Trevista Concord

Type of visit: Case Management - Incident

On 09/16/2026 at 1:30 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a case management visit to follow up on multiple incident reports and SOC341. LPA met with Joseph Dungo, Memory Care Manager, and explained the purpose of the visit. Executive Director, David Clawson, gave verbal authorization for Dungo to sign the report. LPA received incident report for R1 dated 08/24/2026 stating on 08/19/2026 the police department had called the facility to confirm of R1’s residency and R1 was dropped back off to the facility. A review of R1’s physician report dated 07/13/2026, R1 cannot leave the facility unsupervised. Interview with S1 stated that when R1 left the facility, police found R1 and returned R1 back to the facility. Per S1, R1 was moved to memory care unit for higher level of care after communicating with R1’s responsible party. LPA received a death report for R2 dated 08/25/2026 that R2 was sent to the hospital on 08/06/2026 due to change of condition. Per death report, R2 passed away on 08/19/2026. LPA will request for the facility to obtain a death certificate for R2 by 09/30/2026. LPA reviewed incident report for R3 dated 08/24/2026 that on 08/23/2026, S2 pushed the bed to get supplies and didn’t notice that R3 was on the bed. R3 fell and 911 was called to send R3 to the Emergency Room (ER). A review of the facility's internal incident report by S3 stated that S2 did not see R3 on the bed and R3 fell on the floor. It also indicated that R3's physician and responsible party was notified. A review of the after visit summary dated 08/23/2026 stated that R3 was seen for a fall and no injuries were noted. Continue to 809-C... Continued from LIC809... LPA reviewed incident report for R4 dated 08/24/2026 that on 08/23/2026, R4 had a fall in their room and 911 was called to send R4 out to the ER. Facility’s internal incident report dated 08/23/2026 by S4 stated that R4 had a fall and there was blood running down R4’s face. Per internal incident report dated 08/23/2026, R4 was sent to the hospital and R4’s physician and responsible party were notified. A review of the after visit summary dated 08/23/2026 stated that R4 was discharge with stitches and was able to take it off after couple days. LPA reviewed incident report for R5 and R6 dated 08/22/2026 stated that both residents had an altercation with each other in their rooms. Per incident report, it stated that the 911 was called immediately for police and medical assistance. R5 and R6's responsible party and physician was notified of the incident. Per S1, R5 and R6 were roommates during the altercation and R6 has now been placed to a different room. S1 stated that there has not been any altercation between R5 and R6 after the move. LPA reviewed a self-reported SOC341 from the facility dated 09/15/2026 that stated R7 and R8 had an altercation which each other where R7 had slapped R8. Staff intervened and separated both residents. Police department was notified along with both R7 and R8's responsible party and physician. Per S1, the staff had increased monitoring for R7 and R8 and had not observed any altercation after. LPA may return at a later time. THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT: On 08/19/2026, R1 left the facility unassisted and was returned by the police department. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 16, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 25, 2026

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when R1 AWOL'd from the facility and was found by the police which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: By POC date, staff agrees to send an in-service on elopement and send proof to CCLD.

Type of visit: Case Management - Deficiencies

On 07/20/2026 at 09:20 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with David Clawson, Administrator. While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20260713124530) on 07/20/2026, LPA observed Staff 2 (S2) lied to the LPA about using a residents photo recreationally in a group chat with others staff. S2 had stated that other staff were using a residents photo in a group chat but he stated he shut it down months ago. LPA showed a screen shot of the group text messages dating 07/01/26 at 1:45pm showing S2 sharing the photo in the group. This photo was described in the messages as "our most used meme" by S7 on the same date. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 20, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Jul 20, 2026

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility This requirement is not met as evidenced by; based on interviews staff 2 lied about using a photo of a resident in group messages as a "meme" This poses as a personal rights violation to resident in care.the state’s words, verbatim · CDSS document, Jul 20, 2026

Plan of correction: Administrator agrees to submit a letter to CCLD disscusing what training and counciling will be occuring with S2 as well as a self certified letter stating that the administrator has gone over the regulation. Proof of correction will be sent to CCLD by POC date

Type of visit: Case Management - Deficiencies

On 05/07/2026 at 1:00 PM, Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Administrator David Clawson. While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20260506091552) on 05/07/2026, LPA observed that resident 2 (R2) physicians report was found in R1 medical file. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, May 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: May 21, 2026

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Resident 2 (R2) physicians report was found in R1 medical file.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: The facility agrees to remove R2's physicians report from R1 file and check all other resident files. The administrator agrees to review Tilte 22 and send in a self certified letter about resident files. Proof of correction will be sent in to CCLD by POC date.

Type of visit: Case Management - Deficiencies

On 04/23/2026 at 09:15 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Nathaniel Tan, . While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20260414102602) on 04/23/2026, LPA observed the annual fee which was due on November 26, 2025 is not paid as of this date. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87156(a) · Plan of correction due date: May 7, 2026

An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. provides ....after initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. -This requirement is not met as evidenced by: -Based on review, the licensee did not comply with the section above in not paying the annual fee which was due on 11/26/25.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Board Director to pay the annual fee and submit proof by 5/15/26.

