The Vincent

Allegation investigated: Due to lack of supervision, resident pushed another resident

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegation, and met with Administrator/Executive Director, Maria Cortes. During the course of the investigation, the Department reviewed documents and made observations. The following allegation was investigated, "Due to lack of supervision, resident pushed another resident.” Complaint alleged that during a resident outing on 06/21/2026, Resident 1 (R1) stated that while on the bus, they were pushed by Resident 2 (R2). Report stated that R2 pushed R1 and caused them to stumble. Review of R1's file showed that they did not have a diagnosis of mild cognitive impairment (MCI) or major neurocognitive disorder such as dementia. Review of R1’s care plan dated 09/16/2025 and 07/14/2026, showed that R1 did not require one-on-one supervision. Review of R2’s file showed that they did not have a Continued on LIC9099C Unsubstantiated Continued from LIC9099 diagnosis of MCI or major neurocognitive disorder such as dementia. R2’s care plan dated 09/18/2025, showed that R2 did not require one-on-one supervision. Both R1 and R2’s care plans also stated that they did not have a history of disruptive, aggressive, verbal, or socially inappropriate behavior. SOC341 report submitted by the facility on 06/24/2026 was reviewed. Report stated that on 06/21/2026, R1 reported that they were pushed by R2 during their resident outing. Per report, R1 did not sustain any injuries during the incident. Police report dated 06/30/2026 stated that the San Rafael Police Department (SRPD) also investigated the incident. Per report, they closed their case as both residents involved sustained no injuries and their responsible parties were notified. Based on record review, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 24, 2026 · control 21-AS-20260708122653

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

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegation and met with Administrator/Executive Director, Maria Cortes. During the course of the investigation, the Department reviewed documents, conducted interviews, and made observations. The following allegation was investigated, "Facility is not meeting resident's care needs." Complaint alleged that Resident 1 (R1) was observed to have an area of bruising their on right heel several days ago and had increased in size. R1 was recently hospitalized and Complainant was also concerned about their recurrent urinary tract infections (UTIs). Report stated that R1 seemed more confused and R1's responsible party contacted 911. After being evaluated by EMS, R1 was found to be hypotensive. Report further stated that the Complainant spoke with a medication technician who stated that R1 was bedbound and wheelchair bound. Per report, this staff member also stated that they weren't aware that R1 had a pressure wound on their right heel and that staff check on R1 every 2-3 hours. Complainant provided the Department with the Continued on LIC9099C Unsubstantiated Continued from LIC9099 medication technician's name. Complainant also stated that R1's heel wound was observed on a Monday by their responsible party. Per report, R1 was seen at the hospital on a Thursday and was discharged from the hospital on 04/23/2026. Multiple attempts to speak with R1's responsible parties to determine a timeline and when they observed R1's heel were unsuccessful. Review of the facility staff roster and staff schedule for March and April 2026 was conducted. It was observed that there was no medication technician employed by the facility with the name provided by the Complainant. A review of R1's file was conducted. R1's preappraisal dated 10/28/2025 stated that they have a history of refusing care and has recurrent urinary tract infections. Incident report submitted to Community Care Licensing (CCL) on 04/24/2026 stated that on 04/23/2026, R1 was observed to be weak and lethargic. Per incident report, R1 was also observed to have a brown discoloration on their right heel, which was noted to have redness, swelling, and warmth radiating up their leg. Facility contacted 911 for further assessment and R1 was taken to the hospital for further evaluation. Review of R1's after visit summary dated 04/23/2026 stated that R1 had a pressure injury and pneumonia. R1's medical paperwork did not note the stage of R1's pressure injury. Review of facility medication technician communication log for the month of March and April 2026 notated the following: 03/30/2026: facility was waiting to receive a physician order for a UTI test for R1, and to collect a urine sample 04/03/2026: R1 returned from the hospital with new medication orders 04/04/2026, 04/05/2026, 04/11/2026: R1 was observed to attend their meals 04/22/2026, R1 was observed to have a sore on their right heel, Memory Care Director and R1's physician notified. 04/23/2026: Morning shift staff noted to keep R1's ankles floated; Afternoon shift noted that R1 was sent to the hospital for swelling of R1's right ankle. 04/24/2026: R1 was observed to be okay, was prescribed antibiotics, and for staff to continue to float R1's heel 04/25/2026: R1's ankle was observed to still be swollen and feet were elevated. 04/26/2026 and 04/27/2026; R1 observed to be doing okay, feet elevated. Review of facility caregiver end of shift logs for April 2026 did not note any changes in condition for R1 until 04/22/2026. Per caregiver note dated 04/22/2026, R1 received a shower and was observed to have a wound on their right foot. Facility staff reported the change to the medication technician on duty and R1's family was notified. Additional caregiver note dated 04/23/2026 stated that R1 was sent to the hospital. Continued on LIC9099C Continued from LIC9099C Interview conducted with Staff Member 1 (S1) revealed that they observed R1 to have a swollen ankle when they came into work on the afternoon of 04/23/2026. Per S1, they were notified about R1's ankle that same day, as they had been off for the previous two days. S1 stated they did not recall receiving information regarding R1's ankle prior to their two days off. Per S1, after R1 returned to the facility, they observed facility caregivers elevating R1's ankles. Review of facility correspondence showed that R1's ankle discoloration was observed by the Memory Care Director (MCD) on 04/22/2026. Per correspondence, the MCD notified R1's family and responsible party of the change. Review of R1's file showed that on 04/23/2026, facility sent a physician communication fax to notify them of the observed change. A follow up physician communication fax was sent on 04/27/2026. Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Administrator/ Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 24, 2026 · control 21-AS-20260427082427

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

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Legal/Non-Compliance visit and met with Administrator/Executive Director, Maria Cortes. The purpose of today's visit is to conduct a Non-Compliance (NCC) inspection. On 05/13/2026, facility was placed on a Non-Compliance plan for 2 years related to the following areas: Observation of a resident When to call 911/Emergency Services Centrally Stored Medications/Record Keeping Medication Administration LPA requested and reviewed documents for all employees hired from May 2026 - August 2026. Review of documents showed that facility hired 5 individuals during this time frame. Facility has scheduled training for these new employees. Proof of training to be submitted to Community Care Licensing (CCL) by 09/01/2026. LPA conducted a medication audit and reviewed the central storage log for a sample size of 4 residents. It was observed that 3 of 4 residents had documentation errors with expiration date and quantity on the LIC622 (Centrally Stored Medication and Destruction Record). 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. **An Immediate Civil Penalty in the total amount of $250.00 is being assessed today for a repeat violation of Regulation 87465(h). Regulation last cited on 12/12/2025** Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 24, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h) · Plan of correction due date: Sep 4, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:...This requirement is not met as evidenced by: Based on record review and observations made, Licensee did not comply with the section cited above and did not ensure that resident medications were accurately recorded on the LIC622 as required. 3 of 4 residents did not have the correct expiration date or quantity of medication listed on the LIC622. This poses a potential health and safety rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2026

Plan of correction: Licensee to conduct an In-Service training for all direct care staff that administer medication. Training to include the following: Date, Topic, Job Role, Staff Names and Signatures. Proof of training to be submitted by POC due date of 09/04/2026.

Allegation investigated: Facility not assisting resident with medications as prescribed.

