The Park Lane

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Other

On 08/26/26, Licensing Program Analyst (LPA) V. Gorban arrived unannounced to conduct a Health and Safety checks and follow up with complaint investigation visit. During this visit LPA met with resident services director and maintenance services director, stated the purpose of the visit and was allowed entry. During the this LPA toured the facility with maintenance services director conducting safety checks. Based on information gathered during investigation, findings revealed that Licensing office was not notified of the following incidents occurred on July 2nd, 2026. Licensing office was not notified of the facility fire alarm activation which followed by Monterey Fire Department visit and the facility remodeling /construction projects in multiple sections of the facility including dinning room, lobby elevators, and main floor women bathrooms. Deficiency being cited on the attached LIC9099-D. Exit interviewed conducted, report signed and copy of this report with appeal rights provided to RSD for facility records.the state’s words, verbatim · CDSS document, Aug 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Aug 31, 2026

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement was not observed as evidenced by: The facility failed to notify Licensing Agency and follow title 22 reporting requirements, which poses potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: The Licensee will review and educated staff on title 22 reporting requirements. The Licensee will provide a Plan of Correction regarding this deficiency to LPA by email by POC due date.

Type of visit: Case Management - Incident

On 07/21/2026, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct a Case Management visit. LPA met with facility Regional Director of Operations (RD) Terry Rose and stated the purpose of the visit. During visit was discovered that facility recent incident while painting third floor lobby by elevator triggered fire alarm and respond of local fire department. Based on interviews, incident occurred late evening on July 2nd, 2026. Facility have not provided incident report to Licensing office regarding the fire alarm or Fire Department visits. Deficiency regarding reporting requirements cited on attached LIC809-D form. In addition, the facility currently missing active administrator for over 30 days. Deficiency regarding administrators qualifications and duties cited on attached LIC809-D Exit interview conducted, report signed and copy of this report with appeal rights provided to RD for facility records.the state’s words, verbatim · CDSS document, Jul 21, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Jul 27, 2026

Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement was not observed as evidenced by: The License failed to report to the following incidents to the department: 1. fire alarm activation due to late evening painting over smoke detectors. 2. remodel of the main dining room, which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: Licensee will review reporting requirements with leadership team and staff. Following POC due date, will provide correction to LPA by email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Jul 27, 2026

Administrator - Qualifications and Duties.(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not observed as evidenced by: The Licensee failed to ensure the facility has a current and qualified administrator, which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: Licensee actively recruiting new executive director, also using outside recruiting agency and will provide updates to LPA by email by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Vadim Gorban conducted an unannounced facility visit to conduct a Case Management. LPA met with Facility Assistant Administrator Joy Carter and explained the purpose of today's visit. During this visit LPA conducted health and safety tour observing residents in and out about before dinner time. During this visit the facility provided plan of correction to the following deficiencies: 87468 (c) (1) facility received large dimensions personal rights postings to be placed in the facility in the areas residents have full access to. 87633 Hospice care plan is updated in residents files. 87458(a) Facility obtained updated medical assessment for R2. No deficiencies cited Per title 22 regulations. Exit interview conducted with facility Facility Administrator Joy Carter, report signed and copy of this report provided for facility records.the state’s words, verbatim · CDSS document, Feb 24, 2026