Type of visit: Case Management - Health Checks

On 04/1/2026 at 09:15 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced Health and Safety check due to the department receiving a priority 1 complaint. During the health and safety check, LPA observed a multiple staff members and residents throughout the facility. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 1, 2026

Type of visit: Case Management - Deficiencies

On 04/01/2026 at 09:15 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with David Clawson, Administrator. While LPA J. Clancy-Czuleger conducted a Pre-licensing visit for Todos Santos Assisted Living and Memory Care (079201580) on 03/25/2026, LPA was informing the administrator that there were corrections that needed to be done prior to the new license being granted, the administrator responded stating "but those are just physical plant thing, why would that prevent us from passing". This showed the administrators lack of knowledge of the rules and regulations that are applicable over the facility. While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20260327104856) on 04/01/2026, LPA was informed that the facility was aware that a resident had illegal substances on the property and did not report it to licensing. An immediate civil penalty of $250 is assessed for a repeat violation. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Apr 8, 2026

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)....(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: The administrator stating "but those are just physical plant thing, why would that prevent us from passing" when not being granted a new license and asked to make corrections.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: The administrator agrees to review Tilte 22 and send in a self certified letter about kadministrator qualifications. Proof of correction will be sent in to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Apr 15, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: The facility finding an Illegal substance in a residents room and not reporting it to licensing.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: The administrator agrees to review Tilte 22 and send in a self certified letter about reporting requirements. Proof of correction will be sent in to CCLD by POC date. This is a repeat violation and a civil penalty of $250 is assesed

Type of visit: Case Management - Deficiencies

While LPA J. Clancy-Czuleger conducted a pre-licensing visit on 03/25/2026, LPA observed that there was a broken screen, and a missing screen on windows in memory care. LPA also observed that the sink in the assisted living "cafe" is dirty and unkempt. These are repeat violation an immediate civil penalty of $500 is assessed. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. These are repeat violation an immediate civil penalty of $500 is assessed. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 25, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 8, 2026

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the 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: LPA observed the cabinet in the assisted living "Bistro" to be dirty.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: The facility agrees to clean the cabinets inside and out, assisted living Bistro. Proof of correction will be sent to CCLD by POC date. This is a repeat violation an immediate civil penalty of $250 is assessed

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(c) · Plan of correction due date: Apr 8, 2026

All window screens shall be clean and maintained in good repair. This requirement was not met as evidenced by: At least one windows in memory care was missing a screens and another was brokenthe state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: The facility agrees to replace the missing screens and replace or repair the broken screens. Proof of correction will be sent to CCLD by POC date. This is a repeat violation an immediate civil penalty of $250 is assessed

Allegation investigated: Staff did not respond to resident's call button Staff did not ensure resident received medical care as needed

On 03/11/2026 at 3:50 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit with Executie Director (ED), David Clawson, to deliver the findings of the above allegations. LPA explained the purpose of the visit with ED. During the investigation, the Department obtained and reviewed the following documents from the facility: Resident Roster (dated 11/19/2025); Staff Roster; Resident (R1)’s Preplacement Appraisal (not signed); R1’s Resident Service Agreement with Appendix A-B (dated 09/10/2022); R1’s Physician’s Report (dated 08/18/2023); R1’s ECP Assess Needs (dated 10/09/2023, 04/27/2024, 10/29/2024, and 05/03/2025); R1’s invoices (dated 11/01/2025 and 12/01/2025); Resident Billing Information (initial); Accident/Incident Reports – Internal (dated 03/17/2025 and 07/10/2025); Staff Schedules (March 2025); R1’s Resident Information; Substantiated LIC9099- (Page ) On 11/19/2025, LPA interviewed Staff (S1), who stated that R1’s daughter submitted a 60-day written notice for R1 to vacate the apartment; however, according to S1, R1 did not fully vacate the building. S1 stated that the facility does not have possession of the security or pet deposits because those funds were managed by a former management group. LPA reviewed the Resident Service Agreement (Admission Agreement) signed and dated by R1 on 09/10/2022, which lists a move-in date of 09/11/2022. LPA reviewed R1’s Resident Billing Information, which listed a security deposit of $500.00 and a pet deposit of $500.00, totaling $1,000.00. LPA also reviewed the Community Fee provision, which states that the Community Fee is not a security deposit and may only be refundable under certain conditions. The agreement states that if a resident terminates the agreement during the third month of residency, the resident may be entitled to 40% of the balance after a $500 deduction. The agreement further states that after the third month of residency, no portion of the Community Fee is refundable. Documentation reviewed indicated that the Community Fee was waived at the time of admission. Staff (S1) further stated that, according to information provided by the previous management group, the $500 security deposit and $500 pet deposit are forfeited 90 days after the admission date. Based on record review, R1 moved over 90 days after the admission date. Therefore, pre-admission fees are forfeited. Based on the information obtained, there is insufficient evidence to support the allegation that staff did not provide a refund to the resident. Therefore, the allegation is Unfounded. LIC9099-C (Page 2) R1’s Observation Notes (dated 03/01/2025 through 11/19/2025); R1’s 60-Day Notice to Move-Out (dated 06/17/2025); email correspondence (dated 10/19/2025 through 10/20/2025); Resident Pendant Call Log (dated 03/17/2025); and R1’s pendant call activity (dated 07/10/2025 and 07/27/2025). Allegation: Staff did not respond to resident's call button Finding: Substantiated On 11/19/2025 LPA interviewed W1 that stated R1 fell in their room and was unable to get up. W1 stated that R1 activated the emergency pendant, but staff did not respond for approximately 30 minutes. W1 further stated that R1 contacted them by phone, which prompted W1 to come to the facility. W1 reported that upon arrival, R1’s bedroom door was locked, and facility staff did not have a key readily available to unlock the door. Once the door was opened, W1 stated that R1 was found wedged between the bed and the nightstand and unable to get up. LPA reviewed the facility call log, which indicates that on 03/17/2025 R1 activated the call pendant alert system two times. The first activation occurred at 3:14:48 PM with a response time of 26.87 minutes, which was answered by staff. The second activation occurred at 5:08:38 PM, documented as a non-emergency accidental press, and was answered within 0.47 minutes. On 03/07/2026 LPA interviewed, S2, S3, S4, S5 and S6 and all collaborated that residents may activate the call button for extended periods before staff are able to respond due to insufficient staffing and workload demands. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that staff did not respond to Resident (R1)’s call button is substantiated. LIC9099-C Continued... LIC9099-C (Page 3) Allegation: Staff did not ensure resident received medical care as needed Finding: Substantiated On 11/19/2025 LPA interviewed Witness (W1) stated that on 03/17/2025 Resident (R1) sustained a large open wound on their hand. W1 reported that facility staff did not ensure that R1 received necessary medical care. W1 stated that they personally administered first aid to R1 for the injury. W1 further stated that the incident was reported to Staff (S1) on the same day. W1 reported informing S1 that if R1 had hit their head during the fall, R1 may not admit it because it could require a hospital visit. According to W1, S1 advised that the facility’s new health nurse evaluate R1 and follow up regarding the injury. W1 reported that no follow-up evaluation or communication occurred after the report was made. On 11/19/2025 LPA interviewed S1 that stated that the former Director of Nursing left on 03/01/2025. On 03/07/2026 LPA interviewed S2, S3, S4, S5 and S6 all stated if any resident has sustained an injury such as a cut that a medication technician or nurse can administer first aid such a bandage. S2, S3, S4, S5 and S6 do not recall the incident occurring on 03/17/25 with R1. LPA reviewed Accident/Incident Report (dated 03/17/25) indicating that R1 sustained an injury with a cut on left arm and that an ointment was applied to arm. LPA reviewed “Observations for R1” (dated 03/01/25 – 11/19/25) that notes an observation by staff indicating R1 had an unwitnessed fall in their room. Cut was observed on left arm and that staff clean the cut an applied an antibiotic ointment. Based on interviews conducted, the preponderance of evidence standard has been met; therefore, the allegation that staff did not ensure Resident (R1) received medical care as needed is substantiated. LIC9099-C Continued...the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 15-AS-20251118152637

