The Trousdale

Type of visit: Case Management - Incident

On June 30, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to follow-up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit. On June 9, 2026, the facility reported that at 12:58PM, facility staff observed R1 was on the floor in the common area and noted with bleeding from his/her left eyebrow and nose. Subsequently, the administrator viewed the camera footage and observed resident #2 (R1) touched R2, R2 reacted by pushing R1 resulting in R1 fell on the floor and sustained the injuries. During today's visit, LPA toured the Memory Care Unit where R1 and R2 resides. LPA observed R1 was eating and R2 was actively participating in activities. LPA observed both residents appeared with bright affect and both of them stated that they did not remember the incident. LPA interviewed staff members and they reported that they were aware of the incident and they were monitoring both residents more closely and separate them when necessary. They also reported that there were no additional incidents between R1 and R2 after the incident on 6/9/2026. After the incident, the facility obtained medical attention for R1, informed both resident's responsible parties of the incident. No deficiency is cited. This report is reviewed and discussed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Required - 1 Year

On December 10, 2025 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entry, LPA met with Business Office Manager, Arno Manteiro and Resident Care Director, Anne Aquino and LPA explained the purpose of today's visit. The Vice President of Operations, Phil Altman arrived and assisted with the inspection. LPA toured the facility with Resident Care Director and LPA observed the common area with a large dining room, activity rooms, kitchen, medication rooms on different floors, resident rooms, laundry rooms, etc. The memory care unit is located on the 3rd floor and doors are security by the wander guard system. Medications are locked in the medication/work rooms on the 2nd, 3rd, 4th and 5th floor and inaccessible to residents in care. Lighting is sufficient for comfort. Chemicals, toxins, and sharps objects were observed to be locked and inaccessible to residents. 2 days of perishables and 7 days of nonperishable foods were observed for the residents. Fire drill records observed to be sufficient. Hot water temperature in the resident's bathrooms and kitchen were measured at 108- 117 degrees F. A review of (6) resident files was conducted and noted on the LIC 858. A review of (5) staff files was conducted and noted on the LIC 859. No deficiencies cited today. This report is reviewed and discussed with the VP of Operations. A copy is provided.the state’s words, verbatim · CDSS document, Dec 10, 2025

Allegation investigated: Staff mismanaging resident’s medication. Staff did not ensure resident’s medications were refilled in a timely manner.

On May 14, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of a complaint investigation. LPA met with Memory Care Director and explained the purpose of today’s visit. Regarding to the allegation of- Staff mismanaging resident’s medication, the reporting party stated that resident #1 (R1)’s responsible party witnessed staff #1 (S1) who was in training gave all of R1’s medication to R1 at once in R1’s hand resulted R1 struggled not to drop the medications and almost lost a medication in R1’s recliner. According to the responsible party, S1 placed all R1’s medications on R1’s palm so when R1 tried to take it one by one, R1 almost dropped it, however, R1 was able to manage not to drop any and S1 stayed with until R1 took all of the medications. Unsubstantiated As part of the investigation, LPA interviewed staff #2 (S2) who was training S1 on the day of the incident and stated that S1 was in training, and both stayed to ensure that R1 took all the medications then they left the room. After the investigation, this allegation is unsubstantiated because there was no mistake made with R1’s medication administration. It was an accident that R1 almost dropped a pill while taking his/her pills but both staff members followed R1’s evaluation and plan and stayed with R1 to ensure R1 took all the medications before exiting the room as this was observed by the responsible party. Regarding to the allegation of staff did not ensure resident’s medications were refilled in a timely manner, the reporting party stated that on March 30, 2025, the responsible party received a call from the facility reporting that two of R1's medications were running low but the facility had enough to last for a few more days. On the next day (March 31, 2025), the responsible party received a from R1 at 7:01pm and stated that he/she did not take one of the medications that was running low. Subsequently, the responsible party called the facility and verified the medication ran out and delivered the medication that night. The responsible party also stated that the facility was supposed provide notification when R1’s medication has less than two weeks supply. According to the Memory Care Director, the facility has two types of medication refill systems for the residents. When the facility is managing the medications, the facility is responsible to ensure all the refills are done and when the resident or their responsible party is managing the medications, they will be the one to keep track of all the refills and the facility will make a courtesy call 2 weeks before the medications run out. The Memory Care Director stated that R1’s medication is managed by R1’s responsible party and S2 conducted the courtesy call 2 weeks prior to the medications were running low. LPA interviewed S2 who stated that he/she conducted a courtesy call 2 weeks in advance to the responsible party informing them that R1's medication was running low. Based on the documents provided by the facility, under Resident Evaluation, it indicated that R1 does not receive medication administration assistance from the facility instead, resident or family manages all aspects of the refills, including ordering and delivery of medications. Based on 24 hours shift report, it was documented by staff that on 3/30/2025, a courtesy call was made to R1’s family for the refills. After the investigation, this allegation is deemed to be unsubstantiated because R1’s family is managing R1’s medication and courtesy calls were made for the refills. Although the above allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is reviewed and discussed with the memory care director. A copy is provided.the state’s words, verbatim · CDSS document, May 14, 2025 · control 14-AS-20250402145926

