The Village at Rancho Solano Assisted Living

Allegation investigated: Staff did not prevent residents from entering another resident's room

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias. During the course of this investigation LPA conducted interviews, reviewed records, and made observations. Staff did not prevent residents from entering another resident's room – Reporting Party (RP) alleges that two (2) residents (R2, R3) entered residents (R1) room while R1 was not there and looked through R1s belongings, sitting, laying in R1 bed, and moving things. Review of video footage indicated that R2 and R3 did enter R1 bedroom without supervision and spent an extended period of time talking, using R1s furniture, and looking through R1s belongings without the presence of R1. Interview with RP confirmed that neither R2 or R3 were given permission to be in R1s room without supervision. Based upon evidence gathered, there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid. Continued LIC9099C... Substantiated Continued from LIC9099... Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt. Continued from LIC9099... Review of resident care plans indicated that R1 does not require 1-1 supervision. There is not an expectation of constant supervision unless otherwise noted on care plan. Although the allegations 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 allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operation, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 17, 2026 · control 21-AS-20260820151409

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 16, 2026

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement not met as evidence by: Based on video review R2 and R3 were able to enter R1s room unattended using the furniture and going through personal belonings which posed/poses a potential risk to personal rights of residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: Licensee shall submit a plan on ensuring residents do not enter others rooms without permission by Plan of Correction due date of 10/16/2026 by 5:00PM.

Allegation investigated: Staff did not ensure residents rooms were free of odors. Staff are not allowing residents to have visitors.

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias. During the course of this investigation LPA conducted interviews, reviewed records, and made observations. Staff did not ensure residents rooms were free of odors – Reporting Party (RP) alleges that many residents’ bedrooms on first floor memory care smell bad and do not have trash cans with tight-fitting lids. LPA toured first floor memory care hallways and activity room and did observe there to be foul odors. LPA toured a spot check of eight (8) of eight (8) resident rooms and found them to be clean and free of odors. LPA observed that one (1) of eight (8) resident bathrooms did not have a trash can with a tight-fitting lid. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Interview with Memory Care Director (MCD) indicated this resident exhibits a behavior in which they will use any room with a specific trash can as a bathroom. Due to this, they use the specific trash can in the bathroom as an indicator for the resident, this trash can does not have a lid. Staff are not allowing residents to have visitors – RP alleges that facility staff are not allowing resident (R1) from entering residents (R2) room after being invited. Interview with MCD indicated that R1 has shown a history of inappropriate behaviors in the past resulting in elevated monitoring. MCD indicated that R2s dementia diagnosis does not allow them to consent to physical advances, of which R1 has made onto R2. Further interviews with MCD indicated that R1 and R2 are still able to spend time together during activities and in the common area with staff supervision. Responsible parties/POAs for both R1 and R2 are aware of the situation and agree with the decision of the facility. Although the allegations 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 allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operation, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 17, 2026 · control 21-AS-20260803115131

Allegation investigated: Staff did not prevent resident from entering another resident's room and harrasing them Staff did not assist resent with getting dressed

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias. During the course of this investigation LPA conducted interviews, reviewed records, and made observations. Staff did not prevent resident from entering another resident's room and harassing them – Reporting Party (RP) alleges that staff allowed other residents to enter residents (R1) room and sit on R1s bed and chair for 45 minutes before staff intervention. RP also alleged possession of a video showing residents in R1s room. LPA was not able to acquire video after numerous attempts. Interviews with management and staff indicated they were not aware of any incidents of residents entering R1s room nor did they receive any reports indicating this. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Review of Care Notes did not indicate any incident in which other residents entered R1s room. Further review of Care Notes indicated an incident in which R1 showed elevated behaviors and was yelling at a visiting performer alleging that this performer was wearing R1s shirt and had gone in their room to steal items. Staff were able to redirect R1 following this behavior. Staff did not assist resident with getting dressed – RP alleges that they were informed by the facility that R1 was refusing to get dressed for a hospital visit resulting in RP “hollering at them through the Ring camera to get up”. RP stated that R1 was in tears due to being rushed to get ready. Interviews with management indicated it is facility policy to prompt a resident to complete Activities of Daily Living (ADLs) three (3) times, however, they are not able to force a resident if they continue to refuse. Further interviews with management indicated that R1 frequently refused ADLs requiring staff prompting and eventual acceptance from R1, but this was not a guarantee. RP states the facility did inform them of R1s refusals which resulted in RP rushing R1 to get dressed. Although the allegations 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 allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operation, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 17, 2026 · control 21-AS-20260708204222

Allegation investigated: Facility is not free of pests Resident's needs were not being met

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias. During the course of this investigation LPA conducted interviews, reviewed records, and made observations. Facility is not free of pests – Reporting Party (RP) alleges that there are insects in resident rooms. Interviews with management indicated that there is a contract with a third-party pest control that conducts regular visits. Staff are trained to report any pest sightings or reports of pests from residents and the pest control will be called for an additional visit. Interviews with staff indicated that there will be sightings of spiders and small insects which are reported and cleaned. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Staff also indicated they have heard reports of other pests being found, however, when a pest is seen or reported it will be elevated to management to have the pest control come out. Further interviews with staff indicated they will observe pests in the fields that surround the facility, and they will make sure to close doors, however, some residents have direct access to these fields from their rooms and pests may enter through there. Review of pest sighting log indicated that pests have been observed in the facility, however, they are reported by staff and residents, and further steps are taken. Review of third part pest control service report indicated that pest control will come out when called to exterminate pests and install preventative measures. Further review of report indicated that pest traps outside of the facility were consumed. Resident's needs were not being met – RP alleges that resident (R1) did not have their needs met resulting in medication errors, lack of eating, and lack of bathing. RP also alleged possession of a video showing R1 not being fed for multiple days. LPA was not able to acquire video after numerous attempts. Interviews with management indicated that R1 would often refuse to leave their room for meals and would have them brought to their room. R1 would also refuse showers and required staff prompting, facility policy is to prompt three (3) when a resident refuses an Activity of Daily Living (ADL). Review of Physician Report indicated that R1 is ambulatory and able to bathe themselves. Review of care plan indicated R1 requires stand-by assistance only with bathing and will refuse frequently requiring staff prompting. Review of Resident monthly completed tasks indicated that R1 received frequent bathing and food services. Review of Medication Administration Record (MAR) indicated that R1 was receiving medication as prescribed. Although the allegations 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 allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operation, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 17, 2026 · control 21-AS-20260706104725

Allegation investigated: Staff did not obtain medical care for resident in a timely manner Staff instructed resident to stay in their room Licensee does not ensure staff have required training Staff did not ensure resident's incontinence needs were being met

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias. During the course of this investigation LPA conducted interviews, made observations, and reviewed records. Licensee does not ensure staff have required training – Reporting Party (RP) alleges that staff are not given required training by Licensee. Interviews with management indicated that upon hire staff undergo 40 hours of computer training followed by 16 hours of shadowing another caregiver before they are able to provide direct assistance to residents. Following this staff receive 20 hours of training yearly. Further interviews with management indicated that in-service training occurs as a result of new incidents/resident behaviors or based upon questions from staff. Interview with staff indicated that aside from required computer training there are regular in-service trainings on varying topics. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Further interviews with staff indicated these in-services can range from group training's to being given pamphlets to read on their own. Review of ten (10) of ten (10) staff training records indicated that staff are receiving the required training hours as per Title 22 regulations. Review of in-service training logs indicated that staff are receiving additional training hours on topics not covered by initial 40 hours or annual 20 hours of training. Staff did not ensure resident's incontinence needs were being met – RP alleges that resident (R1) was not provided incontinence care when required. Review of Care notes indicated that R1 was returning to the facility from the hospital and a bed was being assembled for them, third party medic advised R1 that they were wearing incontinence supplies and could use them. Review of Care Notes indicated that R1 did require incontinence care, however, as they had just returned from the hospital staff felt R1 was too unstable to be moved multiple times and elected to wait “a few minutes” until the bed was assembled. R1 was then moved to the bed and changed. RP alleges that R1 could have been taken to the bathroom and changed instead of being made to wait. Interviews with management indicated that staff may have been able to move R1 to the bathroom without incident, however, waiting to use the bed for a more stable platform was to ensure safety. Staff did not obtain medical care for resident in a timely manner and Staff instructed resident to stay in their room – RP alleges that R1 was presenting behaviors that should have resulted in emergency services, however, facility staff did not send the resident to the hospital and instead told R1 to stay in their room. Interviews with Health and Wellness Director (HWD) indicated that resident presented with blurry vision and facility staff called emergency services to have them sent to the hospital. Interview with Health and Wellness Coordinator indicated that as soon as they were made aware of residents symptoms they called emergency services. Interview with Memory Care Director (MCD) indicated that emergency services were activated when R1 presented stroke like symptoms. Interview with staff (S1) indicated that resident initially did not present with any symptoms indicative of a stroke and stated they were “sleepy” and wanted to be in their room. S1 suggested R1 sleep, and approximately an hour later R1 used their pendant alarm and started to present with blurry vision, at this time emergency services were activated. Further interviews with S1 indicated that they did not force R1 to stay in their room and instead suggested they get sleep when R1 stated they were feeling tired. Review of R1 chart notes indicated once R1 complained of blurry vision their vitals were taken and emergency services were immediately activated. No deficiencies cited. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 27, 2026 · control 21-AS-20260524201159

Type of visit: Case Management - Legal/Non-compliance

on 8/27/2026 Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a Non-compliance inspection and met with Regional Director of Operations, Jesse Sias. On 3/18/2025 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Personnel Requirements - staffing numbers, competency, & services (ADLs) to meet residents care needs. · Incidental Medical & Dental- Regarding medication discrepancies/timely. · Personal Rights - Cameras & privacy. · Elopements. · Call bells response time. Today, LPA conducted the Non-Compliance inspection. Based on record review, medication audit, and observations, Licensee found to be in compliance as pertains to: · Personnel Requirements - staffing numbers, competency, & services (ADLs) to meet residents care needs. · Personal Rights - Cameras & privacy. · Elopements. · Incidental Medical & Dental- Regarding medication discrepancies/timely. · Call bells response time. No deficiencies cited. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 27, 2026

Type of visit: Case Management - Other

On 8/27/2026 Licensing Program Analyst (LPA) Magdaleno arrived unannounced and met with Regional Director of Operations Jesse Sias. The purpose of this visit was to follow up on an SOC341 submitted by the facility on 7/10/2026. SOC341 states that on two (2) separate occasions on the same day, a resident (R1) called for assistance and staff (S1) answered the call but did not provide requested assistance. Both instances allegedly resulted in R1 not receiving toileting assistance. Interviews with management and staff provided differing information regarding what staff were involved and the timeline of the incidents. Interview with R1 indicated they did not remember the incident, however, R1 also stated they had recently received major surgery and were recovering. LPA requested staff contact information. Further investigation may be necessary. LPA also followed up on a change in facility management, Charles White will be taking over as Administrator. Facility will submit the following documents to CCL in order to update Administrator: Copy of active and current Administrator Certificate Copy of Board of Directors Resolution Meeting Minutes Signed Administrator Resume LIC500 - Personnel Report LIC308 - Designation of Facility Responsibility No deficiencies cited. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 27, 2026

Allegation investigated: Residents reside in the locked facility unit without proper written consent

Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings regarding the allegation “ Residents reside in the locked facility unit without proper written consent” and met with Administrator, May Ramos. On February 12th, 23rd, March 19th, April 6th and July 9th LPA Magdaleno conduct complaint investigation visits to Village at Rancho Solano. The memory care both the first and second floor have a total of nine exit doors. During visits LPA Magdaleno’s tested each door to verify they were operational, had proper signage and were alarmed per regulation. The main entrance of the first-floor memory care has a pin code to enter/exit and the four other doors on the first floor have delayed egress, each exiting to the exterior of the building without barriers. The second-floor main entrance door of the memory care has a pin code to enter/exit and the three other doors on the second floor have delayed egress which all exit to a stairway that led down to an unlocked door that leads outside without barriers. All doors were cleared by the fire inspector, this was confirmed on February 25, 2026. Continued on LIC9099-C page...opr Unsubstantiated Continued from LIC9099 page... Because residents in care are able to egress out of seven of the nine doors in the memory care the environment is not a locked, secured perimeter. Residents are not residing in a locked facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 3, 2026 · control 21-AS-20260204090942

Type of visit: Case Management - Incident

On 08/03/2026, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced at the facility to conduct a Case Management – Incident visit. LPA met with the Assistant Executive Director, May Ramos and the Health and Wellness Director, Ieshaa Ragland. Community Care Licensing (CCL) received a self-reported allegation of potential sexual abuse from the facility through a Special Incident Report (SOC 341). According to the report, Resident 2 (R2) informed facility staff that Resident 1 (R1) disclosed that a maintenance employee attempted to kiss R1 while performing maintenance work in an apartment within the facility. Upon receiving the allegation, the facility immediately initiated an internal investigation. Facility management interviewed R1, R2, the maintenance employee, and other individuals who may have had relevant information. During the visit, LPA conducted interview, and reviewed available documentation to determine the circumstances surrounding the reported allegation and the facility's response. Based on information obtained during today's visit, additional investigation is needed to determine the facts and circumstances surrounding the reported allegation. LPA will continue the investigation by conducting additional interviews and reviewing any relevant documentation as necessary. No deficiencies cited. Exit interview conducted with Assistant Executive Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 3, 2026

Allegation investigated: Delayed Egress not working properly in Memory Care

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Regional Director of Operations (RDO), Jesse Sias. Delayed Egress not working properly in Memory Care – Reporting Party (RP) alleges that the delayed egress doors are not operating within regulation. LPA observed during visit on 03/19/2026 that one (1) of eight (8) delayed egress doors in Memory Care did not have the proper signage as required by Title 22 regulations. During subsequent visits LPA observed that the signage had not been put up. Interviews with management indicated that the signage had been ordered but the shipment was delayed. LPA was informed on 6/19/2026 that the signage had been placed. LPA confirmed during this visit that the signage was in place. There is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. Exit interview conducted with RDO, whose signature on form confirms receipt. Substantiatedthe state’s words, verbatim · CDSS document, Jul 9, 2026 · control 21-AS-20260204090942

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.699(a)(7)(A) · Plan of correction due date: Jul 23, 2026

1569.699 (a)(7) (A) A sign shall be provided on the door located above and within 12 inches (305mm) of the panic bar or other door-latching hardware reading: KEEP PUSHING. THIS DOOR WILL OPEN IN ___ SECONDS. ALARM WILL SOUND. This requirement not met as evidenced by: Based upon observation, one (1) of eight (8) delayed egress doors in Memory Care did not have signage per Title 22 regulations which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Deficiency cleared during visit.

