Town & Country

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced case management visit in conjunction with Unusual Incident/Injury Report (UIIR) dated August 29, 2026. LPA was greeted and granted entry by Memory Care Coordinator Cristina Garcia. LPA explained the reason for the visit. Per UIIR on August 27, 2026, the Nurse was notified by the Medication Technician (MT) of a possible missing dose of the Temozolomide for Resident 1 (R1). Per UIIR, upon further investigation it was determined that R1 had received a duplicate dose of the medication. During today's visit LPA reviewed the Medication Administration Record (MAR) dated August 1, 2026, through August 31, 2026, for R1. Per MAR, as of August 23, 2026, R1 was prescribed Temozolomide Oral Capsule 100 mg, 3 capsule one time a day. A Health and Safety inspection was conducted, and LPA Ramirez observed no Health and Safety concerns during today's visit. Based on observations and records reviewed during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility representative, a copy of Appeal Rights and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Sep 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 21, 2026

Incidental Medical and Dental Care (c) If the resident's physician has stated in writing...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: On 8/27/26 R1 was given a double dosage of Temozolomide; however R1 is only prescribed Temozolomide Oral Capsule 100 mg, 3 capsule one time a day. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 18, 2026

Plan of correction: Licensee to provide an in-service Medication training to staff and email POC to LPA by POC due date.

Allegation investigated: Staff illegally evicted a resident in care

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and witness as well as reviewed and obtained documentation such as eviction notice. Regarding the allegation that staff illegally evicted a resident in care, the investigation revealed the following: On April 30, 2026, facility served a thirty-day eviction notice to Resident 1’s (R1) responsible party. Per review of notice, notice is missing pertinent information such as unlawful detainer verbiage, relocation assistance and department information which required by regulation rendering the notice as unlawful. Facility did not forward the notice to the department. Based on record review, the preponderance of evidence standard has been met. Therefore, the above allegation is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. Deficiency is being cited on the attached LIC-9099D. An exit interview was conducted and a copy of this report as well as the appeal rights were provided at exit. Substantiated The resident was sent out to the Hospital. Review of hospital discharge paperwork shows resident was hospitalized from November 06- November 09, 2024, for “Fractures of the right superior and inferior pubic rami with chronic deformities of the left superior and inferior pubic rami.” There is no evidence of fractures of the right iliac and sacrum. Four out of four staff interviewed state there was always staff with R1 unless the resident was sleeping; however this incident was reported as “Unwitnessed” per incident report. The resident’s family expected staff to always be with the resident and staff obliged per management directive. There was not a specified one on one, it was just understood per family request that a caregiver would be with the resident at all times. Four out of four staff deny the resident was neglected as R1 was continually observed. The resident was always in the activity room and not in the resident’s room as the family demanded the resident was to be kept out of the resident’s room. Appraisal Needs and Services dated November 16, 2023, does not show the resident as a fall risk. On December 29, 2023, facility reported the resident was carrying a laundry basket with the walker when a caregiver assisted the resident back to the room. The resident ended up falling and receiving a skin tear on the knee. First aid was applied. R1 subsequently reported that the caregiver had been rough with them. Facility initiated an investigation and the incident was reported to the family who declined any further action or medical care per facility notes. Four out of four staff deny knowledge of a caregiver being rough with the resident. Facility notes indicate R1 had a fall without an injury on March 22. 2026. Four out of four staff state assisting the resident with toileting and staff were always with the resident. Per facility notes and incident report, R1 requested to sit on patio on September 02, 2024. Staff documented bringing the resident water. When the resident was brought in, R1 had low energy, was warm and red. 911 was called and resident was sent out to the hospital. R1 was subsequently hospitalized for confusion, covid and heat exhaustion. Per Appraisal dated November 16, 2023, R1 was alert and oriented and able to make their needs known. Four out of four staff deny knowledge of how long resident was outside but state the patio is always visible so the resident would not be out of visual range. LPA observed patio is observable from the common area. Staff state R1 preferred to stay on the patio and would protest when staff would bring the resident back in. CONTINUED ON LIC 9099C DATED 08/25/2026 Based on records reviewed and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and copy of the report was provided to the facility. LPA reviewed incident reports provided for all incidents noted in alleged allegations thus facility has been reporting the incidents. Based on record review, the allegations are deemed UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 22-AS-20260501153636

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.683(a)(4) · Plan of correction due date: Sep 8, 2026

In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction... This req is not met as evidenced by: Based on record review, Licensee failed to ensure facility provided a proper eviction notice to R1 and the department that included unlawful detainer verbiage, department information and relocation assistance which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: Licensee agrees to read the regulation and forward a statement of understanding to LPA by POC due date.

Allegation investigated: Staff left a resident soiled for an extended period of time Staff did not meet a resident's incontinence needs

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegations that staff left a resident soiled for an extended period of time and staff did not meet a resident's incontinence needs, the investigation revealed the following: On 12/10/2025, Resident 1 (R1) had an accident in the resident's room and pulled the pendant for assistance. In the meantime, the resident called family who lives in independent living. The family member arrived and went to look for caregiver assistance as the resident and resident's room needed immediate assistance. Review of pendant call record on 12/10/2025 shows a pendant call at 8:36 AM with a response time of 37 minutes. Two out of two caregiver signed statements indicate the two caregivers responded between 9 and 930 AM. Further review of record shows between 12/07-12/10/2025, there were six calls with response times over 30 minutes. CONTINUED ON LIC 9099C DATED 4/18/2026. Substantiated Based on interviews conducted and record review, the preponderance of evidence standard has been met. Therefore, the above allegations are deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. Deficiencies are being cited on the attached LIC-9099D. An exit interview was conducted and a copy of this report as well as the appeal rights were provided at exit. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 18, 2026 · control 22-AS-20251214233319

