The Pines

Allegation investigated: Staff did not ensure resident care plan was followed Resident sustained injuries while in care

Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 07/13/2026 to complete and deliver findings to a complaint received on 02/27/2026. LPA met with Executive Director (ED), Henry Cole, and explained the purpose of the visit. *Report continues on LIC9099-C* Substantiated Allegation: Staff did not ensure resident care plan was followed Based on interviews and record review, the licensee failed to ensure the resident was safely assisted with transfers, resulting in injury. Record Review: A review of Resident 1’s (R1) service plan, dated prior to 02/24/2026, showed that R1 required moderate assistance with transfers due to reduced mobility, balance issues, and strength limitations. The service plan specified that R1 needed hands-on assistance and, when necessary, two staff to assist with transfers to ensure safety. The plan also indicated that R1 could bear weight with support and required staff to use proper transfer techniques. Personnel records showed that a staff member was terminated for failing to provide physical assistance during R1’s transfer and for not following required transfer procedures. Allegation: Resident sustained injuries while in care Based on record review, interviews and observations, R1 required hands-on assistance for safe transfers. Evidence showed that staff failed to provide the required physical support during the transfer on 02/24/2026, which resulted in R1 falling and sustaining multiple injuries. This demonstrated that the licensee did not ensure staff followed the resident’s care plan or provided safe transfer assistance. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49(f). At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to ED, .the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 59-AS-20260227090313

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Jul 20, 2026

Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides… ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by: Based on interviews and document review it was determined that staff did not ensure that R1 is provided assistance in transferring as required in their care plan resulting in injury to resident in care. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Licensee agrees to conduct a staff training concerning the requirement to assist residents with showers. Licensee shall submit the staff sign in sheet with dates and staff signatures as proof of correction by 07/20/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 20, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that resident received assistance with transfers in accordance with the care plan and assessments, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Licensee agrees to submit a statement of understanding for 87464(f)(1) and will submit to LPA through email by 07/20/2026.

Type of visit: Case Management - Incident

On 06/03/2026, Licensing Program Analyst (LPA) Graham Gunby conducted an unannounced case management visit and met with Business Office Manager, Mira Marcus.. The purpose of today's visit was to discuss an incident report related to one resident in care. The incident reports that were discussed were submitted to licensing for a fall that occurred on 05/29/2026. The facility nurse has been addressing the fall and implementing measures to prevent the falls from occurring in the future. The resident resides in the Independent Living and will undergo and new appraisal when returning from the hospital. Facility will submit the new appraisal once completed. No deficiencies were cited.the state’s words, verbatim · CDSS document, Jun 3, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Graham Gunby arrived unannounced to conduct a 1-year annual inspection and met with Mira Marcus, Business Director, explaining the purpose of the inspection. The facility is licensed for (142) residents, (127) of whom may be non-ambulatory and (12) of whom may be bedridden with a hospice waiver for (20). Currently there are (48) residents in the Memory Care Unit, (42) residents in the Assisted Living and (30) in Independent Living Unit. There are (13) residents under hospice care currently. 120 total residents. LPA toured the interior of the Assisted Living Unit (ALU), including the common areas, main kitchen, activities room, gym, salon, library and medication room. The separate Memory Care Unit (MCU) was also toured where many activities were observed. In all areas toured, there were no health and safety concerns. LPA observed 2+day perishable food and 7+day non-perishable food in the main kitchen. The facility also has an emergency supply of food. Freezer/refrigerator temperatures are checked daily. Specific resident diets are posted in the main kitchen, and weekly menus are posted in common areas. Hot water temperature was checked at 118*F. The fire system was last serviced on 06/18/2025. Fire drills have been completed. All required postings are in the common areas. LPA reviewed (10) resident files - (5) from ALU and (5) from MCU. All files were complete and contain current physician's reports/care plans. (5) staff files were reviewed. All staff are cleared/associated and have completed initial/ongoing training as required and have current First Aid/CPR certifications on file. Facility vehicle records show monthly checks are completed. There are no deficiencies issued during today's inspection. Exit interview conducted. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 23, 2025

