1 was contacted and admitted to sleeping on duty. The Director stated that S1 would be terminated for failing to follow facility policy and due to concerns for resident safety. The LPA verified the termination through viewing a “Corrective Counseling Documentation” dated 7/12/26, and a Termination Notice confirming termination effective 7/12/26. Sleeping while on duty violates the licensee’s requirements. The Licensee “Caregiver…Job Description” documents state “NOC shift caregivers must stay awake…”. Because the licensee bases their staffing levels on the ratio of residents who require assistance, the licensee determined that the assigned level of staffing was necessary to meet resident needs, especially in the memory care unit where the staff member was scheduled. LPA did not find evidence that management knew of or know of staff who sleep on duty. A separate allegation of staff sleeping was reported in a prior complaint in December 2025 (Complaint Control #29-AS-20251201150209). In that complaint, sleeping staff were alleged to have contributed to a resident elopement; however, the allegation was unsubstantiated as the cause. The presence of a recent, confirmed incident of a staff member sleeping on duty lends to a potential pattern by staff. Based on interviews and records reviewed, the allegation that staff were sleeping while on duty is found to be substantiated. Although the facility responded promptly and took corrective action by terminating the staff member, sufficient evidence exists to confirm that the violation occurred. The allegation is therefore deemed SUBSTANTIATED. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Copy of report, Appeal Rights, were printed and given to the administrator.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 29-AS-20260708123103

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 24, 2026

87411 Personnel Requirements - General (a) 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 as evidenced by: Based on an interview, and record reviews, the licensee did not comply with the section cited above when a Night caregiver staff slept during their night shift which violates licensee’s policies and poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: The facility on 7/12/26 took corrective action and terminated staff. Facility to issue a staff memo reminding staff of expectations and not being allowed to sleep on duty. Copy of memo to be submitted to LPA by 7/24/26.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rankin arrived at 8:40 a.m. to complete the 1-year annual visit to the facility above. LPA met with Megan Drap, Business Office Director and Designee and explained the purpose of the visit. LPA additionally collected documents for complaint # 29-AS-20260402125617. Physical Plant & Environment Safety: LPA toured the Memory Care (MC) community. Resident rooms and bathrooms were observed in good condition, with operational fixtures, secured grab bars, and non-skid shower surfaces. Cabinets were locked, and disinfectants and cleaning solutions were inaccessible to residents at the time of the visit. Areas requiring lighting or minor maintenance were discussed with the Memory Care Director. The MC unit has secured, coded entry with delayed egress. During the visit, staffing consisted of 2 caregivers and 1 medication technician. The patio and courtyard areas provide adequate outdoor space and shade. Incidental Medical & Dental: Medications stored in the MC medication cart were reviewed. Documentation is completed in the electronic Medication Administration Record (MAR) and the Centrally Stored Medication and Destruction Record (CSMDR). LPA reviewed 3 PRN medications for 2 residents and identified incomplete PRN documentation: Resident 4 (R4) had 13 of 28 doses not recorded, and Resident 5 (R5) had 6 of 11 doses not recorded. A citation was issued. Continued on 809-C Food Service: Culinary staffing has been reduced due to recent layoffs and resignations. Staff from other departments, including directors and the administrator, have been assisting. Residents interviewed stated they have not missed meals and noted changes but reported that staff are making visible efforts to meet their needs. During the visit, LPA observed 1 cook, 1 dishwasher, and 2 servers. Staffing concerns will be address in complaint # 29-AS-20260402125617. During the kitchen tour, LPA observed expired food items in dry storage, including an item previously identified during a prior inspection, as well as open and unsealed packages of food that were cited during a complaint inspection dated 12/12/25. The walk-in refrigerator and freezer were clean, with properly covered items and temperatures within regulation. Flooring, shelving, and cooking equipment fronts were not clean and contained food particles and debris. A “proofing box” used to keep food warm was found turned off; when opened, it contained a tray of food that smelled like broccoli. According to the menu, broccoli was last served on 7/6/26 and 7/7/26. Unidentified flying insects were observed exiting the unit as the tray was removed. Two citations were issued. Personnel Records & Training: Training records for 10 care giving staff were reviewed. Staff met required orientation and annual training hour requirements. Medication staff had annual hours for medication training. The administrator’s certificate is valid through 08/26/2027. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D.) Exit interview completed, Appeal Rights given, and a copy of report printed for the facility.the state’s words, verbatim · CDSS document, Jul 10, 2026

The state marks this report as 14 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rankin arrived at 12:01 p.m. to continue the 1-year annual visit to the facility above. LPA met with Megan Drap, Business Office Director and Designee and explained the purpose of the visit. LPA additionally started investigating new complaint # 29-AS-20260708123103. Medication review not addressed during initial annual visit were discussed and a review of staff and resident records was done: Incidental Medical & Dental: During annual visit on 7/8/26 LPA viewed all medications for the Assisted Living Community from approximately 10:25 am to 12:30 pm and found 5 residents a total of 8 medications that had expired from dates ranging in 2025 to 5/2026, 6 of the medications were found in the overflow supplies, 2 medications were located in the medication cart, a liquid PRN antacid that had expired 6/2025 and a PRN bubble pack of Senna that expired 5/13/26 and the order had been discontinued by the doctor on 6/26/25. One of the expired medications belonged to a resident who passed away in 2025. Two of the medications had discontinue orders and should not have been kept in the resident supply of medications. Citation referencing requirements for destroying medications as required was cited. Staffing, Personnel Records: The facility currently employes 57 staff and 1 Administrator. LPA reviewed 12 staff files. Files reviewed had current 1st Aid/CPR, Health screening with TB results, applications and other required documents. Continued on 809-C Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Six (6) files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, TB results, Personal Rights, and Safeguard for personal property and valuables The facility does not handle cash resources for residents in care. Facility does submit incident reports to the department when required. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). LPA will return at a later date to complete annual inspection. Exit interview completed, Appeal Rights and a copy of report printed for facility.the state’s words, verbatim · CDSS document, Jul 9, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 9:11 a.m. to conduct the 1-year annual visit to the facility above. LPA met with Megan Drap, Business Office Director and Designee and explained the purpose of the visit. A tour of the common areas of the Assisting Living (AL) community was done by LPA. The following was inspected and noted during this annual visit: Resident Rights Information: All required postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, and Theft and Loss policy. Community Care Licensing Complaint poster was the 20 x 26 size and was at the front entrance. The LTCO poster was posted in a common area near the mailboxes of the facility. Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The facility is approved for a capacity of 122 non-ambulatory, which 12 may be bedridden and a current Hospice wavier is granted for 12. The Facility is operating in compliance with the granted fire clearance. Planned Activities: Facility has an activity calendar for the AL community; the daily calendar activities are posted in the elevator and on a table near community bulletin board, as well as a large television is showing the daily schedule on repeat in the common areas, copies of the calendar are also available for each resident which is put in the resident mailbox at the beginning of each month. Activities noted include musicians, Brain Longevity games, technology support for seniors, crafts, etc. During time of visit, LPA observed a musician on the second floor performing for a group of residents. Continue on 809-C Disaster Preparedness: During tour of AL, LPA observed approximately 17 charged fire extinguishers last serviced on 8/20/26. LPA observed 3 stair chairs in the 3 stairways viewed. Physical Plant & Environment Safety: LPA toured common hallways, 4 public restrooms, 2 vacant rooms; 219 and 213, the AL's 4 public laundry rooms, 2 of the sitting rooms, the lobby, the elevators, and checked every housekeeping, maintenance, electrical, and storage room door in the AL hallways to ensure they were secure. LPA found hallways clean, temperature within regulation ranges, and found no safety concerns in areas viewed, at this time. LPA reviewed AL community medication thoroughly from approximately 10:25 am to 12:30 pm. Details will be addressed in return visit. LPA interviewed 3 residents, and spoke with 4 staff. LPA will return at a later date to complete annual inspection. Exit interview completed, copy of report printed for the facility.the state’s words, verbatim · CDSS document, Jul 8, 2026

Allegation investigated: Staff does not ensure facility is clean, sanitary and in good repair.

At 8:55am, on 4/22/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to investigate the allegation of this complaint. LPA met with Administrator Ronold Freeman announced who he was and the reason for the visit. During the visit LPA toured the facility observing all personal and facility laundry machines, interviewed staff and residents, and obtained documentation. On the allegation, staff does not ensure facility is clean, sanitary and in good repair; it was alleged that during resident council meetings conducted on 1/20/2026 and 2/17/2026 residents reported washing machines having mold or mildew inside and it smelled bad. (Conitnued on LIC9099-C) Substantiated It was also alleged that on 1/20/2026, witness #1 (W1) observed four (4) of eight (8) washing machines available for resident use had visible black/brown sludge on the interior rubber gaskets and two (2) others smelled unclean. On 2/17/2026, W1 observed two (2) washing machines available for resident use located on the south side of the second floor, finding significant debris and black/brown sludge on the interior rubber gaskets. On 3/10/2026, W1 observed a washing machine with black/brown sludge on the interior rubber gasket. On 4/2/2026, W1 observed the sludge on six (6) washing machines available for residents to use. The washing machines were not clean and sanitary, the machines are still not being maintained in an acceptable condition. LPA record review of resident council meeting notes revealed that during meetings conducted on 11/18/2025 and 1/20/2026 residents stated that washing machines had mold build up and that it smelled moldy inside. During a meeting conducted on 12/16/2025 residents mentioned a dirty tray that needed to be cleaned under a washing machine on the first floor, on 12/22/2025 the Administrator stated maintenance would take care of it, and during a resident council a meeting conducted on 1/20/2026 residents stated the same tray was still dirty. Review of maintenance logs revealed no record of requests submitted or action taken to resolve each of these concerns. Administrator states they were verbal requests from them directly to the Maintenance Director and they were addressed at that time. During today’s visit LPA, Administrator, and the Maintenance Director toured the facility observing all four (4) public use laundry rooms in the facility with a total of eight (8) front loading residential washing machines. LPA photographed all eight (8) of the washing machines, noting the two (2) located in the second floor south hallway to have a layer of removable residue and debris on the inside of the grey rubber gasket, under this layer was an additional dark brown/black layer of residue that was not easily removable. LPA noted multiple washing machine gaskets were clear of removable residue and debris close to the drain at the bottom but there was dry removable residue and debris toward the top half of the gaskets. Staff stated they were not aware the residue and debris got up there. Regarding the layer of residue difficult to remove, staff stated they have tried different methods to remove it without success; staff demonstrated to the LPA using a plastic brush that this lower layer of residue could not be removed with the brush. Staff also stated that the appliance service company recommends replacing the gasket as the best way to address this issue, but parts are difficult to find as these washing machines are approximately nine (9) years old. (Continued on LIC9099-C) eight (8) washing machines that are available for residents and found four (4) with visible black or brown sludge in the gaskets and two (2) others that smelled unclean. At the resident council meeting conducted on 2/17/2026, residents said the washing machines still smelled, the same day W1 checked two (2) machines on the second floor, south side, and found significant debris and black/brown sludge in the gaskets. On 3/10/2026, W1 observed a washing machine with black/brown sludge on the interior rubber gasket. On 4/2/2026, W1 checked the washing machines again and found unidentifiable sludge in the gaskets of six (6) machines. It is also alleged that facility Administration and staff have not addressed the residents' concerns in a timely manner. Five months after the residents first informed the administrator in writing that the washing machines were not clean and sanitary, the machines are still not being maintained in an acceptable condition. Interviews revealed that the members of the resident council submit their meeting notes, including concerns and recommendations, in writing to the Administrator. A review of resident council meeting notes revealed that during the resident council meeting held on 11/18/2025 regarding some of the washing machines on the second floor having mold inside the door and it was requested the machines be deep cleaned. In written response provided on 12/4/2025 the Administrator stated that a request to maintenance was entered to do a deep cleaning on the machines and it was expected to be completed soon. The maintenance log does not have record of this request being submitted. The Administrator stated that this request to maintenance was a verbal request to the Maintenance Director not a work order. Notes from a resident council meeting held on 12/16/2025 mention a suggestion box note stating that a washing machine on the first floor nearest to the bathrooms has a tray under it with standing water, dust and grime. In written response provided on 12/22/2025 the Administrator stated the maintenance department can address the first-floor machine and that the request was submitted the day of the response. The maintenance log does not have record of this request being submitted. The Administrator stated that this request to maintenance was a verbal request to the Maintenance Director not a work order. Resident council notes for a meeting conducted 1/20/2026 state that during an open discussion residents noted a moldy smell coming from the washing machines and that the tray under the machine on the first floor reported during the meeting held on 12/16/2025 is still dirty. (Continued on LIC9099-C) A response was provided by the Administrator on 1/22/2026 stating housekeepers use a disinfectant on the washing machines, part of the reason for the dirty tray is due to spillage when a detergent dispensing tube is moved to the machine detergent tray, because of this the tray under the machine gets dirty very quickly, maintenance does regularly clean them out, and because this detergent is for facility use only residents were asked to use their own detergent. Staff stated that they also determined this washing machine would continue to run water through the detergent tray causing it to overflow, water would run down the front of the machine into the tray, the company they use to service and repair their washing machines was called out and it was determined a faulty control board was the cause. An invoice from the appliance service company dated 1/16/2025 confirms service, labor and a new control board. LPA noted as of today’s visit the tray under the same washing machine on the first floor has standing liquid in it. Staff stated this tray has been cleaned during this time period. Interviews and records reveal that the Administrator responded to the written resident council concerns and recommendations within the required fourteen (14) calendar days. Although the Administrator responds within the required time it is noted that the concerns presented by residents regarding residue and moldy smells in the washing machines and a dirty tray under the one washer are ongoing issues since at least November 2025 and no routine measures have been taken to ensure the maintenance and cleanliness of these areas. Technical assistance was provided. Based on all interviews conducted, observation, and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. While touring LPA noted the washing machine on the first-floor south hallway with the tray under it to have standing liquid in it. Interviews revealed about a month ago this washing machine was malfunctioning running water through the detergent drawer for an extended period causing water to leak out into the tray; an appliance service company invoice shows these repairs were conducted on 1/16/2026. The Administrator states on another occasion two to three weeks ago in the first-floor laundry room the door on the same washing machine in the tray would not open, to release the door they had to empty the water that was in the washer, maintenance staff opened a plug underneath the washing machine causing water to shoot out past the tray and on to the laundry room floor causing the floor to warp and shift leaving two gaps less than one (1) inch by four (4) inches right in front of the washing machines. LPA documented the flooring issues also noting a white discoloration. Administrator stated there is no scheduled date to repair the floor but one of the maintenance staff should be able to. Staff interviews revealed that on a daily basis housekeeping staff wipe down the inside of the door and exterior of the washing machines; and approximately weekly they run a Tide washing machine cleaner on the clean cycle, but there is no schedule to clean the rubber gaskets, and that additional cleaning of the gaskets they think is required approximately every 2-4 weeks. These washing machines are used by residents in the independent/assisted living portion of the facility, housekeepers, and care staff. LPA toured the commercial laundry room outside of the entrance to Compass Rose, the memory care unit, to find two additional residential washing machines and a larger commercial washing machine; LPA noted one residential machine in use, the other residential and commercial machines to be free of residue and debris. Based on all interviews conducted, observation, and documents obtained, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 29-AS-20260414145959

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 6, 2026

Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observation, interview and record review, the licensee did not ensure the washing machines and a laundry room were clean, sanitary and in good repair which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Administrator states they will create a new maintenance schedule to keep the gaskets clean, seek replacement parts, work with maintenance staff to schedule repair of the flooring and will email the schedules and status of replacement parts to the LPA on or before 5/6/2026.