Type of visit: Case Management - Other

On 01/30/2026, Licensing Program Analysts (LPAs) V Gorban and Shawna Doucette arrived unannounced to conduct a Case Management visit. LPA met with facility Executive Director (ED) Joy Carter and stated the purpose of the visit. LPA served Decision and Order excluding Staff 1 (S1) from being present inside the facility. LPA requested a current and updated Personnel Report (LIC 500) and Guardian account be updated. LPA informed (ED) Joy Carter that S1 is not allowed to be employed and/or on any facility premises. The Decision and Order of Exclusion From All Facilities came into effect as of 01/02/2026 upon receipt of the letter. A copy of the letter was provided during this visit for facility records. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview conducted, report signed and copy of this report provide for facility records.the state’s words, verbatim · CDSS document, Jan 30, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA)'s Vadim Gorban and Shawna Doucette arrived at the facility unannounced to conduct a Required Annual Inspection. LPA's were granted entry by receptionist. Staff contacted Administrator Joy Carter via telephone who responded to assist with the visit. LPA's toured the facility. Residents' apartments were toured and inspected and observed to be clean. Hot water temperature was measured at 147.4 F in memory care. LPA's observed residents to be participating in activities. LPA's did not observe resident rights or CCLD poster posted in the facility. LPA's observed the hall on floor 6 to be under construction. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication cart and in a locked medication room. Cleaning supplies were in a locked storage closet. Facility has a pull station fire alarm and a fire panel and sprinkler system. Fire extinguishers were charged and had service dates of 9/15/25. Fire drill was last conducted 1/22/26. There was outdoor seating for the residents. Resident records, medication and staff records were reviewed. R5's care plan indicated care staff are providing wound care. Staff did not have training for residents on hospice. R5 is listed to be bedridden. Facility does not have a bedridden plan in plan of operation and is not fire cleared to retain a bedridden resident. R6 does not have an admissions agreement. R2 does not have a medical assessment signed by a skilled professional. R2 did not have a reappraisal after R2's condition changed. Current first aid and CPR were on file for staff. Exit interview conducted, report signed and copy of this report with appeal rights provide to administrator for facility records.the state’s words, verbatim · CDSS document, Jan 30, 2026

The state marks this report as 31 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff do not maintain food service areas in a clean and sanitary condition Staff do not ensure facility be kept free of insects and rodents. Licensee does not provide adequate sanitary equipment and supplies for cleaning Staff does not ensure dishware and utensils must be cleaned and sanitized properly.

On 01/06/2026, Licensing Program Analyst (LPA) V Gorban conducted subsequent complaint inspection. LPA met with an executive director. The purpose of this visit is to deliver the findings of the investigation completed by the Department. During the complaint investigation, LPA interviewed residents and facility personnel, conducted a tour of the facility, interior and exterior to ensure there is no potential or immediate health and safety risk at the facility. Allegation: Staff do not maintain food service areas in a clean and sanitary condition. During the facility tour and observation, on 11/26/2025 and 01/06/2026, kitchen area, floors and counter tops appear clean and sanitary. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Report continues on attached LIC9099-C Unsubstantiated Allegation: Staff do not ensure facility be kept free of insects and rodents. Based on records review rodent / pest control agency provide services to the facility on weekly bases to fight ants and rodents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Licensee does not provide adequate sanitary equipment and supplies for cleaning. Records review revealed stored supplies of cleaning solutions, maps, towels, and soap. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff does not ensure dishware and utensils must be cleaned and sanitized properly. Based on observation and interviews no concerns regarding utensils and dishware. Staff interview responded that utensils and dishware washed after each meal. Observation on 01/06/2026 during lunch tour of dining room reveals no concerns regarding the utensils and dishware. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, report signed and copy of this report provided to ED for facility records.the state’s words, verbatim · CDSS document, Jan 6, 2026 · control 24-AS-20251125131533

Type of visit: Case Management - Other

On 01/06/2026, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct a Case Management visit. LPA met with facility Executive Director (ED) Joy Carter and stated the purpose of the visit. LPA served Decision and Order excluding Staff 1 (S1) from being present inside the facility. LPA requested a current and updated Personnel Report (LIC 500) and Guardian account be updated to remove S1 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL). Based on personnel interview, S1 last day of employment was on March 26, 2025 and June 12th, 2025 S1 removed from Guardian records. LPA informed (ED) Joy Carter that S1 is not allowed to be employed and/or on any facility premises. The Decision and Order of Exclusion From All Facilities came into effect as of 01/05/2026 upon receipt of the letter. A copy of the letter was provided during this visit for facility records. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview conducted, report signed and copy of this report provide for facility records.the state’s words, verbatim · CDSS document, Jan 6, 2026

Allegation investigated: Due to lack of staffing, resident are not receiving adequate laundry services. Due to lack of staffing, residents do not receive medication on time.