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA) Cassie Yang and Associate Governmental Program Analyst (AGPA) Dana Garcia arrived unannounced at the facility to investigate the allegation of the complaint. LPA and AGPA met with Executive Director and explained the purpose of the visit. The course of the investigation, LPA conducted extensive interviews and file review of R1's records. For the allegation cited above, Unlawful eviction, based on the information provided, it is substantiated. Please continue on LIC 9099-C. Substantiated LIC 9099-C Allegation: Unlawful eviction Based on file review of R1's eviction letter, it revealed letter was written on June 13, 2025; however, licensee failed to provide effective date of eviction, specific facts with time and/or date, resources available to assist with alternative housing, Community Care Licensing and Long Term Care Ombudsman information, and exact statement as specified in Health and Safety Code Section 1569.683(a)(4). Based on interview conducted with R1, it revealed R1 did not want to relocate to a new facility. R1 stated R1 wished to reside at a bigger community, not at a six bed board and care. Based on information provided by R1's current caregiver, they were informed that R1 is no longer "eligible" to reside at the facility and "needs full care services by a small facility". The Department finds the allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. LPA provided a copy of all personal rights and CCR 87224 Eviction Procedure to facility. Additionally, LPA obtained a copy of R1's admission agreement, LIC 602, eviction letter and progress notes. Deficiencies cited on the attached LIC 9099-D. An exit interview was conducted, copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 59-AS-20250619113826

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(1)(D) · Plan of correction due date: Jul 3, 2025

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts...(1)...shall include the following information: (D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4)... This requirement is not met as evidenced: Based on file review, Licensee did not comply to the section cited above as LPA and AGPA observed R1's eviction letter to be incompleted with the required criterias which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2025

Plan of correction: Licensee is to revise R1's eviction letter and provide a copy to Licensing and R1. Additionally, Licensee is to submit to Licensing a statement of understanding all resident's personal rights. POC is due July 3, 2025. Failure to provide POC by due date may result to a civil penalty.

Allegation investigated: Staff did not prevent resident from being harmed by another resident which resulted in injury.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 7/15/24. LPA met with Henry Cole, Administrator, and stated the reason for the inspection. LPA was on site most of the day to conduct a required annual inspection also. The Department conducted an investigation into an incident on 7/13/24 (7:51 am), between residents (R1/R2) in the Memory Care dining room. Interviews were conducted, video surveillance was viewed along with police and hospital records. Video surveillance showed multiple staff had intervened in less than (20) seconds and within (2) minutes, both residents were being assisted with walking out of the dining room. The police were contacted due to (R1) returning to the dining room and yelling. (R1) returned from the hospital the same day at 1:30 pm. (R2) was redirected and assigned a 1:1 for 48 hours to monitor behavior. Based on review of police and hospital medical records, it was determined that an egregious injury was not sustained by (R1). Based on information obtained, the Department has determined the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 16, 2024 · control 59-AS-20240715140347