Allegation investigated: Staff are not following the proper reporting requirements

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Ronald Freeman and explained the purpose of the visit. During the investigation, LPA conducted an initial visit 12/8/25 where LPA conducted interviews with administrator and staff and obtained relevant documents. During the investigation LPA conducted additional interviews, observations, and record reviews during visits on 12/11/25, 1/27/26, and 4/1/26. Allegation: Staff are not following the proper reporting requirements It was alleged the facility did not report an elopement to Licensing that occurred on 11/27/25. Through the investigation, it was confirmed that an elopement occurred on 11/27/25 at approximately 1:30 a.m. Resident 1 (R1) exited through a side door and was found off facility property. LPA confirmed that no phone notification was made to LPA Rankin or any On-Duty LPA by the first business day of 12/01/25. The first discussion of the event was a phone call to the Administrator from LPA Rankin on 12/03/25 at 4:03 p.m. Continued on 9099-C Substantiated During the brief call, the Administrator stated that Community Care Licensing would be receiving an incident report regarding a new resident, R1, who eloped on 11/26/25 or 11/27/25; the Administrator was uncertain of the date. The Administrator stated the elopement occurred in the early morning hours and that R1 had made it up the driveway and was just onto the parking lot area of the apartments next door, which is not part of the facility property. LPA received a faxed LIC 624 Unusual Incident/Injury Report on 12/03/25. The Resident Services Director (RSD) was noted as the one who submitted the report, and it had the signature of the Administrator. Review of the incident report states R1 “set off [their] wanderguard pendant alarm while attempting to exit through the front doors of the community. Community staff immediately responded and intercepted the resident in the foyer between the double doors.” The incident report did not match what was discovered through the complaint investigation nor what was reported during the phone discussion by the Administrator. The investigation also revealed the facility called Emergency Medical Services (EMS) due to R1’s behaviors, hallucinations and refusal to return to R1’s room. LPA reviewed the electronic health record (eHR) for R1 for the date of the incident, which stated R1 “wanderguard pendant went off by room 137 door. Medication Technician…went to check door. Resident was seen outside of community.” Additional note stated “…spotted resident far away from the community in front of another building…” An image of room 137’s location next to the side door was taken by LPA on 12/08/25 to confirm the location was not near the “front door.” LPA obtained a copy of the EMS report, which states: “Per staff on scene, Pt was wandering outside of the facility.” This also contradicts the initial report that “Community staff immediately responded and intercepted the resident in the foyer between the double doors.” During the visit on 12/11/25, an interview with RSD was conducted for another open complaint, but during interview LPA inquired about elopement incident. RSD’s account matched the events noted in the eHR. LPA asked RSD to explain why their interview did not match the LIC 624 Unusual Incident Report sent to LPA on 12/3/25; RSD was unsure. Prior to leaving, the Administrator stated that the RSD admitted copying an updated narrative from their regional office into the incident report and did not review what the update was. (Continued on 9099-C) page 2 A revised LIC 624 incident report was completed and provided to LPA on 12/11/25. Review of this new report still has an inaccurate narrative which states the resident “exit through the front doors of the community. Community staff…intercepted the resident in the driveway of community…” Front door is often referenced to the lobby front doors, and the resident was not found in the driveway of the community. A review of R1’s Physician Report record indicated that as of the date of the elopement, R1 was not diagnosed with Dementia but with Mild Cognitive Impairment (MCI). Therefore, the regulations regarding elopement reporting would not apply regarding contacting Licensing within 24 hours, and the reporting requirements of providing a report within seven days would apply. The reporting within the appropriate timeframe was done. However, due to the misleading and inaccurate narrative of the original and revised incident reports received on 12/03/25 and 12/11/25, a citation for Title 22, Section 87211(a)(1)(D) is warranted. Based on interviews and record review, while an incident was reported in the correct time frame via a written LIC 624, the document provided did not correctly account for the “nature of the event” as required. The preponderance of evidence has been met; therefore, the allegation is SUBSTANTIATED. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D) An exit interview was conducted; deficiency cited; a copy of this report and the appeal rights was provided. Page 3 On 12/08/25, LPA requested and reviewed four (4) staff files related to open complaints; no concerns were identified at that time. On 12/11/25, during a separate complaint visit, the LPA conducted staff and management interviews. During these interviews, staff and management reported that a staff member had recently been terminated after being found asleep by a supervisor who arrived early to follow up on internal reports of the staff sleeping on shift. The LPA requested and reviewed the additional staff file and confirmed, through internal email documentation and a “Corrective Counseling Documentation” dated 12/3/25, that a staff member was observed sleeping at approximately 4:00 a.m. on 12/03/25 and was terminated effective the same date for violating facility policy. The investigation revealed other staff were still present on the shift and there was no evidence that residents’ needs were not met. Based on the information obtained through interviews and record review, the allegation regarding staff sleeping was found to have occurred; however, the facility conducted an internal investigation, promptly addressed the concern, and terminated the involved staff member on the same date the incident was confirmed. There was no evidence found to prove the residents were at risk. In addition, although an elopement incident did occur, available documentation shows the facility responded in a timely manner and took measures to address the situation. The facility demonstrated corrective action and implemented steps to mitigate potential risks to residents. Therefore, the preponderance of evidence does not exist to prove that the alleged violations occurred as reported, and the allegation is deemed UNSUBSTANTIATED. Allegation: Staff are not properly assessing the residents It was alleged that the administration is allowing residents to move in or live at the facility that are not fit for assisted living. The reporting party stated that Resident 2 (R2) “belongs in a skilled nursing home according to [their] home health nurse.” Interviews from staff and residents claim the facility is accepting residents that have more care needs than previously accepted into Assisted Living including more cognitive issues and residents who are less ambulatory and have higher care needs. LPA reviewed records on 12/8/25 for four residents including R2, all residents had their physician’s report, appraisal/needs and services plan, and functional capabilities assessments. LPA reviewed a sampling of six (6) resident files on 01/27/26, all of which had pre-admission appraisals and current appraisal/needs and services plan as well as re-assessments. There was no indication in any of the documents that any of these residents require 24-hour nursing care, and none of them had any prohibited health conditions. Continue 9099-C Page 2 LPA attempted to review one chef’s timecard; however, they were unavailable because the chef is salaried. The Administrator stated they were not aware of any issues with the chef’s start times. Interviews conducted during the prior complaint and a review of Resident Council minutes (Nov. 2025–Feb. 2026) reflected that breakfast generally runs smoothly Thursday through Monday, but Tuesdays and Wednesdays commonly have delays; however, residents did not attribute the delays to the chef’s arrival time during interviews. Based on observation, interviews, and record review, the allegation that residents lack access to food after the dining room is closed and that proper breakfast is not provided due to the chef’s attendance is UNSUBSTANTIATED. There was not a preponderance of evidence to demonstrate that these allegations are occurring. An exit interview was conducted; a copy of this report was provided. Page 4 Interviews with Administrator and RSD revealed they conduct pre-placement appraisals with residents and obtain functional capabilities assessments prior to admission, in accordance with regulations. Additionally, the facility’s policy states residents will have a reassessment 30 days after move-in, and every six months after, or when a change of condition occurs. Based on the record review, residents admitted to the facility do not violate regulations regarding allowable conditions, abilities, needs, and services. At this time, a preponderance of evidence does not exist to support that the alleged violations occurred as reported; therefore, the allegation is deemed UNSUBSTANTIATED. Allegation: Residents not being provided adequate food service. It was alleged that residents lack access to food after the dining room closes and that proper breakfast items are not provided due to the chef arriving late. Regarding food availability after dining room hours, on 4/1/26 LPA arrived at 7:45 a.m. to observe the bistro. LPA noted fruit, Jell O, yogurt, chips, cookies, and leftover desserts, with additional items such as sandwiches, bananas, and string cheese added after lunch. Residents interviewed reported that food is available, though popular items may run out quickly. LPA also observed the bistro stocked with food items during visits on 11/25/25, 12/11/25, and 1/27/26, and verified that items were replenished after lunch during each visit. Resident Council minutes from November 2025 through February 2026 reflected one discussion regarding the bistro running out of sandwiches, bananas, and coffee after breakfast. The comment was not forwarded to the Administrator as a question or complaint. Residents interviewed by LPA stated that, in their observation, the bistro consistently has a small variety of food options. LPA could not confirm the allegation through observation or interviews at this time. Breakfast is scheduled for 7:00 a.m. According to the investigation, those who reported that the chef has arrived late also stated that when this occurs, residents still have access to cereal, toast, fruit, yogurt, and other bistro items. Continue 9099-C Page 3the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 29-AS-20251201150209

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D)(a) · Plan of correction due date: Apr 30, 2026

Reporting Requirements 87211(a)(1)(D) (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include…date and nature of event… and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as…unexplained absence of any resident. This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not comply with the section cited above when the facility failed to accurately report the facts and nature of an elopement to Community Care Licensing (CCL). This failure to provide complete and accurate information poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: Administrator agreed to assist in revising the LIC 624 for the events of 11/27/25 and read and provide a statement of understanding for regulations Reporting Requirements 87211 and provide training to facility staff, including the Resident Service Directors and, that prepare and/or report incident to CCL, send proof of training via agenda of topics reviewed and in service training sheet with staff signatures.

Allegation investigated: Facility staff are not following mandated reporter requirements

