The Oaks at Paso Robles

Type of visit: Case Management - Incident

On 8/26/2026 at 2:00pm, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Incident visit to the facility. LPA arrived at the facility, met with Administrator Robin Murray, and announced the purpose of the visit. Community Care Licensing (CCL) recently received two separate incidents self-reported by the facility regarding medication errors. During today’s visit LPA conducted interviews and collected additional documents. On 8/4/2026, CCL received a report from the facility stating that on 7/30/2026 Resident #1 (R1) was mistakenly given the medication carbidopa levodopa 25mg/100mg by facility staff. According to the report staff immediately notified R1’s primary care physician and responsible person after realizing the error. Interviews and record review revealed R1 is not prescribed the medication and was given the medication due too staff error. The medication-technician who made the error was counseled and assigned additional online self-paced medication training that was due on 8/9/2026 and as of today’s visit records reveal the training has not been completed. On 8/19/2026, CCL received a report from the facility stating that on 8/7/2026 Resident #2 (R2) did not receive their anticoagulant medication, Coumadin 1mg, for six (6) days. According to the report, the error was discovered when R2’s family contacted R2’s primary care physician inquiring how R2 was doing. R2’s primary care physician contacted the facility at which point the facility discovered R2’s Coumadin order had been discontinued in the facilities electronic medication administration record (eMAR) on 7/30/2026. (Continued on LIC809-C) Review of an order received by the facility from R2’s primary care physician on 7/30/2026 at 3:28pm states to discontinue R2’s Coumadin 1mg tablet current dose, hold the Coumadin for two (2) days, and new dose begins 8/1/2026 of Coumadin 1mg tablet on Mondays, Tuesdays, Wednesdays, Thursdays, Saturdays and Sundays and on Fridays two (2) tablets. Interview and record review reveal R2 received a dose of Coumadin 1mg on 7/29/2026 and did not receive the medication again until 8/7/2026, when the error was discovered and R2 was given two (2) tablets because 8/7/2026 was a Friday. Due to staff error R2 did not receive Coumadin on 7/30/2026 and 7/31/2026 unintentionally following the physician order to hold the medication for two days. Meaning R2 did not receive their Coumadin from 8/1/2026 – 8/6/2026, or six (6) days. Interviews also revealed the error occurred when facility staff received the new order on 7/30/2026 and manually discontinued the previous order in the eMAR. Staff state that the pharmacy typically electronically enters new orders into the eMAR system for the facility and this did not happen. Staff state as a backup the facility will typically create a paper MAR to document new orders until the pharmacy enters the order electronically. Interviews and record review reveal a paper MAR was not created by staff until 8/7/2026 when the error was discovered. Although review of both incidents indicate that different staff were involved in each medication error and the facility self-reported the errors to CCL, it is important to note that the facility was previously cited during inspections conducted in February 2025, March 2025, and December 2025 for similar medication documentation and administration errors, demonstrating an ongoing pattern of noncompliance. Exit interview conducted, deficiency cited on LIC809-D page, report signed, appeal rights and report provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 27, 2026

(a)A plan for incidental medical and dental care shall be developed by each facility... (4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when staff provided R1 a medication they were not prescribed and did not provide R2 their medication as prescribed, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: Administrator states they will submit a plan to the LPA by 8/27/2026 detailing formal counseling plans for staff who made the error and ensure staff training is completed by 9/9/2026. They will email the completed training certificates to LPA on or before 9/9/2026.

Allegation investigated: Staff did not follow resident's care plan. Staff mismanaged resident's medication.

At 10:00am, on 7/9/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to further investigate the allegation(s) of this complaint and deliver final findings. LPA met with Administrator Robin Murray, announced who he was and the reason for the visit. During a visit on 4/15/2026 LPA toured portions of the facility, conducted interviews, and collected relevant documentation. On the allegation, staff did not follow resident's care plan; it was alleged that in October 2025 Resident #1’s (R1’s) level of care was changed from level 2 to level 5. Since this increase, R1’s bathing and grooming needs are not being met yet they have been paying for the level of care increase. (Continued on LIC9099-C) Substantiated Interviews and record review revealed that the facility uses a point-based system to determine each resident’s level of care. There are seven levels of care, with higher levels associated with higher monthly fees. LPA review of R1’s admission agreement indicates that upon admission in November 2024 R1 was assessed at level 2 and a service plan states this is due to requiring assistance with medication management and cognitive/orientation. The admission agreement and facility rate card indicate that a level 2 care is a $1,300 monthly fee. A reappraisal dated 10/30/2025 documented increased care needs, including full two-person assistance for bathing, grooming reminders, and additional support with other activities of daily living (ADLs). This reappraisal placed R1 at level 5 care. The facility rate card lists level 5 care at $3,050 per month. Interviews confirmed that the primary reason for the increase was to provide full assistance with bathing. Facility account summary statements show that R1 began being charged at the level 5 care rate on 10/29/2025 until they moved out of the facility in April 2026. The facility uses the August Health Care Tracker system to document staff assistance with ADLs. The facility provided logs showing consistent documentation of dressing and grooming assistance for R1; however, no entries reflect staff providing bathing assistance or R1 refusal of bathing assistance. Staff interviews indicated that an audit was conducted by corporate personnel. The audit showed that when the increased bathing needs were noted on R1’s service plan in November 2025 it was not transferred over to the care tracker system to notify staff R1 required assistance with bathing. When R1’s responsible party brought this to staff attention in March 2026, staff stated more of an effort was made to provide R1 assistance. The facility has since provided a partial refund for the increase. Based on all interviews conducted and documents obtained, R1 was charged for increased level of care including bathing which they were not receiving from November 2025 to February 2026. 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. (Continued on LIC9099-C) On the allegation, staff mismanaged resident's medication; it was alleged that sometime last year (2025) staff gave R1 the wrong medication. The medication was OxyContin. This allegation was addressed during a case management – incident visit conducted on 3/26/2025 by this LPA. On 3/24/2025 the facility self-reported a medication error stating that on 3/23/2025 at approximately 10:10am staff gave R1 another resident’s medications, including a 0.5mg tablet of lorazepam and a 5mg tablet of oxycodone. The staff realized their error, reported it to the Resident Services Director who does not work at the facility anymore, and at approximately 12:15pm staff called 911. R1 was taken to the local hospital where they were observed, and R1 returned to the facility on the same day. Based on all interviews conducted 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. A citation was issued during the case management – incident visit conducted on 3/26/2025, an additional citation for this allegation will not be issued today. Exit interview conducted, deficiency cited on LIC9099-D pages, report signed, appeal rights and report provided to the Administrator. Review of notes documented by staff in R1’s electronic records reveal that on 3/25/2026 at approximately 4:00pm care staff checked on R1 and found them sitting on their couch with soiled clothing, care staff notified a med-tech and when they asked R1 what had happened, R1 stated they had fallen and passed out in the bathroom. Staff called 911, emergency responders arrived and consulted with R1’s responsible party, and R1 was transported to the local hospital for further evaluation. R1 returned to the facility on the same day at approximately 9:45pm. Review of the Device Activity Report that tracks resident pendant and bathroom pull station use throughout the facility has no logged events for devices R1 could have used to alert staff of their fall. Interviews revealed R1 did have a pendant, and LPA observed a pull station in R1’s bathroom. Based on all interviews conducted 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. On the allegation, staff did not provide transportation to resident; it was alleged that R1 had an appointment last year that Staff #1 (S1) was supposed to take R1 to. S1 was not able to take R1 to their appointment and instead got R1 an Uber to transport R1 to the appointment. It was alleged that someone from the facility should have been there accompanying R1. R1’s admission agreement states that the facility will make available scheduled transportation to medical and dental appointments. Scheduled transportation within a twelve-mile radius of the facility is provided and there may be an extra charge for services outside the service area and for escort services for those who need assistance. (Continued on LIC9099-C) Review of R1’s medical assessment (LIC602A) dated November 2024 states R1 is able to leave facility unassisted using their electric scooter, Lyft, or Uber. R1’s service plan dated 10/31/2025 states R1 is independent with mobility and uses an electric scooter for long distances. Neither R1’s medical assessment or service plan indicate they require someone to accompany them to appointments. A facility log of transportation requests indicates R1 had an appointment on a day in August 2025. Interview’s revealed that although S1 could not take R1 to the appointment Staff #2 (S2) did take R1 to the appointment. Title 22 regulations for residential care facilities for the elderly state that the licensee shall provide assistance in meeting necessary medical needs of residents including transportation needed which the licensee shall do so directly or make arrangements for. Based on all interviews conducted 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. On the allegation, staff did not ensure facility is clean, safe, and sanitary; it was alleged that R1 moved out of this facility and moved to another facility where it was discovered that R1 had small bugs crawling all over them, out of their beard and in their mouth. Interview and record review reveal that R1’s last day at this facility was 4/6/2026 and they moved into another facility on the same day. On 4/7/2026, staff at the other facility assisted R1 with their bathing and grooming needs and noticed small insects crawling throughout R1’s body hair. On 4/7/2026, R1 was diagnosed and treated for a form of body lice. After R1 relocated, but prior to removing their personal items, R1’s responsible party requested the facility have the room and personal belongings inspected for the lice by pest control. On 4/15/2026 the facility had a pest control company out to inspect R1’s room. Review of the pest control invoice dated 4/15/2026 states there was no evidence of lice or related activity observed. No additional cases have been reported among staff or residents. Interviews and resident sign-in/out logs revealed that R1 spent time out of the facility on a regular basis. Based on the information available, it cannot be determined where or when R1 acquired the lice. (Continued on LIC9099-C) Based on all interviews conducted 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. On the allegation, staff did not ensure resident was provided clean clothing; it was alleged that R1 has not been provided clean clothing which the level of care increase should also cover. R1’s admission agreement lists one load of personal laundry per week at $125/month as an additional fee. Invoice statements for R1 do not list a charge for personal laundry. Interviews revealed that the base rate does include laundering of resident linens once a week, however resident personal clothing is an additional fee. Interviews also revealed there was no agreement for R1 to receive personal laundry services from facility staff and the levels of care increases do not include personal clothing laundry services. Staff stated that occasionally they would wash R1’s clothing. The facility does have personal laundry rooms that residents may use freely. Based on all interviews conducted 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. On the allegation, staff did not issue resident's responsible party a refund; it was alleged that R1 has not been reimbursed for the increased level of care that they are paying for and not receiving. It was also alleged that the facility was notified that R1 would be moving out in April 2026, yet the facility had taken a full month of rent out of R1’s account for the month of April. R1’s admission agreement states that termination by the resident is allowed with or without cause by giving the Executive Director (Administrator) thirty (30) days prior written notice and the resident is responsible for the full monthly fee until the thirty (30) day period has expired. The admission agreement also states that within thirty (30) days after the resident’s apartment has been vacated including all personal property a refund will be issued for any amount owed from the facility to the resident. (Continued on LIC9099-C) Review of R1’s admission documents revealed R1’s responsible party setup automatic payments to the facility through an automated clearing house (ACH) setup. The admission agreement states that monthly fees are due in advance by the first day of each calendar month. A review of a final invoice dated 5/1/2026 indicates the facility received the ACH payment on 4/6/2026. Record review revealed R1’s responsible party emailed the Administrator on 3/31/2026 giving a 30-day notice that R1 will be moving out and R1’s last day at the facility was 4/6/2026. Interview and record review reveal that all of R1’s personal items were removed from the facility on 4/15/2026. A final invoice dated 5/1/2026 states the facility issued a refund for rent from 4/16/2026-4/30/2026, a pendant fee and a level 5 care increase from 4/7/2026-4/30/2026, as well as a partial refund for increased care for 11/1/2025-4/30/2026. The refund check for the amount listed on the statement was issued on 4/30/2026, postmarked 5/4/2026. Based on all interviews conducted 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. Exit interview conducted, report signed, and report provided to the Licensee.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 29-AS-20260407133349

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jul 23, 2026

(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with modifications made to the level of care R1 required and was billed for which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Administrator states they have been auditing and reviewing that all steps are conducted to communicate changes in resident services. They stated they will also conduct a formal training with the RSD and staff regarding the policy for updates on service plans and the care... tracker system and email training and staff roster to LPA by 7/23/2026.

Allegation investigated: Staff caused injury to resident in care. Staff handled resident in a rough manner while in care. Staff did not follow reporting protocols as necessary.