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 25, 2026

87468.2(a)(4) Additional Personal Rights Residents in all residential care facilities for the elderly shall have the following personal rights: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above in by to ensure that Resident (R1)’s request for assistance through the call pendant system was responded to promptly. This resulted in R1 remaining on the floor after a fall and unable to get up for approximately 26 minutes until staff responded. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Administrator agreed to conduct an In-Service training on answering the call light buttons with all staff, on all shifts in assisted living and memory care and will send sign-in sheet to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a) · Plan of correction due date: Mar 25, 2026

87465(a) Incidental Medical and Dental Care Services A plan for incidental medical and dental care shall be developed by each facility to ensure that residents receive necessary medical and dental services. This requirement is not met as evidenced by: Based on interviews, and record review the licensee did not comply with the section cited above in by to ensure that Resident (R1) received appropriate medical evaluation or follow-up after sustaining an open wound to their hand. This failure resulted in R1 not receiving timely medical assessment following an injury. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Administrator agreed to conduct an In-Service training on medical care for all residents with all staff, on all shifts in assisted living and memory care and will send sign-in sheet to CCLD by POC due date.

Type of visit: Case Management - Other

On 03/11/2026 at 5:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, David Clawson, and explained the purpose of the visit. While conducting complaint investigation 15-AS-20251118152637 on 03/11/2026, LPA conducted record review and interviews. Based on record review, interviews, and documents obtained during the investigation, LPA determined the following: 1. Resident (R1)’s financial records for 2022 were not maintained at the facility. On 03/04/2026, Staff (S1) stated, “Our business took over operations on March 1, 2025. We do not have financial records for the information you requested back on 9/1/22.” 2. Community Care Licensing Division (CCLD) was not notified of fall incidents involving R1. Facility records indicate R1 sustained a fall on 03/17/2025, and four (4) additional falls on 07/10/2025 at approximately 3:15 AM, 4:30 AM, 4:45 AM, and 5:15 AM. Records further indicate that on 04/06/2025 a call pendant alert was activated with a documented response time of 161.9 minutes, after which R1 was sent out for medical attention. On 03/05/2026, Staff (S2) stated via email, “Unfortunately, we wouldn’t do a LIC 624 when a resident is not sent out. But we created an incident report documenting the incident and the resident refusing to be sent out.” LIC809-C Continued... LIC809-C (Page 2) 3. R1’s Appraisal Needs and Services Plan was not updated to address repeated fall incidents. 4. R1’s records were not provided following a written request from the resident/resident’s representative. These deficiencies were observed and cited in accordance with the California Code of Regulations, Title 22 (see LIC 809D). Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 11, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d) · Plan of correction due date: Mar 25, 2026

87506(d) Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not ensuring that complete and former resident records were maintained and available for review as required. Specifically, the financial records for R1 from the year 2022 were not available during the visit on 11/19/25 and 03/11/26. In which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: The licensee shall ensure that R1’s records including but not limited to financial, billing statements from admission in 2022 are retrieved and maintained in the facility files. The Executive Director shall submit proof of record retrieval (copies or verification of access) to the Department by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Mar 25, 2026

87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not reporting the fall incident with R1 to Licensing which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Administrator agreed to conduct In-Service training will a staff, on all shifts in assisted living and memeory care and will send sign in sheet to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(b) · Plan of correction due date: Mar 25, 2026

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition…(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not updating reappraisals for R1 with the frequent falls which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Administrator agreed to conduct In-Service training with all 3 clinical leaders and including Administrator. Administrator will send sign-in sheet to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.2(a)(19)(2) · Plan of correction due date: Mar 25, 2026

87468.2 (a)(19) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not giving R1 and/or R1's representative copies of R1's records as requested which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Administrator agreed to obtain records and send to R1. Administrator will advise CCLD via email when records have been submitted to resident.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Mar 25, 2026

87465(g) Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not activating 9-1-1 if an injury or other circumstance which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Administrator will conduct In-Service training with all staff on all shifts in assisted living and memory care and will send a copy of sign in sheet to CCLD by POC due date.