Type of visit: Case Management - Other

Licensing Program Analyst, Magdaleno arrived on 7/9/2026 for an unannounced inspection to follow up on substantiated complaint findings, Complaint # 21-AS-20250929084229 On February 04, 2026, the Department concluded a complaint investigation regarding the following allegations: Facility did not seek timely medical and staff did not respond to call button timely. The licensee was cited for California Code of Regulations (CCR) 87411(a) Personnel Requirements and CCR 87466 Observation of the Resident. On February 03, 2026, the Licensee was assessed a $500 Civil Penalty and was informed that an additional civil penalty might be assessed. Assessment of Civil Penalty is allowable based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for Serious Bodily Injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not seeking timely medical attention that resulted in Serious Bodily Injury. Interviews and documentation provided during investigation showed that facility did not respond to resident’s call bell for at least an hour. Resident was found unresponsive with significant blood loss, per Death Report. Additionally, four of seven staff interviewed were not aware that resident required increased monitoring following discharge from the hospital the day prior to death. Continued LIC809C... Continued from LIC809... Today, 7/9/2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on February 04. 2026, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Regional Director of Operations Jesse Sias signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jul 9, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Magdaleno arrived unannounced for the purpose of conducting a Case Management - Other visit and met with Assistant Administrator May Ramos and Health and Wellness Director Ieshaa Ragland. This visit was conducted to follow-up and gather more information regarding an Incident Reports (IR) submitted by the facility on 05/11/2026 and a Death Report (DR) submitted by the facility on 05/14/2026. IR submitted indicated a resident (R1) who developed wounds that were labeled "unstageable" by a third-party nurse practitioner. DR indicated the passing of a resident who was not receiving Hospice care. LPA gathered further documentation. During this visit LPA also amended a report for complaint 21-AS-20260407094438. Amended report signed and received by Assistant Administrator May Ramos. No deficiencies cited. Exit interview conducted with Assistant Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, May 22, 2026

Allegation investigated: Due to behavior problems, staff isolates resident

*Amended Report. Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Assistant Administrator, May Ramos. Due to behavior problems, staff isolates resident – Reporting Party (RP) alleges that resident (R1) is routinely left in their room until lunchtime due to disruptive behaviors. During the course of this investigation LPA conducted interviews, reviewed records, and made observations. Review of Shift Log Notes indicated that R1 will occasionally refuse to get up until afternoon and will occasionally refuse assistance with Activities of Daily Living (ADLs) despite staff attempts. Review of Functional Evaluation indicated that R1 exhibits refusals with care services, and care staff are to promote adherence while maintaining R1’s rights, preferences, and autonomy. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Interviews with staff indicated that R1 prefers to sleep in and can become anxious or aggressive when made to wake up earlier. Further interviews with staff indicated that should R1 exhibit behaviors during group activities they will be redirected to 1-on-1 activities with staff until R1 has calmed, but R1 will never be taken back or left in their room as punishment for behaviors. LPA observed R1 engaging in staff led group activities in the activity room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operation, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, May 7, 2026 · control 21-AS-20260407094438

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a Non-compliance inspection and met with Regional Director of Operations, Jesse Sias. On 3/18/2025 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Personnel Requirements - staffing numbers, competency, & services (ADLs) to meet residents care needs. · Incidental Medical & Dental- Regarding medication discrepancies/timely. · Personal Rights - Cameras & privacy. · Elopements. · Call bells response time. Today, LPA conducted the Non-Compliance inspection. Based on record review, medication audit, and observations, Licensee found to be in compliance as pertains to: · Personnel Requirements - staffing numbers, competency, & services (ADLs) to meet residents care needs. · Personal Rights - Cameras & privacy. · Elopements. · Incidental Medical & Dental- Regarding medication discrepancies/timely. Continued LIC809C.. Continued from LIC809... Review of Response Time Report indicated that average response time for two thousand two hundred and fifteen (2,215) events over the course of fourteen (14) days was eight (8) minutes and thirty six (36) seconds. However, LPA observed four (4) call response times of one (1) +hours, four (4) call response times of two (2)+ hours, and one (1) response time of three (3)+ hours. Licensee found not to be in compliance with Call bells response time. Deficiency cited. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC809D. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Apr 16, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: May 15, 2026

§1569.269 Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs... This requirement not met by licensee as evidenced by: Based on LPA review of facility's Response Time Alert, between 3/29/26 and 4/11/26 9 instances of call alarms went unanswered for 1+hours which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: Licensee to submit plan identifying the how the facility will correct the delays in call button/pendant response time as well as ensure that alert system is in good repair and staff is sufficient to timely answer pendant/call button by Plan of Correction due date of 5/15/2026 by 5:00PM.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Magdaleno arrived unannounced for the purpose of conducting a Case Management - Other visit and met with Assistant Executive Director, May Ramos. This visit was conducted to follow-up and gather more information regarding a Death Report submitted by the facility on 04/02/2026. Resident (R1) had an unwitnessed fall that required medical attention. R1 was sent out to the hospital by the facility where R1 was reported to have passed away. LPA gathered documents and conducted interviews. Further investigation may be required. LPA requested Death Certificate be sent to Community Care Licensing (CCL) as soon as available. No deficiencies cited. Exit interview conducted with Assistant Executive Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Apr 6, 2026

Allegation investigated: Staff do not provide resident adequate food service Staff do not keep the facility free of pest Staff did not ensure resident's finances were safeguard from visitors

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue an Investigation and deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias. During the course of this investigation LPA reviewed records, conducted interviews, and made observations. Staff do not keep the facility free of pest – Reporting Party (RP) alleges that ants were observed in residents (R1) room. LPA observed ants in Memory Care first floor hallway bathroom, the kitchen counter of one (1) of three (3) Memory Care resident apartments, and near Assisted Living third floor garbage chute during tour on 1/15/2026. During subsequent visits LPA did not observe ants in these affected areas and LPA observed power washing occurring on the exterior of the building. Interview with management indicated that ants had been reported and pest control had been visiting regularly, the power washing was also a means to combat the ants. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Review of Pest Control reports indicated that a third-party pest control has been visiting regularly due to reports of ants. Interview with exterminator indicated that all affected areas had been treated and no new areas had been observed, however, exterminator was still making regular visits. Interview with staff (S1, S2) indicated that they had observed ants and would report them to management as per facility policy. Staff did not ensure resident's finances were safeguard from visitors – Reporting Party (RP) alleges that the facility allowed resident (R1) to receive visitors with a history of financial abuse without documenting the visit. Interview with R1 responsible party indicated that there was no restraining order or other court ordered action that would prevent R1 from receiving certain visitors, however, these visitors did have a history of theft in regard to R1’s finances. Responsible party also indicated that they have no knowledge of this occurring at this facility but it might have happened. Title 22 87468.1(a)(11) ensures a resident’s rights to a private meeting with their visitors. Management team indicated that visitors are not barred from the facility unless there is a court order, or if the resident states they do not want to meet with the visitor. Staff do not provide resident adequate food service – Reporting Party (RP) alleges that facility is not encouraging resident (R1) to eat. Interviews with management indicated that care partners/MedTech’s are responsible for dining services in Memory Care. Staff will prompt residents to eat or provide full eating assistance, depending on care plan, and that alternate foods to suit taste will be offered upon refusal to eat. Should refusals continue, an assessment will be conducted to determine if there is an underlying cause. Management also indicated that R1 had their own schedule and would often have meals delivered to them instead of eating in the dining room. Interview with staff (S1) indicated that R1 would occasionally not want to eat at mealtimes and would have food prepared for them at different times, but this was not often. S1 also indicated that staff do not force food upon residents and would listen to their refusals and report them to management. Although the allegations 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 allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operation, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 21-AS-20260109125802

Allegation investigated: Staff did not ensure clear communication was provided to residents responsible party promptly Staff did not ensure copy of requested records were provided to residents responsible party Facility charged for services not provided Staff did not ensure resident records were properly maintained

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a complaint investigation and deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias. During the course of this investigation LPA reviewed records, conducted interviews, and made observations. Facility charged for services not provided and Staff did not ensure resident records were properly maintained – Reporting Party alleges that resident (R1) was billed for care services, such as meal services, that were not provided. As a result of this, RP alleges that facility invoices were not properly maintained. Review of Move Out letter as well as facility invoices indicates that R1 provided a move out notice that was less than 30 days and was continued to be charged for meals/care for the full 30-day billing period. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Upon review, it was observed that facilities Admission Agreement states “You may terminate this Agreement at any time, with or without cause, by giving the Executive Director thirty (30) days' prior written notice of termination. You will continue to be responsible for your full Monthly Fee until the thirty (30) day period has expired or all personal belongings have been removed from the apartment, whichever occurs later.” Further review of Admission Agreement indicated that three (3) meals a day are included in the monthly fee. Staff did not ensure clear communication was provided to residents responsible party promptly and Staff did not ensure copy of requested records were provided to residents responsible party – RP alleges that facility management team informed them that a meeting would take place prior to final bill, however, the meeting did not occur, and the final bill was given with two (2) separate emails being sent to the facility without an answer. RP further alleges that requested invoices were not provided to R1’s responsible party upon request. Review of email correspondence indicates that ledgers were provided to R1’s responsible party upon request, however, these were not the invoices initially requested. Further review of email correspondence indicated that correct invoices were eventually provided, but misunderstanding between the two parties caused a delay. Management team indicated that initial replies were sent, however, the email on file was not correct leading to responsible party not receiving replies. Although the allegations 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 allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 21-AS-20251205090205

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Regional Director of Operations, Jesse Sias. Unlawful Eviction – Reporting Party (RP) alleges that resident (R1) received an eviction notice that was unlawful due to the explanation of eviction lacking supporting information. During the course of this investigation LPA reviewed records and conducted interviews. Interviews with four (4) of four (4) staff indicated that R1 has not refused care or shown aggression behaviors. Interview with management indicated that R1 has started to decline and has shown trouble with medication management, however, R1’s responsible party is refusing to allow for medication reassessment leading to facility being unable to provide the care R1 now requires. Continued LIC9099C... Substantiated Continued from LIC9099... Review of Termination notice indicated that the reason for R1’s eviction is Title 22 regulation 87224(a)(3) “Failure of the resident to comply with general policies of the facility…” but does not provide specific examples or documentation that support this. Based upon evidence gathered, there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 21-AS-20260311131145

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Apr 3, 2026

87224(d)The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement not met by licensee as evidenced by: Resident (R1) was given an eviction notice that did not provided detailed information as specified in the regulation cited as for the reason for eviction which poses/posed a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Licensee to reissue eviction notice following cited regulation to R1 and provide a copy to Community Care Licensing by Plan of Correction due date of 4/03/2026 by 5:00PM. 30-day time period will not start until notice is reissued.

Allegation investigated: Unlawful eviction.

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a complaint investigation and deliver findings regarding the above allegation and met with Health and Wellness Director, Ieshaa Ragland. Unlawful eviction – Reporting Party (RP) alleges that resident (R1) was unlawfully evicted from the facility. During the course of this investigation LPA reviewed documents and conducted interviews. Interview with RP indicated that R1 was stuck at the hospital with the facility being unwilling to take R1 back and recommending a Skilled Nursing Facility (SNF). Further interviews with RP indicated that the hospital had cleared R1 to return to the facility without need of a SNF, but the facility would not take R1 back due to the facilities own “subjective” assessments and would not provide RP with clear objectives to reach before accepting back R1. Interviews with Regional Director of Nursing (RDN) indicated that no eviction paperwork or notices had been provided and that the facility would take back R1, however, they believe R1 required a SNF stay due to a toe amputation. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Further interview with RDN indicated that the facility has attempted multiple times to contact the hospital and have not received any further information regarding R1. Interview with witness (W1) indicated they had observed R1 ambulating and transferring on their own without any issues. Interview with Regional Director of Operations (RDO) indicated that no eviction notice had been issued and the facility would take R1 back after conducting a thorough reassessment. Further interviews with RDO indicated that reassessments with R1 had been attempted, however, the facility and responsible party could not agree upon a date. RDO indicated that R1’s room had been cleaned out by their responsible party without informing the facility. Review of emails correspondence indicated that attempts had been made by both the facility and responsible party to conduct a reassessment with all parties present, however, dates could not be made or were cancelled by either the facility or the responsible party. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Health and Wellness Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 21-AS-20251215123425

Allegation investigated: Facility is not meeting resident's care needs

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a complaint investigation and deliver findings regarding the above allegation and met with Health and Wellness Director, Ieshaa Ragland. Facility is not meeting resident's care needs – Reporting Party (RP) alleges that facility is neglecting resident (R1) and is not providing the care R1 requires. During the course of this investigation LPA reviewed records, made observations, and conducted interviews. Interview with management indicated that R1 had a “small, diabetic ulcer on their toe” that was difficult to see and was noticed by staff “while assisting resident with their socks/shoes”. Further interviews with management indicated that upon reassessment at the hospital they were informed that R1’s toe had been amputated. Interview with Witness (W1) indicated that R1 had developed a toe ulcer “due to negligence” and was not being bathed properly. Continued LIC9099C... Substantiated Continued from LIC9099... Further interview with W1 indicated that R1 “finally stated they had pain in toe. It takes a lot for a dementia person to realize something is wrong” and when staff checked the toe there was an open and weeping ulcer. Upon assessment at the hospital it was found the ulcer had turned necrotic which had reached the bone and required a partial amputation. Review of Resident Notes indicated that toe sore was initially observed on 12/02/2025 and R1 was taken to the hospital by their Responsible Party on 12/05/2025 where R1 was admitted and subsequently had their toe partially amputated. Review of five (5) Resident Shower Sheets for R1 indicated two (2) shower/body check refusals and three (3) successful showers and body checks. Three (3) of three (3) successful body checks indicated that R1 was visually assessed for lesions/blisters/abnormal skin and did not require their toenails to be cut. Review of photographs submitted indicated R1’s toenails had grown past the edge of their toe and were curling down. Further review of photographs indicated that R1’s toe had substantial amounts of slough, was weeping fluid, and had turned a yellow/black color. Based upon evidence gathered, there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Health and Wellness Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 21-AS-20251203165925

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Mar 13, 2026

87465(a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs... This requirement not met by licensee as evidenced by: Resident (R1) did not receive adequate body checks that resulted in partial amputation of their big toe from an ulcer which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2026

Plan of correction: Licensee will submit self-certification regarding adherence to the regulation cited as well as in-service training for staff on completing, documenting, and escalating resident body checks when required by Plan of Correction due date of 3/13/2026 by 5:00pm.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Magdaleno arrived unannounced for the purpose of conducting a Case Management - Other visit and met with Health and Wellness Director, Ieshaa Ragland,. This visit was conducted to follow-up and gather more information regarding two (2) SOC341's submitted by the facility on 03/10/2026. The SOC341's described an incident that occurred in which two (2) residents had an altercation in the Memory Care section. LPA interviewed staff and gathered documents. Review of Care Plans indicated neither resident requires 1-1 care. No deficiencies cited. Exit interview conducted with Health and Wellness Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Mar 12, 2026

Allegation investigated: Unqualified staff provide medical care to residents

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a complaint investigation and deliver findings regarding the above allegation and met with Assistant Executive Director, May Ramos. Throughout the course of this investigation LPA made observations, conducted interviews, and reviewed documents. Unqualified staff provide medical care to residents – Reporting Party (RP) alleges that staff are administering injections without the qualifications to do so. Interviews with five (5) out of nine (9) staff indicated that non-nursing staff were giving injections without using hand-over-hand procedures. Further interviews with these staff indicated that they were not aware of hand-over-hand injection procedures and had been trained to give injections themselves upon starting at the facility. Continued LIC9099C... Substantiated Continued from LIC9099... Interviews with two (2) out of nine (9) staff indicated that hand-over-hand injections are used. Interviews with three (3) out of nine (9) staff indicated that many Assisted Living residents are not capable of or will refuse to follow hand-over-hand procedures. Review of in-service training logs dated 12/4/25 and 12/25/25 indicated that training on hand-over-hand injections has since been given. Interviews with three (3) out of nine (9) staff indicated they were not aware any trainings have been held or were told to sign the in-service log without attending the training. Based upon evidence gathered, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Assistant Executive Director, whose signature on form confirms receipt. Continued from LIC9099A... Interview with one (1) out of five (5) residents indicated that there is an ongoing issue with low staffing due to callouts without backup. Interviews with four (4) out of five (5) residents indicated that staff are friendly and helpful with enough staff to provide assistance and care. Staff did not follow resident’s prescribed medication orders – Reporting Party (RP) alleges that staff do not administer medication to residents at their prescribed times. Interview with three (3) of eight (8) staff indicated that there is a lack of medcarts in the facility leading to too many residents being assigned to each individual cart, making it difficult to deliver medications on time. Interview with one (1) of eight (8) staff indicated that residents have reported hearing management rush staff over walkie-talkies during medication passes leading to resident anxiety. Interviews with three (3) of five (5) residents indicated that they receive their medications on time and have not experienced delays. Interview with one (1) of five (5) residents indicated that they will occasionally have to request their medication be given. Interview with one (1) of five (5) residents indicated that they did not receive their breakfast medication until lunch. Reviews of ten (10) Assisted Living and ten (10) Memory Care Medication Administration Records (MARs) indicated that medication is being logged as administered per prescribed orders. Resident refusals are logged onto the Note page as well faxes to physicians. Facility is not following infection control procedures – Reporting Party (RP) alleges that residents with communicable or infections disease are being retained without use of proper infection control. Interviews with two (2) of eight (8) staff indicated that there have been numerous instances of residents being diagnosed with Clostridium Difficile (C.diff) and Methicillin-resistant Staphylococcus Aureus (MRSA) being retained in the facility. During this investigation, LPA was made aware that a resident (R1) was currently diagnosed and residing in the facility with a diagnosis of MRSA. LPA observed cabinets containing PPE outside of R1’s room for staff use. Interviews with five (5) of eight (8) staff indicated that they were not aware of R1s exact diagnosis, however, they were donning PPE as a whiteboard in the staff room stated R1 had an infectious skin disease. Review of Incident Report received by Community Care Licensing on 2/4/2026 indicated resident was diagnosed on 1/31/2026 and the facility requested an exception to retain a resident with a restricted health condition on 2/4/2026. Review of in-service documents indicated that a training was held on 1/30/2026 on providing care to MRSA positive residents. Although the allegations 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 allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Assistant Executive Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 21-AS-20251125154048

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(b)(1) · Plan of correction due date: Feb 24, 2026

87629 Injections (b)... licensees who admit or retain residents who require injections...(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement not met as evidence by: Five out of Nine staff interviewed indicated non-skilled staff did not receive proper training on injections which poses/posed an immediate health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: Assistant Executive Director and Health and Wellness Director shall submit self-certifications of their understanding that non-skilled staff shall not administer injections by Plan of Correction due date of 2/24/2026 by 5:00PM to Community Care Licensing.