At 10:00am, on 7/9/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to further investigate and deliver final findings of the above allegations. LPA met with Administrator Robin Murray, announced who he was and the reason for the visit. During a visit on 3/18/2026, LPA conducted interviews and collected relevant documentation. On the allegation: staff did not follow reporting protocols as necessary; it was alleged that Resident #1 (R1) was injured by staff during personal care causing R1 to have a raised swollen bruise on their chest approximately three inches long by two inches wide. It was also alleged that R1 reported this incident to Staff #1 (S1) moments after it occurred and on 2/18/2026, R1 told a witness (W1). W1 brought this information to the Administrator’s attention on the same day, 2/18/2026. It was alleged the facility did not report the suspected physical abuse of R1 as required within 24 hours to the proper agencies. (Continued on LIC9099-C) Substantiated Interviews revealed that R1 did have an injury matching the description as alleged and that the injury showed up on approximately 2/17/2026. On 2/18/2026, the Administrator was made aware of R1’s injury by W1 and that the suspected cause was physical abuse from staff. W1 reminded the Administrator of the requirement to report this incident within twenty-four (24) hours to the proper agencies. Record review and additional interviews revealed that the facility submitted an incident report (LIC624) to Community Care Licensing Division (CCLD) on 2/24/2026, indicating R1 had a discoloration on their sternum that they stated was received from care staff and that R1 had also reported it to a med-tech days prior stating they had received it in the shower. The facility reported the suspected physical abuse of R1 to the Local Ombudsman office on 2/25/2026 via a written Report of Suspected Dependent Adult/Elder Abuse form (SOC341). Record review and interviews reveal the facility never reported it to local law enforcement. CCLD cross reported the alleged abuse to law enforcement. Interviews with the Administrator, Memory Care Director, and Regional Nurse revealed differing explanations for why the incident was not reported within the required time frame of two (2) hours verbally to law enforcement and twenty-four (24) hours in writing using form SOC341 to the long-term care ombudsman, law enforcement and CCLD. Despite these differing perspectives, all three individuals are mandated reporters and had sufficient information to ensure timely reporting. The delay therefore reflects a collective failure to fulfill mandated reporting obligations. The facility has since changed their reporting protocol to ensure reports are sent timely. Based on all interviews conducted and documents obtained, the facility did not follow reporting protocols by taking over twenty-four (24) hours to report suspected elder abuse and never reported it to local law enforcement as required by law, 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. On the allegations: staff caused injury to resident in care and staff handled resident in a rough manner while in care; it was alleged that Resident #1 (R1) was injured by three staff pulling and tugging on R1 while they assisted R1 with a shower on a day in February 2026 resulting in a raised swollen bruise on R1’s chest approximately three inches long by two inches wide. R1’s right arm also hurt due to the incident. (Continued on LIC9099-C) LPA record review revealed R1’s medical assessment dated 10/12/2025 states R1 is not able to bathe self and is diagnosed with dementia. R1’s service plan dated 11/13/2026 states under “Bathing” that R1 requires stand-by assist when bathing, it also states R1 requires moderate/max assist with bathing, 1 person assist. A note in R1’s digital chart created at 4:19am on 2/17/2026 states that R1 made the medication technician (med-tech) aware of a bruise on R1’s chest, the bruise is 1.5-inch x 3-inches on R1’s breast bone, and the resident told the med-tech that it was from a shower done the day before. The facility shower schedule indicates R1 is scheduled showers three days a week including Mondays, and 2/16/2026 was a Monday. Staff stated that R1 did have a shower that Monday, 2/16/2026. Staff interviews revealed R1 needs assistance from two to three staff during showers because R1 does not like taking showers or getting their hair wet. Staff and resident interviews revealed that R1 did have an injury matching the description as alleged, that the injury showed up on approximately 2/17/2026, and appeared as discolored skin on R1’s chest; some interviews stated it looked like a bruise. Interviews and record review revealed, though diagnosed with dementia, R1 on multiple occasions consistently described to different people the circumstances, number of staff involved and approximate date of the injury. On 2/18/2026, R1 stated to W1 there were 3 staff tugging and pulling on them in the shower when they refused to have their hair washed, this happened during their last shower and R1 reported this to S1; on the same day, R1 stated to W1 and the facility Administrator that the injury occurred when staff were being rough with them while assisting with their shower and R1 told S1 about it; on 3/13/2026, R1 stated to law enforcement that the injury occurred approximately a month ago when three staff entered their room, grabbed their arms forcing them to take a shower, they told the staff they did not want to shower because they had just had their hair done, and after the staff left R1 reported the incident to S1; and on 3/18/2026 R1 stated to the LPA that three or four weeks ago, three staff forced them to take a shower, during the shower R1 received an injury to their chest, and that they reported it to S1 who does not work at the facility anymore. Additional interviews confirm S1 no longer works at the facility for unrelated reasons and S1 was unable to be interviewed. (Continued on LIC9099-C) While investigating this complaint the facility self-reported two additional incidents regarding staff handling residents in a rough manner. On 3/24/2026 CCLD received an incident report and SOC341 from the facility regarding another resident, Resident #2 (R2), who had a discolored spot and small skin tear on their right hand. Interviews revealed the discolored spot and skin tear occurred during care of the resident when staff grabbed and pulled on R2’s hand while they were turning R2 in bed. On 6/25/2026 LPA received a phone call from the Administrator and an SOC341 on 6/26/2026 regarding an incident that occurred on 6/24/2026 where multiple witnesses observed Staff #2 (S2) hold Resident #3’s (R3’s) hands down so that R3 could not move their arms and then S2 wrapped their arms around R3 and roughly transfered R3 to a wheelchair causing R3 to raise their voice stating “that hurt”. Staff assessed R3 for visible injury. S2’s employment was terminated on 6/25/2026. Based on all interviews conducted and record review, staff handled R1, R2, and R3 in a rough manner resulting in pain and/or injury, at this time the above allegations was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted, deficiencies cited on LIC9099-D page, report signed, appeal rights and report provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 29-AS-20260311171250

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 10, 2026

(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 record review the Licensee did not comply with the regulation above, when staff handled R1, R2 and R3 in a rough manner resulting in injury which is an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Facility terminated S2's employment and provided other staff corrective action. Administrator states they will conduct staff training during the next all staff on 7/21/2026 regarding dignity and handling of residents and email LPA the training notes and staff roster by 7/23/2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Jul 23, 2026

(c) Any suspected physical abuse that does not result in serious bodily injury of an elder... adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours... This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not ensure suspected physical abuse of R1 was reported as required which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: The facility has changed the reporting protocol. The Administrator states they conducted mandated reporter training on 6/16/2026 at the all staff meeting and will emial the LPA the training notes and roster from that training by 7/23/2026.

Allegation investigated: Staff spoke inappropriately to resident in care.

At 9:05am, on 3/18/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to deliver final findings to the allegation of this complaint. LPA met with Administrator Robin Murray, announced who he was and the reason for the visit. During a previous visit to the facility on 12/16/2025, LPA interviewed staff, residents, the administrator at the time, and obtained relevant documents. On the allegation: Staff spoke inappropriately to resident in care; it was alleged that in the main lobby of the facility on a day in December 2025 Resident #1 (R1) was speaking with Administrator Carl Meyer. The discussion between them got very loud and heated. At one point it appeared that Meyer stood in front of R1’s walker to prevent them from leaving. There were multiple residents and staff in the main lobby who observed the conversation. (Continued on LIC9099-C) Substantiated Staff and resident interviews revealed this conversation did take place between Administrator at the time, Carl Meyer, and R1 in the main lobby, and that leading up to this interaction, Meyer had two additional public conversations with R1 and their family that R1 did not appreciate being discussed so publicly. Interviews stated both Meyer and R1 raised their voices at each other, at one point Meyer made a comment about how he runs the facility, not the residents. Toward the end of the conversation, R1 repeatedly stated they did not want to continue the conversation, Meyer was standing in front of R1 preventing R1 from walking away, and when Meyer finished, he moved out of the way. Based on the investigation, the conversation made other residents witnessing the conversation uncomfortable causing them to get up and leave the area. Staff and residents stated during interviews that they felt like Meyer should have had these conversations more discreetly and they are not sure why that didn’t happen. Additional interviews revealed that after this conversation R1 remained in their room for a couple days, not continuing their normal routine of attending every meal, as it had made R1 feel uncomfortable and intimidated. During LPA interview with Carl Meyer, Meyer admitted he should have handled the situation differently. As of 1/14/2026, Meyer no longer worked at the facility. Based on all interviews conducted, 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. Exit interview conducted, deficiency cited on LIC9099-D page, report signed, appeal rights and report provided to the current Administrator, Robin Murray.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 29-AS-20251210162900

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 15, 2026

Personal Rights of Residents in All Facilities (a) Residents… 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 interview, the Licensee did not ensure R1 was accorded dignity when staff spoke inappropriately to R1 which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Administrator states they will review residents rights and communication training with all staff at the next all-staff meeting and will submit training and signed staff roster to LPA by 4/15/2026.

Type of visit: Required - 1 Year

At 9:00am, on 12/16/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Administrator Carl Meyer, announced who he was and the reason for the visit. This is a three story facility with ninety-seven resident rooms, of which twenty-four are in Compass Rose, the memory care unit on the south end of the second floor. The main entrance is located on the second floor. LPA noted a large lobby space when entering the front door with a reception desk, administrative offices, a television displaying activities, announcements, and menu items, and multiple areas for residents and guests to sit and visit. The facility has smoke detectors in each bedroom room and throughout the facility that were tested by Alpha Fire & Security Alarm on 11/20/2025 and a sprinkler system also tested on 11/20/2025. There are two rooms for resident medication storage, one in the memory care unit Compass Rose and the other located in a room on the second floor of the assisted living portion of the facility. At approximately 10:00am LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records (CSMRs), finding nineteen (19) medications not documented on resident CSMRs. Staff could not provide documentation of these nineteen medications centrally stored. LPA was not able to complete the annual inspection and may return at a later time to finish. Exit interview conducted, deficiency cited on LIC809-D, reports signed, reports and appeal rights provided to Administrator Carl Meyer.the state’s words, verbatim · CDSS document, Dec 16, 2025

Allegation investigated: Staff do not ensure resident is provided clean linens Staff do not ensure resident is provided assistance with personal grooming and dressing

On 10/1/2025 at 1:00pm Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to deliver final findings to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. On 07/08/2025, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced initial complaint investigation visit to the facility. During the visit, the LPA requested and received facility documentation relevant to the investigation. LPA interviewed residents, staff, and the Administrator. The LPA determined further investigation was needed prior to issuing findings. On allegations: Staff do not ensure resident is provided clean linens and staff do not ensure resident is provided assistance with personal grooming and dressing. It was alleged that Person #1 (P1) found Resident #1 (R1) left in soiled bed sheets one day in June 2025 and R1’s hair was not brushed. (Conintued on 9099-C) Unsubstantiated LPA reviewed R1’s file which reveals R1 resides in the assisted living portion of the facility. R1’s admission agreement states the facility will provide weekly housekeeping services including laundering sheets and towels. Additional housekeeping, bed making and laundry services are available for an additional fee. Interviews and record review of R1’s care plan dated 7/1/2025 reveal the facility is washing R1’s linens up to three times per week at no additional cost. Record review of R1’s care plan indicates R1 is incontinent of bladder and requires hands on assistance from staff with their toileting needs but is able to participate in much of the task. LPA interviewed R1 and R1 stated the staff have never left them soiled in bed. Their towels and sheets are washed by staff at least once per week or more often. LPA observed R1’s linens on 7/8/2025 and 7/23/2025 noting no stained or soiled linens. Record review of R1’s care plan indicates R1 requires standby assistance from staff when dressing and grooming in the morning. LPA interview with R1 revealed R1 likes to sleep in and would sleep past noon if they could every day. R1 said the staff come in to try to get them up but R1 tells the staff they want to stay in bed longer. R1 stated the care at the facility is good and when the staff help R1 get ready they help them with their dressing and grooming needs. Staff interviews reveal that staff attempt to encourage R1 to get up in the morning, R1 often refuses and wants to sleep in. Interviews reveal R1 really likes one particular staff member so the facility has asked that employee to assist R1 each morning when they can and when they cannot other staff assist R1. Based on observation, all interviews conducted 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.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 29-AS-20250630114830

Allegation investigated: Due to lack of supervision, resident has fallen multiple times resulting in injuries