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Apr 12, 2026

Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance...This req is not met as evidenced by: Based on interviews conducted and record review, Licensee failed to ensure personal assistance with incontinence care was provided to R1 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2026

Plan of correction: Licensee to conduct an in-service on providing incontinence care and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 19, 2026

In addition to the rights.., residents shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient.. to meet their needs. This req is not met as evidenced by: Based on interviews conducted and record review, Licensee failed to ensure R1 was provided timely incontinence care. From 12/07-12/10/ 2025, there are six pendant calls with a response time over 30 minutes which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2026

Plan of correction: Licensee to provide an in-service on responding to pendant calls and forward proof to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on SOC 341's submitted to the department on 02/05/2026 as well as an incident report. LPA was greeted and granted entry into the facility and explained the reason for the visit. SOC 341 dated 02/05/2026 indicated a caregiver had noticed bruising and bleeding on Resident 1(R1). Upon reviewing video surveillance it was determined that S1 had been rough with the resident. LPA reviewed the video footage and observed the staff being rough with the resident. SOC 341 dated 02/05/2026 indicated a caregiver had witnessed S1 being aggressive with R2. Video surveillance confirmed the staff was aggressive with the resident. LPA reviewed the video footage and observed the staff being aggressive with the resident. S1 was terminated effective 02/05/2026 and law enforcement was notified. LPA obtained the video surveillance during the visit. Incident report dated 03/14/2026 indicated medications were being passed in R3 and R4's room. R3 became ill and vomited. While assisting resident, caregiver put R3's medications down unsupervised and R4 consumed seven medications prescribed to R3. Normal protocol is for caregiver to pop the pills and hand to the resident and this protocol was not followed during this incident. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Mar 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Mar 28, 2026

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This req is not met as evidenced by: Based on record review and interviews conducted, Licensee failed to ensure residents are afforded dignity in care. S1 was rough with R1 and R2 which poses an immediate health and safety risk to residents in care. (video surveillance obtained).the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Licensee to conduct an in-service on personal rights and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87464(f)(1) · Plan of correction due date: Mar 28, 2026

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This req is not met as evidenced by: Based on interviews conducted, Licensee failed to ensure basic services were provided to resident. R4 took seven of R3's medications once they were unsupervised by caregiver. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Licensee to conduct a medication in-service and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Town & Country. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 158 non-ambulatory. Facility has an approved hospice waiver for 30 residents and the facility currently has 21 residents on hospice care. Sara Modugno has an administrator certificate expiring on 09/02/2026. LPA Lyman along with Memory Care Liaison Lori Wear toured the facility at 8:13 AM. Administrator Sara Modugno joined the tour in progress. LPA toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. Facility consists of two buildings housing independent, memory care and assisted living residents with multiple outside areas, three dining rooms, beauty salon and activity areas. At approximately 8:15 AM, LPA observed there is door in need of repair in the main entrance area of facility (photo). Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. LPA observed five residents with half bed rails. Water temperature measured between 108.5 and 119.1 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors as well as a first aid manual. LPA observed cleaning supplies are secured. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors are tested annually by Siemons along with fire inspections with the last inspection date of 03/11/2025. Fire extinguishers are fully charged. LPA observed evacuation chair at stairwells. CONT IN 809C DATED 12/18/2025. LPA toured the outside grounds and there is ample shaded seating for residents. LPA observed ample emergency food and water. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility conducts quarterly emergency drills with the last drill conducted on 11/12/2025. Facility provides activities in the form of games, exercise, and outings in the community. LPA observed residents participating in activities during the visit. LPA reviewed select resident and staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Resident #2 does not have an updated medical assessment and Residents #2, 3, and #10 do not have written physician orders for bed rails. Staff files reviewed contained required documentation such as health screen/TB and criminal record clearance. Five out of five staff files reviewed do not contain required annual training. Four out of five staff do not have CPR training. LPA to return at a later date to review medications. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Dec 18, 2025

Allegation investigated: Facility does not have adequate staffing, resulting in residents’ needs not being met

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as staffing schedule. Regarding the allegation that facility does not have adequate staffing, resulting in residents’ needs not being met, the investigation revealed the following: Facility management indicates staffing challenges due to call offs, resignations and terminations. Facility is using agency to fill holes in the staffing schedule. Facility staffs 8 caregivers and a med tech for 1st and second shift and 4-6 caregivers/ med tech for NOC shift. Five out of five staff state facility is using agency to cover holes and is staffed when agency comes in. Five out of five staff state resident needs are being met. LPA reviewed staffing documents CONTINUED ON LIC 9099C DATED 11/12/2025 Unsubstantiated showing the facility is using agency. Two out of two memory care residents stated needs are being met. Based on records reviewed and interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 12, 2025 · control 22-AS-20251110084114