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with Henry Cole, Administrator, explaining the purpose of the inspection. The facility is licensed for (142) residents, (127) of whom may be non-ambulatory and (12) of whom may be bedridden. Currently there are (41) residents in the Memory Care Unit, (42) residents in the Assisted Living and (28) in Independent Living Unit. There are (11) residents under hospice care currently. LPA and Administrator toured the interior of the Assisted Living Unit (ALU), including the common areas, main kitchen, activities room, gym, salon, library and medication room. The separate Memory Care Unit (MCU) was also toured where many activities were observed. In all areas toured, there were no health and safety concerns. LPA observed 2+day perishable food and 7+day non-perishable food in the main kitchen. The facility also has an emergency supply of food. Freezer/refrigerator temperatures are checked daily. Specific resident diets are posted also in the main kitchen and weekly menus are posted in common areas. Hot water temperature was checked in (2) ALU resident rooms and in (2) MCU resident rooms- all readings were 116*F. There are fire extinguishers throughout that were last serviced 6/19/24. All required postings are in the common areas. Administrator's RCFE Certificate #7028142740- exp 5/23/26 was posted. LPA reviewed (11) resident files - (5) from ALU and (6) from MCU. All files were complete and contain current physician's reports/care plans. Medications were reviewed for (2) ALU residents and for (1) MCU resident. Medications are being administered correctly per orders and electronic documentation is current. (7) staff files were reviewed. All staff are cleared/associated and have completed initial/ongoing training as required and have current First Aid/CPR certifications on file. Facility vehicle records show weekly and monthly checks are completed. LPA requested an updated copy of LIC308 and current liability insurance be emailed by 10/23/24. LPA obtained a copy of October staffing schedule. There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 16, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived at the facility to conduct a case management visit regarding an incident that occurred on 8/23/2024. LPA met with Administrator Henry Cole and explained the purpose of the visit. LPA learned that R1 was found in the front parking lot on 8/23/2024 at approximately 4:05am. The facility's video surveillance shows R1 leaving the facility at 3:09am. Before R1 was found by staff, they had fallen in the parking lot. Staff found R1 in a seated position. LPA reviewed the 602 and care plan for R1. LPA and Administrator reviewed surveillance footage of R1 leaving the facility and staff responding. R1 was sent to the hospital where they were diagnosed with a rib fracture and UTI. The facility required R1 to have 1:1 supervision from 8pm - 6am. Facility is following up with R1's care team in order to ensure all medical avenues/interventions have been explored. R1 had lived at the facility since April 2021. Their care needs were reassessed on July 8,2024. Per this reassessment, R1 was not a wander risk, was oriented to time, place, and situation, and independent of bathing, dressing, grooming, and toileting. The facility managed R1's medications. LPA reviewed an updated physicians report completed in December 2023. Per the physicians report, R1 is able to communicate needs, and has no wandering behavior. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.the state’s words, verbatim · CDSS document, Sep 3, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to obtain additional information for an incident report recently submitted to the Department. LPA met with Henry Cole, Administrator and stated the reason for the inspection. The facility submitted an incident report on 7/16/24 related to (1) pill of Norco that was discovered missing from the medication cart on the morning of 7/12/24, when a routine medication count was conducted. The missing medication was thoroughly looked for in the medication cart and surrounding areas, but was not found, so the incident was immediately reported to the Administrator and management. All Med-Tech staff who worked on/around 7/12/24, were interviewed. The one Med-Tech staff (S1)who worked on NOC shift was questioned more in detail but was not able to explain how the medication went missing. Staff (S1) did not want to be interviewed, walked out of the community, and submitted her resignation. Resident (R1) did not miss any doses of PRN Norco 5/325 mg. The camera in the medication room wasn't able to capture the details of how the medication disappeared; so there is only circumstantial evidence that (S1) was responsible for the missing tablet. In May 2024, the facility increased its medication security protocols by installing cameras in/near the medication rooms, requiring that keys be signed in/out by each staff at shift change, and not permitting keys to leave the facility. The facility continues to complete all required narcotic counts to ensure medications are kept secure. It appears the facility followed its medication protocols. There are no deficiencies cited in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 18, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on an incident that occurred in May 2024. LPA met with Henry Cole, Administrator and stated the reason for the inspection. On 5/3/24, the Administrator notified the Department that (10) tablets from a supply of (30) tablets of PRN Norco 5/325 mg were discovered missing from the medication room, around 5:00 am earlier that day, for resident (R1). The Administrator immediately contacted a lock company to re-key the entire medication room and (2) ALU medication carts. An internal investigation was conducted and both Med-Techs (S1/S2) who worked on the NOC shift from 5/2/24 to 5/3/24, denied taking the medication and were given corrective action. LPA was provided with updated information during today's inspection that a staff member, who worked as both a Med-Tech and caregiver, possibly kept the key to the medication room during the shift they were scheduled as a caregiver, following the shift they worked as a Med-Tech. Staff are now required to sign in and out for keys at the start/end of a shift to ensure keys are only given to Med-Techs and also stay on site. The facility promptly notified all parties involved in (R1's) care and installed cameras in the medication room following the incident and there have been no additional medications missing. The Administrator and a Med-Tech staff confirmed (R1) would regularly request Norco 5/325 mg in the evening hours, around the start of NOC shift, for pain relief, and staff was still using the medication received in bubble packs and had not started the new bottle yet. Also, a new prescription for the pain medication, Methodone, written on 5/1/24, was to be administered twice daily. The medication did not run out and the resident received the new pain medication that had just been prescribed. A Technical Advisory note is being issued. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 11, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to obtain additional information for (2) incident reports recently submitted to the Department. LPA met with Henry Cole, Administrator and stated the reason for the inspection. The following residents and incidents were discussed: On 5/14/24, resident (R1), who was independent with her medications, stated she didn't want to live anymore and was going to take the vitamins stored in her room. Staff immediately removed the vitamins and contacted the Police, resident's family and hospice staff. The police arrived to interview (R1) and a 1:1 caregiver was assigned until a hospice nurse and social worker were able to interview resident. The Administrator stated (R1) was falling a lot and is now stabilized. On 6/3/24, resident (R2) lost her balance and fell while walking in the hallways, around 3:15 pm. Resident injured her right elbow and forehead, causing bleeding, and was sent to the emergency room. Resident was admitted and returned to the community later on 6/3/24 (9:40 pm). No follow up appointments were scheduled or any new medications prescribed. (R2) is back in the community and is doing fine. The facility responded immediately and appropriately to each resident and submitted incident reports (LIC624) to the Department timely. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 11, 2024