At approximately 8:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegations. Executive Director, Maria Cortes, arrived during visit at approximately 9:00AM. There is an allegation of “Facility not assisting resident with medications as prescribed.” Complaint alleged that facility did not properly administer Resident 1’s (R1’s) Quetiapine medication as ordered. Per report, on 03/20/2026, R1’s Quetiapine was prescribed as a PRN medication, or “as needed medication." On 03/24/2026, R1's medication was changed to a scheduled medication to be given every night at bedtime. During a visit on 04/09/2026, it was observed that R1’s Quetiapine was listed as a PRN on their medication list. During another visit on 05/07/2026, it was observed that R1’s Quetiapine was still listed as a PRN and was last given on 04/15/2026. Continued on LIC9099C Unsubstantiated Continued from LIC9099 A review of R1's documents was conducted. On 03/18/2026, the facility received a physician order for R1's Quetiapine. This order stated "25MG, take 1/2 tablet (12.5MG) by mouth daily at bedtime as needed for agitation." Review of R1's medication authorization record (MAR) showed that facility staff entered this order manually on paper and administered the Quetiapine from 03/18/2026 to 03/22/2026. On 03/23/2026, the facility received a new order for R1 which stated, "Quetiapine, 25MG, take 1/2 tablet (12.5MG) daily at bedtime." Review of R1's MAR showed that facility staff entered the new order manually on paper and administered Quetiapine from 03/23/2026 to 03/31/2026. Review of R1's medication list for 04/09/2026 stated R1's Quetiapine order as, "25MG take one-half tablet (12.5MG) by mouth at bedtime for insomnia, dementia related agitation." Review of R1's MAR for April 2026 showed that R1's Quetiapine order was manually entered on paper as "Quetiapine, 25MG take half tablet by mouth at bedtime." It was observed that facility administered Quetiapine for April 2026 appropriately per the paper MAR. Facility received an updated medication list for R1 on 05/07/2026. This list also stated that "25MG take one-half tablet (12.5MG) by mouth at bedtime for insomnia, dementia related agitation." Review of R1's MAR for May 2026 showed that R1's Quetiapine order was manually entered on paper as "Quetiapine, 25MG take half tablet by mouth." It was observed that R1 was administered Quetiapine for May 2026 appropriately per the paper MAR. Interview conducted with Health Services Director stated that after sending the new orders to the pharmacy, the pharmacy didn't input or profile R1's Quetiapine orders correctly into the electronic MAR. As a result, facility staff started a paper MAR to document when the Quetiapine was being given to R1. Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 21-AS-20260511105146

Allegation investigated: Resident sustained an injury due to staff neglect Staff did not seek timely medical attention for a resident

At approximately 8:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegations. Executive Director, Maria Cortes, arrived during visit at approximately 9:00AM. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, "Resident sustained injury due to staff neglect, and Staff did not seek timely medical attention for a resident." Complaint alleged that there was a delay in Resident 1's (R1's) care after they had a fall. Per report, R1 was taken to the hospital on 03/12/2026, where they were diagnosed with a lumbar frature. Report further stated that R1 may have fallen 1-2 weeks prior to their hospitalization but that the fall was unwitnessed by staff and R1 did not report their fall. Continued on LIC9099 Unsubstantiated Continued from LIC9099 Review of R1’s medical assessment dated 07/23/2024 stated that R1 had a diagnosis of Osteoporosis and Dementia, was non-ambulatory, and was able to communicate their needs. Review of R1’s Service Plan dated 02/07/2025 stated that R1 utilized a walker, was able to express pain and communicate effectively. It also stated that R1 was a high risk for falls. Review of R1’s Service Plan dated 01/22/2026 stated that R1 had mild impairment and had some difficulty communicating or receiving information. It also stated that R1 utilized a walker, was able to express pain and was a low risk for falls. Review of R1’s Service Plan dated 03/08/2026 stated that R1 had mild impairment, could express pain, and had frequent pain and/or discomfort. It also stated that R1 utilized a walker and was a high risk for falls. This plan also stated that to ease R1’s back pain staff were to provide medication and ensure that R1 could rest, sit in a comfortable position, and avoid standing or walking for too long. Review of Incident Report dated 03/23/2026, stated that on 03/12/2026, R1 was taken to the hospital by family for lower back and leg pain. Per report, R1 was suspected to have a urinary tract infection (UTI) and was receiving antibiotics as treatment. Facility documents also showed that facility faxed R1's primary physician on 03/10/2026 to notify them of the un-witnessed fall and that there were no injuries noted for R1. Interview conducted with Witness 1 (W1) stated that R1 transitioned from the facility’s assisted living to their memory care community in February 2026. Per W1, R1 was experiencing pain prior to transitioning to memory care. W1 was unable to determine if there was a change in how R1 was walking prior to being sent to the hospital. W1 stated that R1 used to use a walker and is currently using a wheelchair while they receives physical therapy to work on their gait. Interview conducted with Witness 2 (W2) stated that prior to moving to the facility’s memory care, R1 was complaining of back pain. W2 was unable to determine if there was a change in how R1 was walking prior to being sent to the hospital. W2 stated that R1 used to use a walker and is currently using a wheelchair while they receive physical therapy to work on their gait. Interview conducted with Staff Member 1 (S1) stated that R1 usually used a wheelchair and has a history of asking for pain medication for their back. Per S1, R1 is able to communicate where they have pain and will point to the area. Review of R1’s caregiver end of shift notes for March 2026 was conducted. Notes for 03/10/2026 – 03/11/2026 did not Continued on LIC9099C Continued from LIC9099C indicate that R1 was having any issues or was in pain. Note for the morning of 03/12/2026 stated that R1 was going to the hospital. Review of R1’s progress notes for March 2026 was conducted. The following entries were observed: · On 03/04/2026, facility notified R1’s family that redness was observed on R1’s lower back, that they complained of pain, and stated they felt like they have a fever. R1 was given medication. · On 03/05/2026, R1 had a urinary analysis test collected and antibiotics were prescribed. · On 03/10/2026, R1 was found on the floor by their bed and no injuries were noted. · R1’s progress notes for 03/10/2026 - 03/11/2026 stated that R1 did not have any issues. · On 03/12/2026, R1 was taken to the hospital for lower back and leg pain. Per progress note entry, R1 had been experiencing pain for a few days. Note continued to state that a urinary tract infection was suspected and that the facility was later notified that R1 had sustained a lumbar fracture. R1’s electronic medication authorization record (EMAR) was reviewed. Records showed that on 03/10/2026, 03/11/2026, and 03/12/2026, R1 received PRN “as needed” medication for pain. Records did not state why pain medication was needed for R1 but noted that the pain medication was effective. Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 21-AS-20260316100024

Type of visit: Office

On 05/13/2026, a Non-Compliance meeting was conducted at the Santa Rosa Regional Office. The following individuals were present in the meeting: Regional Manager (RM), Harpreet Humpal, Licensing Program Manager (LPM), Victoria Bertozzi, Licensing Program Analyst (LPA), Caitlynn Felias, Executive Director, Maria Cortes, Health Services Director, Navneet Kaur, and Vice President of Clinical Services, Jenny Long. The purpose of today’s meeting was to address areas of concerns identified by the Department and to open a new complaint investigation. On 04/21/2025, an Informal Office meeting was held to address the facility's recurrent issues with medication administration. The following areas were discussed during today's meeting: Substantiated Complaint Investigations: Complaint 21-AS-20251210165426 and Complaint 21-AS-20251015120938 Observation of a resident When to call 911/Emergency Services Centrally Stored Medications/Record Keeping Medication Administration On 01/15/2026, under Complaint 21-AS-20251210165426, the facility was issued a $500.00 civil penalty for a violation of Regulation 87466, Observation of a Resident. **Licensee has been informed that the issuance of an additional civil penalty is under review. Additional civil penalty may be assessed based on a violation that the Department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident.** Continued on LIC809C Continued from LIC809 Facility's Non Compliance Plan will be in place for 2 years with an end date of May 2028. The Department discussed having the Technical Support Program (TSP) work with Licensee on the addressed concerns. The Department also opened a Complaint Investigation (Complaint Number: 21-AS-20260511105146) during today's office meeting. Licensee was informed that this new complaint investigation involved concerns with medication administration. No Deficiencies Cited. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 13, 2026

Allegation investigated: Facility is not clean, safe, sanitary or in good repair at all times