Allegation investigated: Staff are not meeting residents’ care needs due to lack of staff.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit to continue the investigation into the above allegation. LPA met with Director of Resident Services (DRS) Sara Modugno and stated the purpose of the visit. On August 20, 2025, the Department received a complaint, and the complaint investigation was initiated by LPA Cho on August 26, 2025 which was continued on today's date. During the course of the investigation, LPA interviewed seven Memory Care (MC) residents/MC staff, and obtained the following documentation: Resident Rosters, Personnel Report, Staff Contacts, (AM/PM/Noc) Shift Schedules/Time Cards for August 13, 15, 16, 2025, Face Sheets, Physician's Reports, and Service Plans. The investigation is as follows: It is alleged that the Staff are not meeting the residents' care needs due to lack of staff, affecting the residents' care in the Memory Care (MC) unit. Unsubstantiated On August 20th, LPA inspected six MC apartment units and observed ample supply of briefs in the cabinets of the resident units. LPA observed donation hygiene supplies in the janitor's room which was secured. Seven out of the seven staff interviewed confirmed that the lead caregiver is in possession of the janitor's room key and found no issues with obtaining the key. Five out of the seven residents confirmed that the hygiene supplies are in their respective units. The remaining two residents could not be qualified due to their medical condition. Therefore, this agency has investigated the complaint and based on the observations made and the interviews which were conducted the following allegation: Staff do not have access to supplies for residents is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Director of Resident Services Sara Modugno, and a copy of this report was provided at exit. Based on LPA's observations, the preponderance of evidence standard has been met, therefore the following allegation, Facility is in disrepair, is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC-9099D. An exit interview was conducted with Director of Resident Services Sara Modugno, and a copy of this report including the LIC9099-D and the appeal rights were provided at exit. Based on the interviews, two out of seven residents denied the allegation while the remaining three residents indicated that staff assistance is not needed due to their independence with their Activities of Daily Living (ADLs), and the remaining two residents interviews could not be qualified due to their medical conditions. Based on the review of the shift schedule and time cards for the month of August 2025, three sample days were reviewed: August 13, 15, and 16, 2025. On Wednesday, August 13th, there were 8 caregivers working the AM shift (6:30am-2:30pm); 7 in the PM shift (2:00pm-10:30pm); and 6 noc shift (10:00pm-6:30am). On Friday, August 15th, 7 caregivers were working the AM/PM shifts and 4 in the noc shift. On Saturday, August 16th, there were 7 caregivers working the AM/PM shifts and 6 in the noc shift. In addition to the full time caregivers mentioned above, there are leads/medication technicians that also assist during breaks and when additional staff are needed upon request which was corroborated by six out of seven staff. The investigation revealed that there was insufficient corroborating evidence to support the allegation of not meeting the resident's needs due to lack of staff, therefore, the investigation is deemed UNSUBSTANTIATED. An exit interview was conducted with Director of Resident Services Sara Modugno, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 22-AS-20250820170219

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 3, 2025

87303 Maintenance and Operation (a) The facility shall be... in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observation accompanied by RSD Madugno, the walkie-talkie experienced a dealy in alert between 2-3mins when the two patio doors were opened which poses a potential Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: RSD stated that the walkie-talkie was replaced and will provide a written procedure ensuring to secure an extra budget for obtaining facility equipments as well as ensuring that the walkie talkies are fuctional movring forward to LPA by POC due date.

Allegation investigated: Facility staff are not properly addressing scabies Facility staff are not ensuring residents have clean bed linens Facility staff do not maintain passageways free from obstruction

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as medication orders. Regarding the allegations that facility staff are not properly addressing scabies, facility staff are not ensuring residents have clean bed linens and facility staff do not maintain passageways free from obstruction, the investigation revealed the following: On 09/03/2025, Resident 1 (R1) was sent out to St. Joseph Hospital for increased weakness after being diagnosed with Dermatitis. Facility was notified on 09/05/2025 that R1 was confirmed positive for Scabies via testing at the hospital. Two residents at the facility were visually confirmed to have Scabies and 17 residents have itching but are not confirmed. Once R1 was confirmed, facility called in a consultant from Risk Resource Solutions to help manage the outbreak as well as public health notification. CONTINUED ON LIC 9099C DATED 09/11/2025 Unsubstantiated Facility notified the department on 09/06/2025. All residents and staff in Memory Care are currently being treated for suspected Scabies. Interview with Housekeeping Supervisor indicated all resident linens and clothing are bundled and treated daily as well as rooms being sanitized daily. Staff state facility has ample linens for residents. Facility conducted an in-service for staff on Scabies prevention. LPA toured the memory care unit and observed staff and visitors wearing PPE as well as a PPE station in the entrance of the memory care. LPA did not observe any doors blocked and four out of four staff deny blocking of doors occur. Based on observations made and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 22-AS-20250904143853

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 08/13/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87309(a) pertaining to Storage Space has been cleared. Licensee has secured toxins. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87464(f)(4) pertaining to Basic Services has been cleared. Licensee provided proof of correction. Licensee has complied with the POC. Licensee has been advised to maintain compliance in all items previously cited. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2025

Allegation investigated: Staff does not ensure that the facility is free of pests Staff are not meeting residents' hygiene needs

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as extermination records. Regarding the allegations that staff does not ensure that the facility is free of pests and staff are not meeting residents' hygiene needs, the investigation revealed the following: Facility provided documentation of pest extermination services provided by Skyline Pest Control on 06/03/2025, 07/01/2025, and 08/04/2025. Four out of four staff deny seeing pests inside the facility. LPA toured the memory care unit and did not observe any pests. Per physician correspondence, two residents are being treated for rashes with Elimite for Scabies and Clobetasol for fungal infections. There is no diagnosis of either Scabies or a fungal infection by physician. Four out of four staff state residents are receiving showers and needs are being met. CONTINUED ON LIC 9099C DATED 08/13/2025 Unsubstantiated Facility provided documentation showing when residents refuse showers. Staff state residents are observed every 15 minutes and incontinence care is provided at a minimum 3-4 times per shift. LPA observed residents relaxing in the facility and all appeared clean. Facility staffing levels are as follows: 6-8 caregivers/ 2 med techs/ lead and an LVN on 1st and second shifts and 5 caregivers/ med tech or LVN on NOC shift. Interviews with staff confirm staffing levels. LPA observed ample staffing during the visit. Based on observations made and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 22-AS-20250811172747