On 06/18/2025, Licensing Program Analyst (LPA) V. Gorban arrived unannounced to commence a complaint investigation. LPA explained the purpose of the visit to Business Manager Sonia Garcia and was allowed entry. During the course of the investigation, LPA conducted a facility tour, conducted interviews, and reviewed records. The Department has investigated the allegations: Due to lack of staffing, residents are not receiving adequate laundry services and do not receive medication on time. Interviews were conducted with residents and facility staff. Based on the information obtained during the interview, there is not enough evidence to prove residents are not receiving adequate laundry service. Residents reported that their laundry is completed timely. Report continues on attached LIC9099-C Unsubstantiated During the investigation, LPA reviewed medications records and conducted interviews. Interviews from residents revealed that residents receive their medications timely. Based on the information obtained during interviews and record review, there is not enough evidence to prove residents are not receiving medications timely. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations: Due to lack of staffing, residents are not receiving adequate laundry services and Due to lack of staffing, residents do not receive medication on time, are UNSUBSTANTIATED. No deficiencies issued. Exit interview conducted. Report signed on-site. A copy of this report with appeal rights was discussed and provided to the facility representative.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 24-AS-20250611154815

Allegation investigated: Staff does not ensure residents' pendants are in good repair.

On 04/24/2025, Licensing Program Analyst (LPA) V. Gorban conducted an unannounced subsequent complaint investigation to deliver findings. LPA explained the purpose of visit to Regional director Aaron Windbigler. The Department has investigated the allegation: Staff does not ensure residents' pendants are in good repair. On 04/24/2025, LPA call systems not operational. Based on records review no incident report provide to licensing office. It was found that whole facility call system was not operational since 4/10/25, and prior to that date, system would not receive half of the calls. Based on observations, interviews conducted, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being issued in accordance with California Code of Regulations, Title 22, on the attached 9099-D. Exit interview conducted. Report signed on-site. A copy of this report and appeal rights were discussed and provided to the facility representative. Substantiatedthe state’s words, verbatim · CDSS document, Apr 24, 2025 · control 24-AS-20250414162715

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Apr 29, 2025

87303 Maintenance and Operation. (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement was not observed as evidenced by: The facility failed to maintain operations of the signal systems call for whole facility residents which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: The facility plan to and replace the system by April 29th and provide a a proof of correction to Licensing office either by fax or email.

Allegation investigated: Allegation: Staff did not transport resident to a medical appointment. Allegation: Facility is not following the menu that is provided to residents in care.

On 04/03/2025, Licensing Program Analyst (LPA) V. Gorban conducted subsequent unannounced complaint visit to deliver allegation findings. LPA explained the purpose of the visit to Jessica Sanchez and was allowed facility entry. Allegation: Staff did not transport resident to a medical appointment. Allegation: Staff did not transport resident to a medical appointment. During complaint investigation, LPA interviewed facility staff and residents on 1/16/25. Based on staff interview, no complaint received from residents regarding transportation to medical appointment. Based on residents’ interviews, no one addressed concerns regarding transportation to medical appointments. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Report continues on attached LIC9099-C Unsubstantiated Allegation: Facility is not following the menu that is provided to residents in care. During complaint investigation, department LPA interviewed facility staff and residents, toured the facility and reviewed records. On 1/16/25, during the facility kitchen tour and staff interview the menu on the list matched to the menu available for residents prepared by kitchen personnel (Italian wedding soup, mixed greens, grilled bratwurst Link, and roast beef sandwich). According to staff and resident interviews, there have been no reported concerns regarding facility food at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, report signed and provided for facility records. Allegation: Staff did not ensure that facility faucets are delivering hot water for residents in care. During facility tour, on 3/21/25 LPA toured the facility and observed the facility with no hot water. According to staff and plumbing services interviews, due to facility heritage structure, the main water lines are sensitive to water fluctuating pressure and temperature in different sections of the facility that may be easily damaged, causing low pressure in some areas of the facility. Based on observations the bathroom water temperature recorded above regulatory requirement, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations being cited on the attached LIC 9099-D. Allegation: Staff did not ensure that facility elevators are operable for residents in care. One out of three elevators did not work properly during power outage resulting in resident being stuck in the elevator. On 12/20/2024, one elevator malfunctioned causing to complete stop with four residents in it. Based on interviews and record reviews no reported injuries to residents, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations being cited on the attached LIC 9099-D. Exit interview conducted report signed and copy of this report with appeal rights provided for facility records.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 24-AS-20250113094804