Allegation investigated: Staff did not ensure that resident took medication as prescribed Resident sustained injuries during an witnessed fall due to staff neglect

On January 14, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to delivery the complaint investigation findings. LPA met with Memory Care Director and LPA explained the purpose of today's visit. Regarding to the allegation of- staff did not ensure resident took medication as prescribed, the reporting party stated on 11/20/2024 at 7:18PM, resident-in-question (R1) was on the phone with the responsible party who overheard the Medication Technician (Med Tech) did not ensure R1 took the medication by leaving the medication with R1 and left the room. The reporting party stated that this concern has been brought up by the responsible party to the facility director(s) in the past to ensure R1 took the medication before staff leaving the room. As part of the investigation, LPA interviewed the memory care director and other residents. Substantiated According to the memory care director, med techs shall ensure residents take their medication(s) before leaving their rooms unless there is a physician's order indicating that staff may leave the medication(s) with the residents. LPA interviewed resident #2 (R2) who stated that he/she gets medications from staff twice a day. In the morning, facility staff made sure he/she took the medication before leaving the room. However, in the evening, he/she took one pill in the presence of staff and staff would leave the the other pill by the bedside table for him/her to take it before bedtime as the medication causes dizziness. Based on the documents provided, both R1 and R2 did not have a physician's order to leave medications in their rooms unassisted. After the investigation, this allegation is deemed to be substantiated as facility staff did not assist residents with their medications. Regarding to the allegation of- resident sustained injuries during an witnessed fall due to neglect, the reporting party stated that R1 sustained bruising and broken skin from a fall and the shower mat was not placed on the floor by staff may have contributed to the fall. As part of the investigation, LPA interviewed the memory care director, the administrator and conducted observations. According to the administrator, the facility provides the non-skid shower mat to the residents and when a resident who is determined to be independent with their Activities of Daily Living including but not limiting to showers, it would be up to the individual resident to place the shower mat on the floor. The administrator acknowledged that the facility did not have a process to ensure the shower mats were placed on the floor for the residents who are independent with showers. According to the memory care director, the non-skid shower mats were supposed to be on the floor but staff would place them on the grab bars to dry after resident had showered. In regards to R1's fall, the administrator and the memory care director were aware of the fall and acknowledged that R1's responsible party requested the facility to place the shower mat on the floor at all times to prevent R1 from falling again and they stated that this was verbally communicated to facility staff. Based on the documents provided by R1's responsible party, LPA observed the shower mat was not placed on the floor on multiple days after R1's fall. During LPA's visit on 12/20/2024, LPA toured R1 and 9 other resident's rooms and LPA observed the non-skid mats were hanging on the grab bar in R1 and 5 other resident's shower rooms and the mats were all dried. After the investigation, this allegation is deemed to be substantiated. After R1's fall, the responsible party requested both verbally and in writing for the shower mat to be placed on the floor to prevent R1 from falling again and both the administrator and the memory care director acknowledged that it was endorsed to them. In addition, they stated the facility staff was in-serviced. However, it was observed by R1's responsible party and LPA that the shower mat was on the floor. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the memory care Director, and Appeal Rights provided.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 14-AS-20241212164653

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 15, 2025

87465 Incidental Medical and Dental Care..(a) A plan for incidental medical and dental care shall be developed by each facility... (4)The licensee shall assist residents with self administered medications as needed. The requirement is not met as evidenced by based on interview, record review and observation, the facility did not assist R1 and R2's medication which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: The administrator/licensee will develop a plan to ensure facility staff assists residents with their self-administration of medication(s) unless there is a physician's order indicating otherwise. The plan shall include staff training. The administrator will provide a copy of the plan to CCL by 1/15/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jan 15, 2025

87303 Maintenance and Operation..(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not me as evidenced by: Based on observation, interview, and record review, the facility did not ensure R1's shower mat was placed on the floor following R1's fall as specifically requested by R1's responsible party for fall prevent which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: The administrator/licensee will develop a plan to ensure facility staff is assisting independent residents with placing the non-skid shower mats on the floor to ensure safety. The plan shall include staff education. The administrator will provide a copy of the plan to CCL by 1/15/2025.