Type of visit: Case Management - Deficiencies

On 03/05/2026 at 12:50 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with David Clawson, Administrator. While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20260227093249) on 03/05/2026, LPA observed in Resident 1's(R1) Medication Administration Record (MAR) that for the medication Ginko Bilboba it would switch between Resident Refused Medication and Medication unavailable. S2 could not confirm if R1 was out of the medication or was refusing it during that time period. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d) · Plan of correction due date: Mar 19, 2026

(d)If the resident is unable to determine...all of the following requirements are met: This requirement is not met as evidence by: Based on observation and record review the facility did not comply with the section above by having an inaccurate MAR which poses a potential health and safety violation for residents in care.the state’s words, verbatim · CDSS document, Mar 5, 2026

Plan of correction: By POC Facility agrees to update and maintain the MAR as well as provide additional training to staff and notify CCLD.

Allegation investigated: Staff overcharged a resident

On 2/26/2026 at 1:00PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with PA met with Joseph Dungo, Community Relations Director. Administrator David Clawson was informed of the visit. On the allegation: Staff overcharged a resident Based on records review and interviews R1 was originally assesed at level 3 of care, but R1's POA had a disscution with the previous mangment to move R1 down to level 2. This was not properly documented and R1 was continuing to be charged at the higer rate. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited. Exit interview conducted. A copy appeal rights, and this report provided. Substantiatedthe state’s words, verbatim · CDSS document, Feb 26, 2026 · control 15-AS-20250829120512

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 26, 2026

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on interviews and record reviews the Licensee did not comply with the section cited above in charging R1 for a higher level of services than they were in.the state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: The administrator corrected R1's billing and documentation to show that R1 was level 2 instead of level three and retroactivly paid back the over charged amount to R1. POC is cleared

Type of visit: Case Management - Deficiencies

On 2/26/2026 at 1:00PM, Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Joseph Dungo, Community Relations Director. Administrator David Clawson was informed of the visit. While LPA J. Clancy-Czuleger conducted a complaint investigation 15-AS-20250829120512 on 2/26/2026, LPA observed in the resident record that resident’s admissions agreement do not state if residents are agreeing to shared or private rooms. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a)(1)(B) · Plan of correction due date: Mar 12, 2026

(a)(1) (B) The text of the admission agreement,... shall be: Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled. This requirement was not met as evidenced by: Based on interviews and record reviews the Licensee did not comply with the section cited above by the facility not having in their admissions agreement if residents are agreeing to pay for a shared or single room.the state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: The facility agrees to add an addendum to all admissions agreements of shared occupancy rooms stating that they agree to the shared room and the associated rate. The facility also agrees to add an addendum to all admissions agreements of single occupancy rooms stating that they agree to the single... room and the associated rate. Proof of correction will be sent to CCLD by POC date.

Allegation investigated: Uncleared staff are providing care and supervision to residents in care Staff are not ensuring that residents' hygiene needs are being met while in care Staff are not ensuring that residents are administered their medications as necessary.

On 01/05/2026, Licensing Program Analysts (LPA), J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPA met with David Clawson, Administrator and explained the reason for the visit.During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. On the allegation: facility Uncleared staff are providing care and supervision to residents in care. Based on record review and interviews, on 08/28/2025 the facility had four staff (S4, S5, S6, and S7) scheduled to work on the staff schedule that were not associated to the facility. On 01/05/2026 S5 and S6 ares still not associated and S4 is not fingerprint cleared or background checked. S7 was associated the the facility on 10/02/2025. Continued on LIC 9099C... Substantiated On the allegation facility Licensee is not ensuring that staff follow proper infection control practices Based on record review and interviews the facility had been submitting incident reports for facility residents who were testing positive with Covid. S1 stated that they had staff who were out sick who either did not test positive that were out for other illnesses or had not tested for covid. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. On the allegation: facility Staff are not ensuring that residents' hygiene needs are being met while in care. Based on record review and interviews, the facility did not have enough staff at that time, staff interviewed stated that they felt like they could not keep up with resident ADL's with the number of staff that they had. S3 stated that they would be barely enough staff scheduled to work and then people would call off and there was no one to cover for them. On the allegation facility staff are not ensuring that residents are administered their medications as necessary. Based on record review and interviews when residents were moving into the facility they were not coming in with a full/mostly full prescription of medications. S2 stated that residents/residents responsible parties were informed that they should be moving in with full/mostly full prescriptions so the facility would have time to get their prescriptions transfers and any authorizations approved before a resident would run out of medication. Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 5, 2026 · control 15-AS-20250822084705

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jan 7, 2026

Criminal Record Clearance. All individuals subject to a criminal record review... Obtain a California clearance...as required by the Department... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having one staff fingerprint cleared which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: Facility has agreed to obtain fingerprint clearance S4. House manager will submit a plan to obtain fingerprint clearance for S4 by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jan 12, 2026

Criminal Record Clearance. All individuals subject to a criminal record review...Request a transfer of a criminal record clearance... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having two staff associated to the facility which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: S7 has been associated to the facility. The facility has agreed to associate S5 and S6 to the facility and submit proof of association by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jan 7, 2026

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... by compliance with the following:(2)The licensee shall provide assistance in meeting necessary medical and dental needs... This requirement is not met as evidenced by: The facility staff did not call for refill in timely manner which resulted in residents missing medication dosages. This poses an immediate health risk to resident in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: Licensee to review facility's procedure in ordering medication refill. Proof to be submitted by 01/07/2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 6, 2026

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement is not met as evidenced by: The facility not having enough staff at that time to preform all resident ADL'sthe state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: The facility has sence hired addtional staff in all departments.

Allegation investigated: Staff did not follow residents care plan resulting in severe malnurishment and dehydration. Staff do not ensure facility is free of mal odors. Staff do not ensure facility is kept in good repair.