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Executive Director, Pari Manouchehri. During the course of the investigation, the Department requested and reviewed documents and made observations. The following allegation was investigated, “Facility is not clean, safe, sanitary or in good repair at all times” Complaint alleged that there is no laundry or hand soap supply in the community. Complaint also stated that the facility walkie talkies don’t work and that resident pendant calls don’t go through or can’t be acknowledged by facility staff. Review of facility’s pendant call logs for November and December 2025 indicated that resident pendant calls were pressed and responded to by facility staff. During visit conducted on 01/15/2026, LPA observed that the Continued on LIC9099C Unsubstantiated Continued from LIC9099 facility pendant call system was operable and that facility staff had functioning walkie talkies. LPA also observed that all public restrooms had hand soap available, and facility laundry rooms had a supply of laundry detergent available for use. Interview conducted with Executive Director stated that soap is ordered through HD Supply and is automatically ordered on a monthly cycle. Facility provided invoices for October, November, and December 2025 showing proof of ordered soap. Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 21-AS-20251208131803

Allegation investigated: Staff did not properly transfer a resident in care resulting in resident sustaining fractures

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Executive Director, Pari Manouchehri. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff did not properly transfer a resident in care resulting in resident sustaining fractures.” Complaint alleged that Resident 1 (R1) sustained fractures to their right ankle and toe due to facility staff not placing R1 properly in their hoyer lift during a transfer. Complaint also stated concerns that R1 sustained a knee fracture due to a fall from their bed. Interview conducted with Memory Care Director revealed that on 08/17/2025, two staff members were assisting R1 while using the hoyer lift. Per interview, R1’s hoyer lift may have been set up wrong because Continued on LIC9099C Substantiated Continued from LIC9099 one of the leg slings came off causing R1’s body weight to shift and fall. The two staff members assisting R1 focused on helping their upper body because they didn’t want R1 to hit their head. R1’s toe and ankle hit the metal of the hoyer lift because R1’s legs are not functional and R1 cannot move them. Per interview, on 08/17/2025, R1 was observed to have no apparent injuries and an internal incident report was made. On 08/18/2025, R1 was observed to have redness so R1’s Responsible Party and Primary Care Physician were notified. Facility requested a home health nurse to come to the facility for further assessment. Review of R1’s incident reports showed that on 08/22/2025, they were sent to the ER where it was found that they had a fractured big toe and ankle. Report also stated that the injury was from a hoyer lift incident that occurred on 08/17/2025 and that facility staff received additional hoyer lift training on 08/19/2025. Review of R1’s progress notes showed the following: · On 08/18/2025, facility staff observed that resident’s left leg was swollen and complained of pain when touched. · On 08/19/2025, R1 was observed laying on top of their hoyer lift sling on the floor. Per progress note, one of the loops of the sling was not on it causing R1 to wing to the side. R1 sustained a bruise on their left arm and a swollen big toe that had redness. · On 08/20/2025, R1 was observed to still have swelling and redness to the area. · On 08/22/2025, R1’s home health agency conducted a visit and requested for an x-ray for R1 · On 08/23/2025, R1 returned to the facility with a fractured ankle and broken big toe. Review of R1’s incident reports and progress notes indicated that a separate incident occurred on 11/18/2025. Per report, R1 was found on the floor by facility staff and was sent to the hospital for further evaluation. Per incident report, preliminary tests indicated that R1 did not sustain any fractures or major injuries. Review of R1's medical records stated that x-rays revealed R1 sustained leg fractures and was admitted to a skilled nursing facility. Facility addressed the knee incident appropriately. Based on record review, interviews conducted, and observations made, the allegation of "Staff did not properly transfer a resident in care resulting in resident sustaining fractures" is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Continued on 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. **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).** Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 21-AS-20251210165426

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 16, 2026

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...This requirement was not met as evidenced by: based on record review and interviews conducted, Licensee did not ensure that Resident 1 (R1) received timely medical care. R1 had an incident with their hoyer lift on 8/17/25. They were observed to have swelling and redness on 8/18/25 but did not get assessed until 8/22/25. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Licensee to submit self-certification that in-service training will be conducted for all care staff on these topics: when to call 911 and observing changes in condition for residents. Self-Certification to be submitted by POC due date of 01/16/2026. Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training to be submitted to CCL for review and approval by POC due date of 01/26/2026.

Type of visit: Required - 1 Year

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a required 1-year inspection and met with Executive Director/Administrator, Pari Manouchehri. 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. Facility has an approved fire clearance for a total capacity of 126 individuals, where 126 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were 89 residents in care and 21 staff members on-site. At approximately 9:30AM, LPA reviewed Facility Staff Roster and found that all staff were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Administrator and observed the following: Facility is a 3 story building for Assisted Living and Memory Care. Facility was clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility has emergency water and food present if facility needed to shelter in place for 72 hours. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for resident use. Hot water temperatures for a sample size of 10 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility has emergency chairs in facility stairwells. Facility's fire extinguishers were last inspected April 2025. Facility's smoke and carbon monoxide detectors, and sprinkler system were last inspected January 2026. Administrator Certificate for Pari Manouchehri (7003752740) was current with an expiration date of 03/24/2026. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 15, 2026

Allegation investigated: Staff did not properly address resident's falls resulting in an injury

At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Administrator, Pari Manouchehri. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegation, “Staff did not properly address resident's falls resulting in an injury.” Complaint alleged that Resident 1 (R1) was admitted to the hospital post-fall and sustained bruising and a large hematoma. Complaint stated this was the second fall R1 had in the past few months at the facility. Interview with Executive Director stated that R1 had a history of aggression, agitation, and being combative. R1 returned to the facility on 07/31/2025 with a private caregiver. Per Executive Director, facility had a care Continued on LIC9099C Unsubstantiated Continued from LIC9099 conference with R1’s responsible party in May 2025 to discuss R1’s behaviors and alternative options but was unable to provide any written documentation of the meeting. Interview with Memory Care Director stated that the facility and R1’s responsible party decided to have a private companion for R1 at nighttime. Memory Care Director further explained during R1’s most recent fall in July 2025, R1 did not have their private companion anymore since it had been decided by R1’s responsible party that it was no longer needed. Correspondence with R1’s Responsible Party (RP) stated that R1 had private caregivers for a few months and slowly reduced their hours over time. Per RP, R1 had private caregivers from 04/27/2025 to 06/09/2025. RP stated that R1 had 24/7 care from 04/27/2025 - 05/13/2025, and reduced hours from 05/14/2025 to 06/09/2025. RP further stated that after R1’s fall in July 2025 it was decided that R1 would go back to have 24/7 private caregivers and begin receiving hospice services. Review of R1’s documentation showed the following: · Incident report submitted to Community Care Licensing (CCL) on 04/24/2025 stated that on 04/19/2025, R1 had gotten stuck with their walker between a recliner chair and the living room couch and was unable to maneuver back out. Report stated that facility staff were trying to help R1 but R1 became resistive. R1 picked up their walker and swung it at facility staff and fell on their right side hitting their head on the couch. Staff were unable to catch R1. Report stated that R1 was admitted to the hospital for evaluation where it was found that they had sustained a right pelvis fracture and contusion to the right side of their head. · Facility Progress Notes indicated that R1 had a fall on 06/05/2025 with no physical injuries notated. R1 attempted to sit in a chair that was too far away and ended up sitting on the floor. Notes stated that R1’s primary care physician and responsible party were contacted. · Incident report submitted to CCL on 07/29/2025 stated that on 07/18/2025, R1 had an unwitnessed fall during night shift. Report stated that R1 was sleeping on the facility’s living room couch. Facility staff stepped away for approximately 5 minutes and when they returned, R1 was observed face down on the floor. Report states that R1 sustained a bump to their head and was sent to the hospital for further evaluation. · R1 returned to the facility on 07/31/2025 with hospice services. Continued on LIC9099C Continued from LIC9099C Facility did not have a care plan available to review after R1’s fall in April 2025. Review of R1’s care plan dated 07/31/2025, stated that R1 had disruptive and aggressive behaviors and that a behavior management plan may be put in place. Per care plan, R1 was at a high risk for falls due to unsteady gait. Facility staff were to frequently check on R1, ensure they were visible while in the common spaces of the facility, and ensure their walker was within reach at all times. R1’s care plan dated 09/29/2025, stated that most of R1’s behaviors were refusals of care or occurred due to other residents and being overstimulated. Staff were to assess R1’s mood and agitation level or implement techniques such as changing of face or redirection. This care plan also stated that R1 required stand-by assistance with transferring and reminders to use their walking device. Facility staff were to frequently check R1, make sure they were visible in the common areas, and ensure their walker was within reach at all times when R1’s private caregiver was not present. Review of progress notes stated that on 08/29/2025, the facility held a care conference with R1’s responsible party to address R1’s care. Additional items such as having designated care staff work with R1, R1 having a higher assessment level than expected, and facility providing weekly updates were also discussed. Review of progress notes and Resident Charge form indicated that facility reached out to R1’s responsible party to discuss updated changes to R1’s September 2025 care plan on 09/07/2025, 09/16/2025, and 09/29/2025 but did not receive a response. Based on record review, interviews conducted, and observations made, Department is unable to determine if a violation of Title 22 Regulations occurred, therefore this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 12, 2025 · control 21-AS-20250723122303