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 8, 2025

87303 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 observed by: The facility failed to maintain bathroom floor clean and sanitary. Water leaks from the ceiling and wet floors created potential hazard. One out of three elevator broke down with residents stuck in it, which poses potential health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: The facility staff will implement staff- housekeeping schedule on consistent rotation basis to ensure facility cleanness. New schedule will be provided to LPA by email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87303(e)(2) · Plan of correction due date: Apr 8, 2025

87303 (e) Water supplies....(2) ... Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Based on observations facility staff failed to maintain faucet water temperature with in required regulations which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: The facility staff will work on implementing maintenance staff measures to ensure boiler operates and delivers water temperature in regulatory parameters. New measurs will be provide to LPA by email by POC due date.

Allegation investigated: Staff did not keep facility free of vermin Staff did not prevent the facility elevators from being malodorous. Staff did not provide lighting for residents in care. Staff did not ensure that residents had access to water Staff did not repair facility microwave in a timely manner

On 04/03/2025, Licensing Program Analyst (LPA) V. Gorban conducted subsequent unannounced complaint visit to deliver allegation findings. LPA explained the purpose of visit to IED (interim executive director) Jessica Sanchez and was allowed facility entry. Allegation: Staff did not keep facility free of vermin. Based on staff interviews and record review, the facility maintains the account with both pest control companies. AD (Administrator) responded that pest control comes twice a week: on Wednesday they treat from rats, and Thursday they treat from roaches. AD stated that to resolve continuous issue they added another pest control company that started on 1/13/25 that comes daily to treat roaches and rats. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Report continues on attached LIC9099-C Unsubstantiated Allegation: Staff did not prevent the facility elevators from being malodorous. During facility visit, LPA toured the facility all three elevator interviewed staff and administrator. Based on observations, interview and records reviews, Facility staff-houseman cleans facility main hallways and facility three elevators, two persons per day, as scheduled. No unpleasant smell was observed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not provide lighting for residents in care. Based on residents’ interview, emergency lifts were provided to residents in care during power outage. Staff stated the facility has power generator that able to support operation during power outage for 72 hours. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: staff did not provide residents had access to water. Based on staff and residents’ interviews, facility notified residents in advance on 1/9/25 by information board, text messaging system and hard copy to each resident of not having water on 1/14/25 due to repair the water line due to scheduled water line repair on 1/14/25. Water bottles were provided to residents. Regarding the showers, facility offered transportation to another facility for showers. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not repair facility microwave in a timely manner. Allegation: Staff did not repair facility microwave in a timely manner. According to staff and residents’ interview, no broken microwave reported to staff or observed, during resident interviews. Based on observations, the facility has three common areas with functioning microwaves. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 24-AS-20250113094804

Type of visit: Case Management - Incident

On 01/08/2025 LPA Gorban visited the facility to conduct health and safety checks of clients in care. LPA introduced self, stated the purpose of the visit and was allowed entry. Administrator was notified of Licensing visit and was able to attend it. During this visit LPA toured inside and outside of the facility, interviewed facility staff and administrator. This visit was conducted in regard to incident report provided to Licensing office that occurred on 12/28/2024 were medication error occurred. During this event resident (R1) was provided and taken wrong medications. Based on file review and interview of facility staff, responsible party was notified and resident was monitored. No adverse side effects observed during monitor period. Based on interviews and records reviews the deficiency cited on attached LIC809-D in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8. Failure to correct the deficiency, or repeat violations, may result in civil penalties. Exit interview with Appeal Rights (LIC 9058) and a copy of this report was provided for facility records.the state’s words, verbatim · CDSS document, Jan 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jan 10, 2025

87465 Incidental Medical and Dental Care. (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not observed as evidenced by: Based on interview and records review the facility failed to ensure R1 medication as prescribed. R1 took wrong medications ( dose of Mitrazapine and Risperidone instead of prescribed Ramipril) which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 8, 2025

Plan of correction: Facility plan is to provide additional staff training and close monitoring of medication dispensing especial for on boarded staff members. Proof of training will be provided to Licensing office /LPA by email by POC due date 01/10/25

