The Terraces of Roseville

Allegation investigated: Facility is not kept clean

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to open complaint investigation. LPA met with Administrator Kristine Clawson during today's inspection. During today's inspection LPA toured the facility and interviewed Administrator. Administrator stated they have replaced flooring in some areas on the 1st floor with lament flooring and they receive carpet cleanings for each floor one every 3 months from an outside company. Administrator stated they have a maintenance team that spot cleans as well. During the facility tour LPA toured the common areas on the 1st and 2nd floor. LPA observed some areas have been replaced and had no marks or stains. LPA observed large dark stain marks throughout carpeted common areas, and areas that looked like a deep cleaning was necessary. The large stain marks appeared to be spills and there is heavy wear tear throughout carpet areas. Due to the information gathered and observed, LPA finds allegation to be substantiated.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 59-AS-20260714090233

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 31, 2026

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 is not met as evidenced by: Based on observation the licensee did not ensure facility flooring was in good repair at all times which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: Administrator agrees to spot clean the large stain areas on both the 1st floor and 2nd floor. Administrator stated they will take concerns of new flooring needs to leadership. Administrator to send LPA pictures of the spot cleaning once completed.

Allegation investigated: Facility staff did not adequately address a change in residents health condition to prevent falls

On April 24, 2026, Licensing Program Analyst (LPA) Graham Gunby conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPA Gunby met with Executive DIrector, Kristine Clawson, and explained the purpose of the visit. During the investigation process, interviews and a review of records were initiated. Documents reviewed showed that R1 is a fall risk and have had several falls in the past. R1 requested the facility remove the carpet in their room to have the same flat surface throughout their apartment. Based on interviews it was indicated that R1's change in condition was addressed immediately. Interviews conducted with the Executive Director and R1, a solution was developed for this situation which resulted in R1 receiving different flooring to prevent falls in the future. An interview with R1 concluded there were no concerns and their problems have been resolved with the facility. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was emailed to ED. Unfoundedthe state’s words, verbatim · CDSS document, Apr 24, 2026 · control 59-AS-20260223155312

Allegation investigated: Facility staff are violating residents’ personal rights Facility staff are not providing incontinence care to residents in need Facility staff are not ensuring facility is clean and in good repair Facility is not addressing resident sustaining falls