Allegation investigated: Staff did not maintain accurate medication records for residents

At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Administrator, Pari Manouchehri. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegation, “Staff did not maintain accurate medication records for residents.” Complaint alleged that there are open medications with no documented start dates and that multiple resident medications were not centrally stored. LPA conducted a medication audit. During review, LPA observed 3 residents with medications that were not centrally stored as required. This allegation is Substantiated. Continued from LIC9099C Substantiated Continued from LIC9099A LPA conducted staff interviews. 3 of 3 staff interviews conducted stated that only the medication technicians and other supervisors have a key to access the medication room. Facility caregivers do not have the key to the medication room during their shift and only access the medication room at the beginning and end of their shift to pick up and return their equipment. These interviews also stated that during this sign in and sign out process for the equipment, the caregivers always have someone else in the room such as the on-shift medication technician, resident care coordinator, or manager to supervise. Base on interviews conducted, this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. Continued from LIC9099A over-the-counter medication in this way is against regulation. Therefore facility is in compliance with Title 22 Regulations. Based on observations made, this allegation is Unfounded. An allegation that is Unfounded, means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents. Continued from LIC9099 A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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. Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 12, 2025 · control 21-AS-20251015120938

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h) · Plan of correction due date: Dec 22, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident… This requirement is not met as evidenced by: Based on observations made, Licensee did not comply with the section cited above and did not ensure that resident medications were centrally stored and recorded on the LIC622 as required. This is a potential health and safety rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2025

Plan of correction: Licensee to submit a detailed plan on centrally stored medication training with supporting documents. Detailed Plan to be submitted by POC due date of 12/22/2025. Licensee to also conduct an In-Service training for Facility's Care Department. Training to include the following: Date, Topic, Job Role, Staff Names and Signatures. Proof of training to be submitted by POC due date of 01/05/2026.

Type of visit: Case Management - Other

At approximately 4:05PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit and met with Journey Director, Sammy Howeidy and Business Office Director, Raymond Rodarte. The purpose of the visit is to deliver an "Order to Licensee/Facility of Immediate Exclusion From Facility" notice for Staff Member 1 (S1). On 06/05/2025, the Department delivered an "immediate exclusion" notice to facility. Per notice, S1 cannot be allowed to work, be present and/or live in a CCL licensed facility, or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Journey Director and Business Office Director stated they understood the notice. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and Confidential Names (LIC811) discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 5, 2025

Allegation investigated: Unexplained injury

At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Executive Director, Pari Manouchehri. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Unexplained Injury.” Complainant alleged that Resident 1 (R1) sustained a fracture and questioned if the facility had handled the incident appropriately. Report received on 12/04/2024 stated that R1’s Responsible Party was notified by both the facility and R1’s hospice team on the same day,10/29/2024, for observed swelling to R1’s shoulder. Review of facility documents showed that R1 was receiving hospice care. Review of Hospice notes showed that hospice agency staff conducted routine visits with R1 for their Activities of Daily Living (ADLs) and did not observe Continued on LIC9099C Unsubstantiated Continued from LIC9099 any changes in condition during the following visits: 10/21/2024,10/24/2024,10/25/2024, and 10/28/2024. Additional notes dated for 10/29/2024 – 10/31/2024 indicated that R1 had an x-ray completed. X-ray results found that R1 sustained a shoulder fracture and would require a sling. The Department was unable to find additional documentation or evidence to identify how R1’s injury occurred or if there were other changes in condition prior to it being observed by facility staff and the hospice agency staff on 10/29/2024. Based on documents reviewed and observations made, the allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 22, 2025 · control 21-AS-20241204092912

Type of visit: Case Management - Deficiencies

At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies Visit and met with Executive Director, Pari Manouchehri. During the course of the Complaint Investigation 21-AS-20241204092912, it was revealed that the Facility did not submit an incident report to Community Care Licensing (CCL) regarding R1's observed change in condition. During the investigation, R1 was observed to have a swollen shoulder by facility staff on 10/29/2024. R1 received an x-ray where it was found that they had a shoulder fracture. This incident was not reported to CCL and was not documented on an LIC 624/Unusual Incident Report Form (deficiency cited, see LIC809D, regulation 87211(a)(1)(D)). 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. Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 2, 2025

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted...within seven days...(D)Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by: Licensee did not comply with the section cited above. Per record review, Licensee did not submit an incident report for R1 timely. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee to submit Inservice Training on the topic of Incident Reporting. Training to include the following: Date, Topic, Name/Job Role, and Signatures. Training to be submitted to CCL by POC due date of 06/02/2025.

Allegation investigated: Staff did not assist with self-administration of medications as needed Staff falsely recorded medication as being dispensed to resident

During the Office Meeting, Licensing Program Manager (LPM) Bertozzi and Licensing Program Analyst (LPA) Felias delivered findings for this Complaint Investigation regarding the above allegations and met with Executive Director, Pari Manouchehri, Journey Director, Sammy Howeidy, Regional Health and Wellness Director, Rochelle Factor, and Vice President of Clinical Operations, Mariam Perez. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff did not assist with self-administration of medications as needed and Staff falsely recorded medication as being dispensed to resident.” Complainant alleged that Resident 1 (R1) had not been receiving their routine eye drop or inhaler medications and Facility Staff were falsifying resident medication records by documenting that R1’s medication was given even if the medication was not available. Complainant also alleged that facility staff are leaving medication with R1 and not ensuring that they are being taken. Continued on LIC9099C Substantiated Continued from LIC9099 LPA conducted interviews with witnesses and facility staff. Interviews conducted provided conflicting information. Interview conducted with W1 stated that facility staff would either forget to put R1’s hearing aids on in the morning or forget to take them off at night, resulting in R1’s hearing aids getting lost and needing replacement. W1 also stated that facility staff did not receive training on how to insert R1’s hearing aids and that the hearing aids were rechargeable and did not use batteries. Interview conducted with Memory Care Director stated that facility staff were taught how to insert R1’s hearing aids by R1’s family as the insertion is different compared to other hearing aid models. Interview also stated that R1’s hearing aids are to be inserted by the facility medication technicians, and they receive a notification from facility staff when R1’s hearing aid filters have been changed. Interview conducted with facility staff stated that they received training on how to insert R1’s hearing aids, that R1’s hearing aids are rechargeable, and that R1’s hearing aid filters are changed weekly. Per interview conducted, R1’s hearing aids are charged in the medication room and only medication technicians are to insert them. Review of facility documents indicated that facility staff were documenting when R1’s hearing aid filters were changed and when R1 would refuse to have their hearing aids put in. Based on interviews conducted and record review, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents. Continued from LIC9099 Review of R1’s physician orders from 08/08/2024 showed the following instructions for R1’s routine inhaler and eyedrops: · Alvesco 160MCG Inhaler (60); Inhale 2 puffs by mouth daily for asthma prevention and control, rinse mouth well after use · Dorzolamide HCL 2% Eye Drops; Instill 1 drop in both eyes twice daily for glaucoma · Latanoprost 0.005% Eye Drops; Instill 1 drop in both eyes every evening LPA conducted interviews with witnesses and facility staff. 3 of 4 interviews stated that they had heard of medication being documented as given or administered when the medication was unavailable or not in the cart. Interview conducted with facility staff stated that they have seen medication in resident rooms that have not been given. Review of Facility documentation showed that a medication training was conducted by the Health and Wellness Director in February 2025. Additional documentation showed that another training was conducted by the Regional Health and Wellness Director on the topics of medication refills, proper documentation, and medication administration in March 2025. Email correspondence and photographs provided to the LPA revealed that a medication audit was conducted on 02/21/2025 where it was found that R1’s medications were not given as prescribed. Interviews conducted with Regional Health and Wellness Director and Memory Care Director confirmed that a medication audit for R1 took place where medication errors were found such as administering expired medications. Based on interviews conducted, record review, and observations made, these allegations are Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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 12/05/2024. (See LIC421FC)** Exit interview conducted. Copy of report, LIC421FC (Civil Penalty), Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 21, 2025 · control 21-AS-20241217093631