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Ron Freeman and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 07/16/2025 where LPA conducted interviews with residents and staff from 11:25am to 3:15pm, and obtained relevant documents. LPA conducted additional interviews with staff on 10/01/2025; with residents on 11/21/2025; and with a witness on 1/16/2026. A review of prior complaint # 29-AS-20250130150442 was completed. The prior complaint involved the eviction of Resident 1 (R1). Interviews conducted on 02/6/2025 and 02/27/2025 were used for evidence. On the allegation: Facility staff are not following mandated reporter requirements. It was alleged the Administrator and staff failed to report alleged abuse of their residents, violating their legal mandate to do so. The reporting party stated an eviction notice was issued to R1. Continued on 9099-C Substantiated The notice indicated the cause of eviction included behaviors by R1 that constituted “harassment or psychological abuse or causes mental suffering of an elder or dependent adult.” It was alleged if the behaviors rose to the level supporting an eviction notice, then the Administrator and staff, as mandated reporters, should have reported the abuse to Community Care Licensing (CCL), the local Long Term Care Ombudsman (LTCO) program, and local law enforcement using the SOC341 forms. Interviews conducted with residents indicated that R1 discouraged them from sitting with preferred companions, interfered with group participation, and was observed repeatedly raising their voice and talking rudely to staff. Two residents stated R1 repeatedly entered another resident’s apartment uninvited to complain, as this resident was the resident council president, but was on Hospice. Multiple residents reported avoiding dining and activities due to R1, some observed other residents crying after interactions with R1, and two residents stated they would move out if R1 remained. Resident Services Coordinator stated during interview R1 was overheard calling residents “dumb” or “not smart,” told some “you don’t belong,” and created a hostile environment. Staff interviewed stated they observed R1 yelling at residents and staff. On one occasion Staff 8 (S8) witnessed R1 throw a purse at a resident over a seating dispute on the bus. Staff noted residents with mild cognitive impairment were targeted and staff claim that some residents feared retaliation if they reported an incident and R1 found out about the report. LPA obtained facility forms titled “Resident/Family Grievance report”. Twenty-two (22) forms were collected, all regarding R1. Eleven (11) of the twenty-two (22) forms document events between 07/03/2024 and 03/09/2025 of R1 refusing seating or activity participation to other residents, repeated unwanted phone calls to Resident 10 (R10), loud/banging noises affecting neighboring residents, demeaning comments to staff, misuse of laundry machines causing disruption in other residents using them, and multiple resident/staff grievances. LPA received an Incident Report from 11/23/2024. The incident report documented a resident reporting to the facility that they were being harassed by R1, R1 was calling their cell phone repeatedly, and resident reported they felt very uncomfortable around R1 because they feel pressured or manipulated to join activities and meals. Continued on 9099-C A letter dated 12/05/2024 was sent to LPA Rankin documenting instances of R1’s insulting and rude behavior to other residents causing them distress, rejecting residents from playing games, persistent unwanted phone calls to residents, loud noises in R1’s apartment, and screaming at staff. Additional documents collected include letter correspondence and an eviction notice for R1. A letter from 11/15/2024 documented verbal harassment of staff, screaming and insults; R1 was reminded harassment violates resident handbook. A letter from 11/28/2024 documented other residents feeling harassed, receiving unwanted attention, and feeling targeted; R1 was instructed harassment must cease and was warned against retaliation. A letter from 12/11/2024 documented turning away a resident from seating, rude conduct, persistent complaints; it was reiterated to R1 harassment was prohibited. A letter from 01/02/2025 noted harassment toward servers. R1’s eviction notice includes summaries of fifteen (15) instances where R1 verbally berated, yelled, and pressured or mistreated staff; and four (4) instances involving R1’s treatment of residents, which were corroborated by the interviews and grievance reports. Although a majority of the reported mistreatment was directed toward staff, residents were also present for some of these incidents and observed these interactions, which, according to interviews and grievances, created an environment of fear and psychological distress for residents, and disrupted their sense of safety and well-being. California Code of Regulations Title 22 87211(a)(1)(D) states the licensee must submit a written reporting to CCL within seven (7) days of “Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.” Mandated reporters must report abuse using form SOC341 per the definitions in Welfare and Institutions Code (WIC) §15610.07(a)(1) [“Abuse of an elder or a dependent adult” means any of the following: Physical abuse, neglect, abandonment, isolation, abduction, or other treatment with resulting…mental suffering.”] and WIC §15610.53 [“Mental suffering" means fear, agitation, confusion, severe depression, or other forms of serious emotional distress that is brought about by forms of intimidating behavior, threats, harassment, or by deceptive acts performed or false or misleading statements made with malicious intent to agitate, confuse, frighten, or cause severe depression or serious emotional distress of the elder or dependent adult.”] Continued on 9099-C The evidence shows that R1’s behaviors constitute incident(s) that threaten the welfare and safety of residents and aligns with the definition of treatment resulting in mental suffering. The evidence demonstrates a pattern of psychological harassment by R1 toward staff and other residents, which negatively impacted the facility environment. Despite being aware of these effects, neither the Administrator nor staff submitted SOC341 reports to CCL, nor to LTCO or law enforcement as required per Welfare and Institutions Code (WIC) 15630. Based on interviews and documentation, there is a preponderance of evidence that the facility failed to meet mandated reporting requirements regarding suspected psychological abuse/mental suffering. Therefore, the allegation is substantiated at this time. This case will be cross-reported to California Department of Justice/Division of Medi-Cal Fraud and Elder Abuse (DOJ/DMFEA) and local law enforcement for failure to follow mandated reporter requirements. An exit interview was conducted, deficiency cited on 9099-D, a copy of this report and the appeal rights was provided.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 29-AS-20250711112047

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 26, 2026

87211(a)(1)(D) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:…Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents… This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when the Administrator/staff did not submit an SOC341 for abuse by R1, which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: The Administrator agrees to ensure that all facility staff receive comprehensive training on Mandated Reporting. The training will include topics related to harassing behaviors, psychological abuse, isolation, and contributing factors such as resident-on-resident abusive interactions. The training will emphasize staff responsibilities in recognizing, preventing, documenting, and reporting all forms of abuse in accordance with Title 22 regulations and Health & Safety Code requirements. Documentation of completed training, including sign-in sheets and training materials, will be maintained at the facility and submitted to CCL by 3/26/26.

Allegation investigated: Staff do not follow reporting requirements Facility has insufficient staffing to meet the needs of the residents

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Ron Freeman and explained the purpose of the visit. During the investigation, LPA conducted an initial visit 7/2/25 where LPA conducted interview with administrator and staff and obtained relevant documents. LPA conducted additional interviews with staff and residents during visits on 7/16/25, 10/1/25, 11/21/25, and 12/8/25. On the allegation: Staff do not follow reporting requirements It was alleged there had been 4 - 5 falls in June at the facility, and staff had been instructed by a manager not to report any of the falls to licensing. Alleged the falls were in both assisted living and memory care. Continued on 9099-C Unsubstantiated On 07/02/25, LPA collected electronic incident reports from the facility which are documented in the facility’s electronic health record (EHR) system. Dates of reports reviewed were from 01/02/25 to 07/02/25. LPA reviewed a total of 133 incident reports from the EHR. Based on this review and comparison to reported incidents submitted to the Community Care Licensing (CCL), LPA observed that falls described as having no visible injuries, minor skin tears, or no complaints of pain were not submitted to the Department. However, all serious incidents involving residents—such as falls resulting in pain, head injuries, or requiring transfer for medical attention—were reported to the Department prior to this complaint. While some fall incidents were not provided to licensing, regulations require that “a written report shall be submitted to the licensing agency… of any of the events specified in (A) through (D)… (A) Death… (B) Any serious injury… (D) Any incident which threatens the welfare, safety or health of any resident…” LPA interviewed staff on 7/2/25, 11/21/25, and 12/8/25 there were no reports of management directing staff not to report an incident. Of those interviewed all stated, they have no knowledge of management directing staff not to report incidents, falls, or injuries. Based on records, interviews, and observations there is not a preponderance of evidence to prove the above allegations did or did not occur therefore the allegations are UNSUBSTANTIATED at this time. On the allegation: Facility has insufficient staffing to meet the needs of the residents It was alleged that the facility has insufficient staffing to meet the needs of residents and that managers have recently covered a 24-hour shift. LPA conducted eight staff interviews and five resident interviews, and reviewed facility records. On 07/01/25, a former staff member reported that at times only one caregiver was present in Memory Care, although two caregivers and a medication technician are expected. On 07/02/25, the administrator acknowledged being down six to ten staff but stated shifts were covered by agency caregivers, managers, and current staff, and that the facility maintained required staffing ratios. Continue on 9099-C During the same visit, staff confirmed at least two caregivers per shift and denied managers working full 24-hour shifts. LPA reviewed schedules and timecards which showed that consistently there are at least two caregivers, if not three in the memory care unit and assisted living unit during daytime shifts, including a medication technician for each side and at minimum three total caregivers and one medication technician to cover the full facility during the NOC shifts. Resident interviews conducted on 7/2/25, 7/16/25, and 11/21/25, revealed occasional comments from residents indicating that staff claimed to be short-staffed when delays occurred; however, these statements were inconsistent and not corroborated by other evidence. Residents acknowledged the use of agency staff and noted that turnover affects consistency, but independent residents reported that there have generally been enough staff to meet their needs. Some residents and staff agreed that evening shifts are busier due to more residents requiring cognitive support. While some delays were reported, there is insufficient evidence to conclude the facility failed to meet care and supervision requirements during the time frame leading up to this complaint. Records indicate the facility has not violated staffing regulations during the time frame of this complaint. Based on interviews and record reviews, there is insufficient evidence to support the allegation that the facility is not adequately staffed to meet resident needs. While the allegations may or may not have occurred, the allegation is deemed UNSUBSTANTIATED at this time. A copy of this report was printed and provided to the administrator.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 29-AS-20250626082420

Allegation investigated: Staff did not follow infection control requirements

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Administrator Ron Freeman and explained the purpose of the visit. During the initial visit on 12/11/25 LPA Rankin toured the facility, took images of relevant areas and interviewed staff. This report is being given at the conclusion of an annual. Allegation: Staff did not follow infection control requirements It was alleged that the facility was not adhering to infection control protocols. Allegation state, on 11/29/25 Resident 1’s (R1) room had bodily fluid “all over” following an emergency and the reporting party stated the room was never cleaned. On 12/7/25 R1 moved from this room, on 12/11/25 LPA toured R1’s room where the emergency occurred, the window was open and it appeared that the carpet had recently been cleaned, there was spots of blood observed on the light switch above the kitchen counter that leads into the sleeping area, on the lower right corner of the refrigerator, a finger sized spot on the wall of restroom about 2 feet off the ground between the toilet and the shower. During the time of LPA’s visit the resident has been out of the room for three days. Continue on 9099-C Substantiated R1 is a resident of the assisted living side of the facility and has more independence. Staff that had seen the room stated that it was not a normal clean up, multiple care staff interviewed stated that resident had a bloody nose with excessive bleeding, incident report states fall and facial trauma. Staff interviewed stated resident was found in their restroom but had started to bleed in their bedroom area and had walked to their restroom. Administrator confirmed regular housekeeping occurred on 12/4/25. Nine staff were interviewed regarding infection control and cleanup procedures. All stated that bodily fluids are cleaned immediately by care staff, followed by housekeeping disinfection. Four staff confirmed they were present during the emergency and began cleaning immediately after R1 was transported to the hospital. Infection control training was conducted on 9/17/25. All staff interviewed demonstrated knowledge of the procedures and the importance of cleaning up as quickly as possible. LPA observed evidence of bodily fluids in R1’s room; however, it could not be confirmed whether these spots resulted from the original emergency incident or occurred while R1 occupied the room after returning. At the time of the visit the room was locked and unoccupied and is expected to be cleaned before reuse. The situation did not pose an immediate health and safety risk to residents in care, this is considered a technical violation and no citations are being issued at this time. A Technical Violation is issued related to this allegation, for section 87470 (a)(2)(C) Spills of blood and other potentially infectious materials and surfaces shall be promptly cleaned and disinfected. Exit interview conducted, and a copy of this report was issued.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 29-AS-20251208105330

Allegation investigated: The facility is storing expired food and failing to properly cover food items.

Licensing Program Analyst (LPA) Rankin conducted an initial 10-day complaint visit to the facility above. LPA met with Ron Freeman and explained the purpose of the visit. During the investigation, LPA Rankin conducted interviews with residents and staff, reviewed and collected relevant documentation, including menus, and meeting minutes for resident council. Toured kitchen and observed breakfast and lunch service and dinner preparation. LPA also attended a “Food for thought” discussion held by the Chef where residents came and discussed items, including concerns. On the allegation: The facility is storing expired food and failing to properly cover food items. It was alleged that the facility is serving expired food and that proper food storage practices are not being followed. During the visit at approximately 12:07 p.m., the LPA toured the facility’s walk-in refrigerator and dry goods storage area. Continue on 9099-C Substantiated On the allegation: Facility kitchen is dirty It was alleged that the facility kitchen is not being maintained in a clean and sanitary condition. During the visit, the LPA conducted a comprehensive tour of the kitchen and dining areas. The following observations were made: A shelf located above the food preparation and hot holding areas had a visible layer of grime. Items stored on this shelf (metal pots, strainers, and plastic containers) were placed upside down, with rims in contact with the surface. A light buildup of grease was observed on top of the oven. Minor food residue was noted under the oven and food prep shelving; however, this was consistent with normal daily kitchen use. All other areas of the kitchen—including the walk-in refrigerator, dry storage, prep counters, and general surfaces—were observed to be clean, well-organized, and maintained in a sanitary condition. While minor cleanliness issues were observed, they did not rise to the level of a systemic or ongoing sanitation concern. The overall condition of the kitchen and dining areas was found to be clean and well-maintained. Based on the limited scope of the observations and the absence of any immediate health or safety risk, the preponderance of evidence standard was not met. Therefore, the allegation is unsubstantiated. On the allegation: Facility has insufficient staff to meet the food service needs of the residents It was alleged that the facility has insufficient staffing to meet residents’ needs related to food preparation and dining room service. During the visit, the LPA observed breakfast and lunch service, conducted staff interviews, attended a discussion with the chef and residents, and reviewed resident council meeting minutes. Based on observations at the time of the visit, staffing levels in the kitchen and dining room during meal periods appeared to be adequate. Resident interviews and those who spoke during the discussion with the chef stated concerns regarding food not being served hot, wait times of 10–15 minutes to place an order, and overall service times ranging from 25 to 45 minutes. Continued on 9099-C Staff interviews reflected mixed feedback. Some staff indicated that meal service runs more efficiently when specific cooks or team members are on duty, suggesting that individual performance impacts overall service quality. Consequently, there are periods when staffing and service delivery are sufficient, and other times when residents may experience delays. Discussions with lead staff, as well as observations of the dialogue between residents and the chef, indicate that the facility is actively working to improve communication, refine procedures, and streamline meal service operations. At this time, concerns regarding food temperature and service delays do not appear to be directly related to staffing levels, but rather to training and process inefficiencies. This was discussed with management during the visit. While the facility was found to be in compliance at the time of the visit, it is recommended that the facility continue to assess staffing patterns and enhance operational processes to ensure consistent and timely meal service. Based on observations and interviews, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. On the allegation: Facility failed to serve meals as planned and posted on the menu It was alleged that the facility does not consistently serve meals as listed on the posted weekly menus. During the visit, LPA reviewed facility menus, both those posted and the revised, "as served menus", interviewed residents and staff, and discussed the facility’s food service system. The facility utilizes a software system called Grove, which is designed to ensure meals meet regulatory nutritional standards and provides structured guidance for menu planning and substitutions. Title 22 regulations do not prohibit substitutions, provided menus are planned in advance, and maintained on file. Menus posted and copies are maintained on file as required. While some residents reported occasional substitutions or not knowing what would be served until arriving in the dining room, the investigation found that, substitutions were infrequent and generally comparable to the originally planned menu items. Per interviews the sides and deserts were the most common changes. Continued 9099-C However, for improved resident satisfaction, it is recommended that the facility enhance communication regarding menu changes—such as posting or announcing substitutions prior to meal service, whenever feasible. Based on a review of the regulation requirements and the facility being in compliance with applicable regulations regarding menu planning and nutritional offerings. This allegation is unsubstantiated at this time. Exit interview conducted, and a copy of this report issued. In the walk-in refrigerator, the LPA initially observed an uncovered container of breakfast sausage links. Upon a second walkthrough, the container had been removed; however, an open, unsealed package of sausage patties was noted. All other food items in the walk-in appeared fresh, no odors or mold was observed and all were properly labeled and covered. In the dry storage room, five food items were found with expiration dates labeled “best by” or “use by” September 2025, indicating they were past their recommended shelf life. Additionally, two packages—one of spaghetti and one of cereal—had visible holes, with food spilling out. A container of raisins, not stored in its original packaging, was covered with plastic wrap that had a hole approximately the size of a quarter. Photographs were taken to document the observed items. These findings are not in compliance Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Section 87555(b)(28), which requires that All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. Based on LPAs observations, the presence of expired and improperly stored food poses a potential health and safety risk to residents. The preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Report discussed, and copies of appeal rights and reports printed.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 29-AS-20251119115422

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(28) · Plan of correction due date: Dec 12, 2025

General Food Service Requirements 87555 (b)(28)All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above when food items were discovered improperly stored, opened, and expired, which poses a potential health and safety risk or personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Items were immediately removed from storage. Disaplinary action for the staff responsible for this area. Training will be conducted and a copy of the training will be supplied to LPA by 12/12/25.