On 12/19/2025 at 10:15 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to deliver findings on the allegations above. The LPA informed Memory Care Manager Joseph Dungo of the reason for the visit. The Department's investigation included, but was not limited to, interviews with staff and a review of the records pertaining to Resident R1, which included facility records and medical records. The Department also inspected the facility, interviewed staff, and reviewed facility maintenance records. The complaint alleges that staff did not follow resident’s care plan resulting in severe malnourishment and dehydration. According to a review of Resident R1’s medical records, there was no indication that R1 suffered from dehydration or malnourishment while a resident at the facility. The medical records do not support the allegation. Continued on LIC 9099 . . . Unsubstantiated . . . Continued from LIC 9099 The complaint alleges that staff do not ensure facility is free of mal odors. The LPA visited the facility and directly observed Room 104, where R1 lived while at the facility. The LPA also inspected the patio drain just outside of Room 104, where the malicious odors were alleged to have originated. The LPA did not smell any malicious odors, and the facility records showed no previous complaints of odors. The review of the records and direct observations by the LPA do not support the allegation. The complaint alleges that staff do not ensure facility is kept in good repair. The LPA visited the facility and reviewed maintenance records. The LPA observed the facility being in full working order. The LPA’s record review showed that regular maintenance is being conducted at the facility. The LPA’s observations and review of the records do not support the allegation. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 15-AS-20251020102235

Type of visit: Case Management - Incident

On 12/1/2025 at 11:00 AM Licensing Program Analysts (LPA) A Gomez arrived unannounced to conduct a Case Management. LPA met with Executive Director, David Clawson and explained the purpose of the visit. LPA received an incident report on 11/19/2025 stating that a resident was found after an un-witnessed fall. On 12/1/2025 LPA spoke Memory Care (MCM)Joseph Dungo who states that R1 had a fall and was sent out to the hospital. R1 is currently at a skilled nursing facility recovering (SNF). R1 is expected to return in a few weeks. MCM states that R1 did not sustain any injuries and is at a SNF as a precaution. MCM states that R1 will be re-assessed before their return by the facility nurse. No deficiencies Cited. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Dec 1, 2025

Type of visit: Required - 1 Year

On 11/20/2025 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Executive Director, David Clawson and explained the reason for the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication carts. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 2/4/2025. There were evacuation chairs in each stairwells. One week of nonperishable and 2-day of perishable food supplies were available. Facility orders food twice a week. Refrigerator’s temperature was recorded at 34 degrees F. Hot water temperature was measured at 115.9 degrees F in a resident's bathroom. Grab bars for each toilet and shower were installed. Non-skid mats were observed in showers. There were adequate lights in each room. Indoor and outdoor passageways were free of obstruction. LPA reviewed 8 residents and 6 staff records starting at 11:45AM. All staff are fingerprint cleared and associated to the facility. LPA reviewed a sample of resident's medication and medication administration records. (Continue on LIC809C...) At 10:15AM, LPA observed freezer temperature was at 16 degrees F due to freezer door not able to close. At 10:30AM, LPA observed unlocked paints and detergents in the upstairs laundry room. Staff threw away and/or locked up the items during inspection. At 3:00PM, LPA was informed that facility have not been conducting disaster drills quarterly or every three months. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22 and Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with David Clawson. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 20, 2025

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff does not ensure window coverings are in good repair in residents room

On 10/21/2025, at 10:45 AM, Licensing Program Analyst (LPA), L. Alexander arrived unannounced conduct a 10-day initial complaint visit and deliver complaint findings for the allegation above. LPA met with David Clawson, Executive Director (ED), and explained the reason for the visit. During the investigation LPA obtained copy of staff roster and resident roster. LPA tour the facility with ED, including but not limited to residents' apartments. LIC9099-C Continued Unsubstantiated LIC9099-C (Page 2) Allegation: Staff does not ensure window coverings are in good repair in residents room Finding: Unsubstantiated On 10/21/2025 LPA L. Alexander interviewed Staff (S) and Resident (R). S1 stated that a few weeks ago R1 pulled the window blinds down and expressed that they didn't like the blinds which were hanging in their room. S1 stated that they decided to order curtains instead for R1's room and since then there hasn't been any issues. LPA observed that the window coverings including the curtain bracket that holds the curtain rod was secured and fasten. R2 was in the room and stated that the window coverings were replaced. R1 was not available during the visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 15-AS-20251013135245

Allegation investigated: Staff are not treating resident with dignity and respect Staff are not providing adequate food service to resident

On 10/10/2025, at 10:40am, Licensing Program Analyst (LPA), L. Hall arrived unannounced conduct a 10-day initial complaint visit and deliver complaint findings for the allegations above. LPA met with David Clawson, Executive Director, and explained the reason for the visit. During the investigation LPA interviewed four (4) staff, seven (7) residents, obtained staff roster, resident roster, and a copy of the menu for the week. Allegation: Staff are not treating resident with dignity and respect During the investigation W1 stated at initial interview kitchen staff Continued on LIC9099C. Unsubstantiated Continued from LIC9099. discriminates against and is targeting her because she is not allowed to go to the kitchen. W1 stated there is a new rule that no one is allowed in the kitchen doorway or in hallway near the kitchen, but W1 has observed another residents there. S1 stated during interview that there has been a conversation about disrespect. S1 stated that kitchen staff was not being disrespectful but had to set a boundary regarding coming to the kitchen. S2, S3, and S4 stated during interview there are slips for residents to fill out if they do not want what is being served. The kitchen request the slip are put in approximately 1-hour before mealtime in order to accommodate. S2 stated when the staff is preparing for meals there isn't time to stop and accommodate one or two residents at that exact time. Six (6) of the residents stated the staff treats them well and with respect. Allegation: Staff are not providing adequate food service to resident During initial interview W1 stated staff is not heating up residents' food that is bought by them personally. LPA observed a food delivery during the visit. LPA also reviewed the facility menu for the week of October 5, 2025 to October 11, 2025. During visit LPA observed kitchen staff cooking and serving what was on the menu along with other items. S2 stated there is a main menu and an alternate menu for residents. S2 also stated if a resident wants food heated it is not a problem just not when the kitchen is in full working mode. S2 request residents to ask before the kitchen is preparing meals or after the residents are served. Six (6) of the seven (7) residents interviewed stated if they do not want what is being the served the kitchen does their best to accommodate them. Based upon the information obtained during investigation and the interviews conducted. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 10, 2025 · control 15-AS-20251007121849