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

87465 Incidental Medical and Dental Care(a)...each facility...shall provide for assistance...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review and interviews, Licensee did not comply with the section cited above and R1 was being administered expired medications. Interviews conducted also stated that medications were being left unattended in resident rooms after being dispensed. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2025

Plan of correction: Licensee to submit self-certification that a written plan and supporting documents will be submitted to CCL by POC due date of 05/01/2025. Plan to include a hybrid model consisting of competency checks, shadowing, and additional training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: May 2, 2025

87208 Plan of Operation(a)The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation... pursuant to Health and Safety Code…This requirement was not as evidenced by: Based on interviews conducted, Licensee did not comply with the section cited above. Medication records were being documented as given when medication was not readily available. This poses an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2025

Plan of correction: Licensee to submit self-certification that a written plan and supporting documents will be submitted to CCL by POC due date of 05/01/2025. Plan to include a hybrid model consisting of competency checks, shadowing, and additional training.

Type of visit: Office

An Office Informal meeting was conducted today in the Santa Rosa Regional Office. The following individuals were present in the meeting: Licensing Program Manager (LPM), Victoria Bertozzi, Licensing Program Analyst (LPA), Caitlynn Felias, Executive Director, Pari Manouchehri, Journey Director, Sammy Howeidy, Regional Health and Wellness Director, Rochelle Factor, and Vice President of Clinical Operations, Mariam Perez. The purpose of today’s meeting was to address recurrent medication errors at the facility and to deliver findings for Complaint 21-AS-20241217093631. The following areas were discussed during the meeting today: Findings for Complaint 21-AS-20241217093631 were delivered (LIC9099) Recurrent Medication Errors that were cited on case management visits or complaint investigations. Citations issued on 11/02/2023, 2/8/2024, 3/1/2024, 3/8/2024, 7/24/2024, and 12/5/2024 Incident Report of a medication error on 04/07/2025. Parties discussed Facility's plan moving forward regarding medication administration. Facility has decided to conduct competency checks along with shadowing to ensure quality assurance. Facility to submit a written plan and supporting documents by due date 05/01/2025. Failure to correct these issues may result in a Non-Compliance Conference and being placed on a Non-Compliance Plan. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 21, 2025

Type of visit: Case Management - Annual Continuation

At approximately 1:10PM, Licensing Program Analysts (LPAs) Magdaleno and Felias arrived unannounced to conduct a Case Management - Annual Continuation visit and were greeted by Administrator, Pari Manouchehri. Facility has an approved fire clearance for a total capacity of 126 individuals, where 126 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPAs were informed that there were 80 residents in care and 22 staff members on-site. At approximately 1:15PM LPAs conducted a spot check of 8 clients files, all required documentation present. At approximately 3:00PM LPAs conducted a spot check of 6 resident medications. 1 of 6 residents were observed to have some medications not centrally stored or documented as required (technical violation issued). No Deficiencies cited during visit. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 5, 2025

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

Type of visit: Required - 1 Year

At approximately 9:00AM, Licensing Program Analysts (LPAs) Magdaleno and Felias arrived unannounced to conduct a required 1-year annual inspection and were greeted by Administrator, Pari Manouchehri. 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. Facility has an approved fire clearance for a total capacity of 126 individuals, where 126 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPAs were informed that there were 74 residents in care and 19 staff members on-site. At approximately 9:50am, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is a three story facility, was at a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected April 2024 and are charged. Smoke and Carbon Monoxide are hardwired with sprinkler system, last serviced 1/22/25 by vendor. A sample of facility sink temperatures were taken and included 14 resident rooms and 1 memory care kitchen sink. LPAs observed that 4 sinks were shown to be out of compliance with Title 22 regulations. LPAs observed a supply of clean linens, hygiene care, 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. LPAs observed at least a 2-day supply of perishable and 7-day supply of non-perishable food, as well as emergency food stores with a 10 year shelf life. Food was found to be stored in a safe manner with open items covered, as well as an emergency water supply. LPAs observed a piano, bookshelves full of books, puzzles, and LPAs were informed that the facility plays table tennis, takes trips to the local farmers market, has trivia nights, and conducts daily exercises. At approximately 12:30pm, LPAs conducted review of 6 staff records. All required documentation present. Pari Manouchehri Administrator Certificate 7003752740 expires 3/24/26. All fees are current as of this time. LPAs and Administrator discussed facility's Emergency Disaster plan, No new updates. Facility’s last quarterly disaster drill was conducted on 12/2/24, with the next one scheduled end of February 2025. Continued on 809C... Continued from 809... LPAs followed up on an incident report that was submitted to Community Care Licensing (CCL) on 02/11/2025. Death Report 1: CCL received a death report on 02/11/2025. Per report, on 02/09/2025, Resident 1 (R1) was found unresponsive by facility staff. Facility staff contacted emergency personnel for further evaluation. Facility made all appropriate notifications per regulation. LPAs requested and obtained additional documentation. LPAs also requested for additional paperwork for Change of Administrator. LPAs requested the following for Pari : First Aid/CPR certificate copy of current driver's license copy of active/current administrator's certificate copy of board of directors' resolution meeting minutes signed (required for all corporations) Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Liability Insurance LIC500- Personnel Report LIC308- Designation of Responsibility LIC610E-Emergency Disaster Plan LPAs unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. No Deficiencies cited during visit. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 13, 2025

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility mismanaged medications Facility staff not administering medications per physician orders

At approximately 9:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Executive Director/Administrator, Corrine Bianco, and Memory Care Direcotor, Sammy Howeidy. During the Investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Facility mismanaged medications, and Facility staff not administering medications per physician orders.” Complainant alleged that facility staff were not administering medication timely and were falsifying medication administration documentation. The Regional Office received six (6) self-submitted incident reports from the facility. These reports stated that for five (5) residents, medication was not administered timely or was missed completely. Review of the 6th incident report stated that a resident was administered someone else’s medication. Continued on LIC9099C Substantiated Continued from LIC9099 3 of 7 interviews conducted with involved parties stated that residents have been observed to receive their medication late, sometimes over two hours, or that residents have been given the wrong medication intended for other residents. (deficiency cited and civil penalty issued, LIC9099D and LIC421IM, regulation 87465(a)(4)). LPA is unable to determine if medication records were falsified, however based on incident reports reviewed and interviews conducted, the allegations are Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $1,000.00 is being assessed for a third violation of Regulation 87465(a)(4) more than once in a 12 month period. Deficiencies last cited on 02/08/2024 and 07/24/2024. (See LIC421IM)** Exit interview conducted. Copy of report, LIC421IM (Civil Penalty), LIC811 (Confidential Names), and Appeal Rights, discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 21-AS-20240909112350

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 6, 2024

87465 Incidental Medical and Dental Care(a)...each facility...shall provide for assistance...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review and interviews, Licensee did not comply with the section cited above. 6 Incident Reports received and 3 of 7 interviews conducted stated that residents have either missed medication, received late medications, or have been given someone else's medication. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Licensee to submit self-certification that In-service training will be conducted by POC due date of 07/25/2024. Training to be done for all staff that administer medications reviewing when to order medications per facility protocol. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 08/05/2024.