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kristine Clawson, to deliver findings into the complaint allegations listed above. During the investigation, LPA conducted interviews, toured the premises, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility staff are violating residents’ personal rights ** Report continued on 9099-C ** Unsubstantiated Interviews conducted with staff members S1, S2, S3, and S4, along with residents R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11 indicated that they had no concerns regarding personal rights violations at the facility. Facility staff are not providing incontinence care to residents in need Interviews conducted with staff members S1, S2, S3, and S4, along with residents R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11 indicated that they had no concerns regarding staff providing incontinence care to residents in need. Physician’s Report (LIC 602A) for resident (R1) dated November 19, 2024 indicates that R1 is not confused/disoriented, is able to follow instructions, and is able to communicate their own needs. LIC 602A for R1 states that R1 has bladder and bowel impairment, but R1 is able to care for their own toileting needs. Level of Care Appraisal for R1 dated December 11, 2024 indicates that R1 requires verbal reminders for toileting. Service Plan for R1 indicates that R1 received "verbal reminder for toileting" every day. LPA reviewed Progress Notes for R1 and did not observe any concerns regarding incontinence care. Facility staff are not ensuring facility is clean and in good repair Interviews conducted with staff members S1, S2, S3, and S4, along with residents R2, R3, R4, R5, R6, R7, R8, R9, and R10 indicated that they had no concerns regarding facility being unclean or in disrepair. During visit conducted on May 15, 2025, LPA observed R1’s apartment and observed apartment to be clean and in good repair. LPA observed resident apartments on August 5, 2025 and August 19, 2025, and observed resident apartments to be clean and in good repair. During visits conducted on May 15, 2025, July 8, 2025, August 5, 2025, August 15, 2025, August 19, 2025, and August 26, 2025, LPA observed premises to be clean and in good repair. ** Report continued on 9099-C ** Facility is not addressing resident sustaining falls Interviews conducted with staff members S1, S2, S3, and S4, along with residents R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11 indicated that they had no concerns regarding staff providing assistance with residents sustaining falls. LPA reviewed Progress Notes for R1 and observed the following regarding falls for R1: January 4, 2025: R1 “slipped from chair to ground, … [R1] says [they] didn’t hurt [themselves] and no pain at the moment.” January 5, 2025: R1 “has no complaints of pain or discomfort.” There were no other documentation at the facility indicating any other incidents regarding falls for R1. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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 was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. LPA obtained and reviewed eviction notice issued to resident (R1). LPA observed notice to be lawful in accordance with Health and Safety Code regulations pertaining to eviction notices for Residential Care Facilities for the Elderly (RCFEs). Reason for eviction notice was for failure “to comply with the general policies of The Terraces of Roseville.” Policy violation included “on April 16, drug paraphernalia was found within the resident’s belongings.” LPA reviewed R1’s admission agreement, which states “residents must not bring any illegal substance (e.g., illegal drugs) into their Apartments or anywhere on the premises of THE TERRACES OF ROSEVILLE and must ensure that their family members, guardians, personal representatives and guests abide by this policy.” LPA reviewed a hospital After Visit Summary for R1 dated April 16, 2025 which states R1’s diagnosis was “Methamphetamine use.” Physician’s Report (LIC 602A) for R1 states that R1 is able to leave the facility unassisted. Interview with staff member (S4) indicated that, on April 16, 2025, the front desk called that R1 needed assistance. S4 stated that they announced themselves before entering R1’s apartment. S4 stated that R1 was not wearing pants and was going to get dressed. S4 stated that they went to obtain pants for R1 and, when they opened the drawer, a pipe rolled right out of the pants. S4 stated that they shut the drawer and called ED. ED came in to talk to R1 and sent R1 to the hospital. LPA reviewed Progress Notes for R1 and observed the following instances documented regarding R1’s drug use: December 5, 2024: R1 was observed leaving the facility with their friend in their apartment “possibly smoking weed” as there was an odor in the hallway outside of apartment and odor came directly from R1’s apartment upon entry. R1 was observed smoking weed with friend. December 6, 2024: R1 was observed smoking weed in apartment “along with other drugs.” Indicates R1 has been sneaking friend in apartment and “does drugs.” A “cloud of smoke” was observed coming from R1’s apartment with an “even stronger smell of weed.” ** Report continued on 9099-C ** December 11, 2024: R1 admitted at hospital and tested “positive for methamphetamine and marijuana.” December 15, 2024: “A strong chemical smell” was observed coming from R1’s apartment. “Resident and guest [were] acting weird.” December 16, 2024: R1 “was on something clearly” and was “speaking like another language (gibberish).” Staff noted “who knows what other drugs [R1] is mixing” with prescribed medications. Staff observed R1’s authorized representative on site to be upset with R1’s “recent drug use.” December 26, 2024: Care staff visited R1 and expressed “concern over [R1] testing positive for meth.” Care staff “explained that drugs are not allowed in the community” with R1. December 29, 2024: R1 and friend were observed “smoking weed” with odor in hallway outside apartment. January 11, 2025: R1 and friend were observed “smoking weed” with odor in hallway outside apartment. April 16, 2025: R1 was observed being “extremely high” and R1 told staff they were high. “Staff came to ED office to report finding a ‘meth’ pipe in the residents drawer while assisting resident with dressing. Staff member stated they grabbed a pair of sweats out of the drawer and when they picked them up the pipe was there. They put the pants back over the pipe and came to report. ED went back up with staff and knocked and entered apartment. They showed [ED] the drawer and ED picked up the pipe. ED asked [R1], ‘what is this?’ [R1] stated it was [friend’s]. ED asked if resident also did meth with [friend] and [R1] said, ‘yes [R1] did.’” Facility recommended R1 be transported to hospital and R1 was taken to ER. May 5, 2025: Odor of weed was observed “emanating” from R1’s apartment. Unusual Incident/Injury Report dated April 22, 2025 indicates that, on April 16, 2025, R1 reported to med tech that they were “high” and staff observed drug paraphernalia in apartment. R1 was transported to the hospital and paraphernalia was removed. R1 tested positive for methamphetamine and was medically cleared for discharge. R1 reported to hospital that they were agreeable to entering a rehabilitation program. ** Report continued on 9099-C ** Based on interviews conducted and records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 59-AS-20250512121914

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Michael Hood arrived at the facility unannounced on 8/05/25 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed six (6) resident apartments and two (2) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 111 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on cite. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the perimeter of the care home to be free of clutter and debris. Smoke detectors and carbon monoxide detectors are hard wired and operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA reviewed eight (8) resident files and four (4) staff files during visit. LPA reviewed two (2) residents' medications and observed medication storage to be locked away and inaccessible to the residents. Facility has a current copy of certificate of liability insurance and LPA obtained a copy. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Aug 5, 2025

Allegation investigated: Staff are mismanaging residents' medications. Staff do not meet the qualifications to administer residents' medications.