Type of visit: Required - 1 Year

At approximately 9:40 AM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a required 1-year annual inspection and met with Health and Wellness Director (HWD) Ieshaa Ragland. Facility is a Residential Care Facility for the Elderly (RCFE) with one hundred and sixty one (161) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for fifteen (15), and is approved for two hundred and forty two (242) non-ambulatory residents of which six (6) may be bedridden and forty five (45) may reside in Memory Care. At approximately 9:50 AM, LPA initiated a tour of the facility with HWD and observed the following: Facility is a three (3) story building with "B" side consisting of three (3) levels of Assisted Living and "A" side consisting of two (2) levels of Memory Care with the third (3rd) story being additional Assisted Living. Facility was a comfortable temperature, and passageways were free from obstructions. Facility's fire extinguishers were observed charged and last serviced 10/25 . Smoke and Carbon Monoxide detectors were last inspected 11/25 by a third party vendor. Water temperature measured between 105.2- and 114.8 degrees F in a spot check of eight (8) assisted living bathrooms, one (1) assisted living shared bathroom, four (4) memory care bathrooms, and two (2) memory care shared bathrooms, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. LPA observed vegetables/pasta sauce that showed signs of spoilage including the growth of white/green substances (deficiency cited). Continued LIC809C... Continued from LIC809... There is a shaded seating area in the backyard with outdoor space for activities. LPA observed multiple activity areas including a central activity room, a bistro, a salon, a theater, and puzzle areas. LPA observed Memory Care and Assisted Living residents participating in activities led by staff. Facility conducts quarterly disaster drills, and the most recent drill was conducted 1/26. LPA reviewed emergency disaster plan which was last updated 1/2025. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. At approximately 12:00 PM LPA conducted a review of eight (8) resident records. All required documentation present. At approximately 1:10 PM LPA conducted review of six (6) staff records. No deficiency cited. At approximately 2:40 PM LPA and HWD conducted a spot check of medication and medication records. Medication is centrally stored and locked. Updated copies of the following documents shall be submitted to CCL within 30 days of this visit: Liability Insurance LIC500 - Personnel Report LIC308 - Designation of Responsibility LIC610E - Emergency Disaster Plan Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC809D. Exit interview conducted with Health and Wellnes Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Feb 19, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Licensee increased resident's fees without proper notice. Licensee does not ensure that residents' laundry needs are being met.

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias. During the course of this investigation LPA conducted interviews, made observations, and reviewed records. Licensee increased resident's fees without proper notice – Reporting Party (RP) alleges that facility was charging an increased fee without informing RP. Interview with RP indicated that subsequent to signing residents (R1) Admission Agreement they began noticing an increased charge for higher level of care that was not noted upon admission. LPA requested any notices of fee increase from the facility to R1/their responsible party and was informed by previous Executive Director (ED) that none had been issued. Facilities yearly blanket rate increase had been issued prior to R1’s admission and previous Executive Director (ED) informed LPA this did not affect R1. Continued LIC9099C. Substantiated Continued from LIC9099... Review of Admission Agreement and Resident Statements indicated that R1 was being charged additional fees not outlined in the initial Admission Agreement. Review of email titled 30-day Assessment did not detail itemization of charges or detailed explanation of new services provided. Further interview with RP indicated that no subsequent evaluation was shared with them detailing the reasons for this increase in fee and attempts to conduct a care meeting with the previous ED were ignored or did not provide the information requested. Licensee does not ensure that residents' laundry needs are being met – Reporting Party (RP) alleges that residents laundry/bedding is not being washed. Review of Resident Monthly Assignment Reports for August 2025 and September 2025 for resident (R1) indicated that the task “care partner to pull dirty laundry” was marked as XX and UND. Further review of Assignment Reports indicated that task “Staff to wash residents’ laundry…once weekly” was signed as completed. Interview with RDN indicated these markings mean no caregiver was assigned to these tasks and they auto closed. Further interview with RDN indicated that care partners are not tasked with completing laundry as this is a housekeeping task and is not tracked on the digital task list. Interview with staff (S1) indicated that staff were told that they are in charge of laundry, with the previous Executive Director (ED) telling them that “care staff should be doing things like taking out garbage, cleaning the room, and doing the laundry”. Further interview with S1 indicated that failure to do so resulted in disciplinary action. Interview with HWD indicated that care partners assisted with housekeeping and laundry until a new policy was enacted in September 2025, with care partners no longer having access to the housekeeping storage room in Memory Care. Review of R1’s Housekeeping Checklist for December 2025 indicated that the tasks “Strip & make bed” and “Remove dirty linens & replace” were marked with either an X or a slash for the entirety of the month. Interviews with housekeeping staff (S2, S3, and S4) indicated that these marking's meant the tasks were not completed. No resident refusals forms were completed during this time. Interview with RP indicated that no agreement was made for any outside party to complete R1’s laundry and facility was to handle all laundering. Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid. Continued LIC9099C... Continued from LIC9099C... Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. See LIC9099D. Appeal rights were provided. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt. Continued from LIC9099... Interview with Activity Coordinator (AC) indicated that there was a “slight lull” in activities during the period that the activities assistants were absent, but there was no break in activities and care givers assisted with activities. AC indicated that aside from the daily activities conducted in Memory Care and Assisted Living, there is a facility wide live show approximately twice a month in the Assisted Living bistro for both Assisted Living and Memory Care residents. Further interviews with AC indicated that there are quite a few Memory Care residents who refuse to participate in activities and staff will encourage them to participate but will not force them. LPA observed regular activities being held in Memory Care and Assisted Living over multiple visits, including large group activities in the Memory Care common area led by multiple staff with residents being encouraged to join and participate. LPA also observed various activity areas in Memory Care for resident usage. These activity areas included exercise and sports equipment, sensory activities, music, painting, etc.. Licensee does not ensure that the facility is kept clean – Reporting Party (RP) alleges that resident floors and bathrooms are not cleaned with visible green/black spots. Review of the Housekeeping schedule indicated at least two (2) housekeeping staff on duty per day. Review of resident task list indicated that housekeeping tasks were not assigned to care staff and closed out automatically, however, interview with Regional Director of Nursing (RDN) indicated that care staff do not provide housekeeping services and those tasks are tracked on physical checklists. Review of Housekeeping Checklist indicated that resident (R1) is receiving regular room cleaning which includes bathroom sanitization, dusting, mopping, etc. Review of Housekeeping refusal form indicated the ability for R1 to refuse housekeeping services. Over the course of multiple visits, LPA observed Memory Care to be clean and free of odors. LPA observed the Housekeeper’s to be going room to room cleaning as well as cleaning the hallways and communal areas. LPA conducted spot checks of resident rooms and observed them to be clean. Although the allegations 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 allegations are Unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operation, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 21-AS-20250918135744

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(f) · Plan of correction due date: Mar 3, 2026

87307(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident…(F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement not met by Licensee as evidenced by: Based on documentation and interviews, R1 was not provided laundering services as outlined in resident agreement for more then one (1) month.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Regional Director of Operations stated in-service training would be conducted on ensuring resident basic laundry needs are being met.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Mar 3, 2026

1569.657(a) For any rate increase due to a change in the level of care... licensee shall provide… written notice of the rate increases… The notice shall include a detailed explanation of the additional services to be provided... and an accompanying itemization of the charges. This requirement not met by Licensee as evidenced by: Based on documentation and interviews, R1 was charged a rate increase without being provided proper notice as outlined in Title 22 regulation 87307(3)(f).the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Regional Director of Operations stated they would submit a self-certification that residents and/or their responsible parties would received detailed and itemized letters of notice regarding rate increases for higher levels of care by 5:00PM on Plan of Correction due date of 3/3/2026.

Allegation investigated: Facility did not seek timely medical Staff did not respond to call button timely

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias. Licensing Program Analyst (LPA) Magdaleno conducted an investigation into the allegations of “facility did not seek timely medical” and “staff did not respond to call button timely”. LPA interviewed staff, outside parties, reviewed facility records, hospital records and county records. Based on interviews with seven (7) facility staff, five (5) out of seven (7) indicated that resident R1’s call bell had been ringing for more than one (1) hour and two (2) staff indicated the bell rang for more than four (4) hours, they all indicated the call bell ringing was showing “invalid zone” or “invalid user” on their phones and they confirmed the ringing was coming from R1s room. Continued LIC9099C... Substantiated Continued from LIC9099... The seventh staff interviewed indicated the pendant was ringing and staff responded to it. Interviews of management revealed that R1 returned the morning of September 4, 2025, to the facility from an ER visit for a UTI the day prior (September 3, 2025), staff were informed that while previously independent, R1 was now on 72-hour checks (as facilities protocol). Four (4) of the seven (7) staff interviewed stated they were not aware R1 required increased monitoring and two (2) of the seven (7) were unaware that the resident had returned from the hospital. The Care Plan for R1 had not been updated since April 29, 2025, the April Care Plan indicates under line item titled “Status Checks” that “Resident is okay with status checks during the day and no status checks at night”. Staff interviewed stated they were not verbally informed of increased monitoring of R1. According to electronic chart notes, R1 was checked September 4, 2025, at 8:36pm, notes indicate, “resident reports ongoing abdominal pain… reminded to use call pendant if pain increases or assistance is needed”. Electronic entry on 9/5/2025 at 3:34 AM indicates “resident is in room with no complaints of pain or discomfort during this shift”. Next electronic entry is 9/5/2025 1:59pm which indicates R1 was found at 8:15am unresponsive. Staff interviewed stated that there were issues with the call bells in a specific zone of the building and management was previously informed of this. Based on evidence received during the investigation the above allegations are SUBSTANTIATED. **An immediate Civil Penalty in the total amount of $500 has been issued for not seeking timely medical care (See LIC-421IM). An additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).** Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. See LIC9099D. Appeal rights were provided. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 21-AS-20250929084229

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 4, 2026

87411 Personnel Requirements - General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement not met by Licensee as evidenced by: R1 alarm pendant was activated and rang for more than 1 hour as "invalid zone" before R1 was discovered.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Deficiency cleared at time of visit, civil penalty assessed in the amount of $500.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 4, 2026

87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs… This requirement not met by Licensee as evidenced by: Facility staff were not informed of additional checks to completed for R1 following hospital discharge.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Deficiency cleared at time of visit,

Allegation investigated: Facility not allowing resident to receive visitors

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a complaint investigation and deliver findings regarding the above allegation and met with Regional Director of Operations, Jesse Sias. Facility not allowing resident to receive visitors – Reporting Party (RP) alleges that facility has barred resident (R1) from receiving visits from a friend. Interview with Regional Director of Operations (RDO) indicated that it is company policy to allow residents to receive visitors unless there is a court order in place. Interview with Resident Care Coordinator (RCC) indicated that R1 has received many visitors over the course of their stay without interference from the facility. Further interview with RCC indicated that one visitor (V1) for R1 had recently been told they were barred from visiting R1 in the facility until further notice. Interview with Health and Wellness Director (HWD) indicated that V1 did have restricted visitation to R1 due to V1 “yelling and berating staff” in common areas of Memory Care which disrupted the other residents present. Continued LIC9099C... Unsubstantiated Continued from LIC9099... HWD went on to state that this restriction was only for a brief time and V1 was allowed to return after a short while following a discussion with the previous Administrator. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 21-AS-20251125153222

Allegation investigated: Facility did not meet resident's care needs

Licensing Program Analyst (LPA) Magdaleno arrived unnanounced to continue a complaint investigation and deliver findings regarding the above allegation(s) and met with Regional Director of Operations, Jesse Sias. Facility did not meet resident's care needs - Reporting Party (RP) alleges that resident (R1) was observed laying on an air mattress without any sheets during two (2) separate visits and the room was unkept and had a musty smell. Further, RP alleges that R1 developed two (2) sores due to lack of repositioning. During the course of this investigation LPA conducted interviews, made observations, and reviewed records. Interview with Home Health Nurse (HR) indicated that R1 had blisters in the past but currently did not present with any, HR declined any further comments. Interview with staff (S1) indicated that R1 had blisters in their back in the past that did not open and were now healed, but S1 stated R1 may have a new blister on their toe. Continued LIC9099C... Unsubstantiated Continued from LIC9099... S1 also stated that R1 can become combative and often refuses any assistance from staff. Interview with Health and Wellness Director (HWD) indicated that R1 had blisters that healed before becoming open sores and therefore were not staged. Interview with R1 indicated that they are checked on, provided assistance when required, have all their meals delivered to them, and have their room cleaned at least once a week. Further interview with R1 indicated that they have had issues at the facility with call alarm waiting times, assistance with shifting in bed, and developed four (4) sores on their back. LPA observed that R1’s room was fully furnished and clean, and LPA did not observe a musty odor present. R1 was observed to be lying in bed with sheets covering them and a caregiver was observed to check on them regularly. Review of third-party Resident Service Note Charting Forms from 06/2025-11/2025 indicated Stage 1 pressure wound that healed within two (2) weeks. Review of Resident notes dated 06/2025-10/2025 show an average of three (3) checks a day for R1 with daily notes documenting R1 refusal of care. Although the allegation may have happened or is valid, the Department has found there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 21-AS-20251010104902

Allegation investigated: Staff neglect resulted in resident injury Staff are not properly trained to use hoyer lift