Allegation investigated: Facility doors are unsafe for residents in care. Staff are not following residents admission agreements.

Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegations. LPA met with Ronald Freeman, to discuss the purpose of the visit and elements of the complaint. During the visit LPA collected staff schedules and observed and tested the function of external doors, interviewed 4 residents, 8 staff, a director and the administrator. LPA also toured restrooms, common areas, and a resident room. On the allegation: Staff are not following residents admission agreements. It was alleged that due to a lack of staffing the residents are not receiving weekly housekeeping and laundry services as stated in their admission agreements. Reporting party (RP) reported that residents are having to wash their own bedding when housekeeping is not available. Continued on 9099-C Unsubstantiated LPA reviewed admission agreement which states under section (h.) “The Oaks at Nipomo will provide routine weekly housekeeping services to your Apartment, including laundering sheets and towels.” Interviews and records confirm the time frame for this concern started after 9/11/25. The facility employs four housekeepers. However, for a brief period, two housekeepers were unavailable due to valid personal reasons, one on extended medical leave and one due to an life-threatening emergency. Staff interviews indicated that while no temporary staff were hired due to State Licensing guidelines which delay background checks, overtime was offered to existing staff to help maintain services, including staff in other departments. The administrator confirmed that staff from other departments assisted with housekeeping duties during this time but declined the overtime to fully cover open shifts. The facility has hired another housekeeper who is currently going through the required background checks. During interviews, report that routine housekeeping services were missed during the dates of 9/24/25 and 9/25/25, but the services were provided within 3 days of their routine date, and any resident needing services sooner were provided support within 24 hours. Residents interviewed did not state they were impacted by this temporary schedule, they have not heard of others stating they have any issues. There is no indication that the issue is ongoing or systemic. The facility made reasonable efforts to mitigate the impact of the staffing shortage, and there is no evidence that the facility willfully failed to uphold the admission agreement. Although there was a brief disruption in routine housekeeping services due to an unforeseen staffing emergency, the facility took reasonable steps to address the issue. The evidence does not support a finding that the facility failed to follow the admission agreement in a manner that was systemic or intentional. Therefore, based on interviews, records reviewed and observation, the allegation is deemed to be Unsubstantiated at this time. On the allegation: Facility doors are unsafe for residents in care. It was alleged that the doors from the dining room to the patio door are difficult for the residents that use wheelchairs or walkers to open in either direction. RP also reported that several people have been hurt trying to get through the doors and that one resident almost fell going through the door last week. RP also reported that the residents have requested handicap accessible doors. RP also reported that residents have brought the issue to the administrator's attention repeatedly and have been told that the doors will not be changed. Continued on 9099-C During resident and staff interviews the LPA found no confirmation that the doors have caused injury to any residents in care. On 9/30/25 LPA reviewed internal incident reports and incident reports provided to licensing for dates of 1/2/25 to 7/2/25 provided for another complaint and found that no reports of falls or injuries were due to the patio doors or any other external doors, total number of reports reviewed was 135. LPA tested both sets of doors, found that they open smoothly and close at a slower rate. Resident interviews showed mixed opinions, with some stating the doors are light, but could be cumbersome or heavy for other residents. The facility confirmed they have had the same doors since licensure in 2018. Interview with residents provided that 2 out of 4 residents interviewed stated the doors were heavy for them. While automatic doors would be a beneficial service to the community who widely use walkers and wheelchairs, the doors are not out of Title 22 regulation compliance. Administrator noted that if they tighten them to close at an even slower rate it would cause the tension to be so great, they would be hard to open. Staff interviewed stated that some residents want to be independent and will not ask for help opening the doors or will wave them away to prevent help, but staff, especially in the dining area do watch for residents and try to aid. Administrator was reminded the facility needs to ensure residents’ needs are met. Based on records, interviews, and observations there is not a preponderance of evidence to prove the above allegations did or did not occur therefore the allegations are unsubstantiated at this time. An exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 29-AS-20250924222649

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rankin arrived at 9:26 a.m. to continue the 1-year annual visit to the facility above. LPA met Administrator Ronald Freeman and explained the purpose of the visit. A tour of the kitchen area of the facility was conducted with the head chief. The following was inspected and noted during the annual visit: Food Service: The facility employs food service staff. The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer and refrigeration temperature is checked and logged, both temperatures were within regulation. All food was covered, stored and marked appropriately in the main kitchen. Food, snacks and drinks are available when the residents want them. A menu is posted for residents in care. Cleaning solutions and equipment were stored separately than food supply. Main Kitchen areas were clean and free from litter, rodents, vermin and insects. LPA will return at a later date to complete the annual visit. Exit interview completed, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Oct 1, 2025

Allegation investigated: Facility failed to follow reporting requirements

Licensing Program Analyst (LPA) Rankin conducted a required 10-day complaint visit to the above facility. LPA met with Administrator Ron Freeman and explained the purpose of the visit. LPA was notified of possible outbreak on August 21st via correspondence with the Administrator. The administrator stated in correspondence that the county has also been contacted, and he was waiting for a response. During the complaint visit LPA interviewed the administrator, Memory care director, 10 staff, and 8 residents. LPA toured common area of the facility while speaking with staff and residents. Unsubstantiated Interview with the administrator and a director were done. Facility had reached out to the public health; first attempt was done on August 21st. Director stated they had been in contact with a public health Registered Nurse (RN), email provided shows that on Monday August 25th RN provided facility with basic information about the “Noro” (Norovirus). Email provided “specific cleaning suggestions.” LPA interviewed 8 residents in the assisted living side. While speaking with residents, 7 out of 8 stated that there have been no changes to schedules, dining processes, activities, and cleaning schedules. Residents interviewed were participating in bingo, sitting in the common halls, and in the dining room. All residents during discussion stated that this is where they usually sit, eat, or this is the activity they love to do. Allowing the LPA to understand that these common areas are part of their regular schedule. All residents stated none of their activities or day to day schedules have been changed over the past 2 – 3 weeks. LPA interviewed 10 staff, 7 of the staff work in the assisted living areas and 3 work in memory care unit. All staff stated that no changes to schedules have been made. 8 out of 10 staff stated that no changes to cleaning have been initiated, no extra cleaning requested, all stated it has been the same schedule and process as usual for the past 2 weeks. The two staff who stated that cleaning was increased were in the kitchen area and stated that cleaning to chair handrails and tables had increased starting around the 25th through the weekend of the 30th. While the residents and staff did adhere to isolating residents with symptoms, and as of today the illness was contained and only 7 – 9 residents had displayed symptoms, and one tested positive for a contagious disease, based on interviews and provided documents, the facility did not comply with the regulations 87470 Infection Control Requirements “(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (1) In addition to the requirements of subsection (a)(2), assigned staff …regardless of having direct contact with residents, shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment and to prevent, contain, and mitigate the transmission of the contagious disease.” the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Copy of report printed along with copy of appeal rights. On the allegation: Facility failed to follow reporting requirements On August 21st at 8:51am the administrator contacted LPA to inform LPA of a possible outbreak, with symptoms of vomiting and diarrhea. The administrator included in correspondence that the county had been called, and he was waiting for a call back. The requirement of reporting possible outbreak to Community Care Licensing was done as required. When a positive test was done on August 27th to show the outbreak was Norovirus, there was only one resident symptomatic, and no additional cases occurred after that. LPA and administrator discussed that any future concerns, the same notification will be made to initiate the concern of a possible outbreak, and communication stating a positive test result has been received will be provided to licensing, even if it is only one case. Based on interviews conducted, and record reviews, at this time the preponderance of evidence standard has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. Exit interview conducted and copy of report provided to administrator.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 29-AS-20250827080301

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(b)(1) · Plan of correction due date: Oct 3, 2025

87470 Infection Control Requirements (b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (1) In addition to the requirements of subsection (a)(2), assigned staff …regardless of having direct contact with residents, shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment and to prevent, contain, and mitigate the transmission of the contagious disease. This requirement has not been met as evidenced by: Based on multiple interviews, 8 out of 10 staff and 7 out of 8 residents stated no addtional cleaning was observed or requested possing a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator agrees the Infection Control policies will be reviewed with all directors and supervisors within the facility. Administrator will provide LPA with a current copy of the Infection Control Policy for facility. Administrator will also provide LPA with a copy of the requirements reviewed with supervisors and directors of their expectation when an outbreak or potential outbreak occurs.

Allegation investigated: Licensee does not ensure that resident's are provided with an adequate supply of hygiene items while in care. Licensee does not ensure that resident is provided appropriate activities while in care.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Ronald Freeman, Administrator and explained the purpose of the visit. During the initial visit on 6/23/25 from 10:55 am to 3:00 pm, LPA Rankin toured the memory care unit at the facility, interviewed two (2) staff, one (1) resident from Memory Care, and two (2) residents from Assisted Living, observed Memory Care residents and the activities, and obtained relevant documents. Additional interviews were conducted with relevant parties on 6/20/25, and 7/1/25. During return visit LPA re-toured the memory care unit and specifically 21 resident restrooms and two (2) staff/resident restrooms. LPA interviewed three (3) staff and one (1) director. (pg1) Continued 9099-C Unsubstantiated On the allegations: Licensee does not ensure that residents are provided with an adequate supply of hygiene items while in care. It was alleged that on multiple visits a witness observed residents in the memory care unit without toilet paper in their restrooms and in some instances with the toilet paper holder removed. During an initial visit on 6/23/25, LPA toured 18 out of 21 restrooms and found that each room except one (1) had toilet paper, all rooms had a toilet paper holder. LPA also toured the 2 restrooms that are used by staff and if needed residents, and all restrooms had toilet paper. LPA interviewed two staff who stated they provide toilet paper to residents, but there are times when a resident who is able to use the restroom unassisted uses their toilet paper and staff do not know until they check on the resident. Prior Staff member via a phone conversation stated that caregivers are to check the toilet paper at minimum when emptying the trash which is done on each shift. The interview with maintenance staff stated they have extra toilet holders on hand due to residents, especially in the memory care unit, mistaking the toilet role holder as a grab bar and pulling the holder off the wall. Staff stated they have never been asked to remove a holder but does know there are times the brackets remain after the holder has been pulled off the wall. Maintenance staff was asked are you having any plumbing issues on the memory care side, staff stated no. At this time all staff interviewed stated they do not have residents with behaviors that are causing them to clog the toilets so no toilet paper is being withheld for that reason. On return visit of 7/2/25, LPA again toured 21 out of 21 resident restrooms in the memory care unit and the two (2) staff/public restrooms and found that all restrooms besides one (1) had toilet paper on the toilet roll holder, the one (1) room with it not on the holder, the toilet paper, and the toilet roll insert were on the counter, accessible to the resident if need. LPA also looked under approximately 10 sinks where staff stated extra toilet paper from family is stored. Some residents did not have additional supplies; staff were able to explain that there are four (4) residents having behaviors with toilet paper on occasion and therefore some families ask the director to keep the supply in the medication room. A pack of toilet paper was observed by the LPA in the medication room. (pg2) Continued on 9099-C All staff interviewed stated that about 85% of residents in memory care are incontinent and wear adult briefs. The process to assist these residents is to assist in toileting and / or changing briefs every 1 – 2 hours. Based on the information obtained, interviews conducted, and observations during the touring of the facility conducted on two occasions from licensing, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is Unsubstantiated at this time. On the allegation: Licensee does not ensure that resident is provided appropriate activities while in care. It was alleged that Resident 1 (R1) has asked to participate in activities on the assisted living side, but staff refuse to let R1 go. The reporting party stated that the activities in the memory care unit do not interest R1. During interviews with staff and residents, it was affirmed that R1 was able to attend events on the assisted living side at one time but has not been able to attend due to the supervision required while R1 is outside of memory care unit. Director and Administrator stated the resident could participate in assisted living events if family participated with R1 or provided someone to attend with R1. LPA reviewed R1’s record and noted that R1 is not currently paying for additional services regarding the following charge noted in the “Residency Agreement” which states an additional fee would be charged for escort to activities is needed: “In addition to the services listed in this Agreement and the services provided under “Residential Services” (Section I.A), residents may receive one or more of the following services, as needed, for an additional fee: (a) Assistance with…Escort to recreational, social, or religious activities provided on-site." Interview with two (2) residents from the assisted living area stated that the friends R1 would participate with have since moved, or passed, additionally R1 would attend meetings and would become disruptive, they also stated R1 would get lost in the elevator and was unsure how to get back down. The residents also stated that the events they had while R1 lived in assisted living, R1 never participated in. R1 enjoyed conversations with specific friends and believes that R1 may still be seeking those friends. The residents interviewed did state that they are willing to meet with or set up calls to visit R1 and ask if there are any items R1 would like discussed in the meetings for complaints and improvements. (pg3) continued on 9099-C Interview with the memory care Director, was stated that they have had events where they specifically ask R1 what they would like to do this particular day, they call it “[R1] picks”, they also asked for someone from the history museum that comes to the assisted living side, to also come to the memory care side which is something and someone that R1 likes to converse with. Director also stated R1 will appear interested one day and when the activity is scheduled, R1 chooses not to participate. They have also incorporated scenic drives in which R1 has participated in. Facility is hoping that provides a chance for R1 to socialize. LPA did note that event is on the activities calendar. LPA interviewed R1 in their room and observed R1 speak with the director about 30 minutes later. R1 was able to state they want to have social conversations, R1 was able during the visit, to carry on a back-and-forth conversation, was pleasant and sociable. R1 did however not remember specifics, could not provide LPA with what activities R1 wanted to participate in, and when R1 was observed in conversation in directors’ office, while pleasant, did not remember the LPA. Based on the information obtained, interviews conducted, and observations of licensing, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is Unsubstantiated at this time. Exit interview done, report given. (pg4)the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 29-AS-20250619151313