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kristine Clawson, to deliver findings into the complaint allegations listed above. During the investigation, LPA conducted interviews, conducted a medication count, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Staff are mismanaging residents' medications. ** Report continued on 9099-C ** Substantiated LPA reviewed an Unusual Incident/Injury Report (SIR) for resident (R4) dated March 27, 2025 for an incident that occurred on March 22, 2025 regarding a medication error. SIR states that, on March 22, 2025, staff gave R4 a cup of their morning medications and set a cup of their spouse's medications on the counter of their apartment while preparing a patch for application. R4 picked up their spouse's cup and started to take their spouse's medications by mistake. R4 ingested five (5) of their spouse's medications. R4 was reported tired but with no adverse side effects. SIR states R4 was monitored and follow-up training with med-techs was scheduled. On May 15, 2025, LPA conducted a medication count for residents R1, R2, and R3, comparing each resident’s Centrally Stored Medication Form (CSM) and Medication Administration Record (MAR) with medications centrally stored for the resident. LPA observed one (1) medication for R1 that had three (3) tabs over the amount documented. R1's MAR did not indicate any refusals or missed passes of medication. LPA observed three (3) medications for R3 that were either over or under the amount documented. Documentation for R3 did not indicate any refusals or missed passes and did not provide an explanation for medications under the amount documented. Allegation: Staff do not meet the qualifications to administer residents' medications. LPA reviewed the facility's Plan of Operation on file with the Department. Regarding training for medication aides, the facility's Plan of Operation states the following: "The annual medication training includes 8 hours of in-service training on medication-related issues in each succeeding 12-month period." LPA observed training documentation kept at the facility for staff members S1, S2, and S3. LPA observed S2 and S3 to have documentation showing that they received necessary training in accordance with Title 22, the Health and Safety Code, and the facility's Plan of Operation. LPA observed that S1 started at the facility as a Medication Aide starting 2019 and received initial training in accordance with Title 22, the Health and Safety Code, and the facility's Plan of Operation. LPA observed that S1 did not complete annual medication training in accordance with the facility's Plan of Operation for the years of 2020, 2022, 2023, and 2024. LPA observed that S1 was in the process of successfully completing their annual medication training for the year of 2025. ** Report continued on 9099-C ** Based on a medication count and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. A civil penalty in the amount of $250 was assessed for the date of July 30, 2025 for a repeat violation within 12 months of a prior violation of a statutory or regulatory provision designated by the same combination of letters or numerals per Health and Safety Code §1548. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 59-AS-20250512100337

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 31, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication count and records reviewed, the facility did not ensure that 2 of 3 residents were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: Facility will conduct an inservice with staff regarding medication documentation. Facility will submit to LPA information regarding in-service training by POC due date of 7/31/2025. A civil penalty in the amount of $250 was assessed due to a repeated violation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Aug 15, 2025

87208 Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. (…) This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that 1 of 3 staff administering medications were receiving training in accordance with the facility's Plan of Operation, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: Facility will ensure that all staff administering medications receive training in accordance with the facility's plan of operation. Facility will create a plan on how to ensure staff are meeting training requirements and submit plan to LPA by POC due date of 8/15/2025.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Resident Care Director (RCD), Sharisse Toves, to conducted a case management health and safety check. Prior to visit, LPA received a death report for resident (R1). LPA obtained and reviewed documentation pertaining to R1. LPA will conduct a follow-up visit if deemed necessary. No deficiencies are being cited as a result of today's visit. Exit interview was conducted. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 8, 2025

Type of visit: Case Management - Other

On May 14, 2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains conducted an unannounced case management visit . This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA met with ED Kristine Clawson and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective May 14, 2025 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, May 14, 2025

Allegation investigated: Staff mismanaged residents' medication.