Allegation investigated: Staff does not ensure cleaning chemicals are made inaccessible to residents in care Staff does not ensure medications are dispensed as prescribed

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA toured the memory care unit and interviewed staff as well as reviewed and obtained pertinent documentation such as medication administration records. Regarding the allegation that staff does not ensure cleaning chemicals are made inaccessible to residents in care and staff does not ensure medications are dispensed as prescribed, the investigation revealed the following: Memory care unit "Grace Gardens" has four kitchenettes in mini dining rooms for residents. LPA observed the door is unlocked in all four and all four had unsecured cleaning spray in an unsecured cupboard. One kitchenette had Windex and cleaning spray unsecured. LPA observed no staff in the kitchenettes but did observe a staff in the dining area. Grace Gardens serves residents with Dementia. Three out of three staff who administer medications state waiting for residents to swallow medications to ensure the medications are taken. CONTINUED ON LIC 9099C DATED 08/13/2025 Substantiated Review of medication administration records show that two out of four residents reviewed are missing medication administration. Interview with Administrator indicates refills were pending however Residents 1 and 2 missed multiple periodic days of medications. Based on record review and observation, the preponderance of evidence standard has been met. Therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights. Based on observations made and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 22-AS-20250805120829

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 14, 2025

Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions.. which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This req is not met as evidenced by: Based on observation, License failed to ensure cleaning supplies were secured. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: Licensee to discontinue storing cleaning supplies in kitchenettes and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 14, 2025

Basic services shall at a minimum include: Personal assistance and care as needed by the resident..., with those activities of daily living such as.. assistance with taking prescribed medications.. This requirement is not met as evidenced by: Based on record review, Licensee failed to ensure residents were provided assistance with taking medication. Residents #1 and 2 missed multiple medications due to refills pending. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: Facility to provide an in-service and forward proof to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Samer Haddadin conducted an announced visit to the facility to conduct interviews and collect documentation related to complaint number 22-AS-20241209152259. Upon arrival, LPA met with Executive Director (ED) Sara Modugno and explained the purpose of the visit. LPA completed the interviews and obtained the requested documents. An exit interview was conducted, and a copy of this report was provided to the ED.the state’s words, verbatim · CDSS document, Aug 13, 2025

Allegation investigated: Facility failed to provide notice to resident when changing room location

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and resident as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegation that facility failed to provide notice to resident when changing room location, the investigation revealed the following: Resident 1 (R1) was moved from Independent Living to Assisted Living on 12/23/2024 due to ongoing health issues. Resident indicates agreeing to the move and facility notes confirm the agreement. Resident confirmed needing additional assistance from staff and had been having the conversation with staff about moving due to mobility issues and hip pain. Resident was re-assessed on 12/18/2024 and provided an updated service plan on 12/23/2024. Physician report dated 12/23/2024 indicates resident is diagnosed with Osteoarthritis. LPA observed resident's room to be clean and in order. Therefore the allegation is deemed UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit Interview conducted and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Jul 10, 2025 · control 22-AS-20250701140411

Allegation investigated: Staff did not assist resident with feeding, resulting in significant weight loss Staff did not seek medical attention for resident in a timely manner Staff did not administer resident's medications Staff did not safeguard resident's personal belongings

On July 2, 2025, Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced visit to this facility to deliver findings regarding the following allegations: staff did not assist the resident with feeding, resulting in significant weight loss; staff did not seek medical attention for the resident in a timely manner; staff did not administer the resident's medications; and staff did not safeguard the resident’s personal belongings. During the investigation, LPA reviewed Resident 1’s (R1) facility file, including medical records, the admission agreement, inventory sheet, E mail records, staff roster , censuses and progress notes. LPA also interviewed staff members who were present during R1’s 32-day stay, as well as residents who lived at the facility before, during, and after that time. Regarding the allegation that staff did not assist R1 with feeding and did not administer medications, progress notes show that on October 6, 2024, R1 initially refused food and medication. However, later that same day, R1 was offered a bowl of cereal and consumed 100 percent of it. On October 9, 2024, R1 again refused both food and medication, Unfounded but was offered liquids and snacks throughout the day. Staff notes document multiple attempts to encourage R1 to eat and take medication. Under Title 22, California Code of Regulations Section 87465(a)(5)(D), residents cannot be forced to take medications or eat, as doing so would violate their personal rights. Staff interviews consistently described R1 as verbally and physically aggressive and noted that R1 often refused care, including meals and medication. Regarding the allegation that staff did not seek timely medical attention, facility records show that R1’s family designated Dr. Eric Khau as the primary physician. When R1 was diagnosed with a urinary tract infection, Dr. Khau prescribed oral antibiotics. Staff followed the physician’s instructions, although R1 continued to refuse medication. Documentation supports that medical attention was provided in a timely manner. As for the allegation related to safeguarding personal belongings, Form LIC 821 “Personal Property and Valuables” did not reflect any listed inventory from the family at the time of admission. Family members later claimed that a jacket, watch, electric razor, and spoon were missing. In response, the facility offered a $2,500 refund, which was accepted by the family in an email dated December 13, 2024. Based on the preponderance of evidence, including documentation and interviews, all allegations are determined to be unfounded. This means the allegations were false, could not have happened, and/or lacked a reasonable basis. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Executive Director Sara Modugno.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 22-AS-20241209152259

Allegation investigated: Facility call system is not operational Facility staff failed to provide adequate care and supervision to a resident in order to prevent the occurrence of falls. Facility is not providing adequate toileting care to a resident.