On 10/1/2025 at 1:00pm Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a subsequent complaint visit to deliver findings for the above allegation. LPA met with Administrator Carl Meyer and explained the purpose of the visit. On 03/13/2025, the Woodland Hills North Adult and Senior Care Regional Office (RO) originally received this complaint regarding neglect/lack of care and supervision. The complaint alleged that Resident #1 (R1) sustained multiple falls and injuries while in care at the facility due to staff neglect and lack of supervision. The complaint also included an allegation that food is not of quantity to meet the needs of residents. On 3/18/2025 the complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jorge Jauregui. (Continued on LIC9099-C) Substantiated On 3/18/2025 the CCLD RO received an additional complaint regarding R1’s care at the facility with the control number 29-AS-20250318102817. Investigator Jaurequi investigated allegations of both complaints during the investigation. On 03/17/2025, from 11:50am to 1:30pm, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced initial complaint investigation visit to the facility. LPA Haner-Tomasko met with Administrator Carl Meyer and explained the reason for the visit. During the visit, the LPA requested and received facility documentation relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings. Investigator Jauregui conducted interviews; on 04/09/2025, at approximately 2:05pm, with the resident representative for R1; on 04/15/2025, from approximately 9:50am to 1:58pm, with the facility Administrator Carl Meyer, staff and residents; at approximately 3:37pm, with Person #1; on 04/18/2025, at approximately 8:15am, with a former staff; on 04/22/2025, at approximately 3:19pm with another former staff; on 07/25/2025, at approximately 8:32am, with Person #2 (P2); on 08/05/2025 and 08/14/2025, additional interviews with Administrator Carl Meyer; and on 08/11/2025, at approximately 1:13pm, an additional interview with former staff. In addition, Investigator Jauregui reviewed medical records from Twin Cities Community Hospital (TCCH), the County of San Luis Obispo, and facility file documents related to the investigation. On 3/17/2025 and 7/23/2025, LPA Haner-Tomasko interviewed additional staff and the administrator. On the allegation: Due to lack of supervision, resident has fallen multiple times resulting in injuries. LPA reviewed documents including R1’s physician’s report, pre-admission appraisal, service plan, and incident reports. R1’s physician’s report dated 03/12/2024 indicates R1 was diagnosed with rhabdomyolysis, dementia, hyperlipidemia, anxiety, anemia, and history of falling. R1 was considered nonambulatory, had a visual impairment, required continuous bed care, was confused/disoriented at times, required assistance with bathing, dressing, grooming, and toileting. A pre-admission appraisal dated 3/7/2025 indicates the resident uses a wheelchair for mobility. Interviews revealed R1 got around the facility in their wheelchair. (Continued on LIC9099-C) A service plan dated 1/27/2025 indicates R1 required standby assistance from staff to bath, dress, groom, transfer and needed frequent help due to disorientation, memory loss, and difficulty completing tasks. The investigation revealed that R1 sustained falls and incidents on the following dates: on 06/08/2024, at approximately 5:17pm, R1 suffered an unwitnessed fall, R1 had a bump and bruising on their forehead, Emergency Medical Services (EMS) was called, and R1 was taken to TCCH. TCCH records reveal R1 was discharged back to the facility on the same day with a diagnosis of closed head injury; on 12/09/2025, at approximately 9:15pm, R1 was found on the floor, EMS was called and R1 was not transported to the hospital; on 12/15/2024, at approximately 7:00am, R1 slipped off their bed, no injuries were observed. EMS was not called; on 12/24/2024, at approximately 2:27pm, while in the hallway staff witnessed R1 lean forward in their wheelchair and fall headfirst, R1 sustained a knot to the left side of their forehead and discoloration to their left eye, EMS was called, and R1 was transported to TCCH. TCCH records reveal R1 was discharged back to the facility on the same day with a diagnosis of forehead contusion and traumatic hematoma of forehead; on 01/01/2025, at approximately 8:00pm, R1 was found by facility staff on their knees next to their bed, EMS was called, and no new visible injuries were observed; on 01/09/2025, at approximately 7:00am, R1 was found by staff on the floor of their bedroom, EMS was called, and no transport to the hospital was needed; on 02/05/2025, at approximately 8:30pm, R1 slipped off their bed and fell to the floor, staff placed R1 in their wheelchair, staff did not see redness or bruising, R1 did not complain of pain, and EMS was not called; on 02/07/2025, at approximately 7:00am, R1 was found by staff with the top half of their body on the floor and their legs on the bed, R1 complained of pain, EMS was called, R1 was transported to TCCH, and R1 returned to the facility at approximately 11:26am. TCCH records reveal R1 has a discharge diagnosis of UTI and fall. Later the same day at 8:30pm R1 slipped off her bed, staff placed R1 in their wheelchair, R1 did not complain of pain, and EMS was not called; on 03/01/2025, at approximately 5:40am, R1 attempted to get out of their wheelchair and fell, R1 complained of pain in their right shoulder, EMS was called, and R1 was transported to TCCH. TCCH notes reveal R1 was diagnosed with a right humeral neck fracture, a distal radial fracture and ulnar styloid fracture of the right wrist. Overall, R1 sustained ten witnessed and unwitnessed falls in nine months. Records obtained do not indicate R1’s service plan was updated after the first six falls and was only updated on 1/27/2025. The service plan dated 1/27/2025 does not indicate R1 is a fall-risk, does not use an assistive device to get around the facility, and did not discuss any fall mitigation plan despite the numerous falls. (Continued on 9099-C) Multiple interviews revealed the facility often operated short-staffed and it was very challenging to provide the required supervision and care to the residents. Staff stated three caregivers in memory care seemed sufficient, but when there were less they could not meet the resident’s needs. The facility staff timesheets from June 2024 to March 2025, are missing numerous dates, and indicated the facility worked understaffed on multiple occasions including dates R1 fell on 6/8/2024, 12/24/2025, and 2/7/2025. Multiple staff stated there was not a plan to help prevent R1 from falling again, but multiple staff independently attempted to keep R1 from falling as R1 had additional falls. A former staff stated the plan to prevent R1 from suffering further falls was for staff to conduct checks more often, but admitted there was no way to confirm if the staff conducted these checks accordingly. R1’s responsible party raised concerned to facility Administrator on multiple occasions that the facility was understaffed however no changes were implemented. Administrator Carl Meyer stated to the Investigator he was not aware of the facilities staff-to-resident ratio, but denied the facility was understaffed. The administrator admitted R1 had a history of suffering falls at the facility approximating five falls and it was challenging to accommodate R1’s responsible parties requests to implement safety interventions, including additional staffing. Carl explained the plan to prevent R1 from further falls was for staff to conduct “constant supervision.” Carl stated administration did not have a way of ensuring the staff conducted regular checks on R1, and he trusted his staff to perform their tasks efficiently. Carl admitted some of the staff did not perform well and were terminated from the facility. Carl acknowledged the facility had to improve their “quality of service”, fill vacant shifts and was implementing an electronic staff log system to ensure the residents are checked accordingly and timely. Carl could not think of a way to prevent R1’s falls and stated they were going to continue occurring due to R1’s mental status. Carl explained the memory care staff were notified multiple times of R1’s tendency to stand up or lean forward from their wheelchair during staff meetings. Carl stated there is no way to prevent a resident from falling, such as R1, unless they have a one-on-one 24-hour care, which was never implemented. Based on the information obtained, the facility did not appropriately update R1’s physician’s report or service plan after R1 experienced changes in condition on multiple occasions. R1 sustained multiple falls, including one resulting in an injury of a bump and bruising to their face/closed head injury, one resulting in forehead contusion and traumatic hematoma. (Continued on LIC9099-C) R1’s physician report upon admission dated 3/12/2024 states R1 had a history of falling, but the facilities service plan for R1 was never updated to indicate their fall-risk. It has been determined that R1 sustained multiple falls and injuries while in care. No evidence was obtained to indicate the facility attempted to meet R1’s needs by mitigating R1’s falls. Ultimately staff neglect/lack of supervision resulted in a right humeral neck fracture, a distal radial fracture and ulnar styloid fracture of the right wrist. Based on the information obtained, the allegation is deemed substantiated at this time. A $500 immediate civil penalty for injury of a resident as the result of a deficiency is assessed today. The administrator was informed that additional civil penalties may be assessed based on Health and Safety Code 1569.49(f). Exit interview, deficiency cited on LIC9099-D, a civil penalty assessed on the attached LIC421IM, report signed, report and appeal rights provided to the Administrator. LPA noted staff interviews revealed there have been occasions where an item from the menu was not sent from the kitchen to the memory care unit, staff reminded the kitchen, and the kitchen staff brought the item. Interviews also revealed the kitchen will sometimes provide a substitute menu item for residents who do not like or cannot eat the primary option. LPA visited the facility nine times between 3/17/2025 and 9/4/2025. During these visits LPA observed and photographed various lunch and dinner meals served to the independent/assisted living unit and memory care during each visit. LPA noted both units being served the same menu items with memory care receiving substitutes or additional proteins on occasion. For example, steamed vegetables instead of salad or chicken/meat in addition to fish. Based on all interviews conducted and LPA observation, 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. Exit interview conducted, report signed, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 29-AS-20250313093906

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 2, 2025

(a)... residents...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 interview and record review, the licensee did not ensure R1’s needs were met when R1 sustained multiple falls including one resulting in multiple broken bones which poses an immediate Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: Administrator stated in the last month the MCD started reporting falls to him on a daily bases and they impliment a fall mitigation plan after 2 falls within a month. The administrator will work with the SDRS on a written plan regarding this new policy and submit to the LPA on or before 10/08/2025. Administrator will also train staff on documenting falls and the MCD on the new policy and submit to LPA on or before 10/08/2025

Allegation investigated: Due to neglect, Resident sustained multiple UTIs while in care. Facility is not clean/sanitary. Facility does not have adequate amount of staff to attend to residents.