Type of visit: Case Management - Deficiencies

While at the facility conducting investigation of a complaint (Control # 15-AS-20250914203842) and upon review of residents' (R1 and R2) files and interview, Licensing Program Analyst (LPA) Delmundo learned that resident (R1) was not given 1 of the prescribed medications from 9/01/25 to 9/08/25 and 1 other medications from 9/01/25 to 9/18/25 due to medications not available. The staff stated that the medications were not refilled. The staff also stated that the other resident (R2) should not be given 1 of the medications per Pain Management Clinic when this resident is administered pain medication; however, there's no order on R2's file indicating such. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. A $250.00 civil penalty is assessed for repeat violation within 12 month period of section 87465(a)(4). Failure to submit proof of corrections by plan of correction due date may result in additional civil penalty. Deficiency, plan and proof of correction and civil penalty were discussed with David Clawson, administrator. Exit interview conducted. Appeal Rights, LIC421FC Civil penalty assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 19, 2025

87565 Incidental Medical and Dental Care. (a) A plan for incidental medical shall be developed by each facility...... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: -Based on review of records and interview, the licensee did not comply with the section above by not obtaining medication refills in a timely manner for R1 and order for one of R2's medications which pose an immediate health and personal rights risks the persons in care. This is a repeat violation.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: Administrator to do the following and submit proof by 9/19/25: 1. Have the order for R2's medication obtained. 2. Ensure residents' medications are refilled timely and self-certify. A $250.00 civil penalty is assessed.

Allegation investigated: Staff does not clean resident's bathroom properly Staff are using other residents dirty washcloths to clean another resident

On 09/16/2025 at 1:30PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Administrator David Clawson. During the initial 10-day complaint visit, LPA interviewed staff and residents. On the allegation of: Staff does not clean resident's bathroom properly. R1 stated that they didnt want male staff cleaning their bathroom. Both R1 and S1 stated that the facility is able to accomidate this request and is now having a female staff do the cleaning. On the allegation of: Staff are using other residents dirty washcloths to clean another resident. R1 had noticed that their grey washclothes had been moved/used in the bathroom. R1 was concerned that Continued on 9099C... Unsubstantiated ... Continued from 9099 others were using them. S1 addresses this concern and informed all staff of the proper towels that facility staff should be using when working with residents. S2 stated that it was entered into R1's care notes and will be closely monitored moving forward. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 15-AS-20250910111702

Allegation investigated: Staff did not prevent resident's room from being unsanitary Staff did not keep facility free of vermin Improper eviction

On 09/04/2025 at 11:20 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Facility Nurse, Maria Collado. Executive Director David Clawson was not available, but was informed of the visit. During the initial 10-day complaint visit, LPA interviewed staff and residents, collected the following documents: Resident roster, Staff Roster, and Facility floor plan, R1's admissions agreement, R1's physicians reports dated 8/28/23, 11/12/18, 7/22/22, 3/2/22, R1's fact sheet. On the allegation: Staff did not prevent resident's room from being unsanitary While touring resident room124 LPA's observed dropings of a rodent on the residents dresser, floor, and bed.S3 stated that both residents in room 124 denied cleaning but, S4 stated that it was just R3 who denied cleaning. Continued on 9099C... Substantiated ...Continued from 9099 On the allegation: Staff did not keep facility free of vermin. It was reported that R2 eloped from the facility because some pest/vermin was running over them while they slept. While touring resident room 124 LPA's observed droppings of a rodent on the residents dresser, floor, and bed. S5 stated that the facility is aware of the droppings and is working on cleaning the room and contacted Eco-Lab a pest control company last week and texted a technician on 9/3/25 to follow up. On the allegation: Improper eviction R1 and R2 eloped from the facility on 8/25/25. R2 returned to the facility later that week while R1 was admitted to a hospital for additional evaluation. Based on interview with witness (W1) the facility staff stated that R1 did not want to come back so they would not take R1 back after their eloping. S5 confirmed that they said to hospital staff that R1 didn't want to come back so they would not take R1 back. R1's 602 from 2018 and 2022 state that R1 has dementia and is unable to leave the facility unattended. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited. Exit interview conducted. A copy appeal rights, and this report provided.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 15-AS-20250828235510

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 18, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the 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: The facility not clean a residents room after rodent droppings were found.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: The facility agrees to clean R2/R3's room and sanitize the room. The facility also agrees to read the regulation and submitted a letter of self certification to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Sep 18, 2025

The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by: The facility refusing to take a resident back after they eloped and addmitted to a hsopital.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Executive Director (ED) will review "Eviction Procedures" regulation and submitted email notice to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 11, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the 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: The facility has a rodent in room 124 and dropings to prove it.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Licensee to within 7 days have a pest control specialist conduct an inspection of the premises and take appropriate measures, and submit proof to LPA by POC date.