On June 16, 2025, Licensing Program Analyst (LPA) Samer Haddadin met with Executive Director (ED) Sara Modugno to deliver the findings regarding a complaint filed on March 26, 2024. The investigation involved a review of facility records, staff and resident interviews, and direct observation. II. Allegations Investigated The Department received a complaint on March 26, 2024, which contained several allegations. The complaint alleged that the facility's call system was not operational, that staff failed to provide adequate care and supervision to a resident to prevent falls, and that the facility was not providing adequate toileting care to a resident. III. Investigative Findings Regarding the allegation that the facility's call system is not operational, the LPA reviewed records for three separate resident calls made using a pendant button, which indicated the system was functional. Furthermore, on June 16, 2025, the LPA and the ED tested the system directly.{**CONTINUE9099C**} Unsubstantiated A test of two separate resident pendants resulted in response times of 26 seconds and 15 seconds, respectively. A test of a call button in a restroom showed a response time of one minute and 55 seconds. These findings confirm the call system is operational. In response to the allegation that staff failed to provide adequate care and supervision to prevent falls, the LPA reviewed the file for Resident 1 (R1), who has been identified as a fall risk. The review confirmed R1 had three falls without injury in February 2024. After each incident, the facility placed R1 on a 72-hour observation watch, consistent with its policy. Records also showed that on April 11, 2024, management met with R1's Power of Attorney (POA) to propose one-on-one caregiver services, which the POA declined. Interviews with four staff members corroborated the facility's protocol for responding to resident falls. Concerning the allegation that the facility is not providing adequate toileting care, interviews were conducted with four staff members, all of whom denied the claim. Additionally, during a facility tour on June 16, 2025, the LPA personally observed two caregivers appropriately responding to a resident's incontinence care needs. IV. Conclusion Based on the observations, record reviews, and interviews conducted, the Licensing Program Analyst was unable to find a preponderance of evidence to validate the allegations. While it is possible the alleged events occurred, the investigation could not produce sufficient evidence to prove that a violation of licensing regulations took place. Therefore, the allegations are deemed UNSUBSTANTIATED. V. Exit Interview An exit interview was conducted with Executive Director Sara Modugno. A copy of this report was provided to her at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 22-AS-20240326115522

Allegation investigated: Facility failed to provide care and supervision resulting in multiple falls

LPA Samer Haddadin conducted an unannounced complaint visit to present findings regarding the above-mentioned reported allegation. Upon arrival, LPA Haddadin was greeted by Executive Director (ED) Sara Modugno, who granted access to the facility. During the investigation, LPA Haddadin toured the facility, interviewed staff members, and reviewed all medical records pertaining to the alleged incident involving resident (R1). Allegation Investigated: “Facility failed to provide care and supervision resulting in multiple falls.” Investigation Findings: Regarding the allegation, R1 was first admitted to the facility on October 1, 2022. A Pre-placement Appraisal, performed by the facility on September 22, 2022, stated the following regarding R1’s overall condition: R1 has severe hearing loss, motor impairment, is a fall risk, requires a wheelchair, has cognitive impairment, and is occasionally confused. LPA Haddadin conducted a record review of R1’s Physician Report, which also states R1 is non-ambulatory, a fall risk, and experiences mental cognitive confusion and short-temperedness. **{CONTINUE ON 9099C}** Unfounded Upon admission, R1 was provided with a pendant to press in case of any emergency, including falls. Additionally, each resident’s room is equipped with a call button that any resident can use to request assistance from facility caregivers or staff. During the record review, LPA Haddadin found six incident reports. Five of these six incidents were falls where the resident used her pendant; however, none resulted in injuries or hospitalization. LPA Haddadin noted that for all fall incidents, a caregiver and a nurse were present, an immediate body check was performed, and blood pressure and oxygen levels were measured, all of which were within normal range. Furthermore, the facility had placed R1 on 72-hour alert charting, during which she was very closely monitored. One documented incident occurred on October 6th. R1 requested medication, having forgotten, due to her confused state of mind and cognitive ability, that staff had already administered it. According to the report, R1 became more agitated, rose from her wheelchair, and began to yell in the hallway, asking for 911. Staff and the nurse on duty calmed R1 down and were able to control the situation. R1’s responsible party was notified of this incident and advised the facility to call 911. Emergency Medical Technicians (EMT) were called for assistance, but R1 was not transferred to the hospital due to her refusal. R1's son was informed and thanked the facility for their hard work. R1’s responsible party advised the facility that R1 could lose her temper and become loud but thanked the facility staff and praised them for their patience. LPA Haddadin conducted interviews with six staff members from different positions and titles within the facility. All interviewees corroborated that the alleged falling incidents occurred. However, these interviews revealed that the facility provided the necessary care and supervision required to assist R1. Conclusion: Therefore, based on the preponderance of evidence gathered through interviews, medical record reviews, and all pertinent paperwork collected by LPA Haddadin, the allegation, "Facility failed to provide care and supervision resulting in multiple falls," was found to be unfounded. This means the allegation was determined to be false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited during today's visit. An exit interview was conducted with the ED, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 22-AS-20221122103427

Allegation investigated: Staff did not ensure the facility was free of pests.