Allegation investigated: Staff allowed conserved resident to sign unauthorized forms. Staff are not properly trained.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation for a complaint received on 4/9/24. LPA met with Henry Cole, Administrator, in his office and stated the reason for the inspection. During the course of the investigation, LPA interviewed the Administrator, Memory Care Director, (5) staff, resident (R1) and (2) family members of (R1's) conservator. LPA reviewed documentation related to (R1's) conservatorship and viewed facility video footage from 4/6/24. The results of the investigation are as follows: Allegation: Staff allowed conserved resident to sign unauthorized forms. The allegation states that resident (R1's) family member visited on 4/6/24, along with an unidentified male, and asked (R1) to sign some documents without the conservator's consent. Cont on 9099C-1... Unsubstantiated 9099C-1... Resident has a diagnosis of Dementia and is also conserved. LPA was provided with court documents from both the Administrator and (R1's) family member showing that (R1's) family member was appointed conservator over (R1's) person and estate on 1/13/22. Resident resides in the memory care unit of the facility. The Administrator, Memory Care Director and family member indicated that there are no restrictions in place for not allowing the female visitor to visit with (R1). LPA conducted an interview with (3) staff who were present on 4/6/24 when (R1) was visited by another family member, who is not the conservator, and an unidentified male. All interviews indicated that resident's family member and the male visitor entered the Memory Care Unit at 1:15 pm and asked to speak to (R1), who was not in her room then. One staff walked with the visitors to locate (R1) who was in a nearby area and then walked (R1) and the visitors back to (R1's) room. While walking back to (R1's) room, staff overheard the female visitor say she "had some papers for (R1) to sign", and immediately reported this information to the lead staff who told the Administrator and the Memory Care Director. Lead staff and the Memory Care Director confirmed this information. The Memory Care Director stated she responded to the information received and walked into (R1's) room, two separate times, during the visit and asked if the visitors needed anything and was told by the female visitor they were "just visiting". The Director confirmed she saw the male visitor holding a clipboard and he continued to wear a hat and sunglasses during the entire visit. The Director stated the she asked (R1) if she would like to visit with the visitors, and (R1) stated she did but was only able to identify the female visitor. The video footage and interviews conducted show the male visitor was carrying an envelope or clipboard with papers when entering the facility and continued to wear sunglasses and a hat until he left the community, an hour later. The male visitor identified himself as a "family friend" and only provided a first name. Staff interviews confirmed that staff are aware of (R1's) specific family member that holds Power of Attorney (POA) but not all staff were clear that (R1) is conserved, or if any other residents are. Staff did indicate they are aware that residents with a diagnosis of Dementia or are conserved, should not be signing any legal documents without approval from their responsible person or conservator. cont on 9099C-1... 9099C-2... Based on information obtained during the investigation, it appears the facility acted promptly in notifying other staff, (R1's) family member(s) and conservator, and also checking on (R1's) safety twice during the visit. There is currently not a restraining order in place against either visitor. LPA finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff are not properly trained. The allegation states staff need to be aware that the resident is under conservatorship and resident should not be allowed to sign any documents from anyone without the conservator's approval. Staff interviews confirmed that staff are aware of (R1's) specific family member that holds Power of Attorney (POA) but not all staff were clear that (R1) is conserved, or if any other residents are, or what the differences are. Staff did indicate they are aware that residents with a diagnosis of Dementia or are conserved, should not be signing any legal documents without approval from their responsible person or conservator. The Memory Care Director stated that staff are trained on visitation and most family members will call and give staff an alert if a resident will have a visitor to the community. The Director stated "we usually recognize the visitors" and if staff doesn't recognize the visitors, they will ask the resident if they would like to have that visitor and the resident will usually indicate he/she would. One staff stated the female visitor visits once in a while and has never been observed to be carrying paperwork with her to visit (R1). A citation was issued on 4/12/24 for the facility not following its visitor policy in requiring all visitors to sign in and out during each visit. LPA finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 59-AS-20240409113054