On 10/1/2025 at 1:00pm Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to deliver final findings to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. On 03/18/2025, the Woodland Hills North Adult and Senior Care Regional Office (RO) originally received this complaint regarding neglect/lack of care and supervision. The complaint alleged that Resident #1 (R1) sustained multiple urinary tract infections (UTIs) while in care at the facility due to staff neglect and lack of supervision. The complaint also included an allegation that the facility is not clean/sanitary. On 3/13/2025 the RO received a similar complaint with control number 29-AS-20250313093906 was also regarding R1 sustaining multiple falls due to neglect/lack of care and supervision. That complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jorge Jauregui. Investigator Jaurequi investigated allegations of both complaints during the investigation. (Continued on LIC9099-C) Substantiated On 03/26/2025, from 09:38am to 03:20pm, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced initial complaint investigation visit to the facility. During the visit, the LPA requested and received facility documentation relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings. On the allegation: Due to neglect, resident sustained multiple UTIs while in care. It was alleged Resident #1 (R1) had several UTIs while in the care of the facility. Review of R1’s file revealed R1 moved into the facility in April 2024, R1’s preplacement appraisal dated 3/7/2024 lists recurrent UTI under Health History and under Services Needed continence is marked “yes” with a note, “uses an adult diaper”. A physician report for R1 dated 3/12/2024 states R1 was not able to care for own toileting needs requiring assistance and did not have bowel or bladder impairment. A Resident Care Summary done by the facility dated 4/5/2024 states toileting needs as stand-by assistance, wears adult briefs for occasional accidents, incontinent of bowel and bladder. R1’s Service Plan completed 1/27/2025 indicates R1 as moderate toileting stand-by assistance with no additional notes. A facility care note for R1 dated 12/15/2025 states “Resident started a new antibiotic today for UTI. Nitrofurantoin mono/mac 100MG Take 1 capsule po 2x daily for 5 days”. The facilities medication administration record (MAR) show staff signed off the nitrofurantoin as administered to R1 per the physician order and this medication is logged into the facilities centrally stored medication record (CSMR) for R1. During R1’s stay at the facility from April 2024 to March 2025 the facility submitted four incident reports to CCLD for R1 with one of those dated 2/7/2025 resulting in a diagnosis of UTI and fall. The hospital discharged R1 with a new antibiotic medication for the UTI and facility notes for R1 dated 2/7/2025 states “Resident returned to the community with a DX of 1; Urinary Tract Infection 2;Fall. Antibiotics to be given, Cephalexin 500MG 1 capsule po every 12 hours for 5 days.” and “Started cephalexin at 8pm”. R1’s CSMR kept by the facility shows the cephalexin logged in by the staff, but the facility was not able to provide record showing each dose of the medication was administered to R1. The facility MAR and CSMR for R1 also indicates the antibiotic medication methenamine hippurate 1gm was started on 2/18/2025. On 3/1/2025 R1 had a fall at the facility, was sent to the hospital, diagnosed with multiple fractures to R1’s right wrist and shoulder, investigated as part of complaint 29-AS-20250313093906. Based on record review R1 sustained two documented UTIs while in the care of the facility, on 12/15/2025 and 2/18/2025. (Continued on LIC9099-C) During the investigation for complaint 29-AS-20250313093906 CCLD Investigations Branch (IB) Investigator Jorge Jauregui interviewed staff, residents, the facility Administrator and R1’s responsible person. Multiple interviews revealed that R1 not receiving proper toileting assistance from staff led to R1’s UTIs. Staff stated the facility was understaffed during R1’s time at the facility and had there been enough staff R1 may not have suffered the UTIs. The Administrator stated that they had no knowledge of R1 having a UTI or R1 prescribed a medication to treat a UTI. The Administrator also stated they believed the UTI developed from poor hygiene as staff were probably not changing her soaked diaper promptly and acknowledged the UTI could have been prevented if staff had changed R1’s soaked diapers promptly or if staff had paid attention to symptoms associated with a UTI. Multiple facility memory care medication technicians stated they did not know R1 had any UTIs and were not aware R1 was prescribed medication to treat the UTIs. Staff reported they lacked training on the causes of UTIs. However, the Administrator stated staff receive training on UTIs and their associated symptoms through courses such as Catheter and Perineal Care and Prevention of Urinary Tract Infections. Staff training record review indicates some staff interviewed received this training in the ten months R1 was in care at the facility, but there is no record of the memory care medication technicians interviewed completing this training during that time period. It is unclear how often staff complete the training. Based on all interviews conducted and record review, 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. On the allegation: Facility is not clean/sanitary. It was alleged there was a strong smell of urine in the assisted living side of the facility as well as the memory care unit of the facility. R1’s chair, wheelchair, stuffed animal, and mattress were stained and dirty. R1’s clothing also smelled. On 3/26/2025, LPA Haner-Tomasko and Administrator Carl Meyer toured the facility viewing several rooms in memory care including R1’s bedroom. At 10:29am in R1’s room LPA noted a strong smell of urine in the room, observed and photographed a soiled mattress, with multiple stains and some dirty clothing on the floor. The Administrator stated these were R1’s belongings and the wheelchair and chair that had been in the room must have been removed by family. Carl stated that the expectation is for staff to notify leadership of any stained furniture so it can be cleaned. (Continued on LIC9099-C) During subsequent visits to the facility due to additional complaints (29-AS-20250506110349 and 29-AS-20250630114830) regarding the facility not providing a clean environment for residents, LPA observed and documented on 5/7/2025 at 11:45am a memory care bedroom with a strong urine odor and in the south/east corner of the room the laminate flooring, baseboard, and wall paint peeling away from the floor and wall. At 12:40pm LPA observed and photographed a soiled chair in a resident’s room in the assisted living unit. On 7/8/2025 from 10:11am to 11:16am LPA observed and photographed stained and soiled bedding in 8 occupied resident rooms throughout the facility. Based on all interviews conducted and LPA observation, at this time the above allegation was found to be substantiated, there is a preponderance of evidence to prove that the alleged violation occurred. During a recent and similar complaint investigation 29-AS-20250506110349 on 7/23/2025 a citation was issued in line with Title 22, Chapter 8, Article 5, 87303(a) and a plan of correction was established. On the allegation: Facility does not have adequate amount of staff to attend to residents. It was alleged the facility does not have enough staff on duty for the number of residents in memory care. Residents cannot go to the outside area because there is not enough staff. Multiple staff interviewed during the investigation stated the facility often operated short-staffed and it was very challenging to provide the required supervision and care to the residents. Staff stated three caregivers in memory care seemed sufficient, but when there were less they could not meet the resident’s needs. The facility staff timesheets from June 2024 to March 2025, are missing numerous dates, and indicated the facility worked understaffed on multiple occasions. Multiple staff including the Administrator acknowledged that they could not provide prompt toileting or brief changing assistance to residents including R1. Based on all interviews conducted and record review, 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. Exit interview, deficiency cited on LIC9099-D, a civil penalty in the amount of $250 for a repeat violation of the same regulation cited in the last 12-months is assessed on the attached LIC421FC, report signed, report and appeal rights provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 29-AS-20250318102817

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 2, 2025

(a)... residents...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 interview and record review, the licensee did not ensure there was staff in sufficient numbers to meet the needs of all the resident’s in care, including R1 who sustained poor hygiene and multiple UTIs which poses an immediate Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: Administrator stated in the last month training for documenting care including toileting was conducted using their new system. Administrator will submit the signed staff training documents to LPA on or before 10/02/2025. This information is reviewed by him daily to monitor refusals and UTIs. Administrator states they have raised wages and always have job postings open. Corporate has asked the facility to have a goal to stop using agency staff by the end of last month (September), but the administrator will conitnue to use the agency staff in order to not be understaffed.

Allegation investigated: Staff handled residents in a rough manner Staff yelled at residents

On 9/4/2025 at 10:00am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to investigate the allegations to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. During the visit, LPA interviewed staff, residents, the Administrator, and obtained relevant documents. On allegations, staff handled residents in a rough manner and staff yelled at residents. It was alleged Staff #1 (S1) forcefully pulls and grabs residents from their wheelchairs, chair, and bed. It was alleged that S1 yells at the residents, telling them they have to wait even though they have already waited a while. Other staff have witnessed S1 yelling at residents. Resident interviews revealed there are times S1 seems rushed to help residents depending on staffing and (Continued on LIC9099-C) Unsubstantiated will rush them, but S1 has not yelled or raised their voice at them and has not treated them roughly. Residents feel like S1 is very helpful when they need assistance from them. Staff interviews revealed they are not aware of any staff yelling, raising their voice, or being rough with residents. The Administrator stated he has personally worked with S1 and has not witnessed S1 yell at or treat residents roughly. Administrator stated S1 has not been written-up or disciplined for how S1 treats residents. Interview with S1 revealed there are times they feel rushed to help the residents and has felt frustrated. S1 stated they have not been rough with residents or yelled at them to wait or hurry up. Based on all interviews conducted and LPA observation, 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. Exit interview conducted, report signed, and report provided to Administrator.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 29-AS-20250827135624

Type of visit: Case Management - Incident

On 9/4/2025 at 10:00am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a Case Management – Incident visit. LPA met with Administrator Carl Meyer and explained the purpose of the visit. On 9/2/2025 at 5:20pm Community Care Licensing (CCL) received an incident report via email from the facility stating that on 8/24/2025 at approximately 10:15am Resident #1 (R1) was reported missing. R1 was last seen walking out the back door by Staff #1 (S1). A staff-wide search was initiated and approximately 30 minutes later R1 was found at Kennedy Club Fitness. LPA record review of R1’s LIC602A Physician’s Report indicates R1 is diagnosed with dementia and is not able to leave the facility unassisted. R1 resides in Compass Rose, the facilities memory care unit. LPA toured the memory care unit with Staff #2 (S2) ensuring the 4 doors in memory care with egress devices are functioning properly. S1 is an agency staff brought in by the facility to cover open shifts. S1 was assigned to work in Compass Rose on 8/24/2025. Staff interviews reveal that S1 told other staff that R1 was trying to exit the egress door in the back of the unit leading to the parking lot. When S1 attempted to redirect R1, R1 began to hit S1 and S1 let R1 out of the facility through that door. Interviews revealed S1 changed their story multiple times and the timing of how long they let R1 out the door ranged from ten seconds to thirty minutes. At approximately 10:15am when S1 told other staff what happened the other staff notified lead staff on duty, Staff #3 (S3). S3 activated the facilities elopement protocol and a facility search began inside and outside the facility. S3 notified the administrator at 10:24am. (Continued on LIC809-C) S3 called R1's responsible person and left a voicemail. At approximately 10:45am Kennedy Club Fitness called the local police to assist R1. When the police arrived they called the facility to see if R1 lived here and the police returned R1 to the facility. Not long after R1's returned to the facility R1's responsible person arrived and facility staff reviewed the incident with them. Administrator admitted no one notified the licensing agency Officer of the Day, by telephone, e-mail, fax, or hand-delivery no later than the next working day following the incident. The first notification to CCL was the emailed incident report dated 9/2/2025 at 5:20pm, nine days after the incident. LPA conducted a visit to the facility on 8/27/2025 and Administrator did not mention the elopement then. When asked why CCL had not been notified per Title 22 regulation the Administrator admitted he must have overlooked it. Administrator and S2 state the four egress doors in Compass Rose are checked to ensure proper functioning monthly. Per facility protocol a monthly elopement drill is conducted with staff and record review shows the facility conducted drills following the incident and the previous two were conducted on 7/31/2025 and 6/26/2025. Record review of S1's training from the agency does not list any dementia training and the facility was unable to provide dementia training for S1 meeting the Health and Safety Code requirements. Exit interview conducted, deficiencies cited on LIC809-D pages, report signed, appeal rights and report provided to Administrator.the state’s words, verbatim · CDSS document, Sep 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(6)(B) · Plan of correction due date: Sep 18, 2025

Care of Persons with Dementia (e)Licensees that use delayed egress devices on exterior doors…shall meet the following…continuing requirements: (6)For each incident of elopement…the licensee shall report the incident to: (B)The licensing agency Officer of the Day…no later than the next working day following the incident... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not notify the licensing agency until nine days after the incident which poses a potential Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Administrator states they will train lead staff on reporting requiments as outlined in this regulation and email LPA with training documents and signed roster of staff trained on or before 9/18/2025.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.625(b)(2) · Plan of correction due date: Sep 18, 2025

Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not ensure S1 was provided dementia training prior to working in the memory care unit which poses a potential Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Administrator states they will conduct an audit of agency staff used regularly to ensure they meet dementia training requirments and submit to the LPA via email the audit findings on or before 9/18/2025. Administrator also states moving forward they will ensure agency staff meet the dementia training.

Allegation investigated: Resident sustained multiple pressure injuries while in care due to staff neglect Resident sustained unexplained injuries while in care Resident's toileting needs are not being met

On 8/27/2025 at 10:30am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to further investigate the allegations to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. During the visit LPA interviewed staff, administrator, and obtained relevant documents. On the allegations: Resident sustained multiple pressure injuries while in care due to staff neglect and resident sustained unexplained injuries while in care. It was alleged Resident 1 (R1) had approximately 4 wounds or pressure injuries about the size of a quarter or half-dollar and what appeared to be bruising on their tailbone and back. (Conitnued on LIC9099-C) Unsubstantiated LPA interviews with resident’s primary care physician, hospice nurse, and resident’s family member revealed R1 was not diagnosed with pressure injuries at the time of this allegation and the unexplained injuries were likely bruises caused by previous falls R1 had sustained at the facility. Based on the information obtained, the allegations are deemed unsubstantiated at this time. On the allegation: Resident's toileting needs are not being met. It was alleged that on 3/30/2025 and 3/31/2025 facility staff did not change R1 all day and in the evening both days Person 1 (P1) assisted R1 clean up and get ready for bed. Interviews revealed P1 was brought on service by R1’s family to provide R1 additional support. Interviews revealed R1 did have a rash where the briefs sit on the resident’s body that may have been caused by not being assisted with their continence needs timely. 6 of 6 staff interviews reveal R1 has occasional accidents, R1 often asks staff for assistance to the restroom, and staff are not aware of R1 having a rash due to not meeting R1’s continence needs. Based on all interviews conducted 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. There were no deficiencies cited at this time. Exit interview conducted, report signed, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 29-AS-20250403134447

Allegation investigated: Staff do not ensure toilet paper is in resident bathroom Staff do not ensure residents have soap in bathroom