On today's date, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility. The purpose of the visit was to deliver findings regarding allegations. LPA Haddadin was greeted by staff and granted entry after stating the visit's purpose. During the investigation, LPA Haddadin toured the facility, interviewed staff members and residents, and reviewed facility records. Investigation Findings Regarding the allegation that "staff did not ensure the facility was free of pests," LPA Haddadin, accompanied by the Administrator (AD), inspected both buildings of the facility. This inspection included the kitchen area, common areas, and six bedrooms in each building. No evidence of pests was found during the inspection. (CONTINUE ***9099C) Unsubstantiated Interviews and Record Review LPA Haddadin interviewed three residents, all of whom denied the allegations. Additionally, three staff members were interviewed, and all denied seeing any pests. A review of facility records indicated that the facility undergoes monthly pest and rodent inspections by a third-party service provider. Service dates noted in the records were February 6, 2025; March 5, 2025; April 2, 2025; and May 5, 2025. Conclusion Based on the preponderance of evidence gathered through multiple interviews and a review of records, the allegation that "staff did not ensure the facility was free of pests" was found to be UNSUBSTANTIATED. This determination signifies that while the alleged incidents may have occurred or the concerns might be valid, there was insufficient evidence to prove that the alleged violation took place. No deficiencies were cited during this visit. An exit interview was conducted with the Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 22-AS-20250218143417

Allegation investigated: Staff are not meeting residents needs Staff do not have access to supplies for residents

Licensing Program Analyst (LPA) Jenifer Tirre met with Executive Director Sara Modugno for the purpose of delivering findings for the above allegations. The complaint consisted of observations and interviews. On March 12, 2025 the department received allegations that staff are not meeting residents needs and staff do not have access to supplies for residents. The investigation was completed by the Department and revealed the following: Regarding allegation “Staff are not meeting resident’s needs”, during visit LPA toured facility and observed staff assisting residents with meals, medications, changing of linens inside bedrooms and assisting residents with toileting needs. LPA also observed several staff members answering resident questions. During investigation LPA Tirre conducted interviews with residents and staff. Based on investigation interviews the following was revealed: six of seven residents stated that facility staff meet their care needs. Six Residents interviewed stated that staff provide assistance with showering, toileting, medications, CONTINUED ON 9099C Unsubstantiated meals and respond to their pendant calls in a timely manner. Seven of seven residents stated that they feel safe at facility and are not in any danger. Based off interviews with staff, Ten of ten staff members stated that they feel they are meeting the care needs of residents. Based off Staff interviews, staff stated they are providing residents with assistance in Activities of Daily Living (ADL’s) and stated that they have not had any complaints from residents or family members on the level of care being provided. Regarding allegation “Staff do not have access to supplies for residents”, during visit, LPA observed that residents have supply of diapers, wipes, toilet paper, under pads, towels and linens inside resident rooms. During tour LPA Tirre observed storage closets that had extra over flow of diapers, under pads, wipes, incontinence products and gloves that are secured. LPA Tirre observed additional overflow of supplies readily available to staff near hydration stations as well as personal laundry room cabinets inside memory care wing. Based off interviews with seven residents, no residents stated they have been short supplied on items. Based on interviews with Staff members, ten of ten staff stated that residents have supplies of diapers, wipes, toilet paper, and towels readily available inside resident rooms. Nine of ten staff stated that facility has overflow of supplies inside storage closets which Director, Coordinators, Nurses and Med Technicians have keys to open for staff to access. Nine of ten staff interviews confirmed that residents under hospice care are being provided products from hospice agencies and residents not on hospice that require diapers, wipes and under pads are being supplied products from responsible parties. Staff interviews reveal that if ever an emergency need and resident does not have supply, staff will pull from overflow storage. Interview with Executive Director Modugno confirmed that facility started labeling supplies for each resident that requires incontinence supplies and that since, facility has not ran out of supplies for residents. Based on observations made and interviews conducted, LPA is unable to corroborate allegations made that staff not meeting residents needs and staff do not have access to supplies therefore although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Sara Modugno, and a copy of this report was provided during this visit.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 22-AS-20250312162740

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 01/28/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 01/25/2025 indicated Resident 1 (R1) had been served shrimp for lunch while having a seafood allergy. LPA observed facility protocol for resident allergies which consists of documentation in the kitchen as well as name cards in the dining room with resident allergies/ food preferences. Facility investigation revealed a new server had mistakenly served the shrimp to R1. Another caregiver realized what had happened and removed the shrimp but not before the resident had taken a bite. Side effects for resident consumption of shrimp include diarrhea. Resident was noted to have no side effects from the shrimp. Resident has since moved out of the facility. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Sara Modugno, Administrator and a copy of this report was given to the facility along with a copy of the LIC 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Mar 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 31, 2025

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This req is not met as evidenced by: Based on interviews conducted and record review, Licensee failed to ensure care was provided to resident. Resident was served shrimp while resident's allergy was noted by facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 17, 2025

Plan of correction: Licensee to conduct an in-service on food allergies and dining and forward proof to LPA by POC due date.