Type of visit: Case Management - Infectious Disease Outbreak

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following the facility reporting an infectious outbreak. LPA met with Henry Cole, Administrator and stated the reason for the inspection. On 4/25/24, the Administrator reported to the Department by phone that (1) resident and (2) staff had become infected. An incident report was submitted later in the day on 4/25/24 reporting the (1) resident was placed on quarantine, cleaning protocols were initiated and physician ordered treatment had begun. The Administrator stated there is strong evidence the outbreak was initiated from hospice personnel who visited the infected resident just prior to the first case, and the first staff to be infected was observed to have interacted with the hospice staff. The Administrator followed up with the Department on 4/26/24 to confirm that the county public health department has determined it to be an outbreak, and specific information for each case was being provided to them. LPA was notified of a confirmed third staff case and two additional suspected staff cases. All cases are being treated for the same outbreak. Residents and their families were notified and provided with prevention and control guidelines for the infection. During today's inspection, LPA toured the affected area of the facility with the Memory Care Director and observed an PPE cart to be outside the resident's room. Additionally, the facility created a hand-washing station inside a vacant resident room and a staff room exclusively on the memory care side. The facility immediately took precautionary measures and followed their Infection Control Plan which included isolating the resident and staff (at home), use of PPE, increased and more frequent disinfection, and hand sanitizing and staff training. The facility will send in a follow up incident report on the staff cases. Three staff are expected to clear on Monday, 4/29/24. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 26, 2024

Allegation investigated: Facility did not follow its visitor policy.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to commence a complaint investigation. Also present to conduct a joint investigation was an Ombudsman. LPA met with Henry Cole, Administrator, in his office and stated the reason for the inspection. During today's inspection, LPA and Ombudsman discussed the allegations with the Administrator, (2) staff, resident (R1) and a family member of R1's conservator. LPA also reviewed video camera footage and the visitor sign-in log for Monday, April 8, 2024, and discussed the facility's visitor's policy as stated in the Resident Handbook. The findings are as follows for the (1) above allegation: Facility did not follow its visitor policy. The other (2) allegations need additional investigation before a finding can be delivered. cont on 9099C-1... Substantiated *9099C-1 LPA viewed video coverage from Monday, 4/8/24, at approximately 1:12 pm where (2) individuals walked into the main lobby and over to the reception area. LPA reviewed the visitor sign-in log for the same day and observed that only the female guest had signed in. Interview with receptionist who was working at the time these (2) guests arrived stated she didn't recognize the individuals or name of the person who signed in and the male individual was not requested to sign the visitor log as required. The same staff stated that there are some visitors who do not sign-in as required and they are trained that all visitors need to sign-in for the fire marshall. Review of the visitor log for the same day confirms that the female visitor did not sign-out when leaving the building at approximately 2:28 pm, per video surveillance footage viewed. The visitor log for the same day also shows (16) other visitors who signed in and (5) who did not sign out. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview. Copy of report and appeal rights provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 12, 2024 · control 59-AS-20240409113054

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Apr 26, 2024

87507 Admission Agreements. (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on video footage, visitor log and interviews conducted, the Licensee did not ensure that the male visitor signed in on 4/8/24 at approximately 1:12 pm, and the female visitor signed out, at approximately 2:28 pm per video footage, which posed a potential health and safety risk to residents in care. The visitor log for 4/8/24 shows (16) other visitors who signed in and (5) who did not sign out.the state’s words, verbatim · CDSS document, Apr 12, 2024