Licensing Program Analyst (LPA) Michael Hood arrvied at the facility and met with Executive Director (ED), Kristine Clawson, to open a complaint investigation into the allegation listed above. During today's visit, LPA reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Staff mismanaged residents' medication. Relevant party reported that there was an incident where medication was found by staff and incident was not reported by the facility. ** Report continued on 9099-C ** Substantiated On March 20, 2025, LPA received a call from staff member (S1) indicating that a medication error was discovered on March 18, 2025, and the facility would be submitting an incident report to the Department. During today's visit, LPA reviewed an Unusual Incident Report (SIR) regarding incident that was reported on March 20, 2025. SIR received states the following information. "On 3/18/25 in the afternoon PM Medtech [staff member S2] found what appeared to be resident's morning medications in [their] apartment, not taken. After examination it was determined to be [their] morning medications. This was reported to the nurse on call and the executive director." SIR indicates that a training was completed for all medtechs on March 18, 2025 regarding proper medication passing. Based on records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents. On March 20, 2025, LPA received a call from staff member (S1) indicating that a medication error was discovered on March 18, 2025, and the facility would be submitting an incident report to the Department. During today's visit, LPA reviewed an Unusual Incident Report (SIR) regarding incident that was reported on March 20, 2025. SIR received states the following information. "On 3/18/25 in the afternoon PM Medtech [staff member S2] found what appeared to be resident's morning medications in [their] apartment, not taken. After examination it was determined to be [their] morning medications. This was reported to the nurse on call and the executive director." Based on records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 59-AS-20250320143434

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 22, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that a resident was receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2025

Plan of correction: Facility conducted an inservice with staff following the incident on March 18, 2025, regarding medication administration. Facility will submit to LPA information regarding in-service training by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED) Kristine Clawson to conduct a case management visit to follow-up regarding a potential fire on cite. Interview with ED indicated that there was no fire on the premises. ED stated that, on 1/15/2025, resident (R1) had placed a remote control in a microwave and smoke from the microwave triggered the smoke alarms. ED stated that staff had evacuated R1 from their apartment and unplugged the microwave. Staff contacted the fire department, who did not identify a fire on the premises. ED stated that R1 is receiving 1:on:1 care and is being observed. ED stated that R1 also received a medication change to address change in condition. During visit, LPA observed R1's apartment and did not observe any damage in apartment. As a result of today's visit, no deficiencies are being cited. Exit interview was conducted with ED. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jan 21, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kristine Clawson, to issue a civil penalty regarding an inspection conducted on 8/21/2024. An immediate civil penalty in the amount of $500 is assessed for the date of 10/23/2024 per Health and Safety Code §1548 for an inspection conducted on 8/21/2024 for a violation that involved the absence of supervision. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 23, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood arrived at the facility unannounced on 9/24/24 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPAs observed seven (7) apartments in Assisted Living and two (2) common area bathrooms. LPAs observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 109.6 degrees F. LPAs checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPAs observed the perimeter of the care home to be free of clutter and debris. LPAs observed smoke detectors and carbon monoxide detectors to be hard wired and operational in the care home. LPAs reviewed four (4) resident files and four (4) staff files during visit. First aid kit is maintained and ready for emergency use. LPAs checked medication storage and found medication to be locked away and inaccessible to the residents. Facility has a current copy of certificate of liability insurance and LPAs obtained a copy. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Sep 24, 2024

The state marks this report as 5 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff did not prevent resident from eloping

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kristine Clawson, to open a complaint into the allegation listed above. During today's visit, LPA toured the facility, obtain documentation pertinent to the investigation, and interviewed ED, Resident Care Director (RCD), and Building Service Director (BSD). Per Special Incident Report (SIR) sent to the Department, the facility reported that staff were unable to locate resident (R1) on the premises on 8/14/24 at approximately 6:00 PM. Facility called 9-1-1 and filed a missing person's report. Resident was located by police at approximately 8:00 PM in the tall grass field behind the property. ** Report continued on 9099-C ** Substantiated Interview with BSD indicated that they observed R1 inside the facility walking with their walker at approximately 5:30 PM. Facility records showed that R1 was in the dining room for dinner, which is served between 4:00 PM to 6:00 PM. Police Department dispatch call records indicate that facility contacted local police department at 7:14 PM to report R1 missing. Interview with RCD indicated that they made the 9-1-1 call. Dispatch call records indicate that RCD reported to police department that R1 was last seen by staff at 3:45 PM. Missing Person Report indicates that R1 was last seen at approximately 3:45 PM and not reported to police department until 7:00 PM that same day. Report indicates that staff stated R1 is often very confused and gets lost very easily. Report indicates that R1 was found by officer in the woods to the rear of the facility, in which R1 was stuck in tall brambles. Interview with ED indicated that, after conducting an internal investigation following the incident and prior to reporting to CCLD, the facility discovered that BSD had last seen R1 inside the facility at 5:30 PM. Interview with RCD indicated that, when they reported to 9-1-1, the staff who they spoke with reported last seeing R1 in the facility at 3:45 PM and RCD reported such to local police department. Interview with RCD indicated that staff at the facility did not report R1 missing to RCD until 6:41 PM, 41 minutes after staff observed R1 missing. ED and RCD stated that, following incident, R1 has moved to a higher level of care outside the facility. During visit, LPA observed field behind property to be maintained. LPA observed that R1's LIC 602A Physician's Report dated 4/16/2024 indicates that R1 has Mild Cognitive Impairment and is unable to leave the facility unassisted. Based on observations, records reviewed, and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 59-AS-20240815133121