Allegation investigated: Facility did not ensure that it was free of pests

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint visit. LPA Mendivil was greeted and granted entry by Sammantha Meza, Liason and Crisitina Garcia, LVN explained the reason for the visit. Head Chef Pedro Miranda arrived shortly after. The Department received a complaint on 12/19/2024 and the initial investigation conducted on 12/26/2024. LPA Mendivil toured the facility and interviewed staff and residents. Regarding the allegation facility did not ensure that it was free of pests, the invesitgation revealed the following: It was alleged that in the Independent Living dining room there were pests present. LPA Mendivil toured the facility on 12/17/2024 for an annual visit and did not observe pests or rodents. LPA Mendivil toured Independent Living dinning room again on 12/26/2024 with Head Chef Pedro Miranda and Sous Chef Anthony Montes. LPA Mendivil observed staff cleaning the kitchen between meal services. LPA Mendivil observed a cleaning log. Unfounded LPA Mendivil observed Public Health Services "Retail Food Facility Inspection Report" dated 06/12/2024 which the facility passed. Based on interviews with 3 out of 3 residents stated they have not seen any pest or rodents in the facility. Residents stated if they noticed any issues they would reach out to housekeeping or notify the front desk. Based on interviews with 6 out 6 staff deny the allegation that facility is not kept free of pests. Therefore based on the preponderance of evidence through observations and interviews the allegation that Facility did not ensure that it was free of pests is determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 26, 2024 · control 22-AS-20241219150833

Type of visit: Required - 1 Year

On this day Licensing Program Analysts (LPAs) Andrea Mendivil and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by Care Coordinator Lori Wear and explained the reason for the visit. Administrator (AD) Sara Modungo arrived during the tour. AD Modungo has a valid certificate that expires on 09/02/2026. At 8:10am LPAs Mendivil and Arias toured the Independent Living and Assisted Living and Memory Care buildings. Facility has 54 residents in assisted living and 58 residents in memory care during today's visit, with 14 on hospice. Facility has a beauty salon, chapel, activity rooms, movie theater and library as well as multiple dining rooms and a bistro area. LPAs observed both the Assisted Living and Memory Care Unit. Assisted Living resident rooms are single occupancy and had the required elements. Memory Care rooms are single and double occupancy. Memory Care has delayed egress doors and an enclosed outside patio for residents. Facility utilizes the electronic medical record. LPAs observed an ample supply of emergency food and water. Smoke detectors tested operational during today's visit. Sprinklers and smoke detectors are also tested by an outside company and last inspection was on 10/23/2024. LPAs toured the outside grounds and observed multiple shaded outside visitation areas. Residents participate in activities such as exercise, music, and outings in the community. Facility had an emergency fire drill conducted on 11/2024 with a third party. LPAs reviewed 5 Assisted Living Facility residents and 5 Memory Care residents and all files contained the required documents. Therefore based on observations no deficiencies are being cited today per Title 22. An exit interview was conducted and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Dec 17, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit at 1:30 PM to follow up on an email received by the Centralized Complaint and Information Bureau (CCIB) on October 14, 2024. LPA was greeted and granted entry into the facility by the Concierge and met with Sara Modugno, Administrator (AD). The purpose of the visit is to verify there is an Administrator at the facility since the Administrator on-file no longer worked with this facility as of February 19, 2024 per Human Resources. Upon interview with current Administrator, who spoke with Chief Executive Officer (CEO) Robert Goerzen via phone, CEO recollects handing the paperwork and speaking to LPA Andrea Mendivil in February 2024 to add Gina Kolb as the Administrator. During this time the facility completed paperwork for a change of capacity but not a change of administrator. Upon review of our database, LPA Ruppert could not corroborate this since there was no supporting documentation that LPA Mendivil visited between January to March 2024. Facility will search their files for the paperwork regarding a change of administrator in February 2024. LPA obtained and reviewed a new and signed LIC 200 form to change the Administrator to Sara Modugno and was given a copy of the Administrator's certificate which expires on September 2, 2026. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Sara Modugno, Administrator and a copy of this report was given to the facility along with a copy of the LIC 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Oct 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87407(k) · Plan of correction due date: Oct 22, 2024

Administrator Recertification Requirements. Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1)The local licensing office...and (2) The Department's Administrator Certification Section (ACS). Based on LPA file review and interviews the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to all persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2024

Plan of correction: Administrator printed and submitted a new and signed LIC 200 to change the Administrator directly to LPA. AD will follow-up with ACS.

Allegation investigated: Due to lack of staff, residents are not changed timely. Staff do not respond to call bell in a timely manner.

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Assisted Living Coordinator Nikka Solomon. During the course of the investigation LPA toured facility, reviewed records, conducted interviews with staff & residents, and requested pertinent documentation such as Resident Roster’s, staff roster’s, Physician’s reports, course completion records, resident care plans, and device activity reports. During investigation LPA reviewed facility records such as Employee Handbook, staffing rosters, in service meeting notes and Device activity reports. Facility rosters revealed that facility Assisted Living has 19 staff on file per 53 residents and Memory Care Grace Gardens has 17 staff per 57 residents. Course completion records reviewed for staff revealed that all staff must complete "Abuse, neglect, and exploitation in the elder care setting training". CONTINUED ON 9099C Unsubstantiated LPA reviewed and verified 11 employee's training was completed in this area. Device Activity Reports for facility call buttons and pendants dated 8/13/24 and 8/22/24 revealed that 55 alarms were pulled and of the 55, 14 alarms were cleared upon departure of assisting resident rooms while remaining 41 were cleared upon arrival. Upon review facility August in service meeting dated 8/22/24 reveals training was conducted regarding pendant response time informing staff to clear pendant as soon as enter room. Training also revealed for staff to ensure to monitor pendants ideally within 10 minutes. Interviews conducted with staff revealed that twelve of twelve staff members state they are to clear pendants and pull cords in a timely manner within 10 minutes. Staff interviews indicated that twelve of twelve staff confirm if staff member are unavailable at time call received, staff are to communicate with care team via radios so that other available staff members can assist residents. All staff interviews revealed facility has coverage of staffing to assist with residents needs. Staff interviews confirm facility uses registry for coverage. Interviews conducted with residents revealed that eight of eight residents confirmed that staff responded to their call buttons in a timely manner of five to ten minutes. Resident interviews revealed that residents do not have issues with staff and facility has adequate staff on the floor. Five of eight residents confirmed that staff assist residents for dressing, toileting and or showering in timely manner. Based on records reviewed and interviews conducted, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: due to lack of staff, residents are not changed timely and staff do not respond to call bell in a timely manner are deemed UNSUBSTANTIATED. An exit interview was conducted with facility representative and a copy of this report was reviewed and provided at the time of this visit.the state’s words, verbatim · CDSS document, Aug 23, 2024 · control 22-AS-20240813123809