Plan of correction: Licensee/Administrator agree to post a sign at the front reception/entry area requesting all visitors sign-in and sign-out when entering/leaving the facility. Photo of the sign to be posted will be emailed to the Department by 4/26/24. Training to be conducted by front desk staff on the visitor policy. Also due by 4/26/24.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on (2) incident reports recently submitted to the Department. LPA met with Henry Cole, Administrator, and stated the reason for the inspection. LPA and Administrator discussed the following: Resident (R1) was sent to the ER on 4/2/24 when care staff were not able to remove the contact from resident's right eye. The contact was removed and resident returned the same day with Polymyxin B – 1 drops to be administered in the affected eye 3 times a day for 7 days. A new eye contact ordered. Facility staff has tried to encourage him to use his glasses but he prefers contacts. This is an isolated incident. Resident (R2) was found to be intoxicated, in his room, on 4/4/24 and sent to the emergency room. Resident has since transferred to a skilled nursing facility for physical therapy and is expected to return in (2) weeks. Administrator stated he has discussed the situation with resident's family members previously and in recent weeks and will discuss obtaining an order from the doctor for a limited daily amount of alcohol. The Administrator stated (R2) is alert and oriented and independent with purchasing alcohol. LPA reviewed resident's physician's report (7/28/23) where it's noted resident consumes alcohol and has a related medical condition. Resident was sent to the ER in February 2024 for a similar incident. Administrator will reach out again to resident's family member(s) to schedule a meeting to discuss obtaining an order for a daily alcohol limit and keep the Department updated. Also discussed was how the incident report should be completed as best possible and submitted to the Department within (7) days of the incident. There are no citations issued in today's report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 9, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Henry Cole during today's inspection. LPA arrived to follow up on complaint investigation, #59-AS-20230804135453. LPA toured the memory care unit with administrator and toured resident room. LPA observed resident room was unlocked and accessible from both doors. No deficiencies cited during today's inspection. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Dec 6, 2023

Allegation investigated: Staff does not ensure resident's nail care needs are being met. Staff does not allow resident access to personal items.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Henry Cole during today's facility visit. LPA investigated allegation of “Staff does not ensure resident's nail care needs are being met.” LPA interviewed facility staff, responsible parties, and reviewed facility documentation. LPA interviewed relevant party in which they stated R1’s fingernails and toenails were not being managed and were very long. Relevant party sent photographs, and LPA observed R1’s fingernails appearing to be overgrown and long. LPA interviewed administrator in which he stated R1 receives visits from a podiatrist every quarter. LPA observed podiatrist documentation in which it states R1 was seen on 11/22/21,4/05/22, 6/20/22, 8/17/22, 10/28/22, 01/17/23, 4/19/23. Continuation on 9099-C. Unfounded Podiatry documentation states R1’s nails were long, and they were trimmed. LPA spoke to R1’s responsible party in which they stated R1 denies care, and at times it’s hard to get resident to accept nail care. The responsible party stated that on August 12th, the responsible party was able to get R1 to a salon and receive a pedicure and manicure. The responsible party states they are happy with the care that is being provided to R1. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated allegation, "Staff does not allow resident access to personal items." LPA interviewed facility staff, responsible parties, and reviewed facility documentation. LPA interviewed relevant party in which they stated the facility is restricting R1's access to her personal belongings which include clothing and toiletries. LPA interviewed the memory care manager in which she stated R1 has a behavior of throwing away personal items. Due to memory impairment, R1 continues to throw away clothing and other items she does not recognize as her own. Facility locks R1’s clothing and toiletries in a closet, and each day (and as needed), a caregiver will unlock and provide R1 with a change of clothes and grooming items. This has prevented R1 from losing personal items. LPA reviewed facility documentation in which it states on 6/09/23 facility staff observed resident outside window screen to be off and R1’s clothes and personal belongings thrown outside. On 6/10/23 staff observed R1’s bedroom window frame off and R1’s clothing was observed to be thrown out the window. On 6/13/23 staff observed R1 bringing out her clothing from her room. On 6/15/23 staff observed R1 had thrown her clothing out the window. LPA reviewed facility care plan in which it states R1 has a history of aggression toward staff, refuses care, and has behaviors of throwing her and her husband’s clothing and grooming items away. LPA interviewed R1’s responsible party in which they stated R1 has thrown many items away and it was getting expensive to replace. The Responsible Party stated they agreed with the facility to have clothing and personal items locked up unless there was staff present. Due to the information gathered, LPA finds allegation to be UNFOUNDED. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 59-AS-20230804135453