Licensing Program Analyst (LPA) Magdaleno arrived unnanounced to continue a complaint investigation and deliver findings regarding the above allegation(s) and met with Regional Director of Operations, Jesse Sias. Staff neglect resulted in resident injury – Reporting Party (RP) alleges that resident (R1) was being transferred via hoyer lift by staff when they fell to the floor breaking their femur. RP also alleges a separate incident in which R1 was being transferred via hoyer by staff when the hoyer lift fell and hit R1’s head. During this investigation CCL staff made observations, reviewed records, and conducted interviews. On 09/14/2025, two staff (S1, S2) were helping R1 move from their bed to their wheelchair. R1 stated the staff “were helping as usual” when they asked, “is it close enough to sit?” R1 stated they “could have sworn the staff said yes” and R1 went to sit. R1 ended up sitting down on the edge of the wheelchair, which caused them to slide down and hit the footplate of their wheelchair. Continued LIC9099C... Unsubstantiated Continued from LIC9099... R1 then “bounced onto the floor.” R1 refused medical treatment and felt minimal pain. R1’s primary care doctor was notified and scheduled an X-ray appointment for R1 a week after the incident, which revealed a femur fracture. R1 reported that they had never had any other concerning incidents or falls during transfers. Facility staff claim that R1’s fall was due to their legs “buckling,” a condition they acknowledge has happened before. However, R1 maintains that on 09/14/2025, they fell solely because they believed someone had assured them it was safe to sit down. During a transfer on 10/22/2025, staff (S3, S4) did not correctly set up the Hoyer lift, causing it to tip over. As a result, R1 was dropped onto their bed and struck in the head by the Hoyer lift. S3 received a written reprimand due to the incident. Staff are not properly trained to use hoyer lift – Reporting Party (RP) alleges that facility staff are not properly trained to use the hoyer lift. Review of facility records indicated that the incident that occurred on 09/14/2025 did not include a hoyer lift, S1 and S2 were providing a 2-person assist to R1. Review of training documents dated 10/22/2025 show two separate training's, one at 0930 and the other at 1330, in order to include staff on different shifts, both training documents included the attendance signatures for S3 and S4. Interview with S3 indicated that the day of the hoyer lift training it was busy on the floor and S3 was not sure they were able to sit through the whole thing. On 10/28/2025 S3 and S4 received 1 on 1 retraining on hoyer lift operation and on 10/29/2025 the facility held a live demonstration on hoyer lift operation led by a hospice agency. Although the allegations may have happened or are valid, the Department has found there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 21-AS-20251028124611

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a Non-compliance inspection and was greeted by Regional Director of Operations, Jesse Sias. On 3/18/2025 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Personnel Requirements - staffing numbers, competency, & services (ADLs) to meet residents care needs. · Incidental Medical & Dental- Regarding medication discrepancies/timely. · Personal Rights - Cameras & privacy. · Elopements. · Call bells response time. Today, LPA conducted the Non-Compliance inspection. Based on record review, Licensee found to be in compliance as pertains to: · Personnel Requirements - staffing numbers, competency, & services (ADLs) to meet residents care needs. · Personal Rights - Cameras & privacy. · Elopements. · Call bells response time. Continued LIC809C... Continued from LIC809... Based upon review of Incident Report submitted 12/1/2025, Resident (R1) was injected with Humalog intended for resident (R2). Licensee found not to be in compliance with Incidental Medical & Dental - Regarding medication discrepancies/timely. Deficiency cited. **A Civil Penalty in the total amount of $250.00 is being assessed for a repeat violation of Regulation 87465(a)(4) more than once in a 12-month period. Deficiency last cited on 05/29/2025. (See LIC421FC)** Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC809D. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Dec 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 5, 2025

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Resident (R1) was injected with Humalog intended for resident (R2) which poses/posed an immediate health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licenses stated they will submit step by step plan on ensuring medications are dispensed properly as well as in-service training log by Plan of Correction due date of 12/5/2025 by 5:00PM.

Allegation investigated: Staff do not ensure that the facility is free of pests.

Licensing Program Analyst (LPA) Magdaleno arrived unnanounced to continue a complaint investigation and deliver findings regarding the above allegation(s) and met with Administrator Morgan Whinery. Staff do not ensure that the facility is free of pests – Reporting Party (RP) alleges that the facility is currently infested with rats with both staff and residents having observed rats. RP further states that there are multiple large rat traps placed throughout the building. During the course of this investigation LPA reviewed records, conducted interviews, and made observations. Review of pest control reports dated 10/02/2025 – 10/15/2025 indicated that traps were inspected and replaced with no activity observed. Interview with Administrator indicated that the facility has pest control visits at least once a week, with five (5) visits occurring over the twenty-two (22) days preceding 10/23/2025. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Administrator also stated that the facility has committed to installing screen doors on first floor resident rooms in order for residents to continue keeping their patio doors open without allowing pests from the surrounding fields to enter. Review of facility emails indicated that orders for screen doors had started. Review of emails between Administrator and resident families indicated that the installation for the screen doors had started. LPA observations that traps have been set up throughout the facility including at exit doors, in the kitchen, and in the dining room. LPA also observed the installation of screen doors on first floor resident rooms had been started. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 21-AS-20251017091847

Allegation investigated: Licensee does not ensure that staff respond to residents' requests for assistance in a timely manner.

Licensing Program Analyst (LPA) Magdaleno arrived unnanounced to continue a complaint investigation and deliver findings regarding the above allegation(s) and met with Administrator Morgan Whinery. Licensee does not ensure that staff respond to residents' requests for assistance in a timely manner. – Reporting Party (RP) alleges that resident call lights go unanswered for 30 minutes or more when staff are busy providing care and management does not provide support. Over the course of this investigation LPA made observations, conducted interviews, and reviewed records. Review of Response Time Report for Pendant Alarms/Bath E-Calls over the course of three (3) days showed thirty-three (33) instances of thirty (30) minutes or longer, five (5) instances of one (1) hour or longer, and one (1) instance of two (2) hours or longer response times. LPA also observed a resident report to facility reception that a call pendant went unanswered for fifty-four (54) minutes. Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid. Continued LIC9099C... Substantiated Continued from LIC9099... Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... Further interviews with care givers indicated that they feel as if they are unable to meet some resident needs such as scheduled bathing in a timely manner due to lack of support during busy times. Interviews with residents indicated that they are provided the care they need and staff are helpful when called upon. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... Interview with Administrator indicated that facility maintains compliance with regulation by requiring hands-on shadow training under the supervision of fully trained staff. Interviews with staff indicated they are assigned shadow partners to conduct hands-on training after initial online training is completed. We have found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 21-AS-20250910094420

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 19, 2025

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. (4) To care, supervision, and services that meet their individual needs... This requirement not met by licensee as evidenced by: Based on a review of Response Time Report for Pendant Alarms/Bath E-Calls showed 39 instances of Pendant Alarms/Bath E-Calls going unanswered for 30 minutes to 2 plus hours which posed/poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: Administrator stated they would provide in-service training logs regarding answering alarms in a timely manner by Plan of Correction due date of 12/19/2025. Additional alarm phones have also been ordered.

Allegation investigated: Personal Rights Staff did not return authorized representatives calls

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Administrator, Morgan Whinery. During the course of this investigation LPA made observations, conducted interviews, and reviewed records. Personal Rights – Reporting Party (RP) alleges that Licensee does not ensure that residents are provided toilet paper or soap, and that Licensee did not replace resident key in a timely manner. Interview with RP indicated that resident (R1) has not been provided with toilet paper since admission and has been made to use paper towels for personal hygiene. Interview with Assistant Executive Director indicated that facility does not provide residents with toilet paper or soap unless residents run out and responsible parties are not able to fill supplies in a timely manner. Continued LIC9099C... Substantiated Continued from LIC9099... Interview with Administrator indicated that facility does provide residents with toilet paper but does not provide soap unless responsible parties are unable to. Interview with Administrator indicated that upon loss of an apartment key, a work order is submitted and will be filled within twenty-four (24) hours. Review of R1 care notes indicated that apartment key was lost for at least five (5) days with the first entry of a lost key stating “door key has been gone for a while”. Care notes document staff explaining to R1 that key will be replaced soon, but no entry regarding replaced key was made following the last entry mentioning the lost key on the fifth (5th) day. Care notes indicated that staff would lock apartment door for R1 but R1 was not satisfied by this. Staff did not return authorized representatives calls – RP alleges that facility did not return phone calls to authorized representative in a timely manner after an incident involving R1. Interview with RP indicated that it took twelve (12) days for facility to return phone calls requesting updates on the health of R1 following an incident that resulted in physical injury. RP states that several staff members directed RP to other staff members who would not or could not answer questions. Per RP, staff stated there was only one staff member who could provide the answers needed, but did not inform RP that this staff member would be out for an extended period of time. Review of Resident Notes indicated that calls with responsible parties are not noted aside from initial incident reporting. Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... Staff did not notice resident's change in condition – RP alleges that staff did not notice change in condition resulting in UTIs and increased weight gain. Interview with RP indicated that R1 gained approximately forty-eight (48) pounds over the course of three (3) years and was diagnosed with two (2) UTIs. Review of weight log indicated that the weight gain did occur. Review of care notes indicated that UTIs were monitored and R1 was sent out to the hospital. Further review of care notes indicated that R1’s health status was being tracked and monitored. Several care note entries did not share unique information and were identical to previous entries over the course of various days. Resident bathroom is not kept sanitary – RP alleges that R1 bathroom is not regularly cleaned resulting in staining and odors. Interview with RP indicated that they observed unhygienic conditions in R1 bathroom on numerous occasions and would inform facility management, but conditions did not change. Interview with Administrator indicated that rooms receive cleaning once a week as well as any other cleaning required by residents. Facility housekeeping does not keep a notes log of services rendered. Review of care notes indicated that staff logged room/bathroom checks for R1 and did not note any odors or staining. Staff are not following residents incontinence plan – RP alleges that staff did not change R1 incontinence pads on a regular basis resulting in UTIs. Reviews of Functional Evaluation and Negotiated Service Plan for R1 indicated that R1 did require incontinence care. Review of care notes did not indicate entries in regard to incontinence plan. Interview with Administrator indicated that incontinence care is only noted for residents on scheduled incontinence plans and is not logged on care notes. Review of R1 Resident Monthly Assignment Report for the month of September 2025 indicated that staff provided assistance to/from bathroom and assisted with incontinence products on regularly scheduled intervals. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 21-AS-20250807114706

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Nov 28, 2025

Personal Accommodations and Services 87307(a)(3)(D) Hygiene items of general use such as soap and toilet paper. This requirement not met as evidenced by: Licensee did not ensure resident was supplied with basic hygeine items as outlined in Title 22 regulationsthe state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Administrator stated they would discuss with house keeping and implement soap dispensation immediately. Administrator would submit statement of implementation by Plan of Correction due date of 11/28/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Nov 28, 2025

Personal Rights of Residents in All Facilities 87468.1(a)(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement not met as evidenced by: Licensee did not ensure representative communications were answered promptly as representative was made to wait twelve (12) days to receive a call back regarding resident health and safety.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Administrator stated they would conduct an -inservice communication and reporting requirements training with reception and leadership team and will submit proof by Plan of Correction due date of 11/28/2025.

Allegation investigated: Facility is not following resident's care plan

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a Complaint Investigation and deliver findings regarding the above allegations and met with Jesse Sias, Regional Director. Facility is not following resident's care plan- Reporting Party (RP) alleges that facility was not following resident (R1) care plan after a change in condition that required increased checks. Over the course of this investigation LPA conducted interviews, made observations, and reviewed records. Review of Negotiated Service Plan indicated that due to two (2) or more falls within a year R1was placed on Fall Intervention status checks for ten (10) days which consisted of increased checks, including day and night checks. Review of Resident Notes indicated that over the course of the ten (10) change of condition status change, three (3) night time status checks were missed including one (1) instance of twenty-two (22) hours and forty (40) minutes between status checks. Continued LIC9099C... Substantiated Continued from LIC9099... Further review of Resident Notes indicated three (3) instances on separate dates of identical entries stating reason for change of condition with no current information on resident condition for that check-in. Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC809D. Exit interview conducted with Regional Director, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 21-AS-20250709165203

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Nov 7, 2025

Observation of the Resident 87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning ... This requirement not met by licensee as evidenced by: 3 instances of missed status check over the course of a 10 day fall intervention plan, including 1 instance of 22 hours and 40 minutes elapsing between checks which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Administrator shall review methods of documenting resident notes before submitting plan on how facility will ensure resident checks are completed and documented by COB on Plan of Correction due date of 11/7/2025.

Type of visit: Case Management - Incident

At approximately 2:30 PM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced on a case management incident visit to follow up on a self-reported allegation of sexual abuse. LPA requested facility submit both a SOC341, as well as, Special Incident Report (if not already submitted). In addition, LPA obtained copies of interview with alleging resident, spouse of alleging resident, as well as, staff. In addition LPA obtained copies of chart notes, and internal emails pertinent to the allegation. Facility is also asked to continue to update Community Care Licensing (CCL) on any developments pertinent to the allegation. No deficiencies cited. Exit interview conducted with Administrator Morgan Whinery, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 30, 2025

Allegation investigated: Staff did not follow resident’s prescribed medication orders

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Morgan Whinery. Staff did not follow resident’s prescribed medication orders – Reporting Party (RP) alleges that facility did not follow resident's prescribed medication and administered residents with higher dosages of prescribed medication then was ordered. During this investigation LPA made observations, reviewed records, and conducted interviews. Review of resident (R1) medication orders indicated that physician order for medication was not to exceed one (1) dose within twenty-four (24) hours with one (1) dose consisting of half (0.5) a pill. Review of R1 Medication Administration Record (MAR) indicated that facility administered multiple doses of medication in under twenty-four (24) hours on five (5) occasions. Three (3) of those occasions consisted of a full pill being administered instead of the prescribed half (0.5) dose. Continued LIC9099C... Substantiated Continued from LIC9099... Interview with Resident Care Coordinator (RCC) indicated that the software used by facility will automatically fill the quantity given as one (1) and staff must physically go back into software to change the quantity to half (0.5). Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **A Civil Penalty for a repeat violation of Regulation 87465(a)(4) more than once in a 12-month period has been cited on complaint 21-AS-20250905090219. ** Appeal rights were provided. See LIC9099D. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 21-AS-20250919095226

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 26, 2025

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on review of MAR, R1 was administered higher dosages then prescribed by physician on five (5) occasion which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Licensee to submit plan on training memory care staff on medication management as well as self-certification that regulation 87465 has been read and understood.

Allegation investigated: Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Morgan Whinery. Staff are mismanaging resident's medication – Reporting Party (RP) alleges that resident (R1) had not been administered their prescribed medication for “a couple of weeks”. During this investigation LPA made observations, reviewed records, and conducted interviews. Review of R1 Medication Administration Record (MAR) indicated that over the course of thirty-one (31) days, R1 had missed fourteen (14) doses of prescribed medication. Further review of MAR indicated that R1 medication had not been filled after running out. Interviews and review of faxes indicated that facility was sending refill requests to the incorrect agency. Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid. Continued LIC9099C.. Substantiated Continued from LIC9099... Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **A Civil Penalty in the total amount of $250.00 is being assessed for a repeat violation of Regulation 87465(a)(4) more than once in a 12-month period. Deficiency last cited on 05/29/2025. (See LIC421FC)** Appeal rights were provided. See LIC9099D. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 21-AS-20250905090219

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 26, 2025

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on interviews and review of MAR, R1 was not administered fourteen (14) doses of prescribed medication over the course of thirty-one (31) days which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Licensee to submit plan on how facility will ensure resident prescription medication is available as prescribed by physician.