Allegation investigated: Staff did not seek medical attention for resident in a timely manner resulting in a questionable death Staff did not keep the residents authorized person informed regarding the resident's hospitalization

On January 14, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the investigation findings. LPA met with Memory Care Director and LPA explained the purpose of today's visit. Regarding to the allegation of- staff did not seek medical attention for resident in a timely manner resulting in a questionable death, the reporting party stated that on 11/13/2024, the facility did not complete a safety check on resident #1 (R1) during change of shift around 6:30 am resulting R1 being on the floor for hours instead of receiving immediate medical attention. As part of the investigation. LPA interviewed the memory care director who stated that R1 did not require any assistance with medication management, activities of daily living, and etc. Therefore, the facility was only providing daily safety checks on each shift at varies times during the shift. The memory care director stated that the safety checks were not scheduled. In addition, the memory care director stated that the facility provided a call pendent for R1 to use for assistance but R1 was often found not utilizing it. Unsubstantiated Based on R1's evaluation/service needs and plan, it indicated that R1 did not required assistance for grooming, eating, walking, dressing, etc. After the investigation, this allegation is deemed to be unsubstantiated as there was no proof indicating the duration of R1 on the floor and there was no document indicating there was an agreement between the facility and the responsible party that the safety checks shall be completed at the beginning of each shift. Regarding to the allegation of - staff did not keep the residents authorized person informed regarding the resident's hospitalization, the reporting party stated that the facility informed him/her that R1 was transferred to the South San Francisco Kaiser due to a fall and when he/she called South San Francisco Kaiser and another Kaiser, he/she was told that R1 was not there. Subsequently, the responsible party called the facility and spoke to staff #1 (S1) who stated that he/she would get more information and call the responsible party back. However, S1 never called the responsible party instead staff #2(S2) called the responsible and by that time, the responsible party had already got a call from the hospital where R1 was transferred to. As part of the investigation, LPA interviewed the memory care director, and S1. According to the memory care director, during the transfer, the paramedics informed S1 that R1 would be transferred to Kaiser South San Francisco and the facility was not aware that R1 was being brought to another hospital until they were informed by the responsible party. The memory care director stated that S1 did not call the responsible party back because the responsible party called S1 when the shift was ending, therefore, S1 endorsed it to the incoming shift med tech (S2) to continue to follow up and called the responsible party back when additional information was obtained. LPA interviewed S1 who also reported that he/she was told by the paramedics that R1 would be transferred to Kaiser South San Francisco and stated that when the responsible party called, the shift was ending so he/she endorsed it to the incoming staff to follow up. After the investigation, this allegation is deemed to be unsubstantiated as the facility was unaware of R1's final destination which was decided by the paramedics after R1 had left the facility. However, during the investigation, the director acknowledged that staff did not get R1's vitals and report the result back to the responsible party as requested by the responsible party. This observation will be cited on Case Management visit under LIC809 and LIC809D. Although the above allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is reviewed and discussed with the memory care director. A copy is provided.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 14-AS-20241127162037

Type of visit: Case Management - Deficiencies

On January 14, 2025, Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20241127162037. LPA met with Memory Care Director and LPA explained the purpose of the visit. During the investigation, the reporting party stated that on 11/11/2024, resident #1 (R1) communicated to the responsible party that he/she was not feeling well and the responsible party requested the facility staff to check resident #1 (R1)'s vitals and to report back. However, no one call the responsible party back and he/she was unsure if anyone did the vitals. LPA interviewed the memory care director who acknowledged that the staff did not do the vitals and did not call R1's responsible party back. Based on the complaint investigation, the facility did not take R1's vitals as requested by R1's responsible party. Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and discussed with memory care director. A copy of this report and the Appeal Rights is provided.the state’s words, verbatim · CDSS document, Jan 14, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 15, 2025

87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision, this requirement is not met as evidenced by based on interview and record review, the facility did not check R1's vitals ask requested by R1's responsible party after R1 expressed not feeling well poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: The administrator/licensee will develop a plan in writing to prevent this from happening again and the plan shall include staff training and the topics that will be covered during the training. The administrator/licensee will provide a copy of the plan to CCL by 1/15/2025.