On 8/27/2025 at 10:30am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to further investigate the allegations to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. During the visit, LPA interviewed staff, administrator, and obtained relevant documents. On allegation: Staff do not ensure toilet paper is in resident bathroom and staff do not ensure residents have soap in bathroom. It was alleged Resident #1 (R1) had no toilet paper on multiple occasions and resident families must provide toilet paper. On one occasion R1 had no toilet paper in their bathroom and their personal supply of toilet paper was locked up. R1 is not able to make needs known to staff, unable to ask staff to get their toilet paper. (Continued on LIC9099-C) Substantiated Staff stated sometimes the scheduled activities were offered to the residents, but not always depending on the needs of the residents throughout the day. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated. On allegation: Staff do not meet residents oral hygiene needs. It was alleged Resident #1's (R1’s) teeth look like they have not been brushed and their family has to help them brush their teeth. Interviews reveled R1 took care of their own oral care needs, but due to all hygiene items being locked up they had to ask staff for access to their toothpaste. On several occasions R1 was often frustrated not having access to their toothpaste and stated “it’s not like I am going to eat it”. Staff were able to provide R1 access to their toothpaste when they asked for it. Record review of R1’s LIC602A Physician’s Report dated 11/22/2024 is mark “yes” next to “at risk if allowed direct access to personal hygiene items”. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated. Exit interview conducted, report signed, and report provided to the Administrator. R1 resides in Compass Rose, the memory care unit. It was also alleged the facility started locking up all personal hygiene items, including hand soap and toothpaste. LPA interview with the facility Administrator on 5/22/2025 revealed that upon admission to the facility each resident and/or their responsible person are provided a list of items to bring to the facility upon admission, but if a resident runs out of their own supply the facility has a back-up supply to provide the resident that they may charge for but often do not. LPA was provided a copy of the list titled “Suggested items to bring when moving in”. Among the items listed are soap and toilet paper. The list does not note any additional cost if the facility provides the items. Review of the facility admission agreement including appendix B (Amenity Sheet, The Oaks at Paso Robles, Fees for Additional Items and Services) reveals no requirement placed on the resident or their responsible person to supply toilet paper and hand soap, or a fee when supplied by the facility. On 5/22/2025 LPA and Administrator toured the facility to observe any back-up supplies of hand soap and toilet paper for resident use. The facility keeps separate inventories of supplies in the assisted living and memory care units for budgeting purposes. At 3:36pm on the first floor in the assisted living side of the facility, LPA and Administrator observed the back-up supply of resident hand soap and toilet paper in the commercial laundry and housekeeping area for residents in the assisted living side. LPA observed the doors to the resident toilet paper supply were chain locked and staff interviews revealed they lock it because the staff from memory care were coming over and taking from the supply. LPA photographed the locked cabinet and when opened by staff 21 rolls of residential toilet paper were documented. At 3:51pm Administrator showed LPA locations where back-up hand soap and toilet paper supplies are stored in the memory care unit; a supply closet between rooms 217 & 218, a housekeeping closet near room 216, and the med-tech room. LPA and Administrator observed there to be no back-up supply of hand soap or toilet paper in these areas, LPA photographed the areas. The Administrator stated they must have overlooked ordering a supply of toilet paper for the memory care unit since they do not currently have a memory care director. Regarding R1’s personal supply being locked up, on 5/22/2025 the Administrator stated this went into effect about a week prior for resident safety, he had asked staff to lock up all liquid hygiene items, including hand soap, and R1’s toilet paper may have been locked up by accident. The Administrator stated he had not notified the responsible parties of this change and was waiting on more specifics from corporate before notifying. There is hand soap available in the public restrooms in memory care and staff are expected to remind or assist residents to wash their hands, the residents may also ask to wash their hands. (Continued on LIC9099-C) Staff interviews reveal this does not always happen and some residents in the unit are not able to ask to wash their hands but can take care of their own toileting needs. Staff also stated there have been occasions since this new policy was implemented when the public restrooms in memory care have not had hand soap for staff or residents to wash their hands and they have brought their own soap to use. On 5/28/2025, a notice was sent out to residents and their responsible person regarding the new policy. Based on the observation, interviews, and information obtained, since supplies necessary for maintenance of adequate hygiene practice were not readily available to each resident including soap and toilet paper, the allegation is deemed substantiated at this time. Exit interview conducted, deficiencies cited on the LIC9099-D page, report signed, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 29-AS-20250521121107

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Sep 10, 2025

Personal Accommodations and Services (a)…The following provisions shall apply: (3)...supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident....if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by: Based on observation, interviews, and information obtained, the licensee did not ensure soap and toilet paper necessary for maintenance of adequate hygiene practice...the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Administrator will work with corporate on a plan to ensure supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident in care. Administrator will submit a written plan to LPA via email on or before 9/10/2025. were readily available to each resident, which poses a potential Health, Safety, Personal Rights risk to persons in care.

Allegation investigated: Staff did not treat resident with dignity.

On 07/23/2025 at 10:14am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to investigate the allegation to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. On allegation: Staff did not treat resident with dignity. It was alleged the facility Executive Director Carl Meyer did not treat Resident #1 (R1) with dignity and has referred to the resident in a derogatory way when speaking to staff. LPA interview with R1 revealed they recently had an issue they brought to Carl's attention and R1 stated they were happy with how Carl resolved the issue. LPA staff interviews revealed that staff are not aware of any facility staff treating residents in an undignified way or referring to residents in a derogatory way. LPA interview with Administrator Carl Meyer, revealed he followed up with R1 on their issue and needed provide R1 with reminders on house rules. (Continued on LIC9099-C) Unsubstantiated Based on all interviews conducted and record review, at this time the above allegation was found to be unsubstantiated, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and reportthe state’s words, verbatim · CDSS document, Jul 23, 2025 · control 29-AS-20250718110005

Allegation investigated: Staff not providing assistance to resident in a timely manner. Residents are not being provided clean linens. Staff does not keep facility free from odor.

On 07/23/2025 at 10:14am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to continue the investigation on the allegations to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. During the visit, from 10:40am to 4:00pm LPA interviewed residents, staff, administrator, and obtained relevant documents. On allegation: Staff not providing assistance to resident in a timely manner. It was alleged that residents have to wait for long periods of time to receive assistance. LPA interviews with staff and Administrator Carl Meyer revealed that staff are expected to respond to resident calls for assistance within 10 minutes. (Conitnued on LIC 9099-C) Substantiated LPA review of the facility call system records for resident calls from 4/1/2025 to 5/1/2025 revealed 130 pendant calls and 10 resident bathroom pull cord alerts with response times over 10 minutes; of which 16 were over 20 minutes, 12 were over 30 minutes, and 6 were over 60 minutes. LPA staff interviews revealed there are times that residents have to wait for extended periods of time to receive assistance since staff are helping other residents. Staff also stated in interviews that the call system does not always function properly, sometimes losing Wi-Fi signal and other times they forget to follow through timely completing all the steps of restoring resident pendant and bathroom devices. LPA resident interviews revealed 6 of 7 interviewed residents state they do sometimes wait for extended periods of time for staff to respond. Based on all interviews conducted and record review, 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. On allegation: Residents are not being provided clean linens. It was alleged that staff are covering the dirty areas of the linens and not providing residents with clean linens. LPA interviews with staff revealed that care staff in the memory care unit are responsible for changing linens 2-3 days each week and more often when soiled. Staff interviews in the assisted living unit revealed housekeepers are responsible for changing sheets once per week and care staff are responsible for changing the linens when soiled. During multiple visits to the facility from 3/17/2025 and 7/8/2025 LPA observed and photographed 7 resident rooms with soiled and stained linens. Additionally LPA noted 6 rooms with stained and soiled mattresses and/or mattress covers. Based on LPA observation, 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. On allegation: Staff does not keep facility free from odor. It was alleged a resident in memory care, Resident #3 (R3), urinates on the floor of their room, the room smells of urine and staff do not always clean it up. On 5/7/2025 LPA and Administrator toured the facility including R3’s room. LPA noted a very strong smell of urine. Upon inspection of the room at 11:54am LPA and Administrator noted in the south/east corner of the room the laminate floor boards, baseboard, and paint on the walls peeling away from the floor and walls. Administrator stated this is due to the resident urinating in various areas of their room including that corner and there was a plan to repair the flooring, baseboard, and paint. (Continued on LIC9099-C) LPA interviews with staff revealed 5 of 5 staff are not aware of R1 being left in soiled clothing. Staff interviews and record review revealed R1 is incontinent, R1 often refuses staff assistance and staff make multiple attempts to assist R1 when they refuse. During LPA interview with R1, R1 stated staff check on them too frequently and staff do provide assistance with their dressing and incontinence needs. R1 stated they have not been left in soiled clothing by staff. Based on all interviews conducted, LPA observation and record review, 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. On allegation: Call button not accessible to residents. It was alleged that not all residents in the memory care unit have call buttons accessible to them. LPA interview with the Administrator reveal there is an emergency pull cord in every resident bathroom and it is Westmont Living's policy to check the residents more frequently in memory care since as they may not be able to operate a pendant. Administrator also stated if a resident requests a pendant the facility provides that resident one. LPA interview with staff revealed that currently two memory care residents carry a pendant with them and the other residents who do not are checked on more frequently. LPA observed each resident bathroom has an emergency pull cord meeting regulation requirements. Based on all interviews conducted and LPA observation, 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. On allegation: Staff do not meet residents’ needs. It was alleged Resident #2 (R2) has fallen multiple times, pushes their pendant for assistance, and it takes a while for staff to respond. LPA call system record review from 4/1/2025 to 5/1/2025 revealed 24 pendant calls from R2 with a response time over 10 mins. LPA record review of R2’s LIC602 Physician Report dated 3/28/2025 revealed R2’s secondary diagnoses to be falls and gait instability and on page 2 of the LIC602 motor impairment is marked “yes” with the physician comment “unsteady gait”. LPA noted R2’s Service Plan dated 4/29/2025 states R2 needs caregiver standby assistance with mobility using a walker or wheelchair daily, and a comment stating, “the Care Team supports me with safe ambulation, mobility and repositioning.” (Continued on LIC9099-C) During LPA interview with R2, R2 stated they recall falling multiple times in the past, staff have responded quickly to their call using their pendant and staff ensured medical treatment was provided. LPA interview with Person #1 (P1), a family member of R2, revealed they have been notified by the facility of R2’s previous falls and are happy with how the facility has handled each time R2 has fallen. LPA record review revealed Licensing received no incident reports for R1 from when resident move in date in April 2025 to the day of LPA’s initial visit for this complaint on 5/7/2025. Based on all interviews conducted and record review, at this time the above allegation was found to be unsubstantiated, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and report provided. LPA staff interviews revealed there is not a consistent housekeeper in the memory care unit. During a visit on 7/8/2025 at 10:25am, LPA toured R3’s room to find the room smells strongly of urine, several floorboards in the same corner missing, the baseboard and paint peeling away from the walls, and the resident’s bed was moved, to covering this corner. Based on all interviews conducted and LPA observation, 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. Exit interview conducted, deficiencies cited on 9099-D, report, and appeal rights given.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 29-AS-20250506110349

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 6, 2025

(a)... residents in privately operated residential care facilities for the elderly 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 section cited above when 6 of 7 residents stated they wait for staff to respond, 130 call response times werethe state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: Administrator stated they will move a screen that displays resident calls at the concierge station on 7/24/2025 more in view of the concierge to provide staff reminders, two weeks ago new staff devices were purchased to receive emergency resident alerts, and will train staff and provide LPA via email training and signed roster on or before 8/6/2025. over 10 minutes, and when staff stated the system does not always work which poses a potential health, safety, and personal rights risk to clients in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 6, 2025

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 interviews and record review, the licensee did not comply with the section cited above when 7 rooms had stained/soiled linens, and when LPA noted R3's room with an odor and in disrepair which poses a potential health, safety, and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: Administrator states the facility has hired additional housekeeping staff, they will schedule housekeeping in memory care daily, create a quality control check to ensure residents are provided clean linens, and schedule R3's room to be repaired. Administrator will email housekeeping schedule, quality control check docmuent and date(s) of scheduled repair to LPA on or before 8/6/2025.

Allegation investigated: Staff is not allowing resident a visitor

On 07/17/2025 at 3:00pm Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to investigate the allegation to this complaint. LPA met with Executive Director/Administrator Carl Meyer and explained the purpose of the visit. During previous visits to the facility, the LPA interviewed staff, clients, licensee, and obtained relevant documents. On the allegations: Staff is not allowing resident a visitor. It was alleged the facility did not allow a hospice volunteer to visit a resident currently on service with the hospice agency. The volunteer, Person #1 (P1), is a former employee of the Oaks at Paso Robles. (Continued on LIC809-C) Unsubstantiated This is an amended report. The hospice resident is being denied the right to see this individual. The Executive Director of the Oaks at Paso Robles is citing a conflict-of-interest company policy. LPA reviewed Westmont Living's Community Visitation Policy for Former Team Members, the document states in part, “If a former team member secures other employment with a company that involves working at the community (e.g., working for a hospice company or as a private caregiver, etc.), they will not be prohibited from doing that work as long as they are professional and clocked in for that employer. The Company reserves the right to prevent any former team member from entering the community. In those cases, the former team member will be notified by the Executive Director that they are no longer permitted on site. After that, if the former team member wishes to visit residents, they would need to meet with the residents away from the community.” LPA interviews revealed that on 4/30/2025 Executive Director/Administrator Carl Meyer met with P1 and informed P1 that they could not return, but another hospice volunteer could visit the resident moving forward. During interviews, Administrator stated P1 had been at the facility multiple times since their separation from the facility, however they had been observed to be gossiping with residents and staff, which lead to the Administrator to ask P1 not to return. LPA attempted to interview R1 on multiple occasions, but they were unable to be interviewed. During the investigation, LPA did not obtain any corroborating evidence indicating R1 explicitly wanted P1 to visit them. Administrator stated they understand if a resident requests a specific visitor, even if it conflicts with their internal policy, they need to accommodate it in some way. Based on the information obtained, the allegations are deemed unsubstantiated at this time. LPA discussed resident visitation rights with the Executive Director and emailed him the Provider Information Notice (PIN) 25-04-ASC on 5/14/2025. Exit interview conducted and copy of report given.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 29-AS-20250505084727