Allegation investigated: Personal Rights

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Morgan Whinery. Personal Rights – Reporting Party (RP) alleges that resident (R1) is being verbally abused by staff in R1’s room. During this investigation LPA made observations, reviewed records, and conducted interviews. Interview with R1 indicated that they did not feel as if they had been verbally abused by staff. Interview with resident/roommate (R2) indicated that they have not witnessed R1 being verbally abused, but R2 did state that they felt staff should better take into account that residents may have visual or auditory impairments that would require greater patience during assistance. R2 also stated staff should maintain respect for the elderly. Interviews with residents (R3, R4, R5) indicated that they do not have any knowledge of R1 being verbally abused. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Interview with Health and Wellness Coordinator (HWC) indicated that “staff are rotated frequently so it isn't just one staff helping the same resident”. Review of R1 care plan and care notes did not indicate reports of R1 being verbally abused by staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 21-AS-20250902164435

Allegation investigated: Personal Rights

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Morgan Whinery. Personal Rights – Reporting Party (RP) alleges that resident (R1) has been placed in facility and memory care without their consent. RP further alleges that R1 does not meet requirements for memory care and is being kept against their wishes without access to communication devices or visitors. During this investigation LPA made observations, reviewed records, and conducted interviews. Review of Admission Agreement indicated that R1 signed their own Admission Agreement without the signature of a responsible party. Review of R1 LIC602 – Physician Report for Residential Care Facilities for the Elderly dated 3/7/2025 indicated that R1 did not have a diagnosis of dementia and is able to leave facility unassisted as well as care for their own Activities of Daily Living (ADLs). Review of Physician’s Change of Capacity letter for R1 dated 8/22/2025 declared that R1 “is incapable of caring for himself/herself and is physically and mentally incapable of managing his/her own financial affairs or making medical decisions”. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Interview with R1 indicated that they do not believe they belong in memory care but are otherwise happy with treatment at the facility. Interviews with Administrator indicated that R1 was initially a resident of Assisted Living and was moved into memory care based on increased behaviors, reassessment, and at the request of R1’s Power of Attorney (POA). Review of R1 POA paperwork indicated that POA is able to make medical decisions, including placement in nursing home, for R1 upon physician declaration of R1 being incapable of making own decisions. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 21-AS-20250813112258

Type of visit: Case Management - Incident

LPA Elias Magdaleno arrived unannounced to conduct a case management - incident visit and met with Administrator Morgan Whinery. This visit was conducted to gather further information regarding a Death Report submitted by facility on 9/12/2025. LPA conducted interviews and gathered documents. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a case management- incident inspection and met with Administrator Morgan Whinery and Assistant Executive Director Bailey Malagon. LPA is conducting a case management visit to obtain more information regarding a self-reported Incident Report received by the Department on 9/2/2025, involving the death of a resident (R1) at the hospital. LPA requested copies of the coroners report and Administrator stated it would be sent when released by the hospital. No deficiencies were cited during todays visit. Exit interview was conducted with Assistant Executive Director, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Sep 11, 2025

Allegation investigated: Staff do not timely respond to the residents alerts Staff are leaving the residents unattended

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Morgan Whinery. Staff do not timely respond to the residents’ alerts – Complainant alleges that response times to resident call buttons are frequently delayed. During this investigation LPAs made observations, reviewed records, and conducted interviews. Review of Family Council Minutes dated 7/9/2025 show concerns with wait times following call button activation with a resident alleged to have waited 47 minutes before alert was answered. Interview with five (5) of twelve (12) residents indicated they have heard of another resident waiting up to 45 minutes for help after call button activation but have not experienced the delay themselves. Of these five (5) residents, four (4) indicated it was the same individual mentioned in 7/9/2025 Family Council. One (1) of twelve (12) residents stated they waited up to fifteen (15) minutes after activating alert button. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Review of Resident Council Meeting Minutes indicated that residents attending had no comments regarding Resident Care/Nursing. Seven (7) of twelve (12) residents interviewed stated they have not experienced or heard of other residents waiting longer then ten (10) minutes for help after call button activation. Over the course of the investigation, LPA observed receptionist calling out alerts for both MC and AL they received to caregiver over radio. Call outs consisted of specific location of the alert or specific resident calling if alert came from a resident specific pendant. Callouts were repeated until a caregiver responded. LPA did not witness any call out go unanswered for longer than ten minutes. LPA opened an alarmed door to the outside and a caregiver came within five minutes to check. Staff are leaving the residents unattended – Complainant alleges residents have been left unattended during clear moments of need and that staff are often unable to meet the needs of the residents due to understaffing. During this investigation LPAs made observations, reviewed records, and conducted interviews. Four (4) of twelve (12) residents interviewed stated they felt or heard concerns from other residents that facility was understaffed on certain days. Four (4) of five (5) staff interviewed felt they were overworked and in need of more staff. Eight (8) of twelve (12) residents interviewed stated they did not have any concerns with understaffing and staff are attentive to their needs. Review of staff Memory Care (MC) and Assisted Living (AL) staff schedules for July and August indicated sufficient staffing for resident care. LPA observed 12 residents in MC first floor main room with six (6) staff rotating care and two (2) dedicated staff leading activities. LPA observed ten (10) residents in MC second floor main room and five (5) caregivers. Administrator stated there are currently no residents on 1-on-1 care plans and facility has started to back hire staff to fill in for callouts. Administrator stated all MedTech positions are hired as dual MedTech/caregiver positions and are trained accordingly. Based upon observations, interviews, and record review we have found that although the allegations 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 allegations/complaint is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 21-AS-20250710112626

Allegation investigated: Staff does not ensure facility is free of rodents.

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Morgan Whinery. Staff does not ensure facility is free of rodents. – Complainant alleged there are rats in resident room and facility is not taking proper actions to fix this. During this investigation LPA made observations, reviewed records, and conducted interviews. Interviews indicated that R1 leaves patio door open towards back field, and rats have been captured in R1 room with photos taken. LPA toured resident rooms, facility gathering areas, hallways, and dining area and did not observe rats, other vermin, or any evidence of rats such as droppings or nests.Facility receives weekly pest control visits from a third-party vendor. Interviews with staff indicated that they have seen and/or heard of rodents in facility and will report them to management immediately as per facility policy. Continued LIC9099C... Unsubstantiated Continued from LIC9099... LPA visit on 6/27/2025 for Complaint 21-AS-20250619110058 and subsequent interview with Administrator indicated that management will call pest control company to revisit facility immediately upon report of a rodent sighting. Pest control reports gathered on 6/27/2025 showed zero (0) captures, no pest activity, and replacement of traps without use between 5/1/2025-6/13/2025. Review of Pest Control Reports dated 7/18/2025 and 8/6/2025 showed zero (0) captures and no signs of activity. Interview with Administrator and R1 revealed that facility has ordered an additional screen door to allow patio door to remain open as per R1 wishes without allowing rodents in. Pest control reports and interviews indicated that facility has conducted full inspection of room to prevent rodent entry. LPA observed, and interviews corroborate, that facility has installed draft blockers at the bottom of front door and patio door to further ensure rodents do not enter. Interview with R1 indicated that no rodents have been spotted in the approximate three (3) weeks since facility has taken these steps. Based upon observations, interviews, and record review we have found that although the allegations 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 allegations/complaint is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 21-AS-20250710114433

Allegation investigated: Facility staff are not adhering to proper food service guidelines

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Morgan Whinery. Facility staff are not adhering to proper food service guidelines - Complainant alleges that facility does not ensure all incoming food and beverage products are dated and rotated. During this investigation LPA made observations, reviewed records, and conducted interviews. During tour of kitchen and food storage areas LPA observed that food was labeled, dated, and stored in compliance with Title 22 regulations. LPA observed three slices of cake that were unlabeled and uncovered, upon questioning staff LPA was informed that they were part of the lunch service that was currently being served, and the residents who would receive the cake had not yet finished eating their main course. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Interview with Administrator indicated that they check the kitchen daily to ensure kitchen staff are following food service regulations. Photos submitted show food as being properly dated and labeled. However, photo submitted of a tub of hot peppers show they had molded. Accompanying message claimed they had been discarded upon discovery of mold and had not been served to residents. LPA visit on 6/27/2025 for Complaint 21-AS-20250619110058 and subsequent interview with Administrator indicated that facility ensures clean food by maintaining backups of equipment in case repair or replacement is necessary, and all food service staff receive regular in-service training as well as third-party training to ensure knowledge on food safety protocols. Based upon observations, interviews, and record review the department has found that although the allegations 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 allegations/complaint are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 21-AS-20250731110242

Allegation investigated: Facility administrator does not have an active administrator certification

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Morgan Whinery. During this investigation LPA made observations, reviewed records, and conducted interviews. Facility administrator does not have an active administrator certification – Complainant alleges Administrator does not have an active administrator certification. Review of the Department’s Active Administrator list indicated that Administrator submitted Certification renewal on 9/18/2024. Further communication with the Administrator Certification Bureau (ACB) revealed that Morgan Whinery Administrator Certification 7022660740 has been approved and is current and active with an effective date of 9/18/2024 – 9/17/2026. We have found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Aug 28, 2025 · control 21-AS-20250818133923

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a case management- incident inspection and met with Morgan Whinery, Administrator. LPA is conducting a case management visit to obtain more information regarding an Incident Report received by the Department on 8/13/2025, involving a resident (R1) being sent out to the hospital and subsequent transfer to a skilled nursing Facility (SNF). LPA obtained copies of R1 care plan and face sheet. No deficiencies were cited during todays visit. Exit interview was conducted with Administrator, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Aug 14, 2025

Allegation investigated: Staff are mismanaging residents' medications.

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Administrator, Morgan Whinery. Staff are mismanaging residents' medications - Complainant speaks of 2 medication errors one for (R1) & one for (R2). CCL completed complaint investigation 21-AS-20241018104643 on 10/29/2024 finding Medication Error substantiated regarding insulin for (R2) citing 87465(a)(4). On 6/13/2025 CCL received “medication error documentation” made on 4/6/2025 by HWD when resident (R1) returned from the hospital (4/2/25) the medication list was not updated, and resident (R1) was receiving 2 anti-seizure medications at the same time instead of discontinuing one of them. Based on interviews conducted and record review, the allegation Staff are mismanaging residents’ medications is Substantiated. Continued LIC9099C... Substantiated Continued from LIC9099... Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... LPAs did not find any other incident reports of elopements, Health and Wellness Director (HWD) informed there has only been the one in 2025 that fits the parameters of this situation of a resident leaving the facility and staff not visually seeing them. Administrator informed and training records obtain corroborate from 3/4/25 to 4/15/25 facility began 2X per week (sometimes more) preventative elopement training drills totaling 17 for this time frame. Complainant also alleges “the facility is dangerously understaffed”. Interview with Administrator and records reviewed revealed for April 2025 facility is fully staffed with 3 LVN’s, approximately 20 Med Techs (AL: 3 on AM, 3 on PM, & 2 on NOC) MC 1st floor (1 AM, 1PM, & 1 NOC) MC 2nd floor (different MT’s ,1AM, 1PM, & 1 NOC) 70 Caregivers-AL (AM-7, PM-7, NOC-4) MC 1st floor(AM-4, PM-4, NOC-2) MC 2nd floor(AM-4, PM-4, NOC-3). Resident assistant level for April 2025 -2 person assists - 7 in MC (split in the 2 units) & 10 in AL (also split between 3 levels), 50 (1) person assist & 94 no assist. Based on information provided, alarms were turned off, and not necessarily due to lack of staffing. There was no information obtained that supported a violation had occurred. Therefore, the allegation Staff does not provide adequate supervision resulting in residents wandering away from the facility is Unsubstantiated. Staff are not properly trained to meet residents' care needs – Complainant alleges unlicensed staff are routinely instructed by management to insert urinary catheters and perform catheter. LPA attempted contact with complainant 3 times but was unable to get response for follow up questions. Interview with HWD revealed there are 6 residents receiving catheter care and Home Health staff does all of the care regarding this. Administrator indicated Facility protocols indicate catheters are allowed and the care partner can ONLY empty the catheter and HWD will arrange with third party (HH, hospice or MD office) to change the catheter and if the catheter is pulled staff are to send them out to hospital to get it reinserted, unless the third party made arrangement to come right away to reinsert at the community. The staff need to be trained how to empty the catheter and what to look for reporting. Each resident with catheter must have individualized in-service and care planned according. Supplies for any catheter needs, are NOT paid by the community. There was no information obtained that supported a violation had occurred. Therefore, the allegation Staff are not properly trained to meet residents’ care needs is Unsubstantiated. Continued LIC9099C... Continued from LIC9099C... Staff does not ensure facility is free of bed bugs- Complainant alleges when resident (R3) was admitted to facility they had a bedbug infestation that was withheld from staff. Documents reviewed reveal R3 care notes from move in to 4/14/25 do not indicate any Bedbugs, Medical/mediation assessment of 4/10/2025 also does not indicate Bedbugs, and R3’s initial assessment of 4/11/25 indicates Resident’s skin is clear and intact & resident utilizes base services laundry, one load of linen & one load of clothing. 4/15/2025 Interview with Administrator indicated they do not have any bedbugs in the facility that they are aware of. 5/29/25 interview with staff HWD also indicated to the best of their knowledge there is no bedbugs in the facility, “We would definitely be getting calls from residents and observing bites and rashes of unknown origin”., therefore the allegation Staff does not ensure facility is free of bed bugs is UNSUBSTANTIATED. Staff do not follow proper infectious disease protocols - Complainant alleges several residents tested positive for MRSA, yet there was no PPE provided outside their rooms. Interview with Administrator in April 2025 revealed there are no contagious diseases currently. Facility had one AL resident (R1) on precaution that came back from the Hospital approximately 2 weeks ago with it but is no longer a concern. This was only contact precautions and R1 was here only 1 day before returning to the hospital. Full isolation containers were outside of room with (gloves/gowns/goggles). Interview with HWD corroborates Administrator indicating R1 was detected with MRSA in urine and went out to hospital next day. Facility implemented containers of PPE outside of this room. Based on information provided there was only 1 resident with contact precautions of MRSA and PPE was implemented outside of their room, although they were only in the facility 1 day prior to being sent out. There was no information obtained that supported a violation occurred. Therefore, the allegation Staff do not follow proper infectious disease protocols is UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... Therefore, the allegation Staff are not properly assessing residents prior to admissions is Unfounded. This agency has investigated the above allegation alleging Staff are not properly assessing residents prior to admissions. We have found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 21-AS-20250414112833

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 11, 2025

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on interviews and facility's incident report of medication error of not discontinuing one of R1’s, 2 anti-seizure medications as indicated by Dr., which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Licensee submitted certification of medication training along with additional 8 hrs of medication training. Citation cleared at time of visit.

Allegation investigated: Licensee does not ensure that proper food safety protocols are being followed by staff. Licensee is not preventing rodents from being in the facility.