Type of visit: Case Management - Incident

On December 3, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to follow up on an incident that was reported by the facility. Upon entry, LPA met with Business Office Manager, Arno Manteiro and Memory Care Director, Anne Aquino and LPA explained the purpose of today's visit. The administrator, Sylvia Chu arrived shortly thereafter. On November 22, 2024, the facility reported resident #1 (R1) and resident #2 (R2)'s son reported to the facility that R1 was hit by (R2) in their apartment and R1 sustained an injury on the head. This incident was unwitnessed by facility staff. After the facility was informed of the incident, the facility worked with the responsible party and decided to moved R1 to another apartment and spoke to R2 who denied hitting R1 and reported that the head injury was due to a fall. The facility reported the incident to CCL, the Ombudsman and the Local Law Enforcement. During today's visit, LPA observed both residents; R1 appeared to be friendly and pleasant and R2 was sleeping in the new apartment. The Memory Care Director and the Administrator reported that both residents are doing well and they will continue to stay in separate apartments for now. No deficient is cited. This report is reviewed and discussed with the administrator and the memory care director. A copy is provided.the state’s words, verbatim · CDSS document, Dec 3, 2024

Type of visit: Required - 1 Year

On December 3, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entry, LPA met with Business Office Manager, Arno Manteiro and Memory Care Director, Anne Aquino and LPA explained the purpose of today's visit. The administrator arrived shortly thereafter. Memory Care Director provided a tour of the common area with a large dining room, activity rooms, kitchen, medication rooms, resident rooms, laundry rooms, etc. The memory care unit is located on the 3rd floor and all the residents wear a wander guard device/pendent that emit an audible alert when they are in close proximity of the door to prevent residents from wandering off the unit. Medications are locked in the medication/work rooms on the 2nd, 3rd, 4th and 5th floor and inaccessible to residents in care. Lighting is sufficient for comfort. Chemicals, toxins, and sharps objects were observed to be unlocked and inaccessible to residents. 2 days of perishables and 7 days of nonperishable foods were observed for the residents. Fire extinguishers throughout the facility were last serviced on 7/31/2024. Fire drill records observed to be sufficient. Hot water temperature in the resident's bathrooms and kitchen were measured at 105- 111 degrees F. A review of (5) resident files was conducted and noted on the LIC 858. A review of (5) staff files was conducted and noted on the LIC 859. The following updated forms/information are requested to be submitted to CCLD BY 12/6/2024: • LIC 500 Personnel Report • LIC 610E Emergency Disaster Plan (signed and dated) • Proof of current Liability Insurance - Administrator Certification No deficiencies cited today. This report is reviewed and discussed with the memory care director and the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Dec 3, 2024

Allegation investigated: Staff mismanaged resident medication

On June 19, 2024, Licensing Program Analyst (LPA), Murial Han conducted a 10-day complaint visit. LPA met with the Business Office Manager upon arrival and explained the purpose of the visit. Momentarily, the Memory Care Coordinator, Anne Aquino arrived and assisted with the complaint investigation. As part of the investigation, LPA interviewed facility staff, resident-in-question (R1) and reviewed documents. Regarding to allegation of staff mismanaged resident medication, the reporting party stated that in October 2023, R1 received 2 shots of flu and COVID-19 vaccines on the same day and the second part of this allegation, the reporting party stated that R1 recently found a medication/pill on the floor in his/her room and it was returned to one of the Medication Technicians (Med Tech) on the same day and this has happened in the past. In addition, the reporting party stated that there should not be any mediation in R1's room as the facility was managing R1's medication. According to the Med Tech (S1) who recalled incident and stated that the medication should not be found in R1's room and they are supposed to make sure resident takes their medication. Substantiated LPA interviewed the facility coordinator who stated that it was discovered by staff #2 (S2) that the medication found in R1's room did not belong to R1 and this was communicated to R1's responsible party. LPA interviewed R1 who was not able to recall the incident and stated he/she gets medications from staff twice a day- morning and night. Based on facility's Program Description under Medication Support, it stated that medication will be centrally stored and monitored by designated and trained community staff unless arrangements have been made with the administrator and R1 and R1's responsible party did not have any arrangements with the administrator to keep his/her own medication in his/her room. Based on R1's services and needs plan, R1 requires complete assistance with all medication administration by the facility. Therefore, there should not be any medication left unattended in R1's room. Based on interviews, and record reviews, this allegation is substantiated as the facility did not ensure centrally stored medication was inaccessible to residents in care. In regards to R1 was administered 2 shots of flu and COVID-19 vaccines on the same day as the 2nd doses were administered without a consent. Based on the documents provided, the pervious Resident Service Director acknowledged that R1 was not supposed to receive another doses of the vaccine and the mistake was due to lack of facility staff present when R1 was being vaccinated. The previous Resident Service Director stated he/she and other staff were assisting the 3rd party Pharmacist with the vaccine clinic to make sure residents have their proper paperwork and consents for receiving the vaccines and toward the end of the day, the staff who was assisting the Pharmacist left to assist another unit as no one was waiting to be vaccinated. Subsequently, R1 went to the vaccine clinic and was vaccinated by the Pharmacist who did not check the consent. LPA interviewed the facility coordinator who validated the information that was provided by the previous Resident Service Director. After the investigation, this allegation is substantiated as the facility did not provide supervision while R1 was being vaccinated. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Memory Care Coordinator and Appeal Rights providedthe state’s words, verbatim · CDSS document, Jun 19, 2024 · control 14-AS-20240617151929