Type of visit: Required - 1 Year

On 01/08/2025, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA met with Administrator (AD) Natasha Prunty. LPA conducted tour inside and out of facility with AD. Residents observed at the facility during lunch time. The facility was observed to be at a comfortable temperature of 76 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 10/04/2024 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered by US Foods twice a week on Tuesdays and Fridays. Refrigerator temperature was maintained at 39.0-degree F. and freezer was maintained at -2-degree F. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested and within regulation requirements. LPA observed securely fastened grab bar and non-skid mat in shower area. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. Adequate PPE supplies was observed. LPA toured laundry room and observed chemicals were stored and locked for staff use only. Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Report continues on attached LIC809-C Residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE): · LIC 308 Designation of Facility Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly · LIC 9020 Register of Facility Clients/Residents Please submit the above forms/information to Fresno CCL by: 01/12/2025 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. No deficiencies issued during this inspection. An exit interview was conducted with the AD. A copy of this report was given to the AD, whose signature on this form confirm receipt of these reports.the state’s words, verbatim · CDSS document, Jan 8, 2025

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

Allegation investigated: Facility staff did not seek timely medical attention for resident Facility staff did not provide refund to resident's responsible person Facility staff did not follow admissions agreement

Licensing Program Analyst (LPA) Sarah Hurt arrived unannounced to deliver findings on the allegations listed above. LPA met with Aaron Windbigler, and explained the purpose of todays visit. Regarding the allegation Facility staff did not seek timely medical attention for resident. Resident fell on 01/14/2024 early morning between 5 a.m., and 6:45 a.m. did not complain of pain. Resident 1's Responsible Party was contacted but was not available. Resident 1 was showing signs of pain in right foot and knee around 10:27 a.m. on 01/14/24 and was “unable to stand and bear weight on leg/foot.” Resident 1 was taken to the hospital by Responsible Party at 8 p.m. on 01/14/2024. Responsible Party stated Resident 1 was in a wheelchair upon arrival and in visible pain. Based on LPA's interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Substantiated Regarding the allegation Facility staff did not provide refund to resident's responsible person. The facility acknowledges Resident 1's Responsible Party is owed refund of 40% of the 6,000 dollar "Community Fee." Resident 1's Responsible Party has not been refunded this portion of the "Community Fee" Based on LPA interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding the allegation Facility staff did not follow admissions agreement. The facilities Admission Agreement documents "D. Community Fee (v) If this agreement terminates and you leave the community, for any reason, during the third month of residency, you will be entitled to a refund of forty percent (40%) of the balance after a $500 fee is deducted. The facility has not refunded Resident 1's Responsible party for entitled portion of fee, therefore is not following Admissions Agreement. Based on LPA interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited Per Title Regulations, Exit interview conducted with Aaron Windbigler, and a copy of this report along with appeals rights provided.the state’s words, verbatim · CDSS document, Nov 20, 2024 · control 24-AS-20240626094201

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Nov 21, 2024

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The following requirement has not been met as evidenced by: Resident 1 fell on 01/14/2024 around 05:00 a.m., despite being in visible pain was not provided medical care until 8 p.m., which poses an immediate, health, safety or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Regional Director of Operations agrees to provide facility staff training on the subject of timely medical care, and submit proof to LPA by POC date of 11/21/2024.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1669.652 · Plan of correction due date: Dec 4, 2024

§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. The following requirement has not been met as eveidenced by: The facility has not refunded portion of "Community fee" to Resident 1's Responsible Party more than 15 days after the passing of Resident 1, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: The facility will refund 40 percent of 6,000 admission fee to Resident 1's Responsible Party and submit to LPA by POC date of 12/04/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 875057(a)(f) · Plan of correction due date: Dec 4, 2024

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. The following requirement has not been met as evidenced by: Resident 1's Admission Agreement reads 40 percent of "Community Fee" should be refunded. Resident 1's Responsible Party has not received refund, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Regional Director of Operations agrees to Sales Marketing staff, and also Business Office on reviewing agreements and refund process, and submit to LPA Hurt by 12/04/2024.