Allegation investigated: Staff did not ensure medications were properly managed for resident in care

At approximately 12:50PM, Licensing Program Analysts (LPAs) Felias and Loera arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Executive Director/Administrator, Corrine Bianco, and Health and Wellness Director, Ashley Perrone. During the Investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff did not ensure medications were properly managed for resident in care." Complainant alleged that the facility ran out of Resident 1 (R1’s) Ativan medication and did not ensure that their refills were replenished timely. Per Complainant, R1 did not receive their Ativan medication during these timeframes: 11/19/2023 through 11/26/2023 and 02/22/2024 through 03/01/2024. Review of R1’s Electronic Medication Authorization Record (EMAR) and Narcotic Log for November 2023 revealed that R1 received their last dose of Ativan on 11/18/2023 and did not receive another dose of Ativan until 11/27/2023. Continued on LIC9099C Substantiated Continued from LIC9099 Review of R1's file did not indicate any communication to R1's Primary Care Physician or pharmacy regarding refills. Review of R1’s Electronic Medication Authorization Record (EMAR) and Narcotic Log for February and March 2024 revealed that R1 received their last dose of Ativan on 3/2/2024. Review of R1's file indicated that the facility notified R1's Primary Care Physician and pharmacy. Per documentation, the facility was actively attempting to have medication refilled but were unsuccessful. Complaint alleged that during a visit on 3/6/2024, the resident’s behavior was “off.” When staff were questioned about resident’s medication, they indicated that the resident had been out of the medication for a week. Staff interviews conducted indicated that the facility protocol is to contact the Physician and pharmacy at least 7 days prior to a medication running out. Based on document review and interviews conducted, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $250 is being assessed for a repeat violation of Regulation 87465(a)(4) more than once in a 12 month period. (See LIC421FC)** Exit interview conducted. Copy of report, LIC809D, LIC421FC (Civil Penalty), LIC811 (Confidential Names), and Appeal Rights, discussed and provided to Executive Director/Administrator, and Health and Wellness Director. Signature on form confirms receipt of documents. Continued from LIC9099A Per staff interviews conducted, facility contacts the pharmacy or primary care physician directly for refills and the responsible party does not transport or order medications. Based on interviews conducted, this allegation is Unsubstantiated. Resident sustained unexplained hand fracture and unexplained shoulder bruise - LPA received photographs of R1’s hand and shoulder bruise. Per photographs, LPA observed that R1’s hand appeared to be red and swollen. Per Complainant, R1 was observed to have a swollen hand on 11/20/2023 at 5:30PM, and that R1 was taken to the doctor for an x-ray. The x-ray showed that R1 had a pinky fracture. Review of facility documents showed that R1 received an x-ray on 11/24/2023 but there was no additional written documentation. LPA was unable to determine if facility staff observed change in R1’s hand prior to it being observed on 11/20/2023 as there is no additional documentation to review. Per photographs received, LPA observed that R1’s bruise was observed to be yellow in color. Complainant was unable to provide an exact date for R1’s shoulder bruise but stated it was at the end of Summer 2023. Facility notes dated 06/09/2023 stated that R1 had a fall with no visible injury, bruising, or pain reported. R1’s responsible party and primary care physician were notified. Review of Facility documents indicated there was no additional documentation or notes for R1 in July or August 2023 related to observation of bruising or changes in skin condition. Staff interviews conducted stated that bruising can happen after a resident falls or if a resident is very active and moves around a lot. Interviews also stated that facility caregivers would notify the facility medication technicians of any changes. Due to lack of documentation and interviews conducted, LPA is unable to determine if violations occurred, therefore these allegations are Unsubstantiated. Facility staff restrained resident – LPA received photographs of R1. Per photograph received, it was observed that R1 in a wheelchair. R1 was parallel to the wall, had a sofa chair to the left of the wheelchair, and a TV stand in front of them. LPA also received written documentation from Complainant stating that on 03/03/2024, R1 was observed to be wedged between two cabinets and a table, on 03/04/2024 R1 was observed to be in the corner of the facility dining room, and on 03/08/2024, R1 was observed to be wedged between two non-moveable heavy objects. Interviews with facility staff stated that R1 has shown behaviors where they will continually grab, pull, and push things. Interviews further stated that R1 will sometimes get stuck because they will surround themselves with facility furniture. Facility notes dated 02/22/2024, 03/01/2024, 03/13/2024, 03/15/2024, 03/18/2024, and 04/04/2024 corroborated R1’s behavior. Physician communication notes dated 03/09/2024 and 03/13/2024 showed that facility was communicating with R1’s primary care physician regarding R1’s observed behaviors. During visit, conducted on 07/19/2024, LPA observed that R1 would try and pull items and tables towards them. LPA observed facility staff move R1 away from the furniture or redirect R1 by using their personal objects. Based on document review, interviews conducted, and observations made, LPA is unable to determine if a violation occurred, therefore this allegation is Unsubstantiated. Continued on LIC9099C Continued from LIC9099C Facility staff does not assist R1 with dressing as needed – Complainant alleged that facility staff are not assisting R1 with their dressing needs because R1 was observed to have their shoes put on the wrong feet and the shoes were tied too tight. LPA received a photograph of R1’s feet which showed that R1’s shoes were on the wrong feet. During visit conducted on 07/19/2024, LPA observed that R1 and the other residents in the facility appeared to be well-groomed and clean. Interviews conducted with staff stated that they have not received any concerns regarding how residents are clothed or dressed. Based on observations made and interviews conducted, LPA is unable to determine if a violation occurred, therefore this allegation is Unsubstantiated. Facility staff did not meet resident’s meal service needs – Complainant alleged that R1 has lost 40 pounds since moving to the facility. Complainant stated they believe R1’s weight loss is due to facility staff not letting R1 finish their meals and taking it away before they are done. Document review showed that R1 moved to the facility on 01/31/2023. Facility management changed to its current management company on 06/01/2023. Review of R1’s weight log from 06/01/2023 to 03/21/2024 showed that R1’s weight did fluctuate over time. R1’s weight in June 2023 was recorded to be 127.6lbs and their weight in March 2024 was recorded to be 121lbs. LPA is unable to review records for R1 prior to June 2023 due to management change. Per staff interviews, resident weights are to be checked monthly. Residents can take as long as they need to finish their meal if they are slow eaters or require assistance with feeding. If the resident is not hungry during meal time, then the food is placed behind the counter for when they are hungry. During visit on 07/19/2024, LPA made observations during facility’s lunch hour. LPA observed that R1 ate well and that facility staff took R1’s plate away once they were finished. Based on document review, interviews conducted, and observations made, LPA is unable to determine if a violation occurred, therefore this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator, and Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 24, 2024 · control 21-AS-20240308142252

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 25, 2024

87465 Incidental Medical and Dental Care(a) A plan... shall be developed... The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review, interviews, and observations made, Licensee did not comply with the section cited above. R1 did not receive medication as prescribed due to facility running out of their medication. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2024

Plan of correction: Licensee to submit self-certification that In-service training will be conducted by POC due date of 07/25/2024. Training to be done for all staff that administer medications reviewing when to order medications per facility protocol. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 08/05/2024.