Allegation investigated: Facility did not seek timely medical care for resident Facility did not meets resident's needs Facility did not provide adequate supervision Facility did not observe change of condition in resident Facility did not conduct reappraisal of resident

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Ronald Freeman and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 7/2/2024 from 2:14pm to 4:30pm where LPA conducted interview with administrator and obtained relevant documents. LPA conducted a visit on 5/29/25 from 12:11pm to 3:17pm, where LPA again interviewed administrator, and re-reviewed records. Additional staff interviews were conducted via phone on 5/30/25 at 1:09 to 1:52 p.m., in person on 6/23/25 at approximately 12:52pm to 1:10pm, and via phone on 6/26/25 at 10:24am to 10:32am and 12:19pm to 12:39pm. LPA attempted to call/interview nine staff listed on the staff roster who were staff in the memory care unit during the timeframe Resident 1 (R1) resided in the facility. Four of those staff were interviewed and the remaining five staff were contacted, but did not respond to requests for interview. Interviews on 6/25/25, 6/27/25 and 6/30/25 were conducted with witnesses. Additional documentation was reviewed and collected on 6/30/25. LPA also reviewed medical records for R1. During interviews with the facility regarding the last entry in the narrative charting dated 12/9/22, staff and administrator stated that a new electronic charting began around this time, this new electronic charting has since been changed to another system and the original electronic charting notes are unavailable due to no access to the prior system, per administrator. Unsubstantiated Prior to admission into the facility, R1 had two hospital visits for concerns of head trauma. Hospital records for R1 indicated on 6/30/2022, a CT scan was completed due to concerns of head trauma, which was negative. R1 was admitted to the hospital on 10/8/2022 and discharged 10/16/2022. R1’s CT scan and hospital records indicate “either ex vacuo subdural prominence or chronic thin bilateral subdural hematomas” and “no acute bleed.” The records indicate R1 will continue their Eliquis medication because there is a “low risk of bleed despite having a single fall.” Records also noted the hospital staff “discussed this with [R1’s family] that with [R1’s] history of multiple falls they should consider taking [R1] off Eliquis or discuss this with [R1’s] cardiologist.” R1 moved into the facility in November 2022. R1’s physician’s report dated 11/7/2022 states R1’s primary diagnosis was “status post fall, L5 fracture, C1 fracture” with secondary diagnoses of dementia, atrial fibrillation, chronic embolism, thrombosis, and hypertension. R1 continued to take Eliquis. The physician’s report indicates R1 was confused/disoriented, able to follow instructions and communicate needs, and needed assistance with bathing, dressing/grooming, and toileting but was incontinent at times. R1’s initial health and service evaluation (assessment) dated 11/10/2022 states R1 was a fall risk and had 3 falls during the 25 days they were at the Skilled Nursing Facility (SNF). R1’s Morse Fall Scale assessment indicated they were a level 3 out of 3 fall risk, and it states, “implement high risk fall prevention interventions.” Facility document “CA Health and Service Evaluation” document has handwritten notes on page 1 that state that “Stand by on off toilet” and “Standby dress” is noted. Handwritten notes also indicate “falls” and “3 in Valley Oaks,” the resident is on “(blood thinners), and “Eliquis free through program.” The assessment indicates R1 had limited mobility, decreased balance and “gait limited,” and R1 would be provided with stand-by assistance for transfers, toileting, bathing, and dressing. There is no signature of who signed the document. The Morse Fall Scale and Evaluation forms note that facility was aware of a recent history of falls and resident was on blood thinners prior to intake. On 11/22/2022 at 2:46am, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had an unwitnessed fall and was found lying on their right side on the floor outside their bathroom. No complaints of pain and no apparent injuries. R1 was reminded to use their pull cord. On 11/23/2022 at 5:48pm, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had a fall when care staff were dressing R1 after a shower. There were no signs of redness or bruising and no complaints of pain. On 11/26/2022 at 9:35am, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had an unwitnessed fall with no complaints of pain and no signs of injury. On 12/9/2022 at 1:57pm, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had an unwitnessed fall in their apartment with no complaints of pain and no signs of injury. On 1/31/2023 at 12:43pm, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had an unwitnessed fall in their apartment, has small skin tear on right hand but no complaints on pain. R1 had numerous visits by Occupational Therapy and Physical Therapy from November 2022 through March 2023, with the goal of getting stronger and preventing falls. R1’s updated health and service evaluation results (assessment) dated 4/26/2023 indicates R1 would receive standby assistance for dressing, reminders and setup assistance for toileting, was continent but wore pull-ups/protective underwear, needed assistance with medication, no additional status checks, was a fall risk, was able to walk with walker, reminders to use their walker to go to meals, independent with transfers, standby assistance for bathing two times per week with a shower chair, provided reminders and setup assistance for grooming/personal hygiene, and uses chargeable hearing aids. The assessment indicates resident was oriented to person, has current history of occasional disorientation to person/place/time/situation, requires some direction and reminding from others, but is able to communicate effectively and make needs known. The assessment states R1 could not leave unassisted, will be provide with staff intervention assistance for wandering in public areas, not exit-seeking/intrusive behaviors, current or history of occasional poor judgement, may resist care at times, needs supervision because resident may make inappropriate decisions. The assessment also indicates R1 could use their emergency response system pull cord. The assessment was signed 4/27/2023 by R1’s responsible party, the resident services director, and the executive director. Current administrator stated that a review of the 4/26/2023 assessment provided that resident was improving based on the service plan being reduced in score, which equates to a reduction in service charges to the resident. On 5/9/2023 at 2:18am, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 was found in bed with a cut near their right eye and a tear on right hand. There was dried blood present, and R1 did not know what happened. First aid was provided. Administrator (who was not the administrator at the time of this complaint), noted based on the facility documents available, there was no indication how severe the cut or skin tear were. Administrator also indicated since R1 needed assistance with transfers, it seems unlikely they could have fallen out of bed and put themselves back in without staff assistance. On 7/5/2023 at 6:24pm, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had a fall in the hallway with no walker, had no visible injury or complaint of pain, and the fall was witnessed by a visitor. On 7/9/2023, R1 was taken by R1’s family to the hospital “for evaluation of jaw pain and swelling.” CT imaging was obtained to evaluate for a possible mandibular fracture, which was negative. CT scan and hospital records indicate R1 had “mixed attenuation right subdural hematoma consistent with an acute on chronic bleed” and “mild atrophy and mild chronic small vessel ischemic changes.” Hospital notes also indicate Eliquis would likely be discontinued due to recurrent falls, and “at least two episodes of subdural hematoma.” There is no indication exactly when the subdural hematoma(s) occurred. R1 was discharged from the hospital on 7/12/2023. An addendum created by the physician on 7/28/2023 noted among other things, antibiotics would be given for an odontogenic infection “fell two weeks ago and cracked a tooth in the same area.” Hospice consultation and records for 7/10/2023 indicate R1’s family member stated R1 had two brain bleeds in a two-week timespan. However, there were no medical records to support this exact statement. R1 was admitted to hospice on 7/12/2023. Multiple hospice records indicated R1 was alert and oriented and could answer some questions. Hospice records from 7/14/2023 also indicated R1’s baseline is independent with most ADLs with stand-by assistance by caregiver, and R1 ambulated with a walker. On the allegation: Facility did not seek timely medical care for resident. It was alleged R1 had a fall in May 2023, which resulted in them losing a tooth. It was alleged R1 was found covered in blood in the morning, but no medical attention was sought. LPA reviewed documentation for R1. No documentation was found specifying resident had a “fall”, however, a Physician Communication document was faxed to R1’s Primary Care Physician (PCP) on 5/9/2023 at 2:18am. The form indicated “your patient sustained an injury last night. [R1] was in bed with a cut near [their] right eye and a tear on right hand.” “…there was dried blood present. [R1] was cleaned and bandaged. [R1] did not know what had happened.” First aid was provided. Physician responded with a signature and date of 5/09/23 per the fax stamp of 5/09/23 at what appears to be 10:38 am. There was only a signature, no instructions noted in the “Physicians Instructions” section. Hospital records from July 2023 refer to a “cracked tooth.” There is no facility documentation of an injury to R1’s tooth. R1’s family member could not provide documentation about the tooth either, but did provide a photo showing a gap in their teeth, indicating a missing tooth. All staff interviewed stated they did not remember R1 losing a tooth. All staff interviewed indicated they knew of the requirement to seek timely medical care for residents, and explained the facility’s protocols. It was also alleged per the reporting party that on 7/8/2023, R1’s jaw was swollen, and a family member took R1 to the Emergency Room (ER). Per the reporting party, the CT scan found “two brain bleeds” “about a month apart.” LPA reviewed a Physicians Communication faxed on 7/5/2023 at 6:24pm which had a return note from the doctor faxed back at what appears to be 7/6/2023 at approximately 09:01am. Physician notes which were signed and dated 7/6/23, state “If [they have] no pain or obvious injury continue to observe.” LPA also reviewed an incident report (IR) submitted by the facility on 7/27/2023 for an incident dated 7/9/2023. The IR states on 7/9/2023 at 4:30pm, R1’s family member called to report they had taken R1 to urgent care for an antibiotic prior to a dental appointment, during which time R1 experienced a change in condition including increased heart rate. The family member took R1 to the ER to be evaluated. The IR states R1 was admitted to the hospital but discharged back on 7/12/2023 with no new diagnosis on their discharge orders but was stated to be appropriate for hospice. R1’s family member confirmed they observed R1’s jaw swollen and that is why they took R1 to the ER. Medical records indicated R1 presented to the ER for evaluation of jaw pain and swelling. The records note R1 was in “no apparent distress,” and was confused at their baseline. Records note some tenderness and induration over the mandible at the midline, which appear to correspond to a broken tooth and gingival erythema with no discrete abscess. Staff interviewed who remembered R1, stated they did not recall R1 having a change in condition on 7/6/2023, except for what the family member reported. All staff interviewed indicated they knew of the requirement to seek timely medical care for residents, and explained the facility’s protocols. Interviews and record review did not reveal any change in condition for R1 during this time that would have required medical attention. Based on the information obtained, the allegation may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. On the allegation: Facility did not meet resident's needs. It was alleged the facility did not meet R1’s needs due to the multiple falls sustained. R1 entered the facility as a known fall risk in November 2022 and sustained multiple falls. R1 also received Occupational and Physical Therapy as a fall intervention from November 2022 to March 2023, and R1’s falls decreased overall since admission. R1 did not require additional supervision, such as a 1 on 1 caregiver, and required less care based on their reappraisal in April 2023. The investigation did not reveal any indications that R1’s care needs were not met. There was no additional charting notes or documentation that supported the facility did not meet R1’s needs. Based on the information obtained, the allegation may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. On the allegation: Facility did not provide adequate supervision. It was alleged that due to a lack of staffing, R1 was provided inadequate supervision. LPA interviewed staff who stated that to their remembrance, the year of 2022 and 2023 the staffing was 2 caregivers consistently on each shift, in addition to a medical technician. One staff who worked NOC stated they remember being fully staffed, with the exception of some weekends and that there would be 2 caregivers on the Memory Care side during their shifts. Another staff interviewed started in approximately August of 2023 and stated that while they were there, the facility was fully staffed, or staff would cover shifts as needed. R1 needed stand-by assistance with some activities of daily living, but did not require constant supervision or a 1:1 staff per their service plan. As noted, R1’s service plan score reduced in April of 2023 as they required less services. Additionally, multiple hospice records from July 2023 indicate R1 was alert and oriented and could answer some questions. Staff schedules from the timeframe of the complaint were unavailable, due to the length of time since the incidents occurred. Based on the information obtained, the allegation may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. On the allegation: Facility did not observe change of condition in resident. It was alleged in May 2023, a family member saw R1 and noticed R1 was missing a tooth; however, R1’s responsible party was not informed about this. Interview with R1’s family member revealed that during the visit on 5/9/23, they noticed a front tooth was missing, and R1 still had blood on their face. The family stated they asked caregivers about R1 and what had happened. Per the family member, the caregivers seemed to acknowledge an incident happened during the night and cleaned R1 up, but did not indicate R1 was missing a tooth. LPA requested documentation supporting the allegations and family was unable to provide. The documentation provided by the facility did not indicate R1 had a fall or was missing a tooth. A Physician Communication form faxed to R1’s PCP on 5/9/2023 at 2:18am indicated R1 had a cut near their right eye, a tear on the right hand, and there was dried blood present. First aid was provided. No additional instructions were provided by the physician. During interview with family, photos were provided to LPA showing in December of 2022, R1 had all bottom teeth and in photo taken in 2023, there is a missing tooth in the bottom right side of R1’s mouth. Staff interviewed stated they did not remember R1 losing a tooth, and there was no documentation related to a lost tooth. Therefore, there is insufficient evidence to show that R1 was not observed for a change in condition. It was also alleged per the reporting party that on 7/8/2023, R1’s jaw was swollen, and a family member took R1 to the Emergency Room (ER). Per the reporting party, the CT scan found “two brain bleeds” “about a month apart.” Physician’s Communication forms faxed on 7/5/2023 at 6:24pm were sent informing R1’s PCP of a fall. The form was faxed back on 7/6/2023 at 09:01am and stated if R1 had no pain or obvious injury, continue to observe. LPA also reviewed an incident report (IR) submitted by the facility on 7/27/2023 for an incident dated 7/9/2023. The IR states on 7/9/2023 at 4:30pm, R1’s family member called to report they had taken R1 to urgent care for an antibiotic prior to a dental appointment, during which time R1 experienced a change in condition including increased heart rate. The family member took R1 to the ER to be evaluated. The IR states R1 was admitted to the hospital but discharged back on 7/12/2023 with no new diagnosis on their discharge orders but was stated to be appropriate for hospice. Interviews and record review did not reveal any change in condition for R1 during this time. Interview with family members contradicts that the resident was taken to urgent care or had a dental appointment on 7/9/2023. The family stated R1 was directly taken to the ER due to the time of day that they observed the swelling. Family members stated that the purpose of the ER visit was to get antibiotics due to the swelling in R1’s jaw, and that during the assessment at the ER the resident did have a change in condition with R1’s heart rate, which further prompted the discussion of a fall occurring a few days prior and led to the CT Scan being done. Family stated that R1 could not go to the dentist due to the stress and confusion it causes R1. Based on the information obtained, the allegation may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. On the allegation: Facility did not conduct reappraisal of resident. It was alleged the facility did not conduct reappraisal of R1 upon change of condition. R1 was admitted to the facility in November 2022 and was initially assessed on 11/10/2022. It was alleged R1 sustained five falls at the facility between November 2022 and March of 2023, which was supported by documentation. R1 did receive physical therapy and occupational therapy from 11/17/2022 to 3/17/2023. On 4/26/2023 an updated assessment was completed in which R1’s care level was lowered based on the facility’s reassessment of resident. An additional incident was alleged, and documentation supports, that on 5/9/2023 R1 was found in bed with a cut near the right eye, a tear on the right hand, and dried blood present. R1’s physician was notified, and no additional medical attention was deemed necessary. The family alleges that a tooth was missing following this incident, but the investigation did not reveal any documentation to support this claim. While an additional incident occurred following the re-appraisal on 4/26/23, the resident records provided by the facility, the reporting party, and by the family do not show a “significant change in condition” that would necessarily require a reappraisal. Based on the information obtained, the allegation may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jun 30, 2025 · control 29-AS-20240628143308