Allegation investigated: Staff left resident in soiled diapers resulting in a rash. Resident sustained pressure sore while in care.

On 11/14/2024 Licensing Program Analyst (LPA) V Gorban arrived to complete an unannounced complaint visit to deliver findings. LPA met with RSD Eva Reiter. Administrator was contacted and notified. LPA discussed reason for visit and was permitted entry into facility. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms. Allegation: Staff left resident in soiled diapers resulting in a rash. During this investigation department requested and reviewed records. During staff interview no statements or records of residents left in soiled diapers available and /or provided by facility. During resident interview no dates when resident being left in wet diaper provided. The records provided stated residents was attended every couple hours throughout the day. Records review revealed the door note not to bother during night time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Report continues on attached LIC9099-C Unsubstantiated Allegation: Resident sustained pressure sore while in care. During complaint investigation department completed interviews with staff, resident, family member, and reviewed facility records. R1 was observed to be on hospice. Hospice records indicated that R1 had a redness at time of admittance to Hospice. However, the redness was not noted whether it had grown in size. The facility records indicated resident was checked was check every couple hours by facility staff. The records provided stated residents was attended every couple hours throughout the day. Records review revealed the door note not to bother during night time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiency were observed during this visit. Exit interview conducted, report signed and copy of this report provided for facility records.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 24-AS-20240812163914

Type of visit: Case Management - Incident

On 11/14/24, Licensing Program Analyst (LPA) V Gorban arrived to the facility unannounced to conduct a case management visit. LPA met with Administrator Natasha Prunty and explained the reason for the visit. During this visit LPA toured the facility, observing residents in care performing safety check. Based on interview and records review the facility had incident on October 26 th, 2024 that resulted in water shut off for period of couple hours. Incident was not reported by SIR to Licensing Regional office, Fresno. This incident is cited on attached LIC 809-Dthe state’s words, verbatim · CDSS document, Nov 14, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 16, 2024

87211 Reporting Requirements. (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events. This requirement was not observed as evidenced by: The facility failed to provide a written report to Licensing office in regard to water been shut off fro couple hours on October 26th, 2024, which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: The facility administrator will provide plan of correction to LPA by email be POC due date.

Allegation investigated: Facility tested positive for black mold and asbestos

This is an amended report. On 02/11/2025, Licensing Program Analyst (LPA) V Gorban unannounced visited facility stated above to commence a complaint investigation, stated the purpose of the visit, and was allowed entry into the facility by staff. Resident services Director Eva Reiter, administrator Natasha Prunty was notified of Licensing visit and was able to attend the visit. Allegation: Facility tested positive for black mold and asbestos. During this visit LPA toured the facility performing safety checks, also LPA interviewed staff, Administrator, and residents. Department also requested and obtained facility documents. Based on documents review mold and asbestos was observed and tested positive on the first floor, section of facility administrative offices. Repair of the affected area completed. Based on staff interviews mold was observed in offices in June of 2024 and mold remediation and asbestos abatement began in September of 2024. The preponderance of evidence standard has been met; therefore the above allegation is found to be SUBSTANTIATED. Exit interview conducted and copy of this report with appeal rights provided for facility records. Substantiatedthe state’s words, verbatim · CDSS document, Oct 29, 2024 · control 24-AS-20241025161754

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 31, 2024

87303 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 observed as evidenced by: Based on observations during facility visit on 10/29/24 and files review the facility had asbestos and black mold in area administrative offices on the first floor of the facility administrative offices section. This poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: The administrator provided a proof of correction on removing mold and asbestos to LPA by email by POC due date.