Type of visit: Case Management - Incident

On 3/26/2025 at 09:38am, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management visit. LPA arrived at the facility, met with Administrator Carl Meyer, and announced the purpose of the visit. On 3/24/2025, LPA received a call from Administrator Carl Meyer stating there was a medication error, where Resident 1 (R1) was given Resident 2 (R2)’s medication. On 03/26/2025, Community Care Licensing received a self-report from the facility. LPA interviewed staff and reviewed records about the medication error. On 03/23/2025, at approximately 10:10am, Staff 1 (S1) gave R2’s medications including, 0.5mgs of lorazepam and 5mgs of oxycodone, to R1. S1 realized the error immediately and reported to Resident Services Director Maria Middleton. Staff called 9-1-1 around 12:15pm and R1 was taken to the hospital, where they observed R1 at the local Emergency Room. R1 returned to the facility on 3/23/2025. The facility was previously cited for a medication error on 02/27/2025, and the plan of correction included medication training for all staff that handle medications. The training was completed on 03/19/2025 and records reviewed showed S1 also completed the medication training on 03/10/2025. While reviewing R1 and R2's medications and Centrally Stored Medication Record(CSMR) LPA noted the lorazepam and oxycodone not listed on the CSMR for R2. LPA also noted 1 of each medication missing from their respective bubble packaging recorded on 3/23/2025. (Continued on LIC809-C) S1 was temporarily suspended until further investigation was conducted, upon return to work S1 will not handle medications. S1 gave facility notice of resignation with last day of 04/06/2025. Exit interview, deficiencies cited on 809-D, report given, and appeal rights given.the state’s words, verbatim · CDSS document, Mar 26, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 27, 2025

87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 gave R1 the wrong medications, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: S1 was temporarily suspended until further investigation was conducted, upon return to work S1 will not handle medications. S1 gave facility notice of resignation with last day of 04/06/2025. Administrator will create a checklist for med-techs to conduct the 6 medication rights and 3 checks to follow for each medication pass. Administrator will email the checklist to LPA by 3/27/2025. Administrator will train the staff handling medications on how to use the new checklist. Administrator will personally shadow each medication technician.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Apr 9, 2025

87465(h)(6) Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when R2's lorazepam and oxycodone were not centrally stored on the Centrally Stored Medications Record.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Administrator will create a written protocol for trained staff to centrally stored medications and directors to review received medications on a daily bases by 04/09/2025. Administrator will email LPA the protocol by 04/09/2025.

Allegation investigated: Staff did not administer residents’ medication.

At 9:00am on 02/27/2025, Licensing Program Analyst (LPA) Jeffries and Haner-Tomasko arrived to the facility unannounced to issue final findings on the allegation to this complaint. LPA's met with Administrator Carl Meyer, announced who they are and the reason for the visit. LPA's also conducted facility annual for 2025 and issued final findings on two other different complaints on this visit. As to the allegation of, “Staff did not administer residents’ medication.” It was alleged that Resident 1 (R1) was paying for medication management that was not being conducted correctly during the time period of July 2023 through October of 2024 (approximately 398 days). It was discovered through interviews, observations, medication audit, and physical medication count; that on 01/22/2025, Licensing Program Analyst Jeffries (LPA) conducted a phone interview with Family Member 1 (F1). F1 stated that the facility had returned 5 different types of medication to F1 after R1 was no longer a resident of the facility in October of 2024. On 01/30/2025, LPA Jeffries conducted an interview with facilities Memory Care Director, Staff 1 (S1). CONTINUED on LIC9099-C Substantiated S1 stated that the prior Resident Service Director had shredded R1’s Centrally Stored Medication Records (CSMR) and could not produce those records as requested by LPA Jeffries. S1 did have Medication Administration Records (MAR) for R1 and were reviewed by S1, Facility Administrator, Carl Meyer, and LPA that shows which medications were administered as prescribed. On 01/30/2025, Facility Administrator and LPA conducted a documented medication audit comparing Medication Prescriptions, Medication Invoices, MAR dates and times and the physical medications that were returned to F1 upon R1’s exit of the facility. That Medication and Document audit showed that for medication 1(Md1) there were 450 total pills sent to the facility, and 18 were returned to F1 indicating that there were approximately 30 pills over the number of MARs indicated. For medication 2 (Md2), there were 450 pills provide to the facility with 106 pills returned to F1, indicating 344 MAR as indicated which is approximately 54 pills of medication there were not administered despite MAR indicating those pills were administered to R1 on facility MAR. There were 540 pills of medication 3 (Md3) that were provided to the facility, and 176 were returned to F1, indicating 346 MARs indicated, which is approximately 56 pills that were not administered when MAR indicated they were administered to R1. There were 540 pills of medication 4 (Md4) provided to the facility, and 245 were returned to F1 indicating there were approximately 103 pills that were not administered to R1. There were 450 pills of medication 5 (Md5) that were sent to the facility, and 365 pills returned to F1, which is approximately 83 pills that were not administered to R1. LPA noted that on 01/29/2025 and 01/31/2025 physical medication counts were conducted with no discrepancy in count of the numbers of pills returned to F1, before and prior to the full medication audit to ensure accuracy. At this time there is enough evidence to support the allegation of, “Staff did not administer residents’ medication.” and is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 29-AS-20250122091828

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Feb 13, 2025

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care ... (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The requirement was not met by evidence of R1 missing hundreds of medication passes which puts the Resident in immanent danger.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: The Administrator shall conduct a comprehensive medication audit, with all residents in care to ensure that medications are in sync with Physicians orders, CSMR, MAR and physical medication count with a summary plan for audit submitted to LPAs emails by 02/28/2025. And audit completed with in two weeks on or before 03/14/2025. And submit proof of audit in CSMR, MAR, Physician Prescription Order and physical medication count to LPA by email on or before 03/14/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Feb 28, 2025

(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6)When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. By evidence of S1 stating that R1's Centraly Stored Medication Records (CSMR) had been shreeded, which poses in immanent danger to Resident in care.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: The Administrator shall have all staff who distribute medications and staff that manage the staff who distribute medication completed a comprehensive medication training of no less than 2 hours by a authorized vender of Department of Social Serviced, State of California. Administrator will provided LPA by email a list of employees who will take that class and the vender and class subject title by email on 02/28/2025 and will have all staff completed the training by 03/14/2025. And submit proof of training to LPA by email on or before 03/14/2025.

Allegation investigated: Facility staff did not dispense medications according to physician's orders. Facility staff did not ensure residents had drinking water. Facility staff did not meet resident's incontinence care needs.

At 9:00am on 02/27/2025, Licensing Program Analyst (LPA) Jeffries and Haner-Tomasko arrived to the facility unannounced to issue final findings on the allegations to this complaint. LPA's met with Administrator Carl Meyer, announced who they are and the reason for the visit. LPA's also conducted facility annual for 2025 and issued final findings on two other different complaints on this visit. As to the allegation of, “Facility staff did not dispense medications according to physician's orders.” It was alleged that on 08/08/2024 and 08/09/2024 that Staff 6 (S6) administered the residents' 4pm medications and 6pm medications at the same time and not according to physicians’ orders in memory care unit. It was discovered through interviews and documentation that on 08/19/2024, LPA Jeffries attempted to interview residents 1-5 (R1, R2, R2, R4, and R5), basic screening question did result in cognitive normal answers or silence. On 08/19/2024, LPA Jeffries conducted an interview with S1 who stated that there was no resident who had medications that were prescribed for both 4pm and 6pm. CONTINUED on LIC9099-C Unsubstantiated On 08/19/2024, LPA Jeffries reviewed staff scheduled that shows staff alleged distributing medications as not prescribed per physician’s orders was not scheduled at the facility on the days of the allegations. On 08/16/2024, 08/19/2024, 02/19/2025 and 02/02/23/2025 LPA made attempts to contact Reporting Party with contact information left, for clarification on allegations, however no contact was unable to be established on all attempts and no call back contact from Reporting Party. On 08/20/2024, LPA reviewed medication administration training for all MedTech’s scheduled in the month of August 2024 to be up to date per Community Care Licensing Regulations. On 08/19/2024 and 02/21/2024, LPA reviewed facility internal documentation medication pass for alleged event and noted that the staff alleged of not dispensing medications according to physicians’ orders was assigned to any med passes on 08/08/2024 and 08/09/2024 additionally was not working according to staff scheduling as noted above. At this time there is not enough evidence to support the allegation of, “Facility staff did not dispense medications according to physicians’ orders.” and is unsubstantiated at this time. As to the allegation of, “Facility staff did not ensure residents had drinking water.” It was alleged that residents in memory care were not provide water when dispensing medications, looked dehydrated, and hadn't had any water to drink for several hours. It was discovered through observations, photographs, and interviews that, on 08/19/2024, LPA Jeffries conducted a physical tour of the facility focusing on the memory care unit. LPA observed 3 pitchers of water, all more than 50% full, two pitchers of water in the common area and one pitcher of water in the dining area on a cart all accompanied with paper cups. LPA Jeffries took photographs of the three water stations. LPA also noted that at least 4 of the 8 residents sitting at the common area table during activity time had cups of water. On 08/19/2024, LPA Jeffries attempted to interview residents R1, R2, R2, R4, and R5, screening question did result in cognitive normal answers or silence. On 08/19/2024, LPA Jeffries conducted an interview with Direct Care Staff 1 (S1) who stated that they bring water with them when dispensing medications, as well as the water stations placed throughout the memory care unit. At this time there is not enough evidence to support the allegation of, “Facility staff did not ensure residents had drinking water.” and is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Facility staff did not meet resident's incontinence care needs. It was alleged that resident sat in their room in urine and feces unattended by care staff. It was discovered in a prior investigation that R6 had behaviors related to incontinence. It was discovered through interviews, observation and documentation that on 05/23/2024 LPA Jeffries conducted interviews with Direct Care Staff 1 (S1) who stated, Both R1 and R2 have exhibited behaviors that involves handling their stools. S1 stated that both residents Physicians have been notified of the behaviors, all care staff have been addressing the behaviors as they happen, and house cleaning staff attend to the residents as needed. S1 also stated that they can call housekeeping at any time for emergency clean ups in memory care. On 05/23/2024, LPA Jeffries conducted an interview with Administrator Carl Meyer who stated that the housekeeping staff is available and will respond when called to do emergency clean ups in memory care unit as needed. On 06/10/2024 LPA conducted interviews with S2, S3, and S4 all who stated that Resident incontinence is always addressed when needed, basic clean-up is done by care staff, and housekeeping is available for emergency clean up on request. On 05/23/2024, 06/10/2024, and 08/19/1014 LPA Jeffries observed sufficient direct care staffing in memory care unit. On 05/31/2024 LPA reviewed staff training records to be current and within regulation standards for direct care staff interviewed. At this time there is not enough evidence to support the allegation of, “Staff do not ensure that residents’ incontinence needs are met.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 29-AS-20240815101438

Allegation investigated: Staff do not ensure that the facility is maintained sanitary.