Type of visit: POC

On 9/04/2025 at 11:20am, Licensing Program Analyst (LPA) J. Clancy-Czuleger and A. Christy arrived unannounced to conduct proof of correction (POC) visit. LPAs met with Facility Nurse, Maria Collado. Executive Director David Clawson was not available, but was informed of the visit. On 08/15/2025 LPA J. Clancy-Czuleger conducted a complaint visit citing the facility on 4 deficiencies and listing the POC due dates as 08/26/2025 and 08/29/2025. The following deficiency were not cleared by visit: 87470(a)(2)(A)- Surfaces such as floors,... shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary 87303(a)- The facility shall be clean, safe, sanitary and in good repair at all times 87303(c)- All window screens shall be clean and maintained in good repair 87219(h)(2)- Outdoor activity areas that are easily accessible to residents Civil penalty of $2800.00 is assessed for the period of 08/26/2025 to 09/04/2025 for failure to correct deficiency. Facility is subject to ongoing daily civil penalties until deficiencies are corrected. Exit interview conducted. A copy of this report, LIC 421FC and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 4, 2025

Type of visit: Case Management - Incident

On 08/28/2025 at 12:25 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Maria Collado, LVN. LPA received an incident report on 8/20/2025 stating that a resident was given the wrong medication. Facility staff confirmed that R1 was given the wrong medication. On 8/25/2025 LPA received a phone call from facility staff Maria Collado that two residents who live in the facilities memory care unit eloped sometime Sunday night/Monday morning. Residents were located and one was returned to the facility and the other is in the hospital, no injury occurred but is being kept for additional observation. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Civil penalties were assessed totaling $500 due to repeat violations. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 11, 2025

(a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ... This requirement was not met as evidence by: Based on interviews the facility did not meet the requirement above by not having enough staff which lead to two residents in memory care eloping from the facility which posed an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: By POC date, Licensee will hire an additional staff member for the memory care unit. Proof of correction will be sent to CCLD by POC date. A civil penalty of $250 has been assesed on this day for a repeat violation

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Sep 11, 2025

Incidental Medical and Dental Care. A plan for incidental medical...shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: Based on records review and interviews, licensee did not comply with the section cited above by given a resident the incorrect medication.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: By POC date, Licensee will hire an additional Med Tech. Proof of correction will be sent to CCLD by POC date. A civil penalty of $250 has been assesed on this day for a repeat violation

Allegation investigated: Staff mishandled a resident's medication Staff did not ensure a resident consumed an appropriate amount of liquid Staff did not timely address a resident's change in medical condition

On 08/15/2025 at 11:10AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Administrator David Clawson. During the initial 10-day complaint visit, LPA interviewed staff, collected the following documents: R1's Care notes, R1's Phisicains report, R1's admissions agreement, R1's MAR's, and R1's incident reports. On the allegation: Staff mishandled a resident's medication. On 7/14/2025 the facility followed discharge order for R1 to stop buprenorphine-naloxone 8-2 mg Subl (SUBOXONE) along with four other medications. On the allegation: Staff did not ensure a resident consumed an appropriate amount of liquid. The memory care staff remind all residents in care to drink water and other liquids throught the day. R1 did not have discharge instructions for additional liquids or monitoring of liquids. Continued on LIC 9099C... Unsubstantiated ... Continued from LIC 9099 On the allegation: Staff did not timely address a resident's change in medical condition. On 8/9/2025 when facility staff observed that R1 was confused and Lethargic they notified R1's family and PCP. R1 was taken to the hospital and evaluated where it was found that R1 had a UTI. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 15-AS-20250813123748

Allegation investigated: Staff did not prevent facility from being unkempt. Staff did not place a screen on resident's window. Staff did not sanitize after body fluids was found in common area Facility is locking memory care outdoor space

On 08/15/2025 at 11:10AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator David Clawson. On the allegation: Staff did not prevent the facility from being unkempt. Based on observations and interviews. S1 stated that until this week they did not have housekeeping staff designated to the memory care. When asked how the memory care was being cleaned before this week S1 said that the on-shift staff would rotate throughout the facility, and if memory care needed them, they would radio. On the allegation: Staff did not place a screen on residents’ windows. Based on observations, LPA observed that there were at least 4 windows in the memory care courtyard without screens. Continued on LIC 9099C... Substantiated ...Continued from LIC 9099 When asked, S1 said that they were unaware that there were any missing screens. LPA also observed that some of the screens that were there, had holes and were in disrepair. On the allegation: Staff did not sanitize after body fluids was found in common areas. Based on observations and interviews on 7/7/2025 staff were informed that the courtyard smelled of urine. On 7/18/2025 staff were informed that feces was found in the courtyard, on 7/19/2025 the feces was still in the courtyard accessible to residents. On the allegation: Facility is locking memory care outdoor space. Based on observations and interviews, the memory care door is locked from the inside at all times. The memory care courtyard is accessible from the resident rooms that are along the perimeter of the courtyard, and through a door in the memory care hallway. The hallway door is able to open from the outside to enter into the hall but is locked for those attempting to go out into the courtyard. LPA observed a stick being placed on the ground in the doorway to keep the door open. Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 15-AS-20250801142840

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(a)(2)(A) · Plan of correction due date: Aug 26, 2025

Surfaces such as floors,... shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement was not met as evidenced by: The facility being informed on 7/7/25 that urine was found in the courtyard and not cleaning/sanitizing it until after 7/19/25.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: The facility agrees to clean and sanitized the memory care outdoor space. Proof of correction will be sent to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 29, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the 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: LPA observed dirty dishes in the cabinet in the memory care rec room, as well as dirt on the walls and cabinets.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: The facility agrees to clean the cabinets inside and out, in the memory care rec room. Proof of correction will be sent to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(c) · Plan of correction due date: Aug 29, 2025

All window screens shall be clean and maintained in good repair.This requirement was not met as evidenced by: four windows in memory care were missing screens and at least two more had rips in their screens.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: The facility agrees to replace the missing screens and replace or repair the broken screens. Proof of correction will be sent to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(h)(2) · Plan of correction due date: Aug 29, 2025

The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. This requirement was not met as evidenced by: the memory care patio being locked from the inside not allowing access to residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: The facility agrees to unlock the patio door during daylight hours (weather permitted). Proof of correction will be sent to CCLD by POC date.