Type of visit: Case Management - Incident

At approximately 3:00PM, Licensing Program Analysts (LPAs) Felias and Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Corrine Bianco, and Health and Wellness Director, Ashley Perrone. The purpose of today's visit is to follow up on self-reported incident that were submitted to Community Care Licensing (CCL). Incident Report 1/SOC-341: CCL received an incident report and SOC-341 on 07/19/2024. Reports stated that on 07/06/2024, Staff Member 1 (S1) witnessed Staff Member 2 (S2) place their hand over Resident 1's (R1) mouth with soap suds during a shower due to R1 being agitated. S2 was suspended pending internal investigation and sent notice to the facility of their resignation on 07/16/2024. Facility made all appropriate notifications per regulation. Per report, facility will be conducting elder abuse training the week of 07/22/2024 and 07/29/2024. LPAs requested documentation. Facility to submit proof of elder abuse training once completed. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Executive Director/Administrator, and Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 24, 2024

Allegation investigated: Personal Rights Staff mismanaged medications

At approximately 1:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Health and Wellness Director, Ashley Perrone. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Personal Rights and Staff mismanaged medications.” Complainant alleged that facility staff made videos that discussed resident care with other staff members present. Per Complainant, the videos were about 45 minutes long and recorded information that also showed resident medication. LPA was unable to view the videos as the Complainant did not have a copy of them and was unable to provide additional information regarding the videos. Continued on LIC9099C Substantiated Continued from LIC9099 LPA conducted an interview with Staff Member 1 (S1). During interview, S1 informed LPA that they were alone in the medication room making a video of themselves when another staff member approached them to provide resident care updates. Per S1, they forgot that the video was still recording. S1 informed LPA that the videos did not contain any identifiable medical information and that the videos had been posted on their personal social media page. S1 immediately deleted the videos when it was discovered that information regarding resident care was included. S1 informed LPA that they had training regarding the incident. Based on interview conducted, this allegation is Substantiated. Complainant alleged that facility staff mismanaged medications. Per Complainant, Resident 1’s (R1) narcotic medications were found with another resident's narcotic medication when they moved to a new facility. LPA reviewed incident report that was submitted to the Department on 03/04/2024. Report stated that on 02/19/2024, S1 released the resident's narcotic medication to their new facility. On 02/20/2024, it was discovered that R1’s narcotic medication was with this resident's narcotic medication. Per report, R1’s narcotic medication was appropriately destroyed on 02/19/2024 and a new supply of narcotic medication was received on 02/22/2024. Review of R1’s Electronic Medication Administration Record and Physician Orders indicated that their medication was prescribed as a PRN or “as needed” medication. Record review indicated that R1 did not take the PRN medication. Facility submitted documentation to the Department showing that S1 had an in-service training on the following topics: Narcotic, Controlled Substances and Preventing Drug Diversion, Six Rights of Medication Administration, Confidentiality Policy, and Release of Medications. Based on review of documents, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $250 is being assessed for a repeat violation of Regulation 87468.2(a)(2) more than once in a 12 month period. (See LIC421FC)** Licensee submitted Inservice Training for S1 to the Department on 03/04/2024. Deficiency cited for Regulation 87468.2(a)(2) cleared during visit. Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC809D, LIC421FC (Civil Penalty), Appeal Rights, and Plan of Corrections Letter discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents. Continued from LIC9099A A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240301160352

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Jul 19, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a)...residents...shall have all of the following...:(2) to have their records and personal information remain confidential and to approve their release...This requirement was not met as evidenced by: Based on interviews and document review, Licensee did not comply with the section cited above. Facility staff posted a video with resident care information and failed to ensure narcotic medication confidentiality. This poses an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: Licensee submitted Inservice Training for S1 to the Department on the following topics: Narcotic, Controlled Substances and Preventing Drug Diversion, Six Rights of Medication Administration, Confidentiality Policy, and Release of Medications on 03/04/2024. Deficiency cleared during visit.

Type of visit: Case Management - Annual Continuation

At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Executive Director, Sam Faye, and Regional Health and Wellness Director, Roschelle Factor. 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. Facility has an approved fire clearance for a total capacity of 126 individuals, where 118 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were 70 residents in care and 23 staff members on-site. At approximately 9:25AM, LPA reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. LPA reviewed staff files. LPA observed that some staff did not complete their annual 2023 training (see LIC809D, Health and Safety Code, 1569.625(b)(2)). LPA reviewed First Aid/CPR certifications. LPA observed that medication technicians had appropriate certification. Direct Care Staff had first aid certification but it was not through a qualified medical agency. LPA received documentation regarding the first aid training that direct care staff received (see LIC9102, Health and Safety Code, 1569.618(c)(3)). LPA reviewed medications. LPA discussed with management regarding centrally stored medication and ensuring that it is written correctly in their central storage log (see LIC9102, regulation 87465(h)). 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. Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator, and Regional Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 12, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Executive Director, Sam Faye, and Regional Health and Wellness Director, Roschelle Factor. 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. Facility has an approved fire clearance for a total capacity of 126 individuals, where 118 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were 71 residents in care and 25 staff members on-site. At approximately 9:30AM, LPA reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:00AM, LPA reviewed memory care resident files. All files were found to be well organized, thorough, and contained the required documentation. LPA unable to complete Annual visit. Annual Continuation to be conducted on a later date. LPA to return to finish review of staff files and resident medication. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Updated Administrator Certificate Documents to be submitted to Community Care Licensing (CCL) by due date of 06/17/2024. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director and Regional Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 17, 2024

Type of visit: Required - 1 Year

At approximately 9:15AM, Licensing Program Analysts (LPAs) Felias and Florio arrived unannounced to conduct a Required 1 Year visit and met with Executive Director, Sam Faye, and Regional Health and Wellness Director, Roschelle Factor. 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. Facility has an approved fire clearance for a total capacity of 126 individuals, where 118 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were 69 residents in care and 23 staff members on-site. At approximately 9:45AM, LPA reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:30AM, LPA conducted a walk-though of the facility with Executive Director and observed the following: Facility is a 3 story building for Assisted Living and Memory Care. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 10 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. LPAs reviewed Assisted Living Resident files. Resident Files were all found to be well organized, thorough and contained the required documentation. Facility's fire extinguishers was last inspected April 2023. Facility's fire sprinklers were last inspected January 2024. Facility's last emergency drill was conducted March 2024. LPAs unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 28, 2024

Allegation investigated: Staff did not administer resident's medication as prescribed

At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Regional Health and Wellness Director Roschelle Factor, Regional Operations Specialist, Sahar Mosalla. During the course of the Investigation, LPA requested and reviewed documents, conducted interviews, and made observations. Reporting party alleges that Staff did not administer resident’s medication as prescribed. Reporting party stated that Resident 1’s (R1’s) Simbrinza eyedrop prescription was changed from twice a day to once a day for an unknown reason. Review of R1’s file showed that the facility received an electronic order from the pharmacy dated 12/16/2022. The pharmacy order stated for the Simbrinza eyedrops to be given once a day. File review showed that there was no physician’s order in R1’s file requesting for the change on how the medication was to be administered and also showed that the facility did not ask for clarification for the eyedrop prescription until June 2023. Continued on LIC9099C Substantiated Continued from LIC9099 Review of Facility’s Program Plan for Medication Management stated the following “written physician orders for all medications are maintained in the resident’s chart…” Staff interviews conducted stated that a physician order is to be received by the facility and faxed to the appropriate pharmacy for the medication to be filled. Based on review of documents, interviews conducted, and observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Facility conducted an in-service training covering Medication Management which reviewed Medication Orders and Changes on 01/25/2024. LPA was provided with a copy of training documentation and cleared the deficiency cited today, 02/08/2024, during visit. Exit interview conducted. Plan of Corrections reviewed and developed with Regional Health and Wellness Director and Regional Operations Specialist. Copy of report, LIC9099D, Plan of Corrections, and Appeal Rights discussed and provided to Regional Health and Wellness Director and Regional Operations Specialist. Signature on form confirms receipt of documents. Continued from LIC9099 Review of Facility’s policy “Transferring Medication for Home Visits and Outings” stated the following “When a resident leaves the community for a short period of time during which only one dose of medication is needed, the Designated staff person gives the medications to a responsible party in an envelope (or similar container) labeled with the resident’s name, name of medication(s), and instructions for administering the dose…the person entrusted with the medications agrees in writing as to the amount of medication received on behalf of the resident and the appropriate dosing amount and schedule.” Review of R1’s file indicated that R1’s eyedrops and medication instructions were provided to R1’s Responsible Party so it could be administered to R1 while out of the community. Based on review of documents and observations made, this allegation is Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit Interview conducted. Copy of Report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 21-AS-20231102122712

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 9, 2024

87465 Incidental Medical and Dental Care(a) A plan... shall be developed... The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review, interviews, and observations made, the Licensee did not comply with the section cited above. R1 did not have a physician's order on file to verify a medication change that was being given. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Licensee conducted In-Service Training on Medication Management which reviewed Medication Orders and Changes for all medication technicians on 01/25/2024. Deficiency cleared during visit.