Licensing Program Analysts (LPAs) Magdaleno, Deniz, and Licensing Program Manager (LPM) Bertozzi arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Morgan Whinery. During this investigation LPAs made observations, reviewed records, and conducted interviews. Licensee does not ensure that proper food safety protocols are being followed by staff. – Complainant alleges "the dining staff does not date food and beverage products and does not put away food in safe manner. For example, raw chicken is stored above ready to eat foods. Complaint alleges that the water filters are expired by over 3 months. Additionally, a lot of cooking equipment either doesn't work or doesn't work properly. Complaint alleges that staff does not print out temperature logs in a timely manner, forges the missed days, and that there is nothing to test the ph of the sanitizer nor is there a log." Continued LIC9099C... Unsubstantiated During this investigation LPA observed that food was labeled, dated, and stored in compliance with Title 22 regulations. LPA observed temperature log was posted and is signed off daily. Interviews with staff indicate water filters are managed and replaced by a third-party vendor based upon vendor’s own service schedule. Vendor representative arrived during this visit and informed LPA that water filter in kitchen is used solely to reduce calcium build up in the steamer, not for drinking purposes. Interview with Dining Director indicated that if they observe that the water filter needs to be changed, they will contact the vendor. Interviews with staff indicate that should equipment fail, it is either repaired or replaced promptly by either in-house maintenance team or manufacturer. PH levels of sanitizer are not regulated by Title 22. Licensee is not preventing rodents from being in the facility. – Complainant alleges “There are rats in the kitchen”. During this investigation, LPA toured the kitchen and dining areas and did not observe rats nor other vermin, nor any evidence of rats such as droppings or nests. Facility receives weekly pest control visits from a third-party vendor. Interviews with staff indicate that there have been no recent sightings of rodents and if there are any sightings they are reported immediately, and the pest control company will return as soon as the same day. Review of reports from pest control company indicate that there was a facility reported pest sighting 6/13/2025, but no pest was found by vendor. Reports show visits dating back to 5/1/25 had zero (0) captures and no activity of pests were found, and traps were replaced without use. Based upon observations and interviews, we have found that although the allegations 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 allegations/complaint is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted. Copy of report discussed and provided to the Administrator. The signature on the form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 27, 2025 · control 21-AS-20250619110058

Allegation investigated: Facility staff are not properly assessing resident(s) in care. Facility staff are not providing adequate food service to residents in care.

On 6/27/2025, Licensing Program Analyst (LPA) Ali Deniz and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to deliver complaint investigation findings regarding the above alligations and met with Morgan Whinery, Administrator. Facility staff are not properly assessing resident(s) in care – Complaint alleges that resident, R1 received a letter from the facility indicating that their rent would change in July 2025. R1 questioned staff about the reason for the rent increase and was informed that it was due to their level of care. Complaint indicated that R1’s current level is 0 but had been raised to a Level 2 adding that they were never assessed or consulted by any doctor or staff member at the facility. Per interview with Administrator, the facility had a rate structure change in October, 2024 that removed Level 0 so the first level is Level 1. This change added $150 to each resident who was at a Level 0. To offset the additional money, the facility reduced the room and board rate for resident, R1 in December 2024. Per Administrator, R1 has not any increases due to care. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Facility staff are not providing adequate food service to residents in care – Complaint alleges that the quality of food served at the facility has declined indicating that recently for dinner teriyaki chicken was served, but there was no teriyaki sauce on it. Discussion with Administrator indicated that a resident who was on a low sugar diet would not be provided a sauce with sugar but they would be offered an alternative. Four of four residents interviewed indicated no issues with food service. Based upon record review and interviews, we have found that although the allegations 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 allegations/complaint is UNSUBSTANTIATED. No deficiencies cited.the state’s words, verbatim · CDSS document, Jun 27, 2025 · control 21-AS-20250502105056

Allegation investigated: Staff do not ensure that residents are able to come and go from the facility freely Staff are limiting residents visits

On 6/27/2025, Licensing Program Analyst (LPA) Ali Deniz and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to deliver complaint investigation findings regarding the above alligations and met with Morgan Whinery, Administrator. Staff do not ensure that residents are able to come and go from the facility freely, Staff are limiting residents visits – Complaint alleges that facility is locking the front doors to the facility at 5:30pm which restricts residents’ freedom of movement and is a barrier for family members and friends to visit adding that the facility does not provide prompt attention when someone calls on the phone to be let in. Per interview with Administrator, the facility started locking the doors earlier at the request of some residents who were concerned about safety. The sign on the front door indicates that the doors will close at 5:30pm and instructs visitors to call the “After Hours Phone” for entrance and assistance. Continued on LIC9099-C Unsubstantiated Continued from LIC9099 Per interviews, some residents have waited 5-6 minutes to be let into the building after hours and it was reported that sometimes the call goes to voicemail. Review of the minutes from the March 2025 Family Council shows that this situation has been discussed. Interviews with two family members and six residents revealed that of of the individuals who return to the building after 5:30pm, there are no known issues. One resident who was identified as frequently coming in and out of the building is provided a key. Two of six resident indicated they have visitors after 5:30pm but those visitors have not stated they have had difficulty accessing the building. Interview with Administrator revealed that they have not received any complaints about the doors being closed at 5:30 for multiple months and provided a copy of the most recent Resident Council Meeting. Although the allegations Staff do not ensure that residents are able to come and go from the facility freely and Staff are limiting residents visits may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies cited.the state’s words, verbatim · CDSS document, Jun 27, 2025 · control 21-AS-20250303122510

Allegation investigated: Staff unlawfully evicted a resident Staff is retaliating against a resident

On 6/27/2025, Licnesing Program Analyst (LPA) Ali Deniz arrived unannounced to deliver complaint investigation findings regarding the above alligations and met with Morgan Whinery, Administrator. During the course of the investigation, documents reviewed and unannounced site visits made to facility. Complaint alleges that the facility has unlawfully evicted a resident as a retaliation. The following determinations are made: Per review of Special Incident Reports provided to the department from January 2023 to May 2025, thirty-four incidents were documented of resident altercations with other residents or staff. Of the thirty-four incidents, twenty-three residents were identified. Three of twenty-three resident had more than three altercations from 2023 to 2025. CCL staff questioned Administrator about the three residents. Per Administrator, R1 had medication changes and has not had any altercations in multiple months. Per CCL staff review of Special Incident Reports, R1 has not had an altercation since December 2024. Contunied on LIC9099-C... Unsubstantiated Continued from LIC9099... Prior to January 2025, R1 had nine altercations with other residents. Resident, R2 has had nine documented altercations with other residents and continues to have aggressive behavior despite medication changes. Per conversation with Administrator, facility is seeking other options, which may include filing for eviction due to aggressive behaviors. Resident, R3 has had thirteen documented altercations with other residents and has been provided an eviction due to aggressive behavior. Eviction notice for R3 identifies seventeen incidents as reasons for the eviction. Items include aggressions towards staff, residents, property destruction, yelling and threatening to kill people. As reported by Administrator, in all instances the facility has attempted interventions including but not limited to increased supervision, medication changes, consult with residents' physicians and communication with families/responsible parties via care conference. Based on interviews and documentation, the allegations that the facility unlawfully evicting resident and staff retaliating against a resident are unsubstantiated. Although the allegations 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 allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jun 27, 2025 · control 21-AS-20250501122313

Allegation investigated: Staff are not following the general food service requirements

Licensing Program Analysts (LPAs) Deniz and Hansen arrived unannounced to initiate a Complaint Investigation regarding the above allegation and were able to deliver findings. LPAs met with Director of Business, Tony Ibarra as Administrator, Morgan Whinery was unavailable. During the course of the investigation, the Department made observations and conducted interviews with staff and residents. There is an allegation of "Staff are not following the general food service requirements.” The complainant alleges that “dining menus are posted but changed daily without notice, being false advertisement." LPAs conducted a walkthrough of facility kitchen and dining area and found required menu postings were visible for residents on kitchen door, tables and hand-outs. Interviews with 3 kitchen staff revealed there are prefixed menus with specials and additions. Facility submits food order to supplier that sometimes does not deliver all of what was ordered. On these days, the food staff will have a pre huddle regarding the changed items so they can relay to resident’s alternative options when ordering their meals. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Staff informed last minute menu changes happening due to ordered items not being delivered only occurs once or twice a month. One of three residents interviewed stated items on the menu not being available happen more often than not and then the alternatives are also not available. Although, 2 other residents interviewed had conflicting information indicating this seldom happens and there are substitutes. There is differing information obtained in the investigation regarding the allegation that “staff are not following the general food service requirements”. There was no information obtained that supported that a violation had occurred. Based on the interviews conducted and observations made, and related information obtained during the investigation, the allegation “Staff are not following the general food service requirements” is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies cited. Exit interview conducted. Copy of report discussed and provided to the Administrator. The signature on the form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 29, 2025 · control 21-AS-20250519145314

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Deniz & Hansen arrived unannounced at facility for the purpose of conducting a Case Management regarding a self reported medication error. LPAs met with Business Office Director, Tony Ibarra, Administrator Morgan Whinery was unavailable. LPAs are following up regarding a self reported Incident Report received by Community Care Licensing (CCL) on 5/27/2025 of a medication error. The error occurred on 5/16/2025 while med tech was dispensing medication. Medication technician inadvertently provided resident (R1) oral antibiotics instead of doctors prescribing order of topical antibiotic, Regulation 87465(a)(4). (See LIC809-D). Hospice, family, and primary care physician contacted. R1 was monitored with no signs of adverse reaction. LPAs obtained internal investigation, medical assessment, care plan, EMAR & care notes, and corrective action. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, May 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 30, 2025

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on facility's submitted incident report reporting medication error, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Licensee submitted certification of medication training along with additional 8 hrs of medication training. Citation cleared at time of visit.

Allegation investigated: Staff are not following resident's care plan Staff is not ensuring residents' personal rights

On 5/15/2025, Licnesing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint investigation findings regarding the above alligation and met with Morgan Whinery, Administrator. Staff are not following resident care plan- Reporting party alleges facility raised the level of care rate because they said the resident needed 2 staff members to help with ADL but reporting party indicates resident usually only gets help from 1 staff member. During the investigation process LPA conducted 3 visits (2/20/2025-3/6/2025, & 5/15/2025), staff interviews, and obtained resident's Care Notes, Physician's Report, Care conference documents, and Service Plan. Resident resides in memory care unit. Interviews and documents revealed resident (R1) was admitted to facility 10/2024 and was increasted one level in 12/2024 due to becoming combative when staff were providing care and with insuline management. First episode was shortly after moving in. LPA was unable to obtain evidence that a violation occured. Unsubstantiated. Continue on LIC9099C Unsubstantiated Continued from LIC9099 Staff is not ensuring residents' personal rights- reporting party alleges there is a resident that wanders and has wandered into this resident's room at 3AM and climbed into bed with them making them very scared, aggressive and upset. Interviews conducted with staff and Administrator revealed in November 2024 facility began to allow resident who could manage a key to lock their doors in memory care. R1 is able to use and keep their own key. There has not been any incidences since the keys have been implemented. LPA was unable to obtain evidence that a violation occurred. Based on interviews, record/document reviews, and related information obtained during the investigation the allegations Staff are not following resident's care plan and Staff is not ensuring residents' personal rights UNSUBSTANTIATED Although the allegations 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 allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, May 15, 2025 · control 21-AS-20250210131006

Allegation investigated: Staff did not provide resident medication as needed

Licensing Program Analysts (LPAs) Shannan Hansen & Ali Deniz arrived unannounced to initiate a complaint investigation regarding the allegation listed above and delivered findings. LPAs met with Administrator Morgan Whinery. Staff did not provide resident medication as needed- Complainant alleges on 4/25/25 they observed, resident (R1) requested PRN medication inhaler from multiple staff (S1 & S2), who informed R1, they could not have it. On 4/29/2025 LPA’s Hansen & Deniz conducted record review of resident’s Care Plan and Assessment dated 3/14/2025 which indicates R1 requires assistance with all medications and has diagnosis of MCI. Emar records indicate on 4/24/2025 R1 was administered PRN inhaler at 3:06pm. Emar does not indicate any PRN request from R1 on 4/25/2025, only routine medications. LPA’s also obtained facility PRN protocols which appear facility follows. Interview with staff (S1) revealed PRN medications for R1 are administered by staff. Continue on LIC9099-C Unsubstantiated Continue from LIC9099- S2 informed the incident occurred on the afternoon of 4/24/2025 where S2 observed R1 at front desk requesting additional PRN inhaler and intervened as R1 had been provided this less than 30 minutes prior, which eMAR records corroborate S2’s statement. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff did not provide resident medication as needed is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation/complaint is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 21-AS-20250425113614

Allegation investigated: Staff did not respond in writing to the concerns of Resident Council in required time frame Staff did not post Resident Council meeting in central location

Licensing Program Analyst's (LPA's) Hansen & Deniz arrived unannounced for the purpose of delivering findings on the above complaint allegations. LPA's met with Administrator, Morgan Whinery. Staff did not respond in writing to the concerns of Resident Council in required time frame – Complainant alleges the Executive Director is required to respond to the concerns of the Resident Council in writing within 14 days of receiving them, the Executive Director (ED) had not responded in writing. During this investigation LPA conducted 2 unannounced facility visits (3/25/2025 & 4/15/2025) and conducted interviews with staff and residents who indicated The Resident Council meeting questions/concerns are responded to one week (7 days) later, at the Town Hall meeting which is presided over by the ED. R1 stated, in an appropriate time frame and the ED gives the responses in writing prior to the Town Hall meeting, the ED always answers the questions . The questions from the council meeting are in black and the ED responses are in red beneath them. Continue on LIC9099-C Unfounded Continued from LIC9099: On 3/25/2025 LPA obtained 3/25/2025 Town Hall meeting document showing ED responses to Resident Council meeting minutes in red below the black questions from the Town Hall meetings. The ED prints 35 copies and hands them out at the Town Hall meeting. There was not sufficient information obtained to support a violation occurred. This agency has investigated the complaint alleging Staff did not respond in writing to the concerns of Resident Council in required time frame. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Staff did not post Resident Council meeting in central location – Complainant alleges facility did not post meeting information in a central location, the only place the meeting notification was posted was on the door of the Theater room. On 3/25/2025 LPA conducted the first of 2 unannounced facility visits and observed 6 different locations with Town Hall meeting (which is changed out routinely with Resident Council meetings) posted (see LIC 812 pics). Interviews conducted with ED and R1 informed meetings are posted two weeks prior to the Resident Council meeting in the Lobby, the elevator’s, on bulletin boards (2), at the bistro & dining room, by the mail room, in Newsletters, & calendars in each resident mailbox at the beginning of the month. They get taken down the day after and townhall meeting flyers or Spring flyers go up. On 4/15/2025 at LPA’s second unannounced visit to the facility observed multiple locations Resident Council meeting notices were posted (see LIC812 pics). There was not sufficient information obtained to support a violation occurred from investigation conducted as at all unannounced visits multiple postings were observed and documented. Therefore, allegation Staff did not post Resident council meeting in central location is UNFOUNDED. We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Continued from LIC9099-A: The ED informed The Resident Counsel President will invite me every couple of months to the meetings, when they feel it is needed, this is an open invitation, but they will let me know. The ED feels the meetings should have some private time without the ED there, but the ED is always available. Per LPA interview the President knows they can walk down to the office and get the ED or text to come, which has happened before. Former complaint addressed this issue in 21-AS-20241204123831 finding-Unsubstantiated. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation There is no staff liaison to assist with resident council is UNSUBSTANTIATED. Although the allegations 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 allegations/complaint is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 21-AS-20250319094235

Type of visit: Case Management - Incident

While at facility opening a 10-day, Licensing Program Analyst (LPA) Hansen conducted a case management of a self-reported incident report received on 3/19/2025 indicating R1 expressed thoughts of self-harm. LPA reviewed records and facilities plan to ensure R1’s care and supervision. No deficiencies cited during today’s visit.the state’s words, verbatim · CDSS document, Mar 25, 2025