Allegation investigated: Due to lack of staff, colostomy care was provided by unqualified staff Due to lack of staff, residents did not receive their medications on time

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Assisted Living Coordinator Nikka Solomon. During the course of the investigation LPA toured facility, reviewed records, conducted interviews with staff & residents, and requested pertinent documentation such as Resident records, Resident rosters, staff rosters, Medication Administration Records, and Course Completion History. During investigation LPA conducted interviews with staff. Staff interviews revealed that one resident in facility required colostomy care. Staff interviews with six of twelve staff confirm that staff that assist with colostomy care residents require assisted hands on training for three weeks before assisting care independently. Staff interviews confirmed that not all staff receive this training only Medical Technicians, Nurses and Lead Caregivers. CONTINUED ON 9099C Unfounded Interviews conducted with residents revealed that eight of eight residents confirmed that residents do not have issues with staff and facility has adequate staff on the floor. Eight of eight residents confirmed that they do not have issues with medication and confirm that they receive medications in timely scheduled manner. Eight of eight residents confirm that staff are available to them when needing assistance. Interview with Resident 1 (R1) confirmed that R1 requires assistance with changing Colostomy bag. R1 stated that all staff that have provided assistance with Colostomy bag change out bag every five days. R1 confirms that staff are well trained when changing bag and R1 confirmed they have not had any issues with staff who provide colostomy care. R1's Physician's report confirms Colostomy care assistance is required. Medication Administration Records reviewed for eight residents, revealed that residents are receiving medications prescribed. Records indicate when resident medications were discontinued and if resident refused medications. Based on interviews conducted and records reviewed, this agency has investigated the complaint alleging Due to lack of staff, colostomy care was provided by unqualified staff and residents did not receive their medications on time. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/ or is without reasonable basis. An exit interview was conducted with facility representative and a copy of this report was reviewed and provided at the time of this visit.the state’s words, verbatim · CDSS document, Aug 23, 2024 · control 22-AS-20240813150102

Allegation investigated: Staff may be financially abusing residents Staff violated residents' personal rights

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Assisted Living Coordinator Nikka Solomon. During the course of the investigation LPA toured facility, reviewed records, conducted interviews, made visual observations and requested pertinent documentation such as Resident Roster’s, staff roster’s, Physician’s reports, employee handbook, resident care plans, food service invoices and Resident Council meeting notes. During investigation LPA reviewed facility records and records reviewed revealed that three residents (R1, R2 & R3) recently moved from facilities Assisted Living corridors to Memory Care Unit Grace Gardens. Reviewed Resident Physician’s reports and Care plans confirmed residents R1, R2, & R3 had a proper diagnoses for Memory care placement. CONTINUED ON 9099C Unfounded LPA conducted a record review on facility invoices for grocery and supplies. Records dated from July 5, 2024, to July 23, 2024 from four different vendors revealed that facility is receiving food supply on a weekly basis. Interviews conducted with staff reveal that twelve of twelve staff confirmed that facility has no issues with finances or utilities. Interviews with Residents confirmed that eight of eight residents have not experienced facility being in disrepair. Eight of eight residents confirmed that no staff have tried persuading residents to move over to Memory care unit Grace Gardens and residents claim no staff have financially abused them. Eight of eight residents and twelve of twelve staff all confirm that facility is providing residents with three meals daily, providing medications on daily schedule, as well as confirming facility has had no issues with electricity & water. Interviews with eight of eight residents confirms that residents feel respected, personal rights are being honored and residents appreciate level of care being provided by staff. Observations made revealed that facility is providing food & beverage, medications, activities, running water, and power. Observations made confirm facility is following infection control policies. Based on interviews conducted and records reviewed, this agency has investigated the complaint alleging Staff may be financially abusing residents and staff violated residents' personal rights . We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/ or is without reasonable basis. An exit interview was conducted with facility representative and a copy of this report was reviewed and provided at the time of this visit.the state’s words, verbatim · CDSS document, Aug 23, 2024 · control 22-AS-20240805144055

Allegation investigated: Staff handles resident in a rough manner.

On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Director of Residential Services Stephanie Jukic and explained the reason for the visit. The department received a complaint on 10/16/2023 and LPA Mendivil conducted an initial 10-day visit on 10/25/2023. During the course of the visit LPA interviewed staff and residents. LPA Mendivil obtained copies of pertinent documents such as physician reports and staff schedules. Regarding the allegation Staff handles resident in a rough manner, the investigation revealed the following: Based on interviews with 2 out of 2 staff all indicate they do not handle residents in a rough manner. Interviews with a witness report that they do not have concerns about staff being rough with residents. Unsubstantiated Interviews with 2 out of 4 residents indicate staff are not rough with them. The 2 other residents were not oriented to time and space and could not provide answer LPA Mendivil’s questions. Therefore, based on the preponderance of evidence through interviews and records reviewed the allegation that staff handles resident in a rough manner is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 21, 2023 · control 22-AS-20231016164232