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 12:11 p.m. to conduct a 1-year annual visit to the facility above. LPA met Administrator Ronald Freeman and explained the purpose of the visit. A tour of the residential areas of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 97 bedrooms and 97 bathrooms, and 8 public restrooms currently occupying 99 residents and employs 67 staff. LPA toured common areas both in the Memory Care Unit and the Assisted Living areas. Areas reviewed were clean, safe and sanitary. The lighting and lamps are sufficient for the use of the facility and for residents’ comfort. Rooms 207, 224, and 240 were toured, these rooms are currently vacant. Showers have non-skid textured floors, and secured grab bars. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, and Theft and Loss policy. CCL Complaint poster was 20x26 in size and was at the front entrance. The LTCO poster was posted in the common area hallway of the facility. The current license was posted at entry. Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The facility is approved for a capacity of 122 non-ambulatory, which 12 may be bedridden and a current Hospice wavier is granted for 12. The Facility is operating in compliance with the granted fire clearance. LPA will return at a later date to complete the annual visit. Exit interview completed, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, May 29, 2025

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 staff handle resident in a rough manner.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Administrator Ronald Freeman and explained the purpose of the visit. LPA De Leon conducted the initial 10-day complaint visit, toured facility memory care unit, observed lunch service, requested records and interviewed staff at 10:45am, 11:00am, 12:40pm, 1:10pm, 1:20pm, 2:52pm and 3:11pm and interviewed residents at 11:20am, 11:45am, 2:00p and 2:20pm. LPA conducted a subsequnet complaint visit on 02/27/2025 and interviewed additonal staff from 10:45am-1:30pm. On the allegation: Facility staff handle resident in a rough manner. LPA De Leon interviewed staff, residents, and reviewed facility memory care records for staff and residents. Staff interviews revealed 1 out of 7 staff heard about an incident with a new NOC Caregiver Staff handling a resident roughly. Continued 9099-C Substantiated LPA requested and reviewed disciplinary records for Memory care staff caregivers which revealed a Corrective Counseling Documentation record for Staff 1 (S1) on 01/21/2025. S1 required corrective counseling for several incidents on this form, with one being during S1’s training period, it was reported that S1 spoke harshly and treated a resident roughly with taking a residents blood pressure reading, then on 01/07/2025 there was another incident regarding a resident 1 (R1) being agitated and would not return to the R1’s room, S1 was advised by another staff not to provoke the R1 any further, S1 went against the advice given and took R1 back to the R1’s room while in the room it was claimed the R1 hit S1 in the chest, S1 said S1 had to grab R1 and sit R1 down in a chair in R1’s room. S1 was questioned about the incident by another staff and S1 changed S1’s story. S1 was advised to write an incident report but wrote a note instead, R1 was assessed after the incident and new skin tears were observed on R1. Management had concerns with S1 so S1’s probationary period has been extended to 03/15/2025 although S1 has violated the Facilities prohibited conduct when S1 was caring for a resident in an unprofessional, rough, or demeaning manner on two separate incidents. S1 had other counseling incidents on the same form but none of those other incidents involved residents. Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator. On the allegation: Facility staff does not provide adequate food portions to residents. The facility has a Main Commercial Kitchen in the Assisted Living portion of the building, the cook prepares the food and portions the food into large servings containers with lids in warming trays and sent to the memory care kitchen to be plated and served. The portion of food is based on the memory care census of residents. LPA observed the lunch meal served in the memory care unit as the complaint was specific to the Memory Care Unit (MC). LPA observed the lunch meal to be a ½ of a large burrito with sides of spanish rice and black beans, which looked like an adequate serving for a lunch meal. LPA did not observe any substitution of food for this meal in the MC kitchen, staff interviews indicated if someone didn’t want to eat what was served, staff can call to the dining room and get something else for a resident. LPA interviewed a witness 1 (W1) that indicated the portion size was adequate for the lunch meal, but no other substitutions seemed to be offered and the resident that W1 was visiting did not like or want to eat the black beans and would have preferred to eat a taco over a burrito, just easier for the resident to eat on own. LPA observed several residents eating the meal served, many ate most of the serving, didn’t observe anyone getting more food, seen several residents still sitting with half to full plates. W1 visits often and feels some residents need help eating and may not be getting that and some may be slow eaters and just take longer to eat. Staff interviews revealed they learn the residents likes and dislikes and will always get residents another meal if residents do not like the meal being served, if staff see someone eat less at breakfast they offer them more at lunch, the staff feel the portions are good size and that the MC kitchen always has a lot of leftovers. LPA observed several portions of food remaining after service was done and most residents had left the dining room area. Based on the lack of evidence this allegation is Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 29-AS-20250203141805

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Feb 28, 2025

(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above, S1 handled R1 roughly causing skin tears and making R1 return to R1's room against R1's will which is an immediate health, saftey and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: Administrator agreed to re-train S1 in facility policy and procedures for abuse, reporting, and personal rights of residents in care and provide proof of trianing to CCL.

Allegation investigated: Staff did not provide a proper eviction notice to resident in care

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Administrator Ronald Freeman and explained the purpose of the visit. LPA De Leon conducted the initial 10-day complaint visit, toured facility, requested records and interviewed staff at 10:45am, 11:00am, 12:40pm, 1:10pm, 1:20pm, 2:52pm and 3:11pm and interviewed residents at 11:20am, 11:45am, 2:00p and 2:20pm. LPA conducted a subsequent visit and interviewed staff and residents from 10:45am-1:30 pm. On then allegation: Staff did not provide a proper eviction to resident in care. LPA reviewed records regarding Resident 1’s (R1’s) eviction letter, Admission Agreement with Resident Handbook, and House Rules, and Letters to R1 from the facility, as well as interviewed staff and residents. Continued 9099-C Unsubstantiated LPA De Leon reviewed R1’s Eviction Letter dated 01/27/2025, Admission Agreement with Resident Handbook with House Rules. The eviction letter includes Article II. E.2.a.(3) of the Agreement which states that the Community may, upon thirty (30) days written notice, evict a resident if (3) resident fail to comply with the general policies of the Community, this is also in the Admission Agreement page 12, this agreement was dated and signed by R1 on 09/08/2022. The policies are described in the Admission Agreement on page 19 under I. Miscellaneous 1. Rules and Regulations c. which states, Residents must not be disruptive, engage in conduct that poses a danger to themselves or others at the community, create unsafe conditions, or be physically or verbally abusive to other residents or staff. On Pages 31-35 Appendix D of the Resident Handbook House Rules page 34 states: Respect for Others: Residents, their guests and family members, must display respect for others in the community. Neither verbal or nor physically abusive behavior towards residents, employees, visitors, and/or anyone who is present in the Community will be tolerated. In Appendix E on page 36 The Oaks at Nipomo statement of Residents Personal Rights pursuant to title 22, California Code of Regulations, Section 87468.1(a) Residents in all residential care facilities for the elderly shall have all the following personal rights (1) To be accorded dignity in their personal relationships with staff, residents and other person and well as (2) To be accorded safe, healthful and comfortable accommodations, furnishings, and equipment. The interviews conducted during the course of the investigation of R1’s Eviction, R1 is infringing on other resident’s personal rights and causing a hostile environment for staff as well as other residents. LPA reviewed letters to R1 dated 11/15/2024, 11/28/2024, and 12/11/2014 all letters were regarding R1’s harassing staff or other residents and reminders about R1’s needs to follow house rules. R1 has been counselled on several occasions from 2023-2025 regarding harassment to staff and residents and on 01/27/2025 an eviction was issued. According to 7 out of 10 staff interviewed revealed R1 to be very rude to staff and other residents, tries to get into other residents’ business, harasses and makes some staff feel uncomfortable. According to 9 out of 9 residents interviewed R1 has been rude, harassing, yelled and belittled other residents in dining and activities. Several residents will no longer join R1’s table for meals or partake in activities that R1 has joined. Based on the evidence this allegation is Unsubstantiated, the eviction is lawful, at this time. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 29-AS-20250130150442

Allegation investigated: Staff handled resident in a rough manner Staff did not assist with medication as prescribed Staff did not address a resident's change in medical condition

Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit and issued final findings on the allegations above. During the investigation, LPA Miller, toured the facility and interviewed staff, and residents on October 22, 2024. LPA reviewed relevant documents. LPA met with Ronald Freeman, administrator and explained the purpose of the visit. On the allegation: Staff handled resident in a rough manner Reporting party (RP) alleges that they observed Resident 1 (R1), to be in severe pain and directed staff to stop their actions, (i.e.), stop changing R1’s brief. Continued on 9099-C Unsubstantiated This is an amended report. Freeman disputes that staff handled resident in a rough manner. Freeman stated that staff is required to reposition Resident 1 (R1) to prevent bed sores and also when changing soiled briefs. R1 groans each time they are repositioned, and it is not unusual. Freeman stated that a witness (W1) was not aware that R1 groaned each time they were turned. Multiple care staff were provided to R1 to mitigate any discomfort and support R1’s body while being repositioned. A credible witness (CW1) advised Freeman that Staff 1 (S1) and W1 had a verbal dispute regarding turning the resident on 2/21/24 at approximately 12:30 p.m. S1 disregarded W1’s direction to stop and Staff continued to change R1’s brief. CW1 subsequently advised that W1 will not return and to date, has not returned to facility. S1 refutes that they handled R1 in a rough manner. S1 further stated that R1 was not screaming, but moaning as R1 normally did when repositioned. S1 advised LPA that this was W1’s first encounter with R1. S1 alleges W1 became agitated at hearing R1’s moaning and was concerned for R1. W1 called their supervisor, who instructed staff to stop. S1 advised W1 that R1 could not be left in a soiled brief and left unclothed. Staff ultimately changed brief and put R1 back in bed. Krystal Cornejo (Cornejo), Resident Services Director, stated that she never observed any staff handle R1 in a rough manner, nor did she receive any complaints of staff handling R1 in a rough manner. Cornejo was not present on the date of the incident that occurred on 2/21/24, however, Cornejo is familiar with R1 and is aware that it was not unusual for R1 to make grunting and moaning noises. Cornejo stated that R1 could state when their body was hurting and staff did not report that R1 was screaming on the date of incident. Multiple staff stated that they never observed anyone handle resident in rough manner, nor did any residents complain about being handled in a rough manner. 7 of 7 residents stated that they are treated with dignity and respect by staff. 7 of 7 residents stated that staff do not handle them in a rough manner. Based on multiple interviews, there is not sufficient evidence to support this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. (Continued on 9099-C) On the allegation: Staff did not assist with medication as prescribed Reporting party (RP) alleges that Staff 1 (S1) advised that R1 had not received medication for approximately 20 hours nor was R1 pre-medicated before changing brief. Freeman disputes that staff did not assist with medication as prescribed, but will defer to Krystal Cornejo (Cornejo), Resident Services Director. Cornejo stated that R1 was on routine pain medication and was administered as prescribed. S1 refutes that they advised Hospice nurse that R1 went without pain medication for 20 hours. S1 stated that pain medication was administered 30 minutes prior to changing R1. LPA reviewed the MAR that reflects that R1 was provided pain management from 2/1/24 through 2/21/24, including an AM dose of Lorazepam on 2/21/24 and Methadone from 2/14/24 to 2/21/24. There is no evidence to support that staff did not administer medication as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. On the allegation: Staff did not address a resident's change in medical condition Freeman stated that R1 was a resident prior to being on hospice. As R1’s condition declined there was a change in services and staff kept up with R1’s change of condition. Krystal Cornejo (Cornejo), Resident Services Director, advised that Resident 1 (R1) was admitted to facility 8/2/2021 and had issues with mobility, but was independent and managed her own meds prior hospice. R1 crashed a motorized scooter into wall, went to hospital, and had a change in condition. Shortly thereafter, R1 was admitted to hospice on 11/14/2023. (Continued on 9099-C) Facility provided documentation to support that R1’s change of medical conditions was addressed in the 1/23/24 Service Plan and Hospice Care Plan. Cornejo advised that facility ensured that R1 was routinely monitored, every two hours. R1’s family assisted, and staff was called as needed. R1 was a 2-person assist, but because of mobility issues, facility had additional staff present to transfer appropriately. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, copy of report issued.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 29-AS-20240403105525