Type of visit: Office

A Non-Compliance Conference (NCC) was conducted today in the Santa Rosa Regional Office. Present in the meeting were, Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Bethany Moellers, and Licensing Program Analyst (LPA) Shannan Hansen, Licensing Program Analyst (LPA) David Leibert met with Facility: Chair/CEO, Chris Hollister, Co-President/COO, Richard Williams, Regional VP Operations, Erica Ogle, Regional Director of Health & Wellness, Sangeeta Devi, SVP Health & Wellness, Dr. Sandi Petersen, Administrator/ED, Morgan Whinery, QA/Risk Manager, Jay Stowers, and Joel Goldman of HansonBridgett for the purpose of reviewing issues during Non-Compliance Conference. This office meeting is being conducted to discuss concerns identified by the Community Care Licensing Agency. CCL has investigated 14 complaints in 2024 starting from 6/24/2024 and 6 complaint investigations in 2025 (2 of which have been substantiated) the other 4 are still under investigation. Area of concerns are: * Personnel Requirements (87411(a)) - staffing numbers, competency, & services (ADLs) to meet residents care needs - 3/6/2025, 12/17/2024, 11/19/2024, 6/20/2024. * Incidental Medical & Dental (87465(c)(2)) Regarding medication discrepancies/timely - 3/6/2025, 10/29/2024, 10/18/2024, 8/8/2024. * Personal Rights (87468.1(a)(1)) - Cameras & privacy * Elopements - (87411(a)) 2/21/2025 * Call bells-response time - 11/19/2025, 11/18/2025 * Facilities future compliance TSP service: Licensee was informed of and is interested in engagement. No deficiencies cited during the Non-Compliance Conference.the state’s words, verbatim · CDSS document, Mar 19, 2025

Allegation investigated: Personal Rights

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. This investigation consisted of a review of documents, site visits to the facility and statements from witnesses and the parties. The following determinations are made: Resident (R1) resides in the facility's memory care unit and shares a room with another Resident (R2); Family members of R1 express concerns that R2 has entered R1's area on many occasions resulting in R1's personal rights being compromised; Facility staff have made hourly wellness checks on R1 in an attempt to prevent R2 from entering R1's area uninvited; Family members have provided videos taken on 2/21/2025 and 3/7/2025 which depict R2 entering the bed of R1 while the bed is occupied by R1 and one depicting R2 entering the bed of R1 which is unoccupied after R2 has removed R2's pants, exposing R2's buttocks. Based upon the videos and statements, there is a preponderance of evidence to prove that the allegation of a personal rights violation has been SUBSTANTIATED and is valid. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Mar 18, 2025 · control 21-AS-20250221094940

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Mar 20, 2025

87468.1(a)(3) Personal Rights of...Residents…all residents…shall have personal rights to be free from …interfering with daily living functions such as…sleeping… *** Based on statements and videos, this requirement has not been met as evidenced by: Resident R2 has repeatedly ventured into Resident R1’s space and handled R1’s belongings and is seen on video taken on 2/21/25 entering R1’s bed while an apparent sleeping R1 is occupying the bed. This posed an immediate violation of R1’s personal rights.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: Administration will provide a written plan to CCL by POc date that outlines how the facility will protect R1 from further personal rights violations.

Allegation investigated: Licensee did not properly notify resident or representative of rate increase. Licensee did not ensure facility cleanliness was maintained.

Licensing Program Analyst Leibert arrived unannounced and met with Administrator for the purpose of delivering findings on this complaint. During the course of the investigation, statements were taken, documents reviewed and unannounced site visits made to facility. The following determinations are made: LPA observed copies of documents on file for Resident (R1), dated 6/28/2024; The documents observed provide notice of rate increase and level of care methodology which became effective 09/01/2024; The documents show they were provided to R1; This was also confirmed during interviews with the Administrator; The documents observed comply with regulations governing the rate increase notifications; Records in facility file are ambiguous with regards to the status of a Representative for R1 and LPA has not been able to verify a POA for R1. Unannounced visits for this complaint on 1/13, 2/11, 2/21/25 and the annual inspection of 2/20/25 by LPA Hansen found facility to be clean and sanitary, including bathrooms and dining room. Although the allegations may be true, base on statements, documents, and observations, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 18, 2025 · control 21-AS-20250107102659

Allegation investigated: Facility staff did not follow physician’s orders in a timely manner

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation. LPA met with Business Office Director Tony Ibarra. Complainant alleges – Facility staff did not follow physician’s orders in a timely manner when resident’s physician ordered a test on 1/25/2025 that was not taken or received by lab until 2/5/2025. On 2/20/2025 LPA visited facility and obtained documents and conducted interviews. Documents indicated on 1/23/2024 resident (R1) was observed being confused for a few days, staff informed physician to send order. On 1/24/2025 physicians ordered urine culture. On 2/4/2025 records indicate sample collected and on 2/5/2025 dropped off at lab. Interview with staff (S1) revealed after realizing the sample had not been taken on 2/4/2025 per doctors order a sample was taken which caused a 12 day delay in doctors’ orders due to miscommunication. Continue on LIC9099-C Substantiated Continue from LIC9099 Based on interviews and record review the allegation Facility staff did not follow physician’s orders in a timely manner is Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit Interview Conducted.the state’s words, verbatim · CDSS document, Mar 6, 2025 · control 21-AS-20250214123528

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 7, 2025

87465(a)(1) Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. ***Based upon records reviewed and statements taken, this requirement has not been met as evidenced by: Medical tests ordered for R1 on 1/24/2025 were not made until 2/4/2025. This posed an immediate risk to the health of R1.the state’s words, verbatim · CDSS document, Mar 6, 2025

Plan of correction: Administration to submit written plan which addresses how facility will ensure compliance with 87465(a)(1) going forward. To be submitted to CCL by POC date in order to clear the deficiency.

Type of visit: Case Management - Annual Continuation

At approximately 9:40AM, Licensing Program Analysts (LPAs) Hansen and Contreras arrived unannounced to continue a 1 Year Required Visit, and met with Business Office Director (BOD), Tony Ibarra & Ieshaa Ragland, Health and Wellness Director (HWD) as Administrator, Morgan Whinery was not available. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPAs were informed that there were 118 residents in Assisted Living and 60 in Memory Care for a total of 178 residents in care. LPAs were also informed that there were 43 staff members on-site. On 3/6/2025 at approximately 9:45 am LPAs conducted a sample review of ten residents & ten staff records. LPAs reviewed resident’s files and learned that 10 out of 10 residents have an updated reappraisal/needs & care plan on file as well as medical assessments at this time and were all found to be well organized, thorough and contained the required documentation as required by Title 22 Regulation. During staff file review, LPAs observed that 10 of 10 personal files were not readily available for review (see LIC809D). CCL will return to review files at a later date. LPAs followed up on incident report that was self-submitted to Community Care Licensing (CCL). Incident Report : CCL received an incident report from the facility on 03/05/2025. Report states that on 03/03/2025, at aprox 2:45pm staff noticed facility alarm door 1 on floor 2 was unarmed when conducting routine door checks, head count conducted finding R1 missing. Facility conducted search, informed law enforcement & family. R1 was found 2 hours later at 4:45pm by law enforcement and returned to facility by law enforcement, after assessment, no injuries noted. Review of R1's physician's report and care plan indicates they are unable to leave unassisted and has a dementia diagnosis (deficiency cited, see LIC809D, Regulation 87705(b)(2). LPAs are requesting the following documents to update facility file: Continue on LIC809-C Continued from LIC809 Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 03/21/2025. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, Mar 6, 2025

Allegation investigated: Staff is not providing assistance in attending resident council meetings for those residents who request it Staff are not serving meals timely Staff are not following special diet orders

Licensing Program Analyst Leibert arrived unannounced and met with Tony Ibarra for the purpose of delivering findings on this complaint. This investigation consisted of interviews, document reviews, and six unannounced site visits on 12/10, 12/17, 12/26/24, 01/13, 2/11, 2/21/25 . The Complainant was asked if Complainant knew of any residents denied assistance in attending resident council meetings; Complainant stated, "Not that I know of;" Notices for Council Meetings are posted in lobby; Six of six unannounced site visits at lunchtime found that meals were served timely with adequate staff and that residents were served promptly; It's been reported that the 2024 Christmas meal may have resulted in some residents waiting approximately an hour to be served based upon Complainant statement and statement of Witness # 2; Six of Six unannounced inspections of the kitchen, dining room and dining service found no violations of Title Twenty-Two Regulations; Complainant states that Resident (R1) has not been provided the special diet prescribed by R1's physician; When interviewed, family member of R1 complained of a lack of variety in the food served but did not indicate the food was not compliant with the prescribed diet; A review of the facility's protocol for special diets complies with regulations. Based upon interviews with staff and a review of the Unsubstantiated Resident's facility's file , LPA confirmed that R1 is on a restricted diet and that kitchen staff are aware of the restricted diet; The Facility's Assistant Chef was interviewed and expressed knowledge of the restricted diet and provided a list of the foods prepared for R1 which comply with the restrictions. Although the allegations may be true, based upon the documents reviewed, statements taken and observations at unannounced site visits, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report left.the state’s words, verbatim · CDSS document, Mar 4, 2025 · control 21-AS-20241204123831

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(c) · Plan of correction due date: Mar 4, 2025

87468© Personal Rights. Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. ***Based on statements and observation, this requirement not met as evidenced by: Inspection on 12/10/24 found complaint sign posting was not required size and no residents’ rights posted. This posed a potential denial of residents’ personal rights. POC: Cleared at time of visit. Required postings are currently in place.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: POC: Cleared at time of visit. Required postings are currently in place.

Allegation investigated: Staff did not prevent a physical altercation between residents Licensee does not have sufficient staffing to meet the needs of residents in care

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. Resident (R1) was involved in physical altercation with another resident on 10/28/2024. Staff (S1) observed R1 pushing another resident's wheelchair which resulted in yelling and a physical altercation between R1 and the other resident. According to the Incident Report dated 11/14/2024, staff intervened between the residents and separated the residents. No injuries were noted. Staffing levels were noted at the time of R1's elopements from the facility on 10/13 and 11/12 and during the altercation noted above. Twenty-three residents were present in the unit during the incidents. On 10/13 and 11/12, 5 staff were present and on 10/28, 6 staff were present. Although the allegations may be true, based upon the statements and documents reviewed, there is not a preponderance of evidence to prove the allegations are, or are not, valid. Therefore, the allegations are UNSUBSTANTIATED. Report left. Unsubstantiated . The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Civil Penalty in the amount of $500 issued for Zero Tolerance of Absence of Supervision.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 21-AS-20241217141015

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 25, 2025

. Facility personnel shall be sufficient in numbers, and competent to provide the services necessary to meet resident needs. *** Based upon interviews and records reviewed, this requirement not met as evidenced by: On 10/13/2024 R1 left facility without staff’s knowledge and remained away therefrom between 7:30pm and 9pm when R1 was returned by Law Enforcement. R1’s has dementia cannot leave facility unassisted. This posed an immediate risk to the safety of R1.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: Facility to submit written plan to ensure the prevention of elopements from facility going forward. Plan to be submitted to CCL by POC date in order to clear the deficiency. ***Civil Penalty issued in the amount of $500.00 for Zero Tolerance of Absence of Supervision.****

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Feb 28, 2025

CA H&S 1569.657(a)For any rate increase (for) change in level of care …the Licensee shall provide…written notice..within two business days. *** Based on statements and documents, this requirement not met as evidenced by: R1’s Representative was provided written notice of increase effective 10/04/24 on 10/09/24 and effective 10/21/24 on 10/25/24. This posed a potential risk to the personal rights of the Resident.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: Administration will review 1569.657 and submit written plan that outlines how facility will comply going forward. Plan to be submitted to CCL by POC date in order to clear the deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Feb 28, 2025

87211(a)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of…Any incident which threatens the welfare, safety or health of any resident….***Based on statements and documents reviewed, this requirement has not been met as evidenced by: Responsible Person for R1 was not provided copies of Reports for R1’s elopements from facility on 10/13 and 11/12 until 01/22/2025. This posed a potential risk to the personal rights and safety of R1.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: Administration will submit a written plan outlining how facility will comply with 87211 going forward. Plan to be submitted to CCL by POC date in order to clear the deficiency.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Shannan Hansen & Ethel Contreras arrived unannounced at facility for the purpose of conducting a Required 1 year inspection. LPAs met with Administrator, Morgan Whinery. Facility is a 3 story building that currently has 110 residents living in the assisted living (AL) portion and 52 residents living in the Memory Care (MC) portion of the community. There are 13 residents receiving Hospice Services at this time and the facility has a Waiver approval for up to 15 Hospice residents. At approximately 11:20am LPAs toured the facility with Administrator & Maintence, Frank Taitano. The tour of the facility included eleven resident apartments, activity rooms, library, salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 73 to 78 degrees F. Exits and pathways were free from obstructions. Delayed egress doors from the memory care units have audible alarms when doors are opened without access codes. Hot water temperature measured within regulation of 105 to 120 degrees F in four of eleven rooms tested; although four memory care rooms and three assisted living rooms were found to be between 120.2 degrees F to 125.2 degrees F as observed by LPAs, Administrator & Maintence at approximately 12 PM (see LIC 809-D), Resident bathrooms had required slip resistant mats and grab bars. While touring memory care at approximately 12:10 PM LPAs and Administrator observed laundry room unlocked with cleaning chemicals on the shelf (see LIC 809-D), staff locked door. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchen were inspected and maintained per regulation. Menus with snack and beverages are available to residents. Activity schedules are posted. Facility has a theater in AL & memory care and multiple indoor and outdoor sitting areas and a private dining area. Fire extinguishers were last serviced 1/9/2025. Fire safety system including smoke detectors and carbon monoxide detectors and sprinklers were last inspected by Fire Dept. on 12/11/2024. Disaster drills are conducted quarterly with the last being 2/10/2025. Facility has ordered five generators to power essential areas of facility should there be a power outage. Continue on LIC809C Continued from LIC809 At approximately 2:00 PM, LPA reviewed a sample of AL & MC centrally stored medication records and found to be in compliance. LPAs began review of 10 resident and 10 staff records but were unable to finish and will return at a later date to complete inspection. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Facility staff are not providing adequate assistance to residents in care.

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. Complainant alleges that Memory Care staff have left residents unattended in the dining area and cites a 10 minute period on 11/26/2024 when no staff were present in dining area to assist residents. During the course of this investigation, 4 unannounced site visit were conducted; documents obtained and statements taken. The following determinations are made: An internal poll was taken on 12/5/25 to determine satisfaction with care being provided; 18 of 20 family members of residents questioned responded with positive responses to questions regarding quality of care being given; 5 of 5 staff questioned regarding the supervision provided on 11/26 indicated residents were not left in dining area unattended; Complainant was asked to provide identity of possible witnesses to the allegation but did not provide further information. Although the allegation may be true, or valid, based upon the observations, documents and statements, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 11, 2025 · control 21-AS-20241202114011

Allegation investigated: Facility staff are not providing residents with a reasonable amount of privacy while in common areas of the facility

Licensing Program Analyst Leibert arrived unannounced for the purpose of investigating this complaint. LPA interviewed the Administrator, Morgan Whinery, and discussed the allegation. It has been alleged that the facility placed video cameras in common areas that record audio as well as video. Cameras were placed in common areas, mostly at the exit areas. The Administrator indicated that the cameras were installed approximately two weeks prior and that she was unaware that the audio was activated. LPA verified that the audio function was turned off on January 11, 2025 and is no longer functioning. Administrator indicated she initially did not know how to shut off the audio function but did so when she obtained the directions after learning that audio was not allowed. Based upon the statements made by the Complainant and Administrator and LPA's observations, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Jan 13, 2025 · control 21-AS-20250103115603

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 13, 2025

Personal Rights of Residents. Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. ***Based upon statements and observations, this requirement not met as evidenced by: Cameras placed in the common areas of facility had the audio function activated. This posed an immediate violation of the residents' personal rights.the state’s words, verbatim · CDSS document, Jan 13, 2025

Plan of correction: Cleared at time of visit. Administrator has de-activated the audio function of the cameras on 01/11/2025 and states that cameras will be utilized for video only going forward.