At 9:00am on 02/27/2025, Licensing Program Analyst (LPA) Jeffries and Haner-Tomasko arrived to the facility unannounced to issue final findings on the allegations to this complaint. LPA's met with Administrator Carl Meyer, announced who they are and the reason for the visit. LPA's also conducted facility annual for 2025 and issued final findings on two other different complaints on this visit. As to the allegation of, “Staff do not ensure that the facility is maintained sanitary.” It was alleged that “the facility and residents' rooms smells like poop because of the residents urinating and defecating everywhere.” It was discovered through observation, interview and documentation that on 05/23/2024 in a facility physical inspection with Facility Administrator Carl Meyer and LPA Jeffries, observed R1’s room had an overwhelming smell of ammonia, and trace evidence if fecal matter on the floor. LPA noted that there was an attempt to clean the room however that the ammonia and urine smell was overwhelming to LPA that LPA had to leave the room at first approach to catch his breath. Administrator stated that he agreed that the smell was also overwhelming during that physical inspection of R1’s room. CONTINUED on LIC9099-C Substantiated On 05/31/2024, LPA reviewed R1’s facility charting notes dated 05/24/2024, stating “ ***Late entry from 05/23/2024*** Resident apartment had strong ammonia like odor upon entrance. This may have been due to pervious alleged urination onto the PTAC unit in (R1’s) apartment. PTAC unit was removed, pressure washed, sanitized and then installed back in place. A urine odor removal spray was also applied. On May 24th the odor appears to have reduced. – Serviced on May 23, 2024 at 01:00PM”. At this time there in enough evidence to support the allegation of, “Staff do not ensure that the facility is maintained sanitary.” and is substantiated at this time. Exit interview, report read, citation issued, report and appeal rights provided. S6 also stated that there is no physician prescribed diets at this time. On 06/10/2024, LPA Jeffries conducted interviews with Residents 6, 7, 8, and 9 (R6, R7, R8 and R9) all stated that the food is of good quality, size and verity. On 05/23/2024, LPA Jeffries conducted interviews with S5 and S6 who both stated that the food the facility provided is of good quality, verity, and proportions. LPA reviewed facility weekly meal plans from April through May of 2024 that list a varied meal services with a verity of food choices. On 06/02024 LPA Jeffries reviewed facilities annual diet and culinary services audit with a 95.45% score. At this time there not enough evidence to support the allegation of, “Staff do not ensure that residents’ dietary needs are met.” and is unsubstantiated at this time. As to the allegation of, “Staff do not ensure that residents’ incontinence needs are met.” It was alleged that, Resident 1 (R1) and R2 rooms “smelled like poop” because of the residents urinating and defecating everywhere. It was discovered through interviews, observation and documentation that on 05/23/2024 LPA Jeffries conducted interviews with Direct Care Staff 1 (S1) who stated, Both R1 and R2 have exhibited behaviors that involves handling their stools. S1 stated that both residents Physicians have been notified of the behaviors, all care staff have been addressing the behaviors as they happen, and house cleaning staff attend to the residents as needed. S1 also stated that they can call housekeeping at any time for emergency clean ups in memory care. On 05/23/2024, LPA Jeffries conducted an interview with Administrator Carl Meyer who stated that the housekeeping staff is available and will respond when called to do emergency clean ups in memory care unit as needed. On 06/10/2024 LPA conducted interviews with S2, S3, and S4 all who stated that Resident incontinence is always addressed when needed, basic clean up is done by care staff, and housekeeping is available for emergency clean up on request. On 05/23/2024, 06/10/2024, and 08/19/1014 LPA Jeffries observed sufficient direct care staffing in memory care unit. On 05/31/2024 LPA reviewed staff training records to be current and within regulation standards for direct care staff interviewed. At this time there is not enough evidence to support the allegation of, “Staff do not ensure that residents’ incontinence needs are met.” and is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Staff do not ensure that residents are provide with a safe environment.” It was alleged that, R4 makes sexually inappropriate comments to residents and staff. It was discovered through documentation and interviews that on 05/23/2024 LPA Jeffries conducted an interview with S1 who stated that all memory care staff have been educated and trained on intervention techniques with R4’s behaviors. Staff have been instructed to redirect R4 when these behaviors are exhibited. On 05/31/2024 LPA reviewed staff training records to be current and within regulation standards for direct care staff interviewed. LPA reviewed R4’s facility care level service plan which indicated that R4 has a moderate assist for these behaviors. Additionally, there are facility notes addressing daily behaviors of R4 with a specific of date May 16th addressing the frequency of these behaviors. Additionally, there is a note on 05/23/2024 pertaining to medication changes and possible consideration for eviction due to not being able to meet increasing care needs if they persist. LPA noted that on 05/23/2024, 06/10/2024, and 08/19/1014 LPA Jeffries observed sufficient direct care staffing in memory care unit. At this time there in not enough evidence to support the allegation of, “Staff do not ensure that residents are provide with a safe environment.” and is unsubstantiated at this time. As to the allegation of, “Staff do not provide residents with activities.” It was alleged that facility does not provide memory care with activities. It was discovered through interviews, documentation and observation that on 05/23/2024 LPA Jeffries interviewed S1 who stated that memory care has scheduled activities every per day. On 05/23/2024, 06/10/2024, and 08/19/1014 LPA Jeffries observed sufficient direct care staffing in memory care unit and activities for residents being conducted. LPA noted by observation that not all residents participated in the scheduled activities. On 06/10/2024, LPA Jeffries conducted interviews with S2, S3, and S4 who all stated that the facility provided daily activities for memory care residents. On 05/31/2024 LPA Jeffries observed facility activities schedule for memory care. At this time there in not enough evidence to support the allegation of, “Staff do not provide residents with activities.” and us unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 29-AS-20240522102559

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87265(b)(3) · Plan of correction due date: Mar 11, 2025

87625 Managed Incontinence (b)…Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met by evidence of “ammonia like smell” in R1’s room and poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: Administrator will email LPA (Garrett.Haner-Tomasko@dss.ca.gov) a copy of facilities emergency cleaning policy and statement of facility procedure to address emergency sanitation protocols no later than 03/07/2025.

Type of visit: Required - 1 Year

At 9:00am on 02/27/2025, Licensing Program Analysts (LAP) Haner-Tomasko and Jeffries arrived unannounced at the facility to conduct the facility annual inspection and to deliver on 3 separate complaint findings. LPAs met with Administrator Carl Meyer and Director Maria Middleton(S1), announced who they are and the reason for the visit. At 9:30am S1 and LPAs toured the inside and outside of the facility. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility is a 3-story building with 97 resident rooms total, 24 are memory care rooms. All rooms have an on-suite bathroom. The memory care unit has a courtyard area for residents to be outside, there are furnishing with umbrellas to protect residents, guest and staff from outside elements. Each floor has multiple community use restrooms, laundry rooms, snack bar and refreshment areas, and an assortment of recreation rooms such as painting room, workout equipment room, and television rooms. There are multiple offices, storage areas, and utility closets throughout the facility. The facility has four stairwells locations each have a fire evacuation chair located at the top of each stairwell. There are two elevators located in the central areas of the facility. The facility has a large reception area for guest and visitors. LPA noted that during the physical walking tour of the facility LPA was able to audit several resident rooms. LPA noted that all rooms were properly equipped by regulation standards. LPA noted that all appliances were in good working condition, the temperature of the facility was regulated between 70-75*(f), and that assisted grab bars were firmly secured on the walls. Infection Control: The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. Staff are trained annually in infection control precautions. Facility has 30-day supply of PPE. (Continued LIC809-C) Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed a sample of staff training records. Staff handling medications had annual training of 8 hours of medication training. Staffing: The facility employs approximately 43 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed a sample number of files for current 1st Aid/CPR, Health screening with TB results, training and fingerprint clearance. Administrator has current certification. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. LPA reviewed a sample number of files for signed Admission Agreements, Medical Assessments, Pre-Admission appraisals, and Appraisal Needs and Services Plans. Resident Rights Information: Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice were publicly posted. CCL Complaint poster and LTCO poster were posted in multiple common areas of the facility. The current license along with PIN's were posted. Internet is provided in each resident room for confidentiality and privacy. Planned Activities: The facility offers activities to all residents in care. Daily activities are displayed on television screens throughout the facility and provided in print each day. A lecture on heart health for residents was actively in session during the tour and the memory care unit was conducting a craft activity. The facility also offers additional activities that can be found in common areas throughout the facility to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has a piano for resident use. The facility has sufficient space to allow for indoor activities. (Continued LIC809-C) Food Service: The facility employs food service staff. The kitchen and dining room are located on the second floor (ground level from the east side main entrance). The memory care unit has a self-contained kitchenette. The facility handles and prepares food safely. The facility has 2 days perishables and 7 days non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Modified diets prescribed by a physician are followed for those residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Incidental Medical & Dental: During resident interviews it was found transportation to medical appointments is provided by the facility if needed and upon request. Disaster Preparedness: The facility has four stairwells throughout the facility each has a fire evacuation chair located at the top of each stairwell. There are two elevators located in the central areas of the facility. Residents with Special Health Needs: LPA observed doors of residents using oxygen have “Oxygen in Use” signs posted outside their room doors. Home health agencies come in to assist residents who need help with oxygen administration and staff are trained in accordance. LPAs conducted interviews with 5 Residents and 4 Staff. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Feb 27, 2025

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

Allegation investigated: Resident sustained pressure injuries while in care. Facility staff is not maintaining proper fire safety precautions at the facility. Residents are not provided proper food service. Staff do not order resident's medication in a timely manner. Staff did not assist resident with their doctor's appointment.

At 8:00am on 06/10/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to delivering final findings to the allegations to this complaint, as well as a second complaint, and a complaint visit on a thrid complaint. LPA met with facility Administrator, Carl Meyer, announce who he is and the reason for the visit. As to the allegation of, “Resident sustained pressure injury while in care.” It was alleged that resident was neglected and obtained bed sores. It was discovered through documentation and interviews that on 01/17/2023, LPA Jeffries reviewed all R13 medical files and documentation and discovered a facility Health and Service Evaluation report indicated that they were tracking “current or historical skin condition” (nothings specific specified) dated 10/16/2022. On 12/01/2022 Resident 13 (R13) had been diagnosed with COVID, documented on LIC624(Unusual Incident/Injury Report), with notification to R13’s Physician, Responsible Party, and submitted to Community Care Licensing. On 12/11/2022 R13 was observed with blisters on both of his hips, and presented symptoms of pneumonia, this was documented by facility Resident Care Director who called Emergency Services to transport R13 to the hospital. CONTINUED on LIC9099-C Unsubstantiated This was documented by the facility on an LIC624 (Unusual Incident/Injury Report), with notification to R13’s Physician, Responsible Party, and submitted to Community Care Licensing. On 01/12/2023 LPA Jeffries interviewed Staff 1, and 2 (S1, S2) who both stated that they did not observe R13 to have any rash or soars on his body before 12/01/2022. Interviews on 01/12/2023 with S1-S6 stated that residents who are on COVID protocols during this time residents are checked and accessed by direct care staff a minimum of 6 times per day. On 01/12/2023, LPA interviewed R1-R12, all stated no issues with care, and no issues with facility. R13 was not available for interview. Based on documentation of Care evaluation in October, and LIC624’s in November of 2022, resident care protocols during COVID outbreak, and Resident and Staff interviews, there is not enough evidence to support the allegation of, “Resident sustained pressure injuries while in care.” and is unsubstantiated at this time. As to the allegation of, “Facility staff is not maintaining proper fire safety precautions at the facility.” It was alleged that all of the fire extinguishers are overdue for their annual inspection/certification. It was discovered through observation, interviews and documentation that on 01/04/2023 and 01/12/2023, LPA Jeffries conducted a full facility walkthrough and observed more than 30 fire extinguishers throughout the entire facility all to be tagged and in working pressure range. LPA also observed and collected documentation of Inspection, Testing, and Maintenance of facilities integrated sprinkler system performed by Alpha Fire Unlimited on 08/23/2022. LPA Jeffries also collected documentation of last fire drills conducted on 12/28/2022 and 12/29/2022 to cover all three floors of the facility, which exceeds regulations standars. At this time there is not enough evidence to support the allegation of, “Facility staff is not maintaining proper fire safety precautions at the facility” and is unsubstantiated at this time. As to the allegation of, “Resident are not provided proper food service.” It was alleged that Employees often do not wear their masks while serving meals and lack of staffing in the dining. It was discovered through interviews and observation that on 01/12/2024 LPA conducted interviews with R1-R12 all residents had no issues with food or food service, and staffing was also not an issue with Resident interviewed. On 01/04/2023 and 01/12/2023 LPA Jeffries made observations of staff who were all masked during respective visits. On 01/12/2023, LPA Jeffries interviewed S1-S6 stated that they have been following infection control policies and have been wearing appropriate Personal Protective Equipment (PPE) at all times while working. On 01/17/2023, LPA Jeffries collected and reviewed full facility schedule for December of 2022 and noted that call offs were noted but did not impact service in dining at the facility. At this time, there is not enough evidence to support the allegation of, “Residents are not provided proper food service.” and is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Staff do not order resident's medication in a timely manner.” It was alleged that medication was running out and not ordered in a timely manner. It was discovered through documentation, and interviews that on 01/12/2022, LPA interview R1-12 who all stated they have never had an issue with medication, never missed a dose of medication, or had the wrong medication provided while at this facility. On 01/12/2023 LPA Jeffries interviewed S1 and S6 who stated that medication have been coming on time and residents in care have not missed any medications in all medication passes the their knowledge. On 01/17/2023, LPA Jeffries reviewed Medication Administration Record (MAR) for 83 residents in care during the month of December 2022 and January 2023 and noted that there were zero missed medications of that two-month medication review and no incident reports submitted for medication errors. At this time there is not enough evidence to support the allegation of, “Staff do not order resident’s medication in a timely manner.” As to the allegation of, “Staff did not assist resident with their doctor's appointment.” It was alleged that two residents had issues with toenails have been neglected to the point of both having nail fungus. This issued was addressed in a separate complaint (29-AS-20230320095114) as follows: As to the allegation of, “Staff failed to observe resident’s nail care needs.” It was alleged that two residents were neglected to the point of having nail fugus. It was discovered through interviews, documentation and observation that on 03/23/2023, LPA conducted interview with Administrator, Administrator stated that the Podiatrist, Dr. Tisngson, DPM was at this facility today (03/23/2023) and was scheduled to treat two residents (R1 and R2). Administrator stated that R1 had a visit with the Podiatrist and R2 refused Podiatrist treatment on this visit. Administrator stated the Podiatrist routinely visit the facility monthly. On 03/23/2023, LPA attempted to interview R1 and R2. Both R1 and R2 could not answer basic cognitive screening questions. On 03/30/2023, LPA conducted a full review of R1 and R2’s medical files. R1 had a ‘Podiatric Evaluation and Treatment’ conducted by Dr. Tisngson, DPM, singed and dated on 03/23/2023. R2 had medical chart notes stating, “RSD (Podiatrist) tried to check residents’ toenail today, but resident refused….” Additionally, R2 had chart notes on 03/16/2023, that stated, “Resident went to see a Podiatrist today …” On 03/23/2023, LPA interviewed, Direct Care Staff 1-4 (S1, S2, S3, and S4). S1-4 all stated that R2 does not respond to hygiene prompts, and refuses self-care help on a daily basis. Interviews of R3, R4, R5, and R6, all say that facility care staff do a good job at addressing any issues they have and feel safe and cared for in this facility. On 03/23/2023, LPA also viewed fire extinguishers throughout the facility to be in regulation compliance (87203), staffing to be in sufficient numbers and resident counsel meeting being conducted monthly with scheduled meeting posted on facility bulletin board. At this time there is not enough evidence to support the allegation of, “Staff failed to observe resident’s nail care needs.” and is unsubstantiated at this time. CONTINUED on LIC9099-C Based on previous findings above, there is not enough evidence to support the allegation of, “Staff did not assist resident with their doctor’s appointment.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jun 10, 2024 · control 29-AS-20221228105128

Allegation investigated: Facility staff yell at residents. Facility staff inappropriately handled resident in a rough manner. Facility staff do not adequately supervise residents. Facility staff do not treat residents with dignity and respect.