Allegation investigated: The facility apartments not being kept clean and free from odors. Facility staffing is not sufficient in dining to meet the needs of the residents

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met with Ron Freeman, Administrator and explained the purpose of the visit. LPA De Leon conducted the initial complaint visit on 12/11/2023 toured the 2nd floor, requested records, conducted interview with staff at 11:05am, 11:30am, 11:45am, 12:00pm, 12:30pm, 12:45pm, 1:00pm and 1:30pm and residents at 2:52pm and 3:00pm. On the allegation: The facility apartments not being kept clean and free from odors. LPA conducted interviews with staff and residents which revealed a 2nd floor apartment had foul odors. On 04/29/2024 an incident report was provided to LPA Miller that R1 was transported to the hospital for mental health evaluation. Administrator stated R1 did not return to the facility after that date. Continued 9099-C Substantiated The facility ruled unsanitary living conditions and the Fire Chief deemed the room a bio hazard, A bio hazard cleaning crew was brought in to remove the bio hazard and clean the room. Resident 1 (R1) was issued an eviction on 05/30/2024 with the following dates of noncompliance to keep room clean and free from odors 11/15/2023, 12/11/2023, 02/06/2024, 02/29/2024, 03/21/2024, 03/24/2024, 04/29/2024 along with multiple other dates ranging from 02/24/2024-03/19/2024 with refusals of care needs, room cleaning, and laundry services. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation: Facility staffing is not sufficient in dining to meet the needs of the residents. LPA interviewed staff and residents which revealed the dining room staffing is getting better but still short a few positions, dishwasher, busser and server. Staff stay late or staff come in early when they can. The staff call offs are what make the dining room short staffed when no one can cover the shift. Staff have had to work shorthanded, and the wait times can increase for residents. Staff stated you can’t look at the schedule because it does not reflect for call offs or no shows so you really can’t tell if the kitchen is short staffed by looking at the schedules. Facility census was 98 residents on 08/24/2023. LPA emailed Administrator on 08/29/2023 and asked what it looks like if the kitchen and dining are fully staffed. Administrator stated 1 AM cook, 2 AM servers, at 11:00am the PM staff of 1 dishwasher and 1 additional server come in for lunch and the PM service, 1 PM cook and 1-2 more servers for dinner. LPA De Leon reviewed the staff schedules for 12/01/2023-12/11/2023 for kitchen/dining staff. The facility census was 108 residents on 1/11/2023. On 12/02/2023 the facility was short 1 am server, on 12/03/2023 the facility was short staffed 1 am server, on 12/04/2023 the facility was short staffed 1 am server, on 12/05/2023 the kitchen was short staffed 1 cook in the pm, on 12/10/2023 the kitchen was short 1 am server, and on 12/11/2023 the kitchen was short staffed 1 am server. Staff stated the Food Service Director/ Chef does help cover positions when the facility is short staffed but not all the time. Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 29-AS-20231204161250

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 4, 2024

(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews and records the Licensee failed to comply with the regulation above, R1 was living in unsanitary living conditions which posed a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Administrator agreed to give invoices for the clean up of the bio-hazard and any other invoices for cleaning and sanitizing R1’s apartment.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(18) · Plan of correction due date: Sep 4, 2024

(b)The following food service requirements shall apply:(18)Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the regulation above, Residents have longer wait times in dining room when the kitchen staff are shorthanded which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Administrator agreed to provide LPA 1 month of schedules and the time clock hours actually worked for all kitchen staff for the month of August of 2024. Provide how many staff and positions for a fully staffed kitchen with a census of 100 residents and an up to date LIC 500.

Allegation investigated: Facility staff handles residents in a rough manner resulting in skin tears. Facility staff using profanity towards residents. Facility staff does not wear gloves when preparing food.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings in the complaint investigation. LPA met with Ronald Freeman Administrator and explained the purpose of the visit. LPA De Leon conducted the initial investigation on 01/20/2023, LPA toured the kitchen with Administrator, LPA collected the following records: Resident Roster with telephone numbers, Staff Roster with Telephone numbers, Staff schedule for January 2023 for Kitchen staff, caregivers and med-tech's, Kitchen menu, Kitchen cleaning checklist, Any disciplinary records for staff 1 (S1) or any other staff using profanity, any incident reports of Residents with food poisoning, Any resident evictions for January 2023, and Infection Control Training Records for all staff, LPA interviewed staff at 1:19pm, 2:02pm, 2:20pm, 2:45pm, and 3:20pm. Continued 9099-C Substantiated LPA De Leon conducted a subsequent visit to the facility on 08/23/2023. LPA collected additional records: staff schedules, resident roster and staff schedules for August 2023, Staff disciplinary records for 2023, and Call pendant logs. LPA conducted interviews with staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, and 4:15pm. LPA interviewed residents at 12:15pm, 12:30pm, 12:45pm, and 2:55pm. LPA De Leon conducted additional staff interviews on 08/24/2023 at 11:18am and resident interviews at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm, and 5:05pm. On the allegation: Facility staff handles residents in a rough manner resulting in skin tears. LPA interviewed staff which revealed 3 staff felt S1 handled residents in a rough manner and several residents told staff that they did not want assistance from S1. LPA reviewed disciplinary records for S1 which revealed S1 had a corrective counseling documentation dated 01/10/2023 where a peer reported S1’s approach with residents was a concern, S1 could be intimidating in size and tone of voice. The facility had a documented discussion with S1 for prohibited conduct -Caring for resident in an unprofessional manner and speaking to a resident in an unprofessional or discourteous manner, S1 was re-trained in customer service, dementia care, and proper re-directing techniques. On 02/21/2023 an internal investigation was conducted by the facility from 02/21/2023-02/24/2023 for allegation of elder abuse by S1. S1 was put on leave 02/21/2023 and was terminated based on the investigation and interviews from residents and staff for a violation of policy- prohibited conduct as of 2:45pm on 02/24/2023. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation: Facility staff using profanity towards residents. LPA reviewed records for S1 due to an internal investigation on 02/21/2023 conducted by the facility from 02/21/2023-02/24/2023 for allegation of elder abuse by S1. S1 admitted to using profanity when discussing a resident or care related conversations with other staff. Staff interview revealed staff heard S1 use profanity in front of residents. Based on the evidence this allegation is Substantiated. On the allegation: Facility staff does not wear gloves when preparing food. LPA De Leon interviewed staff which revealed staff 2 (S2) does not wear gloves when preparing food in the kitchen. Disciplinary records were reviewed on S2, S2 no longer works at the facility, and S2 was let go for other reasons. Based on the evidence this allegation is Substantiated. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator. LPA De Leon conducted a subsequent visit to the facility on 08/23/2023. LPA collected additional records: staff schedules, resident roster and staff schedules for August 2023, Staff disciplinary records for 2023, and Call pendant logs. LPA conducted interviews with staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, and 4:15pm. LPA interviewed residents at 12:15pm, 12:30pm, 12:45pm, and 2:55pm. LPA De Leon conducted additional staff interviews on 08/24/2023 at 11:18am and resident interviews at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm, and 5:05pm. On the allegation: Facility staff did not properly store food causing residents to have food poisoning. LPA conducted interviews with staff and residents which revealed some residents got sick from a meal served by the facility in 01/2023. The interviews conducted do no mention anything about food storage or food poisoning. The facility did not have any incident reports of food poisoning and none of the residents went to the ER for any type of food poisoning. LPA conducted unannounced visits on 01/20/2023 and toured the kitchen, all food was stored properly. LPA found no evidence to support food poisoning or improper storage of food by facility staff. Due to the lack of evidence to support this allegation it is deemed Unsubstantiated. On the allegation: Facility staff threatened to evict resident. LPA interviewed staff and residents which revealed no residents were threatened with eviction. According to staff interview a resident said a physical therapist not an employee of the facility told a resident that they needed to do the required physical therapy or could risk eviction if the resident didn’t do the rehab. Another staff said the physical therapist is stern to the clients about rehab and some residents do not like to hear it. Based on the evidence this was not a facility staff therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Facility kitchen is dirty. LPA De Leon conducted an unannounced visit on 01/20/2023, toured the facility Commercial kitchen and did not find it to be dirty. LPA conducted interviews with 15/16 staff which revealed staff did not think the kitchen was dirty. Resident interviews revealed 11/11 had not seen the inside of the kitchen, but a resident reported that other residents had and those residents were impressed with the kitchen, so the resident would not think it would dirty, if other residents were impressed. LPA reviewed schedules for kitchen staff with job duties which revealed the kitchen could be short staffed at times. It was stated in interviews that when short staffed if something did not get done on a staffs shift, it was done by staff on the next shift. Due to the lack of evidence this allegation is deemed Unsubstantiated ay this time. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 29-AS-20230119132542

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Aug 29, 2024

(a)... (8)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the regulation above, S1 handled residents roughly and was terminated from employment due to abuse complaints which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Administrator agreed to hold a training on all Personal Rights and Mandated Reporting and Abuse for all staff, provide proof of training with staff signatures and an up-to-date LIC 500.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a) · Plan of correction due date: Aug 27, 2024

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the regulation above S1 used profanity talking about the residents with other staff and using profanity in the presence of the residents which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Administrator agreed to re-train all staff on the facility’s policy and procedures for resident care. Provide proof of training with staff signatures and an up-to-date LIC 500.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(15) · Plan of correction due date: Sep 3, 2024

(b)The following food service requirements shall apply:(15)All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. This requirement was not met as evidenced by: Based on interviews the Licensee did not comply with the above regulation, staff preparing food did not wear gloves which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Administrator agreed to train all kitchen staff in AL/MC regulation 87555 Food Service, facility policy and procedures for food handling, preparing, cooking, and serving. Provide Proof of Training and an up-to-date LIC 500 to CCL.