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jun 20, 2024

87465 Incidental Medical and Dental Care..(h) The following requirements shall apply to medications which are centrally stored:..2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidenced by based on interviews and record review, R1's medication shall be centrally stored and inaccessible to R1, however, R1 found medication in his/her room which posed an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: The administrator/licensee will develop a plan to ensure centrally stored medication is inaccessible to residents, and the plan shall include staff education. The administrator will submit a copy of the plan to CCL by 6/20/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 20, 2024

87464 Basic Services..(f) Basic services shall at a minimum include: (1) Care and supervision.. this requirement is not met as evidenced by based on interviews and record review, there was no facility staff present providing supervision to ensure consent was obtained prior to R1 receiving 2nd doses of Flu and COVID-19 vaccines which posed an immediate health and safety risks resident in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: The administrator/licensee will develop a plan to prevent this from happening again and the plan shall include staff training. The administrator/licensee will provide a copy of the plan to CCL by 6/20/2024.

Type of visit: Case Management - Annual Continuation

On January 9, 2024, Licensing Program Analysts (LPAs) Murial Han arrived unannounced to conduct an annual continuation for an annual required inspection that was conducted on December 27, 2023. Upon arrival, LPA was greeted by the receptionist, Vivian Gonzales and LPA explained the purpose of the visit. Momentarily, LPA re-introduced myself to the Residential Living Advisor, Brienne Detar, Resident Care Coordinator, Joshua Lambengco and Business Office Manager, Aureliano Monteiro and explained the purpose of today's visit. The administrator arrived shortly thereafter and assisted with the rest of the inspection. During today's visit, LPA was provided a tour by the Sales Coordinator, Maria Fe De Jesus and LPA toured the Assisted Living Units and observed temperatures in the resident's apartments and bathrooms to be adequate. The entire facility appeared to be cleaned and tidy. In addition, LPA interviewed residents, facility staff and reviewed files. LPA reviewed 4 resident records and all of them contained admission agreement, medical assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, admission agreement, Resident Identification information, Pre-appraisal assessment, etc. LPA reviewed 5 staff files and all of them contained personnel records, health screening, COVID-19 vaccination information, Job Description, Abuse Statement, First Aid/CPR, fingerprint/criminal background clearance. LPA observed 1 out of 5 staff files did not contain the initial staff training records and according to the director, it was not completed. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 9, 2024

Allegation investigated: Facility did not follow residents care plan regarding alcohol