Type of visit: Case Management - Other

At approximately 11:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit and met with Regional Health and Wellness Director, Roschelle Factor, and Regional Operations Specialist, Sahar Mosalla. The purpose of today's visit is to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 01/29/2024. Report stated that on 01/21/2024, three medications were found in a medication cup in Resident 1's (R1) bedroom. Facility conducted an in-service training for all medication technicians. Facility made all appropriate notifications per regulation. Incident Report 2: CCL received an incident report on 02/02/2024. Report stated that on 01/23/2024, Resident 2 (R2) was given an extra dose of medication at the request of R2's Responsible Party. Facility conducted an in-service training for all medication technicians. Facility made all appropriate notifications per regulation. Incident Report 3: CCL received an incident report on 02/02/2024. Report stated that on 01/27/2024, Resident 3 (R3) was given an extra dose of medication. Report stated that R3 was given half a tablet of medication by Staff Member 1 (S1), and then was given one full tablet of medication by Staff Member 2 (S2). Facility conducted an in-service training for all medication technicians. Facility made all appropriate notifications per regulation. LPA also requested for updated Administrator Paperwork. During visit, LPA was informed that Facility has a new Executive Director, Sam Faye. LPA requested for the following documents to be submitted to the Regional Office so they can be processed as the new Administrator. Administrator Documents to be submitted to CCL by 02/18/2024. Continued on LIC809C Continued from LIC809 Administrator Documents · LIC 308 (Designation of Facility Responsibility) · Active and Current Administrator Certificate · First Aid Certificate · Administrator Resume · LIC 500 (Personnel Report) · LIC 501 (Personnel Record) · LIC 503 (Health Screening Report - personnel) · Proof of TB test · LIC 9182 (Criminal Record Exemption Transfer Request) · LIC 508 (Criminal Record Statement) · Copy of Driver's License or Passport that is not expired · Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations) Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Facility conducted a in-service training covering Medication Management and Narcotics and Controlled Substances on 01/25/2024. LPA was provided with a copy of training documentation and cleared the deficiency cited today, 02/08/2024 during visit. Exit interview conducted. Plan of Corrections reviewed and developed with Regional Health and Wellness Director and Regional Operations Specialist. Copy of report, LIC9099D, Plan of Corrections, and Appeal Rights discussed and provided to Regional Health and Wellness Director and Regional Operations Specialist. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 8, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 9, 2024

87465 Incidental Medical and Dental Care (c)If resident...unable to determine... need for nonprescription PRN medication... facility...shall assist..with self-administration...(2)Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on document review, Licensee did not comply with the section cited above. R1, R2, and R3 were not given medications as prescribed and R3 was also given PRN medication. This poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Licensee conducted In-Service Training on Medication Management and Narcotics and Controlled substances for all medication technicians on 01/25/2024. Deficiency cleared during visit.

Allegation investigated: Facility did not keep resident's information confidential

At approximiately 12:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegation and met with Health and Wellness Director, Mildred Santos. Corporate Director of Operations, Scott Bissey, was available by telephone. During the course of the Investigation, LPA conducted interviews and requested and reviewed documents. There is an allegation that Facility did not keep resident's information confidential. Based on interviews conducted, LPA confirmed that a resident was sent out to the hospital with another resident's medical paperwork and information. Therefore, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Continued on 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 deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Plan of Corrections reviewed and developed with Health and Wellness Director and Corporate Director of Operations. Copy of report, LIC9099D, Plan of Corrections, and Appeal Rights discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 5, 2024 · control 21-AS-20240104133216

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Jan 6, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a)In addition to the rights listed in Section 87468.1...residents...shall have all of the following...:(2) to have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by: R1 went to the hospital with R2's medical paperwork and R2's medical information was not kept confidential as required. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 5, 2024

Plan of correction: Licensee to ensure that all residents' personal and medical information are kept private and confidential as required. Licensee to submit self-certification stating that an Inservice Training will be conducted with all Care Staff to review Regulation. Certification to be submitted by POC due date of 01/06/2024. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 01/15/2024.

Type of visit: Case Management - Deficiencies

At approximiately 1:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies Visit and met with Health and Wellness Director, Mildred Santos. Corporate Director of Operations, Scott Bissey, was available by telephone. During the course of the Complaint Investigation dated for 01/04/2024, LPA conducted interviews. LPA learned that a resident went to the hospital with another resident's confidential medical paperwork. This incident was not reported to Community Care Licensing (CCL) and was not documented on an LIC 624/Unusual Incident Report Form (This deficiency has been cited, see LIC809D, Regulation 87211). 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. Exit interview conducted. Plan of Corrections reviewed and developed with Health and Wellness Director and Corporate Director of Operations. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 5, 2024

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

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not comply with the section cited above and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 5, 2024

Plan of correction: Licensee to provide training to all care staff reviewing the Regulation: 87211 Reporting Requirements and how to properly fill out the LIC 624 form. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 01/15/2024.

Type of visit: Case Management - Incident

At approximately 10:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Shawn Mooney. The purpose of today's visit is to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 08/21/2023. Report stated that on 08/18/2023, Resident 1 (R1) informed facility staff that they had a fall and had pain on the right side of their ribs and their hip. Facility staff notified Emergency Personnel and R1 was sent to the hospital to be evaluated. R1 had a diagnosis of a right hip fracture and was scheduled to have surgery. Facility made all appropriate notifications per regulation. Per conversation with Executive Director and Health and Wellness Director, R1 went to rehabilitation after a successful surgery. Their Responsible Party decided to move them back home. At this time, R1 is no longer a resident of the facility. Incident Report 2/SOC-341: CCL received an incident report and SOC-341 report on 09/07/2023 and 09/19/2023. Reports state that on 09/02/2023, Resident 2 (R2) reported to their Responsible Party that they wanted Staff Member 1 (S1) kept away from them. R2 stated to their Responsible Party that S1 grabbed their arm and wanted to have sexual relations with them. Responsible Party reported conversation to facility staff. Facility conducted an internal investigation. During investigation, it was revealed that when R2 was at another facility, there was an individual there that wanted to have sexual relations with R2. R2's Responsible Party and Facility have observed R2 to often be disoriented and confused. Facility conducted an In-Service Training focusing on how to interact with R2 and their symptoms. Facility has re-assigned S1. Facility made all appropriate notifications per regulation. Per conversation with Executive Director, there have been no other occurrences involving R2 and S1. Facility to submit In-Service Training and requested documentation to CCL. Incident Report 3/SOC-341: CCL received an incident report and SOC-341 report on 10/03/2023. Reports state that on 09/30/2023, Resident 3 (R3) and Resident 4 (R4) were observed to be watching a movie together. R4 started to cry and R3 asked them to stop. When R4 did not stop crying, R3 hit R4 in the face. Facility staff separated R3 and R4. Facility made all appropriate notifications per regulation. Continued on LIC809C Continued from LIC809 Incident Report 4/SOC-341: CCL received an incident report and SOC-341 report on 11/02/2023. Reports state that on 10/31/2023, Resident 3 (R3) and Resident 5 (R5) were observed to be sitting on the couch together watching a movie. R3 was observed to hit R5 in the face unprovoked and also grabbed R5's arm tightly. Facility staff separated R3 and R5. Facility made all appropriate notifications per regulation. Per conversation with Executive Director, R3 had a medication change and has been monitored for any behavioral changes. Facility also notified R3's Physician of the incidents. Facility has also increased staff supervision for R3 by providing a one-on-one caregiver until their medications and behaviors have been stabilized. No Deficiencies Cited during Visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 7, 2023