At 8:30am on 06/10/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to delivering final findings to the allegations to this complaint, as well as a second complaint, and a complaint visit on a thrid complaint. LPA met with facility Administrator, Carl Meyer, announce who he is and the reason for the visit. As to the allegations, “Facility staff yell at residents.” It was alleged that a caregiver Staff 7 (S7) yelled at residents. It was discovered through documentation, and interviews that, On 01/12/2023 interviews of S1-S6 all stated that they had never heard S7 raise their voice or yell at residents. In interviews with R1 – R16 on 01/12/2023, all residents denied any staff ever yelling or raising their voice with residents. LPA reviewed facility only termination notice during this time frame (January 2023 – March 2023) and there was only one termination of staff due to an unrelated contractual conflict. At this time there is not enough evidence to support the allegation of, “Facility staff yell at residents.” And is unsubstantiated at this time. CONTINUED on LIC-9099-C Unsubstantiated As to the allegation of, “Facility staff inappropriately handled resident in a rough manner.” It was alleged that S7 pulled a pencil out of the contracted hand of R14 so hard the pencil cracked and broke. It was discovered through documentation and interviews on 01/12/2023 in interviews of S1 and S2, both stated they were on duty at the time of the alleged incident, both present during the incident in question, and both S1 and S2 stated that the pencil was broken with a sharp point while in the hand of R14, both stated that S7 pulled the broken pencil out of the hand of R14 for their safety. Both S1 and S2 describe the incident as careful and ethically conducted for the safety or R14. LPA reviewed facility document of submitted Unusual Incident Report (LIC624) dated 01/05/2023 indicating S7 retrieving broken pencil to prevent possible injury of R14’s hand, with no further incident and facility charting notes dated 01/13/2023 at 3:05pm corroborating LIC624. Administrator stated internal facility inquiry with all staff involved revealed same conclusion. Interviews on 01/12/2023 of R1-R12 all stated that they had no issues with staff and feel safe in this facility. On 01/12/2023 interviews of S1-S6 all stated that they had never heard S7 raise their voice or yell at residents. At this time there is not enough evidence to support the allegation of, “Facility staff inappropriately handled resident in a rough manner,” and is unsubstantiated at this time. As to the allegation of, “Facility staff do not adequately supervise residents.” and “Facility staff do not treat residents with dignity and respect.” It was alleged that, resident was asleep at the table with her hand in her plate of food, and staff are eating take-out food same dining rooms with residents.” It was discovered through interview on 01/12/2023 of S1-S6 there is always enough staff and facility calls temp. services for staff they the facility is short staffed. S1-S6 all stated that if a resident falls asleep in the common areas including the dinner table, they let them sleep unless they are in a hazardous position or subject to falling out of the chair. Interviews with S3-S6 all stated that staff do not eat in the same area as the residents. Interviews on 01/12/2023 of R1-R12 all stated that they had no issues with staff and feel safe in this facility. At this time there is not enough evidence to support the allegations of, “Facility staff do not adequately supervise residents.” and “Facility staff do not treat residents with dignity and respect.” and both are unsubstantiated at this time. Exit Interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jun 10, 2024 · control 29-AS-20230106094616

Allegation investigated: Staff failed to observe resident’s nail care needs.

On 05/23/2024, at 8:30am, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final findings to the allegation to this complaint. LPA also issue final findings on additional complaint and conducted initial investigation visit on a third complaint on this visit. LPA met with Administrator, Carl Meyer, announced who he is and the reason for the visit. As to the allegation of, “Staff failed to observe resident’s nail care needs.” It was alleged that two residents were neglected to the point of having nail fugus. It was discovered through interviews, documentation and observation that on 03/23/2023, LPA conducted interview with Administrator, Administrator stated that the Podiatrist, Dr. Tisngson, DPM was at this facility today (03/23/2023) and was scheduled to treat two residents (R1 and R2). Administrator stated that R1 had a visit with the Podiatrist and R2 refused Podiatrist treatment on this visit. Administrator stated the Podiatrist routinely visit the facility monthly. CONTINUED on LIC9099-C Unsubstantiated On 03/23/2023, LPA attempted to interview R1 and R2. Both R1 and R2 could not answer basic cognitive screening questions. On 03/30/2023, LPA conducted a full review of R1 and R2’s medical files. R1 had a ‘Podiatric Evaluation and Treatment’ conducted by Dr. Tisngson, DPM, singed and dated on 03/23/2023. R2 had medical chart notes stating, “RSD (Podiatrist) tried to check residents’ toenail today, but resident refused….” Additionally, R2 had chart notes on 03/16/2023, that stated, “Resident went to see a Podiatrist today …” On 03/23/2023, LPA interviewed, Direct Care Staff 1-4 (S1, S2, S3, and S4). S1-4 all stated that R2 dose not respond to hygiene prompts, and refuses self-care help on a daily basis. Interviews of R3, R4, R5, and R6, all say that facility care staff do a good job at addressing any issues they have and feel safe and cared for in this facility. On 03/23/2023, LPA also viewed fire extinguishers throughout the facility to be in regulation compliance (87203), staffing to be in sufficient numbers and resident counsel meeting being conducted monthly with scheduled meeting posted on facility bulletin board. At this time there is not enough evidence to support the allegation of, “Staff failed to observe resident’s nail care needs.” and is unsubstantiated at this time. Exit interview, report read, report singed, and report provided.the state’s words, verbatim · CDSS document, May 22, 2024 · control 29-AS-20230320095114

Allegation investigated: Staff allow resident to continue self-neglect.

On 05/23/2024, at 8:30am, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final findings to the allegation to this complaint. LPA also issue final findings on additional complaint and conducted initial investigation visit on a third complaint on this visit. LPA met with Administrator, Carl Meyer, announced who he is and the reason for the visit. As to the allegation of, “Staff failed to observe resident’s continued self-neglect.” It was alleged that, Resident (R1) smells of urine and is generally observed to be wet with urine.” It was discovered through interviews, observations, and documentation, that on 01/26/2023, LPA conducted an in-room interview with resident 1 (R1). R1 stated that they did have an incontinence problem and stated it was due to, “not being able to move as fast as (they) use to.” R1 stated that staff is always there to help, however R1 also stated, “I am still independent and use their (staff) help when I need to.” R1 stated that they have been buying items on Amazon lately and have not thrown some of the packaging away. CONTINUED on LIC9099-C Unsubstantiated R1 stated that, they did not want staff to touch the items in (their) room. R1 also stated that they feel safe and cared for in the facility and had no issues with the facility. In interview of Staff 1-4 (S1, S2, S3, and S4) on 01/26/2023, all stated that they have prompted R1 for assistance and help and R1 refused help with cleaning and hygiene. On 01/26/2023, LPA made observations of R1’s room and noted at least 4 Amazon packages in R1’s room, LPA noted that there was no apparent odor emanating from in or around R1’s room and no incontinence issues during the interview and visit on 01/26/2023. Interview with Administrator on 03/23/2023, LPA interviewed Administrator, who stated, R1 now has additional cleaning support, and additional incontinence support as part of R1’s care plan. On 03/23/2023, LPA also viewed fire extinguishers throughout the facility to be in regulation compliance (87203), staffing to be in sufficient numbers and resident counsel meeting posted monthly with scheduled meeting posted on facility bulletin board. At this time there is not enough evidence to support the allegation of, “Staff failed to observed resident’s continued self-neglect.” and is unsubstantiated at this time. Exit interview, Report read, report singed, and report provided.the state’s words, verbatim · CDSS document, May 22, 2024 · control 29-AS-20230124131216

Type of visit: Required - 1 Year

At 9:50am on 02/26/2024, Licensing Program Analyst (LAP) Jeffries arrived unannounced at the facility to conduct the facility annual inspection. LPA met with Administrator Carl Meyer, announced who he is and the reason for the visit. Administrator and LPA conducted a physical walking through tour of the full facility and the facility's outside perimeter. LPA noted that the facilities administrator is collaborating with the city of Paso Robles to address a water run off from recent storms that effect the sidewalk and road on the west side of the facility. Administrator plans on mitigating the extra rain water run off with diverting flow from the south driveway. LPA was able to observed an unobstructed pathway in the front of the facility and suggested to the administrator to provide warnings to residents and staff during heavy rain run off conditions. LPA noted that the remainder of the outside area of the facility is clean and in good repair. The facility is a 3 story building with 97 resident rooms of which 24 are memory care rooms. All rooms have an on suite bathroom, and assorted rooms share a "jack and Jill' type bathroom. The resident rooms are assorted number of one bedrooms, and suites. There is one room of the facility that is a 2 bedroom configuration. On each floor and in the memory care unit there are rooms for social and recreation gatherings. The memory care unit has a courtyard area for resident to be outside, there are furnishing with umbrellas to protect residents, guest and staff from outside elements. Each floor has multiple community use restrooms, laundry rooms, snack bar and refreshment areas, and an assortment of recreation rooms such as painting room, workout equipment room, and television rooms. There are multiple offices, storage areas, and utility closets throughout the facility. The facility has two stairwells location on the north and south sides of the facility both have a fire evacuation chair located at the top of each stairwell. There are two elevators located in the central areas of the facility. The facility has a large reception area for guest and visitors. The kitchen and dining room are located on the second floor (ground level from the east side main entrance). The memory care unit has a self contained kitchenette. LPA noted that during the physical walking tour of the CONTINUED on LIC-809-C facility LPA was able to audit several resident rooms. LPA noted that all rooms were properly equipped by regulation standards. LPA noted that all appliances were in good working condition on the temperature of the facility was regulated at 72*(f), this day the temperature outside was 51*(f) when LPA entered the facility. LPA noted that all assisted grab bars were firmly secured on the walls, LPA noted that the facility had at least 8 fire extinguishers on each floor, all of which were tagged current and in the green pressurized reading. LPA observed most recent fire inspection report from Alpha Fire Unlimited dated 02/15/2024 which indicated that the fire detection and water distribution system pass pressurization test and is functioning properly. LPA noted that all hallways, and entrenches were free and clear of obstacles. LPA noted that this facility has its own on site emergency generator and LPA observed ample amount of emergency water on the first floor. LPA observed at least two days of perishable and at least seven days of non-perishable foods on hand in the kitchen, Administrator and LPA reviewed menu requirements and screening procedures for doctors ordered, and prefrontal diets. LPA conducted a sample audit of resident and staff files. LPA noted that Resident 1 (R1) did not have a Tuberculosis Test on either of the LIC602s in their file and a citation was issued. LPA noted that all other mandated forms were current in resident and staff files. LPA screened all staff criminal record clearance and all staff working are cleared. Administrator and LPA conducted a complete review of all of the annual care tools modules. LPA noted that the only violation was the citation mentioned above and was cited in the care tools module form. LPA noted that there were no other citations, violations or technical issued as a result of this annual facility inspection, Exit interview, citation issued, appeal rights, and report provided.the state’s words, verbatim · CDSS document, Feb 26, 2024