Allegation investigated: Resident developed multiple pressure injuries while in care Staff do not ensure the facility is kept free of mal odors Staff do not ensure dental care needs of resident are being met Staff do not ensure rooms are kept at comfortable temperatures for residents in care

On 09/10/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent complaint visit and deliver findings for the above complaint allegations. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Memory Care Director Donna Lao who stated Administrator Eva Reiter is unavailable to attend meeting. During the course of complaint investigation, the department toured the facility, reviewed records, and conducted interviews. R1 is under the care of Hospice with no notes indicating pressure injuries and wounds. The facility was observed free of odors and comfortable temperature with tower fans observed in the resident's room. Resident’s teeth are being brush daily by staff and the resident have been seen by a dentist. Based on observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided to Memory Care Director, whose signature confirm receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 10, 2024 · control 24-AS-20240718113028

Type of visit: Case Management - Incident

On 09/06/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct a case management inspection. LPA met with Resident Services Director Eva Reiter and announced the purpose of the inspection. Executive Director Billy Mitchell was no longer with the company and was not available to assist with the visit. The purpose of the inspection was to follow-up on an incident which occurred on 08/12/2024. On 8/12/2024, care provider (CP1) was sharing with resident (R1) inappropriate videos of himself engaging with intimate contact with an unknown female. CP1 was suspended on 08/12/2024 pending investigations. Responsible party of R1 was not notified of the incident due to resident request. Staff was terminated on 08/30/2024. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on the attached LIC 809-D. Failure to correct the deficiency may result in civil penalties. An exit interview was conducted, and a copy of this report provided to the licensee via email. Appeal Rights (LIC 9058) were provided to the licensee. Exit interview conducted, report signed and copy of this report provided for facility records.the state’s words, verbatim · CDSS document, Sep 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 9, 2024

87468.1 Personal rights. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations. This requirement was not met as evidenced by: Based on records review the facility staff (S1) shared personal inappropriate video content of him with another individual with residents (R1 and R2) in care. This poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: The facility staff provided internal investigation and terminated S1. RSD also will provide in-service training to all staff on residents privacy and dignity and will provided a report to LPA by email by POC due date.

Allegation investigated: Facility staff is retaliating due to complaint that was filed against facility

On 08/15/2024, Licensing Program Analyst (LPA) V Gorban unannounced visited facility stated above to commence a complaint investigation, stated the purpose of the visit and was allowed entry into the facility by staff. Resident Services Director Eva Reitler was notified of Licensing visit and was able to attend the visit. During this visit LPA toured the facility performing safety checks, also LPA interviewed staff, Administrator, and residents. After the tour LPA discussed the findings with the RSD. Allegation: Facility staff is retaliating due to complaint that was filed against facility. During this visit LPA interviewed Administrator, staff and residents. Based on observation and interviews no retaliation against staff was revealed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated Exit interview conducted and copy of this report provided to Administrator for facility records. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 15, 2024 · control 24-AS-20240813154344

Allegation investigated: Staff did not ensure roof was fixed timely

On 7/1/2024, Licensing Program Analyst (LPA) D. Ayers conducted an unannounced complaint inspection. LPA met with Resident Services Director Eva Reiter and Memory Care Director Donna Lao and announced the purpose of the inspection. The purpose of this visit was to deliver the finding of the investigation completed by the Department. During the course of the investigation, the department inspected the facility, conducted interviews, and reviewed records. The following allegation has been determined to be Unsubstantiated: 1) Staff did not ensure roof was fixed timely: Based on observations and record review, the licensed portion of the facility was not in need of repairs to the roof. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. A copy of the report was provided to the licensee vial email. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 1, 2024 · control 24-AS-20240422111901

Allegation investigated: Staff did not ensure that facility has adequate food for the residents. Staff did not ensure that facility has hot water for the residents. Staff did not respond to the residents' pendants when asking for help.