Allegation investigated: Facility refused to provide transportation for the resident's appointment.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Ronald Freeman and explained the purpose of the visit. During the investigation, LPA Rankin conducted an initial visit on 8/19/24 from 10:58am to 2:15pm, toured the common areas of the facility, interviewed staff, interviewed residents, and obtained documents. LPA conducted additional interview with resident 1 (R1) on 8/23/2023 at 9:05 am. Continued to 9099-C Unsubstantiated On the allegation: Facility refused to provide transportation for the resident's appointment. It was alleged that staff refused to provide transportation back from a scheduled medical appointment. R1 stated the appointment was last minute due to an infection, doctor was able to accommodate an urgent appointment. R1 stated the facility agreed to take them, but R1 would need to pay for transportation through another source to get home. R1 did not want to pay for alternative transportation and felt the facility should pay. R1 is unclear on the original transportation agreement verbiage as it was 2 years ago. Documents collected by LPA showed for this event on 8/8/24, the request for transportation was made on 8/7/24 for an appointment on 8/8/24 at 10:30am and a second request made on 8/8/24 for an appointment on 8/8/24 at 1:30pm. Per facility interview, the 1:30pm appointment is when the facility told R1 they were able to take R1, but not pick R1 up, that R1 would need to use alternative transportation. Document also obtained from the transportation binder at the facility, per facility, they requested R1 write a list of all future appointments that R1 knew about, to prevent future missed appointments. Some of the noted dates on the list were observed to be added to the transportation schedule. The following documents note the transportation requirements set forth by the Plan of Operation, Residency Agreement (Admission Agreement) and the Resident Handbook. The Plan of Operation (rev 12/6/23 and prior versions) state under “Basic Services (1.) …Community will ensure that medical and dental needs are met. This will include (a.) In ensuring transportation is provided, Community staff shall transport residents or make arrangement for this service with an outside transportation service…. (11.) Assistance will be given to all residents in arranging all transportation needs.” Residency Agreement, signed by R1 states: (A.) Residential Services…” Assistance with transportation to and making arrangements for obtaining incidental medical and dental care. (1.) Living Accommodations (n.)Transportation. The Oaks at Nipomo will make available scheduled transportation to medical and dental appointments……Scheduled transportation within a twelve-mile radius of the Community is provided….. Charges for these services are set forth in Appendix B. Continued to 9099-C Appendix B states: “Transportation…Services” “The Community will provide a complimentary transportation on a scheduled basis….” Resident Handbook (Rev 3/1/18) states under Transportation: “The Community provides residents scheduled transportation within the surrounding areas. Requests on appointment days are first come, first served, and are provided within a limited area. Reservations for transportation may be scheduled by notifying the Concierge.” Copies of Residency Agreement and Appendix B were collected with R1’s signatures. In addition, the following documents were collected from the facility; a “Welcome Home” packet sample which included a flyer “The Oaks at Nipomo Transportation Schedule” which notes …” complementary transportation to medical appointments within a 12 mile radius…” “Monday 1:00 pm – 3:30 pm (limited availability), Tuesday & Thursday 9:00 am – 4:00 pm.” With a small note “Please make sure you give at least 5 business day notice so we can make arrangements for your transportation.” Per facility this packet is given to new residents when they arrive at the facility. Also provided was a list of five alternative transportation options: Senior Go, Dial-a-Ride, Whilshire Community Services, Uber, and Lyft. All services require prior scheduling except for Uber and Lyft. The allegation is deemed unsubstantiated at this time. Based on interviews and the facility documents obtained the facility provided ways for R1 to pre-schedule transportation requests and provides a minimum of 5 alternative transportation methods when the facility cannot assist. In this instance the resident scheduled the declined transportation on the same day as the appointment. Opportunities for R1 to take other transportation was given as an option, but due to the limited time frame and location, the only options where Uber and Lyft. LPA provided a Technical Advisory that the facility update at minimum their “Transportation” flyer/notice to clearly define their process for transportation with expectations as to the pre-scheduling timeframe and the operating days/hours. This should be posted in common areas, and on the activity bulletin board. Continued to 9099-C This requirement is also listed in the facilities licensee Operating Policy. Policy Number: LIFE-009 “2. The Community will establish the regular schedule. 3. The bus schedule will be posted on the activity bulletin board.” The initial “Welcome Home” packet does not specify the “give 5 business day notice” requirement, and other documents state “scheduled” transportation which can be miss interpreted and/or forgotten after residents remain in care. LPA also provided a Technical Advisory that facility management monitor requested scheduled transportation's to ensure a consistency is maintained when providing transportation during scheduled hours, so residents do no get accustom to schedule alterations and this type of accommodating schedules becomes an expectation. Exit interview conducted, copy of report given.the state’s words, verbatim · CDSS document, Aug 23, 2024 · control 29-AS-20240813082147

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin conducted an unannounced visit to the facility to conduct the facility annual inspection. LPA met with Sheryl McCaskill, Operation Specialist, and explained the purpose of the visit. The following was inspected and noted during the annual visit: Staffing: The facility employes 67 staff and 1 Administrators. Staff records are kept confidential. LPA reviewed 10 staff files and found all staff personnel documents to be complete. Personnel Records & Training: The facility keeps confidential files for each staff member. A review of training records was started and will be concluded during the follow-up annual visit. Administrator Certificate expire on 08/26/2025. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Three out of ten (10) files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. The final review of records will be done at a later date. The Facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required. Disaster Preparedness: The current emergency disaster forms were reviewed. The facility conducts quarterly disaster drills, last one was done on 6/25/24. Tour and additional required annual reviews will be conducted at a later date. Exit interview, report read and report provided.the state’s words, verbatim · CDSS document, Jul 11, 2024

Allegation investigated: Staff do not assist residents with showering. Staff do not answer residents' pendants in a timely manner.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met Raquel Counsins, Memory Care Director with and explained the purpose of the visit. LPA De Leon conducted the initial 10-day visit on 12/13/2022 at 9:30am, LPA conducted staff interviews at 10:30am, 12:30pm, 1:10pm, 2:30pm, and collected records requested. On 08/23/2023 LPA De Leon conducted a subsequent visit to the facility interviewed staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, 4:15pm and interviewed residents at 12:15pm, 12:30pm, 12:45pm, 2:55pm, On 08/24/2023 collected records, conducted interviews with staff 11:18am, with residents at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm and 5:37pm. Continued 9099-C Substantiated On the allegation: Staff do not assist residents with showering. LPA conducted interviews with 15 random staff and 12 random residents. Resident interviews revealed 5 out of 12 residents has issues with showers being rescheduled due to a lack of staffing available on their scheduled shower date and time. Staff interviews revealed 8 out of 15 staff said when the facility works short staffed with 2 caregivers or less showers run late, get rescheduled or when staff is available residents no longer want to take the shower. R1 has had 25 missed showers due to one of the shower days being Sunday on the PM shift and staff was not available to help assist R1 with showers. R1 pays for a care plan with two shower days per month with assistance. R1 had brought up the missed showers with the Nurse and the Administrator at that time and they had agreed to give coupons for guest dining to make up for the missed showers. R1 wanted dollar for dollar in coupons for the missed showers. R1 stated as of 08/24/2023 R1 had not been reimbursed for the missed showers as the facility had decided they were not going to give coupons for guest meals to reimburse R1 for the 25 missed showers on the dollar-for-dollar bases. R1 was still waiting for the facility to decide how to refund R1 for the missed showers. Staff interviews revealed that when the facility has 3 caregivers on the floor all the showers can be completed but when it goes down to 2 caregivers on the floor it gets harder to complete all the daily tasks and when 1 caregiver is on the floor alone several daily tasks can not get completed. Based on the evidence this allegation is Substantiated at this time. On the allegation: Staff do not answer residents' pendants in a timely manner. LPA interviewed with 8 out of 15 staff which revealed that if the facility is fully staffed, they can answer the residents’ pendants in 10 minutes or less. Staff had recently reported staff meetings where the pendants calls were reviewed with expectation on staff answering calls in 5-10 minutes. Staff stated if they have 3 caregivers on the floor they are able to meet all residents needs timely but when the facility has call offs and they become short staffed with 2 caregivers, they can work extra hard and still able to get most of the assigned duties completed, it is when the facility is short staffed with 1 care giver on the floor staff stated it is impossible to get all assigned tasks completed in a timely manner. LPA conducted interviews with 5 out of 12 residents which revealed when pushing the pendant, it took longer than 10 plus minutes to get staff assistance, at times staff took 30 plus minutes to assist, or staff did not come at all. Continued 9099-C LPA reviewed another 11 randomly chosen residents from the facilities resident roster to review call pendants logs from 12/01/2022-12/13/2022. The logs revealed 8 out of the 11 residents had pendants calls with waiting times of over 11-30 minutes long. Residents Pendant Logs revealed: One resident had 12 calls during this time period of 12/01/2022-12/12/2022 that were in excess of 10 plus minutes 11 min, 12 min, 2-13min, 14min, 16 min, 17 min, 21 min, 27 min, 3-30 minutes. Another resident had 11 calls during the same time period ranging from 11 minutes to 30 minutes. Another resident had 5 calls during this same time period ranging from 11 minutes to 30 minutes. Another resident had 13 calls during this same time period ranging from 15 minutes to 30 minutes. A shared apartment had 2 calls over 19 and 20 minutes during the same time period. Another resident shows 3 calls ranging in 11-30 minutes. Another resident reviewed had 29 calls ranging from 11 minutes to 30 minutes. The remaining 3 residents did not have any calls over 10 minutes. Based on the evidence this allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Staff and emailed copy to Administrator. On the allegation: Staff do not meet residents' incontinence needs. LPA interviewed staff and residents which revealed residents with incontinence care plans are conducted with rounds every 2 hours for staff to assist residents. Residents have call pendants and pull cords to use if assistance is needed at any other time. Call pendants are answered in order and according to needs of the residents. Some resident interviews stated some of the calls are not answered timely. Staff interviews revealed even when working short staffed on shift the incontinence needs of the residents are always taken care of on rounds, a few residents can be wet when checking on rounds, but all residents are checked and changed, residents are neglected, no residents have rashes or sores to indicate incontinence needs are not being met. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Staff do not properly supervise residents. The facility is an assisted living with a memory care unit on the premises serving senior residents that have added care plans based on the need of each resident. Assisted Living residents and Memory care residents have round -the -clock caregivers and medication technicians (Med-Tech) available by pendant or pull cords for assistance. The assisted living residents have the capability to call the front desk for non-urgent matters as well as call 911 for any urgent medical matters. The residents that have added supervision due to incontinence or memory care issues have 2-hour rounds conducted by the care giving staff to help. Some residents have added care plans for assistance with daily living for bathing, dressing, transfers, and 2-person assist. Residents interviewed did not have any concerns with supervision. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report printed for staff and emailed to Administrator.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 29-AS-20221205120051

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 26, 2024

(f)Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the regulation above several residents did not get showers according to the shower schedule which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: Administrator agreed to staff according to resident’s census and needs of the residents, provide staffing schedules, LIC 500, Resident Roster, all Care and Med-tech staff take a training course on grooming and hygiene, shower schedules, Continued below: and refusal process and provide proof of training with staff signatures to CCL. Provide refund to R1 for 25 missed showers and provide proof of refund to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 26, 2024

(a)...shall have all of the following personal rights:(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the regulation 8 out of 11 residents waited over 11-30 minutes to get assistance from staff which posses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: Administrator agreed to provide training on Personal Rights 87468, 87468.1, 87468.2 and mandated reporting provide proof of training with staff signatures to CCL.

Allegation investigated: Staff did not discard contaminated food.

Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit and issued final findings on the allegations above. During the investigation, LPA, Miller, toured the Memory Care Unit and interviewed staff, and residents on February 8, 2024, from 1:39 p.m. to 3:15 p.m. LPA also obtained and reviewed relevant documents. LPA met with Ronald Freeman, administrator and explained the purpose of the visit. On the allegation: Staff did not discard Contaminated food. On February 5, 2024, a witness visited the facility, and observed open containers of food in the small fridge in the pantry area, including a container with mold growing on it. See photograph of moldy juice box. The memory care director stated that staff is instructed to check the refrigerator on a daily basis. In addition, the NOC shift in memory care is required to go through the refrigerator and check for expired foods once a week as outlined in the NOC Caregiver Duties check list. In the event, food is expired, the director or staff will communicate with the kitchen chef, to bring items that are needs. Substantiated Three of three Staff members stated that the main kitchen brings a cart with hot food. The prepared food is kept in a steam table and then plated for residents. At the end of each meal, leftover plates are wrapped and labeled with the time, date and name of resident. Staff stated that lunch plates can be left out on the counter for up to one hour, then placed in the refrigerator and then tossed in trash by 2:00 p.m. Staff stated that expired foods are tossed out and Staff always reviews the expiration date before serving residents. Staff has never observed moldy food in refrigerator, including moldy juice boxes. Staff 1 stated that the Director of Kitchen, ensures that food supplies like hot chocolate and cereal are well stocked and checks for expired foods. Staff serves dinner at 5:00 p.m. Staff stated that wrapped plates can sit on a counter until 7:00 p.m. but is thrown away and not served to residents. Staff observed expired food in the refrigerator about a year ago. Staff further stated that resident family members often bring food and place in the refrigerator with their name and room number. Staff is not aware of anyone from main kitchen checking the refrigerator for expired foods. However, main kitchen staff stocks the refrigerator and cleans the kitchen. Staff stated that in the event a resident does not eat dinner, the plate is wrapped, labeled and may remain on the counter top unrefrigerated as late as 10:30 p.m. Staff stated that this occurs three times a week. Staff has offered these plates to night shift staff and if they are not eaten by staff, they dispose of food in trash. Kitchen Staff typically stock and dispose of expired foods. Staff stated that there have been occasions when juice has been expired and he has had to dispose of item. In one instance there was an opened bottle of juice that had been sitting for more than a month. Staff reminds staff to be vigilant and notifies a supervisor that he has disposed of the item. Staff is not aware of a scheduled date to go through the refrigerator and check for expired foods. Based on the information obtained, the allegation is deemed Substantiated at this time. The door under the sink is typically locked but the locking mechanism is lose and onsite maintenance will repair it February 9, 2024. Nothing under the sink is a danger to residents, but glass vases will be moved to a locked storage closet. The memory care director further advised that resident was hoarding forks and spoons, as such, the kitchen implemented a magnetic silverware catcher. The equipment was washed weekly and effective February 7, 2024, the equipment is washed daily. Three of three staff has no knowledge of a trap under sink and has no knowledge of any rodent issues. There was an issue with ants during the recent rainstorms and pest control came in last week to resolve it. Staff stated that small frogs and crickets enter the building from under the exit door and dining room door, during rainstorms. Staff stated that the magnetic silverware catcher was procured within the last four months and is cleaned weekly. Staff stated it will be cleaned more often. The cabinet under the kitchen sink has not been locked because chemicals are no longer kept in that location. Staff stated that they cleaned the magnetic silverware catcher on one occasion and has advised staff to clean it. Staff stated that the equipment is cleaned daily but it is very hard to get very clean. Staff stated that the magnetic silverware catcher is always dirty and is not sure how often it is cleaned. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 29-AS-20240206161459

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(23) · Plan of correction due date: Feb 12, 2024

All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement was not met as evidence by Based on interview and observation, the licensee did not comply with the section cited above when Staff failed to properly store food in refrigerator and was left out for several hours, which posed a health risk to residents in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Administrator agrees to issue a written memo to all staff who oversee the food areas of the facility, explaining expectations regarding the food and food safety. Administrator will provide a list of signatures of staff acknowledging the memo.

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