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 22, 2024

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 records reviewed and interviews conducted, the facility did not ensure that resident R1 was properly supervised, resulting in AWOL, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: Facility will conduct an in-service training following the AWOL with all staff regarding missing residents/elopement. Facility will provide proof of training to LPA by the POC due date of 8/22/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 22, 2024

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the facility did not ensure to contact 9-1-1 timely after observing R1 AWOL from the facility, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: Facility will conduct an in-service training following the AWOL with all staff regarding reporting protocols. Facility will provide proof of training to LPA by the POC due date of 8/22/24.

Allegation investigated: Facility staff are not responding to call buttons in a timely manner.

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kristine Clawson, to conclude a complaint investigation into the allegation listed above. During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility staff are not responding to call buttons in a timely manner. ** Report continued on 9099-C ** Substantiated Interviews conducted with Business Office Director (BOD), staff members S1 and S2 stated that standard response times to resident call buttons is anywhere between ten (10) to fifteen (15) minutes. Interview with staff member (S3) indicated that standard response time is immediate, with the longest delay witnessed being over ten (10) minutes. BOD stated that, per ED Nathan Condie, that the facility does not have a written policy regarding response times. Interviews with residents R1, R2, R3, and R4 indicated that they have had to wait for assistance from staff anywhere between thirty (30) minutes to two (2) hours. LPA observed call button logs for resident R1, R2, R3, R4, R5, R6, R7, and R8 for the month of April 2024. LPA observed multiple call button response times exceeding 15 minutes and reaching as long as 107 minutes. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. The ED’s signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 59-AS-20240425133343

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 5, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based interviews conducted and records reviewed, the facility did not ensure call buttons for residents were responded to in a timely manner, resulting in response times reaching as long as 107 minutes, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: Facility will conduct an in-service training for all care staff regarding call button response times. Facility will submit proof of training to LPA by POC due date of 7/05/2024.

Allegation investigated: Facility staff restrained resident in care by placing wheelchair or obstacles to prevent resident from getting out of bed.

On 02/09/2024, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing (CCL) received on 12/01/2023. LPA met with Business Director, Shaunte Burnett, and explained the purpose of the visit. During the course of the investigation, the Department conducted interviews with facility staff and obtained pertinent documents relevant to the complaint investigation such as residents’ (R1 and R2) physician’s report, incident reports, confidential facsimile transmittal, medication administration records, and medication list. Continue on page LIC 9099-C. Unsubstantiated Allegation: Facility staff restrained resident in care by placing wheelchairs or obstacles to prevent resident from getting out of bed. – Unsubstantiated. According to the complainant, unspecified staff left R1 alone in bed for long hours, and placed wheelchairs or obstacles to prevent R1 from getting from bed independently. The Department received an interview statement from a resident (R1). R1 indicated staff entered R1’s room at approximately 1-2 AM and placed wheelchair and electric scooter on the right side of the bed which prevented R1 from using transfer pole to get in and out of bed. The Department reviewed R1’s physician’s report and level of care assessments. The physician’s report indicated R1 had bladder impairment, bowel impairment, and requires continuous bed care. R1 can care for all personal needs, bath self, dress/groom self, feed self, and care for own toileting needs. R1 is not able to ambulate without assistance. According to R1’s level of care assessment, R1 requires standby assist when toileting. The Department interviewed and received statements from a total of five (5) facility staff and two (2) residents. Interview statement received from staff (S1 and S5) indicated has not observed R1’s wheelchair or electric scooter placed in the area to prevent R1 from getting in and out of bed. Interview statement received from staff (S3) stated based on the pictures that R1 provided to the facility the incident did occur and it is true that staff (S6) barricaded R1’s bed area with wheelchair and electric scooter. S3 stated did not observe the incident in person. S3 stated staff (S6) are no longer working at the facility. The Department attempted to interview S6 via telephone. The Department conducted a thorough investigation and is unable to determine if the above allegation did occur. Due to the information above, CCL finds 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. An exit interview was conducted, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Feb 9, 2024 · control 59-AS-20231201121801