Licensing Program Analyst (LPA) Sarah Hurt arrived unannounced to deliver findings on the allegations listed above. LPA met with Administrator, Billy Mitchell, and explained the purpose of today's visit. Regarding the allegation Staff did not ensure that facility has adequate food for the residents. LPA interviewed five facility residents who stated the facility does provide three meals day, and there has never been a day where the facility has not supplied food. Resident 1 stated there was a few weeks recently when the kitchen would run out of items but it was usually small side items, and full meals were always provided. Based on interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Unsubstantiated Continued.. Regarding the allegation Staff mismanaged the residents' records. Facility staff did not have required Centrally Stored Medication Log for Resident 4's medication being stored by the facility. Resident 6's medication being stored by the facility is not logged on the facilities Centrally Stored Medication Record. Based on LPA interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Exit interview conducted with Administrator, Billy Mitchell, and a copy of this report, along with appeals rights provided. Continued.. Regarding the allegation Staff did not ensure that facility has hot water for the residents. LPA's interviewed five facility residents who all stated the facility has hot water. Resident 2 stated there was an incident during a weather related power outage where they did not have hot water for a few hours, but it was fixed before the day was over. Administrator stated recently during a weather related power outage there was a maintenance issue when the power was restored effecting the facility hot water. Administrator stated maintenance was notified, and the hot water was restored within the same day. LPA Hurt measured several facility resident room water temperatures to be within required 105 and 120 degrees. Based on interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Staff did not respond to the residents' pendants when asking for help. LPA's interviewed 5 facility residents who all stated despite having to wait longer at times on the weekends they are assisted timely when they push their pendant. Resident 3 stated when she pushes her pendant facility staff come fast to check to see if assistance is needed. LPA Hurt facility records titled "Device Activity Report" which documented wait times for assistance to be on average under 15 minutes. Based on interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Administrator, Billy Mitchell, and a copy of this report, along with appeals rights provided.the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 24-AS-20240212083924

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 30, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: .(4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Resident 4 was not provided prescribed medication as facility did not provide the medication to person responsible for administering, Resident 5 has not been given prescribed weekly medication for more than 2 weeks, which poses an immediate, health, safety or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Administrator agrees to conduct in service training on communication between medication technicians, the pharmacy, and the delivery of the medication and submit proof to LPA by PO date of 03/30/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(6) · Plan of correction due date: Apr 12, 2024

87465 Incidental Medical and Dental Care (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed.(B)The name of the prescribing physician.(C) The drug name, strength and quantity.(D) The date filled. (E) The prescription number and the name of the issuing pharmacy.(F) Instructions, if any, regarding control and custody of the medication. The following requirement has not been met as evidenced by: Resident 4's medication was being stored by the facility with no Centrally Stored Medication Record, Resident 6's medication stored by the facility is not logged on the Centrally Stored Medication log, which poses a potential, health, safety or personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Administrator agrees to provide in service training with medication technicians on medication documentation 04/12/2024.

Type of visit: Required - 1 Year

On 2/22/2024, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Executive Director Billy Mitchell and announced the purpose of the visit. LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. Fire extinguishers were recently serviced and facility had a sprinkler system. The facility kitchen was clean and had an adequate supply of perishable and non-perishable foodstuffs. Food was stored properly. LPA observed emergency food supply and personal protective equipment. Facility had adequate supply of emergency food and first aid supplies. LPA reviewed emergency-disaster plan, including evacuation plan and emergency drills. Plan of operations included requirements for dementia care. Common areas were clean, well-lit, and odor-free. LPA toured a sample of resident bedrooms and bathrooms, which were observed to be clean, with all fixtures and appliances functioning properly. Bathrooms were clean and were equipped with required grab-bars and non-skid mats. LPA toured facility memory care unit. LPA observed centrally stored medications in assisted living and memory care to be properly stored and secured, and medications appeared to be administered properly. Facility had an activities coordinator and assistants, and LPA reviewed planned activities. LPA reviewed a sample of resident and staff files. Files contained required documentation and records. LPA requested the following files to be provided by 2/29/2024: LIC 500, LIC 308, LIC 9020a, LIC 610E. No deficiencies were cited during the inspection. A copy of the report was provided and exit interview conducted with Executive Director.the state’s words, verbatim · CDSS document, Feb 22, 2024

Type of visit: Case Management - Other

On 01/18/24, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit. LPA introduced self and was allowed entrance by staff. LPA met with Billy Mitchell, Executive Director (ED) and stated reason for the visit. LPA arrived at the facility to conduct case management visit to relay information about Immediate Exclusion order for Staff (S1). ED was advised an exclusion has been ordered and issued by the Department and provided an exclusion order document for the S1. LPA verified with ED that S1 has not worked in facility. ED responded that S1 has not been with the facility since 3/07/2019 . ED was advised to disassociate S1 from facility staff roster and guardian. No deficiencies sited during this Case Management visit. Exit interview was conducted, report signed on-site, and a copy of this report provided to ED for facility records.the state’s words, verbatim · CDSS document, Jan 18, 2024