On December 27, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the investigation findings to complaint number 14-AS-20231030105833. LPA met with the administrator and explained the purpose of today's visit. Regarding to allegation of facility did not follow resident's care plan regarding to alcohol, the reporting party reported that upon admission, it was stated in resident #1 (R1)'s care that R1 shouldn't be served alcohol and facility continued to give R1 alcohol despite being reminded by family. As part of the investigation, LPA interviewed administrator, facility director, staff, and reviewed documents. According to the administrator, facility director and staff, R1's was served a minimal amount of alcohol during facility's daily Happy Hour event until a few months ago when they obtained an order from R1's physician stating that R1 was not supposed to have alcohol. Substantiated Based on the documents provided by the facility, R1's admission physician's report (LIC 602) dated on August 2, 2022 indicated that R1 was not supposed to have alcohol and an additional physician's order (LIC602) dated on August 11, 2023, reiterated that R1 was not permitted to have alcohol consumption due to current diagnosis and current medication regime. After the investigation, this allegation is deemed to be substantiated as per R1's physician's reported dated on August 2, 2022 and August 11, 2023 that R1 was not supposed to have alcohol. However, the facility failed to follow the physician's order dated on August 2, 2022 and served R1 alcohol. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the memory care Director, and Appeal Rights provided. According to facility director, R1 did not required assistance for bathing/showering until September 2023 when the facility received an order from R1's physician to treat R1's foot condition. After obtaining the physician's order, facility updated R1's functional evaluation and started providing assistance to R1 for bathing/showering. In addition, the facility director reported that there were many days that R1 did not want to take a shower and when that happened, it was re-offered to him/her again on the same day at a later time. Based on the documents provided by the facility, LPA observed facility was providing treatment to R1's foot per physician's order and facility staff assisted R1 for showers and when R1 refused, it would be offered again on a different shift. After the investigation, this allegation is deemed to be unsubstantiated as R1 stated that his/her foot condition has been a pre-existing condition and facility staff has been providing showers to R1 on a weekly basis. In addition, the facility provided activities of daily living based on the functional evaluation outcomes. Furthermore when R1 refused to take a bath/shower, facility staff encouraged and offered it again. Although the above allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is reviewed and discussed with the memory care director. A copy is provided. Regarding to the allegation of - facility failed to safeguard resident's property, the reporting party stated that facility destroyed R1's recliner that was brought from home. As part of the investigation, LPA interviewed the administrator, toured R1's apartment and reviewed documentation. LPA interviewed the administrator who acknowledged that the facility discarded R1's recliner because it was infested with bed bugs and they were instructed by the infection control company to get rid of it. However, the facility communicated to the responsible party that R1's account will be credited when a new recliner is purchased. Based on the documentation provided, it stated that facility has agreed to reimburse the responsible party when a new recliner is purchased. After the investigation, this allegation is deemed to be unfounded. Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis. This report is reviewed and discussed with the memory care director and a copy is providedthe state’s words, verbatim · CDSS document, Dec 27, 2023 · control 14-AS-20231030105833

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 28, 2023

87468.1Personal Rights of Residents in All Facilities..(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 is not met as evidenced by facility did not follow R1's physician's order upon admission as indicated on the LIC602 "no use of Alcohol" and served R1 alcohol until a 2nd physician's order of no alcohol was obtained which posed an immediately health risk to resident in care.the state’s words, verbatim · CDSS document, Dec 27, 2023

Plan of correction: The administrator/licensee will develop a plan to ensure facility is following the physician's order for all residents and the plan shall include staff in-services. The administrator/licensee will provide a copy of the plan and estimated time of in-service completion to CCL by 12/28/2023.

Type of visit: Required - 1 Year

On 12/27/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator and explained the purpose of today's visit. Administrator provided a tour of the common area with a large dining room, activity rooms, kitchen, medical clinic, beauty salon, fitness room and kitchen. Facility directors provide a tour of the memory care unit that consists of private and shared one and two bedroom apartments, dining room, activity rooms, etc. The memory care unit is located on the 3rd floor and during tour, LPA observed the delayed egress doors by the two stairwells are working properly and the entrance to the unit is secured with a wanderguard system door. The memory care residents wear a wanderguard device/pendent that emit an audible alert when they are in close proximity of the door to prevent residents from wandering off the unit. During testing of the wanderguard door, resident #1 (R1)'s wanderguard device/pendent did not emit an audible and according to staff, the battery for the device needed to be changed. Medications are locked in the medication room and inaccessible to residents in care. Lighting is sufficient for comfort. Chemicals, toxins, and sharps objects in the memory care kitchen/dinning room were observed to be unlocked and accessible to residents. During tour of the kitchen, LPA observed 2 days of perishables and 7 days of nonperishable foods for the residents. LPA observed expired food items in the walk-in refrigerator. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced on 7/13/2023. Hot water temperature is measured at 105- 111 degrees F. LPA is not able to complete the entire inspection today and will return on another day to complete the inspection. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with memory care director. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 27, 2023