Type of visit: Case Management - Incident

Licensing Program Analyst Leibert arrived unannounced for the purpose of following up on an incident reported by facility on 11/06/2024. The spouse of a resident (R1) had alerted staff to a possible infection. Staff arrived, assessed R1 and indicated 911 should be called. The spouse objected but the med tech who was present called 911 and R1 was taken to a medical facility. R1 has not returned to the facility and has been transferred to skilled nursing from the original medical facility. If and when R1 returns to the facility staff will provide observation to insure proper healing. No citations issued today. Report left.the state’s words, verbatim · CDSS document, Dec 10, 2024

Allegation investigated: Facility staff did not respond to resident's calls for assistance timely

Licensing Program Analyst (LPA) Nakagawa conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of a complaint investigation and delivering findings of the above allegation with Morgan Whinery, Administrator. Facility was toured, observations made, facility records were reviewed and interviews were conducted. The complaint alleges that Facility staff did not respond to residents' call for assistance timely. LPA conducted an inspection of memory care, reviewed records of call bells for 11/01/2024 through 11/15/2024 and conducted interviews. LPA's review of call bells found that most calls are answered within 3-8 minutes; a reasonable amount of time although call logs indicate that there were multiple calls each day during 11/1/2024 through 11/15/2024 which took from 15 to 31 minutes. Continued on 9099-C Substantiated Continued from 9099.... LPA's inspection of pull cords in bathrooms found one cord which was not responsive on the day of inspection. Review of response system shows that care staff and front desk are notified of service request on their phones. Based on documents reviewed, observations made, and interviews conducted, the allegations that Facility staff did not respond to resident's calls for assistance timely has been Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. (See 9099-D) Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 21-AS-20241118124213

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 19, 2024

87411(a) 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 has not been met as evidenced by: Based on records reviewed and interviews conducted, facility staff were unable to respond to call buttons in a timely manner. Records reviewed indicated that multiple call buttons had response times of 20 minutes or more. This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Licensee to submit a self-certification statement that a plan of action will be written regarding facility staffing and call light system by POC due date of 11/20/24. Plan of action to detail how facility will ensure there is sufficient staff available to respond to resident care needs in a timely manner. In addition, broken pull cord to be repaired. Plan to be submitted to CCL by POC date of 11/22/2024.

Type of visit: Case Management - Incident

On November 6, 2024, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management visit in response to a self-reported incident report. LPA met with Morgan Whinery, the Executive Director, who reported that on November 6, 2024 a resident in care (R1) made statements that they were raped to management. LPA verified that local police, responsible party and Ombudsman were notified. LPA requested documents and conducted interviews. No citations issued.the state’s words, verbatim · CDSS document, Nov 6, 2024

Allegation investigated: Facility staff are not meeting clients dietary needs

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken and documents obtained and reviewed. The following determinations are made: Complainant suggests that staff have not insured that Resident (R1) is getting sufficient nutrition; R1's Physician Assessment of 6/2024 indicates that R1 has been cleared for a regular diet; R1's Functional Evaluation of 10/2024 indicates R1 requires meal reminders; R1's Care Notes from September and October, 2024 show a pattern of refusing to eat meals or only consuming a portion of a meal. Although the allegation may be true, or valid, based on statements and documents, there is not a preponderance of evidence to prove the allegation is, or is not, true. Therefore, the allegation is UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 5, 2024 · control 21-AS-20241010142317

Allegation investigated: Facility staff are not ensuring resident shower is maintained for clients use Facility staff does not ensure facility is free of tripping hazards

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken from witnesses and interested parties as well as documents obtained and reviewed, inspections made and photographs taken. The following determinations are made: The shower fixture in Resident's (R1's) apartment has broken on several occasions in the recent past; Three separate work orders marked high priority indicate the fixture was repaired by facility maintenance; Facility places a red carpet at facility entrance to welcome new residents; carpet is in place temporarily and removed after the welcoming process; Complainant states the carpet is a risk hazard and not secured in place; Administrator states the carpet is secured with tape and that no-one has tripped on the carpet. Although the allegations may be true, or valid, based on documents, statements, and photographs, there is not a preponderance of evidence to prove the allegations are true or, not true. Therefore, the allegations are UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 5, 2024 · control 21-AS-20241028094900

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Nov 12, 2024

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. ***Based upon photographs and statements, this requirement not met as evidenced by: 10/25/24 photographs of R1’s shower depict mold on the floor and wall. This poses an immediate risk to the health of R1.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: Administration will submit a written plan that addresses how shower maintenance will be achieved going forward and will provide retraining to maintenance staff. Plan to be submitted to CCL by POC date in order to clear the citation

Type of visit: POC

Licensing Program Analyst Leibert arrived unannounced for the purpose of conducting a proof of correction visit. LPA met with the Administrator and reviewed the citation issued October 01, 2024 for H&S 1569 and the documentation submitted by the Administrator. The citation is cleared. Report left.the state’s words, verbatim · CDSS document, Nov 5, 2024

Allegation investigated: Staff did not ensure reporting requirements were followed

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation, statements were taken and documents reviewed. Complainant has alleged that Facility did not follow reporting requirements. A medication error occurred on 10/14/2024 and discovered on 10/15/24. An incident report (SIR) was created by the facility on 10/18 which was received by this Department on 10/21/2024, which is within the required time frame. The report indicates that the Responsible Person and this Department were notified. Based on statements and documents, this complaint is deemed UNFOUNDED, meaning that it is false and/or, without a reasonable basis. The complaint is DISMISSED. Unfoundedthe state’s words, verbatim · CDSS document, Oct 29, 2024 · control 21-AS-20241018104643

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 29, 2024

87465(a)(4) Incidental Medical and Dental Care. …The licensee shall assist residents with self-administered medications as needed… Based on records and statements, this requirement not met as evidenced by: On 10/14/24 R1 was administered a medication not ordered and the wrong dose of a medication that was ordered. The ordered medication dosage was incorrectly listed in the Medication Administration Record. This posed an immediate risk to the health of R1.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Cleared at time of visit. Staff involved in the medication error has been retrained in the requirements of 874665.

Allegation investigated: Facility is not meeting resident's care needs Facility is charging resident for services not being given Facility staff are not trained

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken, documents reviewed and site visits made. The following determinations are made: Complainant alleges that facility is not meeting R1's care needs, staff are not trained in Hoyer lift and Body Mechanics, and that R1 is charged for services not provided; Resident Care Notes and shower logs indicate a pattern of refusal of care by R1; Facility has provided training records for staff on Hoyer lift and Body Mechanics; Neither Complainant nor R1 has identified any services that are charged but not provided in response to this Department's request for examples of services not provided but for which R1 is charged. Although the allegations may be true, or valid, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 10, 2024 · control 21-AS-20240911163325

Allegation investigated: Staff illegally evicted resident

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. Complainant has alleged that facility has refused the return of R1 to the facility following a hospitalization due to a prohibited condition that would preclude R1's residency in the facility. R1 has a CVC catheter. During the course of this investigation statements were taken, documents reviewed and a consult occurred with a Program Clinical Consultant. Based upon the statements, documents and consult, the following determinations are made: The type of CVC catheter (Perm-Cath) used by R1 is not a prohibited condition that would preclude R1's residency in the facility; R1 was illegally evicted by the facility when R1 was not allowed to return. Based upon these determinations, statements, and documents, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Oct 10, 2024 · control 21-AS-20240918175043

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Oct 15, 2024

Eviction Procedures. The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) ***Based on statements and documents, this requirement not met as evidenced by: R1 was not allowed to return to facility from hospitalization due to a medical condition that is not a prohibited condition. This posed an immediate violation of R1’s personal rights.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Facility management agree to review the regulations governing prohibited and restricted conditions and to consult with CCL in the event there is a situation where resident’s medical condition is in doubt. Management to submit a declaration confirming the review by POC date in order to clear the deficiency.

Allegation investigated: Facility staff did not provide written notice of rate increase

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this Complaint. During the course of this investigation, documents were obtained and reviewed and statements were taken. The following determinations are made: Complainant alleges that facility did not provide written notice of rate increase; Administrator has produced a written document dated 6/28/2024 addressed to the Complaint Subject and the Responsible Person which outlines the rate increases effective 9/1/2024. Based upon the document reviewed, the allegation is determined to be UNFOUNDED, meaning that it is false and, or, without a reasonable basis. The complaint is DISMISSED. Unfoundedthe state’s words, verbatim · CDSS document, Oct 1, 2024 · control 21-AS-20240822130836

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.6557 · Plan of correction due date: Oct 8, 2024

H&S code section 1569.657 For any rate increase due to a change in level of care..licensee shall provide ..resident and resident representative..written…detailed explanation of additional services provided and itemization of charges. ****Based on documents and statements, this requirement not met as evidenced by: Facility did not provide R1 detailed explanation of services and charges for changes in level of care. This posed an immediate violation of personal rights. POC: Facilitythe state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Facility shall refund additional charges for services but may rebill for the additional services provided the services are outlined in the Admission Agreement and itemized as required by H&S 1569.657. Facility to provide proof of refund and written plan to correctly bill future charges in order to clear the deficiency. Due by POC date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Oct 15, 2024

87555(b)(7) General Food Service Requirements. Modified diets prescribed by a resident's physician as a medical necessity shall be provided. ***Based on documents and statements, this requirement has not been met as evidenced by: Kitchen staff were reminded by Administration on two occasions to follow diet prescribed by R1’s physician in the assessment of 1/7/2023. This posed a potential risk to R1's healththe state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Administration shall provide a written plan that outlines how facility will ensure that special diets are served to residents when ordered by the physician. Plan due by POC date in order to clear the deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 15, 2024

87211(a)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident …***Based upon statements, this requirement has not been met as evidenced by: Administrator has stated that written incident reports have not been provided to R1’s Responsible Person. This posed a potential risk to the personal rights and health of Residents in Care.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Cleared at time of visit. Facility now provides written incident reports to the residents’ Responsible Persons.

Allegation investigated: Resident sustained a pressure injury due to lack of care from staff Staff are billing resident for services not being rendered by staff Staff do not ensure that resident receives daily activities Staff do not ensure that resident is adequately fed

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation five site visits were conducted, statements were taken and documents were obtained and reviewed. The following determinations are made: The Complaint Subject (R1) and spouse (R2) state that they have received satisfactory care from staff and do not desire to engage in facility sponsored activities; R1's Physician states Physician has received no negative reports regarding care from Hospice and Home Health nurses; R1's Hospice Nurse reports no concerns regarding facility's care provided to R1, including weight maintenance. Although the allegations may be true, or valid, based upon statements and reviewed documents there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 1, 2024 · control 21-AS-20240624152843

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Oct 1, 2024

87464. Basic Services. Basic services shall at a minimum include:...Personal assistance and care...such as dressing, eating, bathing..***Based on documents, this requirement not met as evidenced by: Care report for 8/2024 indicate R1 was not showered 8/16 thru 8/31/2024. This posed an immediate risk to the health and personal rights of R1.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Cleared at time of visit. Administration has provided proof of refresher training to staff on the subject of showers provided in August and September, 2024.

Allegation investigated: Staff are not providing laundry services to a resident in care.

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. Complainant has alleged that soiled clothing has been observed in residents' (R1 & R2) apartment and that the laundry service is not adequate. During the course of this investigation, statement were taken and documents reviewed, as well as site visits made to the facility. Unannounced visits to residents apartment have not confirmed the allegation as clean clothes were observed in the closets. Furthermore, when interviewed, residents R1 & R2 stated they were satisfied with the laundry service and had no concerns regarding the condition of their clothing. Although the allegation may be true, based upon the statements and observations, there is not a preponderance of evidence to prove or, disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 17, 2024 · control 21-AS-20240830123526

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(B)(18 · Plan of correction due date: Sep 20, 2024

General Food Service Requirements. Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. ****Based on statements, this requirement has not been mete as evidenced by: Residents have waited up to 2 hours for food service in the dining rood. This posed an immediate violation of residents' rights.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Administration will provide a written report of current and future steps to be taken to insure that the residents are served meals timely and that sufficient staff are on duty to serve the residents. Report due to CCL by POC date in order to clear the deficiency

Allegation investigated: Staff were not giving resident showers Staff were not assisting resident with oral hygiene

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken, documents were obtained and reviewed and site visits were made to the facility. The following determinations are made: Shower logs for the available period for R1 indicate that R1 was given showers in compliance with R1's care plan; Care notes indicate R1 periodically refused staff efforts to provide care, including showers; Complainant claims to have documentation from R1's dentist that would support the allegation that staff do not assist with oral hygiene; Complainant has not produced any documentation regarding R1's oral hygiene; This Department has made many requests for the documentation. Although the allegations may be true, based upon the statements and documents, there is not a preponderance of evidence to prove or, disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 6, 2024 · control 21-AS-20240726091308

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 9, 2024

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. Based on statements and documents, this requirement was not met as evidenced by; On 4/22/2024, Staff did not note that R1 was feverish and required medical attention for UTI. This posed an immediate risk to the health of R1.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Administration will provide refresher training to staff on the requirements of 87455 and provide an agenda to CCL by POC date, with follow-up confirmation of training, in order to clear the deficiency.

Allegation investigated: Licensee did not ensure that resident received medical attention in a timely manner. Licensee did not ensure that staff followed infection control practices as necessary.

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the disposition of this complaint. Complainant has alleged that a resident contracted a contagious infection and that staff were subsequently afflicted with the infection due to the facility's management not following accepted protocols to deal with the condition. This investigation has resulted in the following determinations: The Complainant has no direct knowledge of the allegations, was told of the allegations by a third party who has not been identified, and has not identified the resident or staff involved; The Administrator states that there has been no reported cases of infection that match the alleged one during the course of the last six months. Although the allegation may be true, or valid, based on the statements made, there is not a preponderance of evidence to prove or, disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. No citations issued today Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 13, 2024 · control 21-AS-20240802134502

Type of visit: Case Management - Deficiencies

Licensing Program Analyst Leibert arrived unannounced for the purpose of following up on 2 incident reports involving medication errors. LPA met with the Administrator and discussed the incidents. On July 22, 2024, two residents, R1 and R2, missed their scheduled pm injections and on July 23, 2024, R1 missed a AM injection. The error was discovered on 7/23/24 and it was determined that the nurse scheduled to work the shift did not come to work and med techs on duty did not know that management was not made aware of the issue when it occurred. As a Result, all 17 staff who dispense medications were given additional training by Omnicare Pharmacy on August 01, 2024. R1 and R2 were given additional wellness checks and suffered no apparent difficulties. All required notifications were made. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Aug 8, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 8, 2024

87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. ***Based on documents and statements, this requirement has not been met as evidenced by: On July 23 and July 24 R1 and R2 were not administered injections ordered by the physician. this posed an immediate risk to the health of the residents.the state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: Cleared at time of visit. 17 staff who provide medication administration have been retrained on administration of medications.

Type of visit: Required - 1 Year

On 01/22/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator Assistant, Francine Taitano, and explained the purpose of the visit. LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident apartments and common restrooms. There are three activity spaces which had a plethora of supplies for the activities that are scheduled throughout the month. The menu is posted and offers a variety of options for the residents. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. Facility has a 2-day perishable and a 7-day non-perishable amount. Hot water temperature was measured in five apartments and measured between 105-120 F. LPA observed several fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA reviewed a total of five (5) residents' files and five (5) staff files, which contained most of the required documents. However, three of five staff files reviewed did not include first aid training. Several topics were discussed. Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.the state’s words, verbatim · CDSS document, Jan 22, 2024