Type of visit: Case Management - Incident

On 8/15/25 at 11:10 AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted a case management visit as a result of an elopement that occurred on 6/25/2025. LPA met with Executive Director David Clawson and explained the purpose of the visit. While at the facility on an unrelated incident LPA was made aware that R1 had eloped from the facility on 6/04/2025, 6/15/2025, 6/21/2025 and that R2 had eloped from the facility on 8/09/2025. Both R1 and R2 are memory care residents. All egress doors were operational at the time of elopements. On 08/09/2025 at around 1:30 pm, R2 stepped out of community and fell while walking. Paramedics were called and brought resident to John Muir Hospital for evaluation. Resident Came back next day, Concord Police, and R2's family were notified. On 6/21/25 staff reported that R1 was out on the street and was Immediately assisted and redirected back to the community. On 6/15/25 at approx. 7:45pm R1 was observed wandering outside of the building. Resident aide assisted resident back inside the building. On 6/04/25 staff reported that the memory care door alarm was on and R1 was out in the parking lot and was redirected back to memory care. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Facility did not prevent R1 from eloping The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.the state’s words, verbatim · CDSS document, Aug 15, 2025

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

(a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ... This requirement was not met as evidence by: Based on interviews the facility did not meet the requirement above by not having enough staff which lead to multiple elopements by of residents in memory care which posed an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: By POC date, Licensee will submit to CCLD a detailed written plan on how they will address incidents of elopement and safety and also how they plan to mitigate this type of situation. Facility will send sign in sheet for elopement inservice. Proof of correction will be sent to CCLD by POC date.

Allegation investigated: Staff mishandled a resident's medication

On 08/06/2025 at 09:55 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator David Clawson. On the allegation:Staff mishandled a resident's medication;Based on records review of the the Centrally Stored Medication Destructions Records; Medication Administration Records and care notes, R1's medication refills were not ordered prior to R1 running out of medication. Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 15-AS-20250611163220

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

Incidental Medical and Dental Care. A plan for incidental medical...shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not obtaining medication refills in a timely manner which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Executive Director has agreed to create a new procedure for medication refills and conduct training for staff. ED will submit new procedure and staff sign in sheet to CCLD by POC date.

Allegation investigated: Staff do not maintain facility sanitary Staff do not serve residents food of good quality

On 06/6/2025 at 09:05AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator David Clawson. During the initial 10-day complaint visit. LPA interviewed staff, and residents. On the allegation: Staff do not serve residents food of good quality Based on record review and interviews, it was found that there has not changed chiefs or food vendors since the change of management. Both S1 and S2 stated that the facility has a weekly menu, but the kitchen staff has an always available menu if any resident does not like the main meal of the day. One situation occurred with food service involving a new staff member, who re-served a plate of food that was already served to and denied by a resident. Management was notified and the server was trained proper food service. Continued on LIC-9099C... Unsubstantiated ...Continued from LIC-9099 On the allegation: Staff do not maintain facility sanitary Based on observation and interviews the facility has 8 shower rooms on the first floor, and 12 rooms on the second floor with on suite showers. S1 stated that the shower rooms on the first floor get cleaned 3-4 times per week by the housekeeping staff. S4 stated that the resident rooms with showers get cleaned about three times per week but the residents are able to request additional cleaning as needed. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 15-AS-20250604113955

Allegation investigated: Staff not maintaining resident’s hygiene

On 06/6/2025 at 09:05AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator David Clawson. On the allegation: Staff not maintaining resident’s hygiene Based on observation and intoerviews, R1 was found to be covered in dried feces. S3 stated that they were shocked when it was pointed out and that they cleaned up R1 as soon as they knew. S3 said that they had newer staff at that time and they were still learing the care rutines. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited. Exit interview conducted. A copy appeal rights, and this report provided. Substantiated Continued from LIC 9099-A On the allegation: Staff are not properly trained to provide care for residents, based on record review and interviews, New staff receive on boarding training including but not limited to hydration, nutrition, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 15-AS-20250317123152

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 20, 2025

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on observation and interviews there was not adequate staffing to meet residents needs.the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: Executive Director has hired additional staff to meet care and hygiene needs of residents

Allegation investigated: facility is engaging in punitive acts towards residents in care

On 06/6/2025 at 09:05AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator David Clawson. On the allegation: facility is engaging in punitive acts towards residents in care Based on record review and interviews Staff 1 (S1) stated that under the new management they want to try and fill the facility to capacity which is 160 residents. S1 stated that 30 day written notices were sent out to all residents in memory care who did not currently have a roommate to inform them that the facility intended to fill the bed space, and they may receive a roommate in the future. Continued on 9099-C... Unsubstantiated ...Continued from LIC-9099 S1 stated that only two residents in assisted living received the notice, and those residents were in shared rooms and were not up to date on payments. S1 stated that both Resident 1s (R1) and Resident 2s (R2) admissions agreements did not specify that they were paying for single rooms, and the facility has the ability to fill vacant spaces. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 15-AS-20250408133937

Allegation investigated: Staff mistreated a resident while in care Staff mishandled a resident's medications while in care

On 06/6/2025 at 09:05AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator David Clawson. During the initial 10-day complaint visit. LPA interviewed staff, collected the following documents: R1’s Physicians report, R1’s SNF record, R1’s SNF order summary, Observation notes for R1, R1’s Self-Administration of Medication Assessment, Faxes from R1’s PCP, and medication logs for six residents. On the allegation: Staff mistreated a resident while in care Based on record review and interviews, R1 has a history of yelling and cursing at the staff members who were not handling their medications in the way they wanted. In R1’s observation notes indicate 10 different incidents that R1 was rude to or yelled at med tech staff between 5/6/25 and 6/3/25 when the resident un-enrolled from the facilities medication management program. Continued on LIC 9099-C... Unsubstantiated ... Continued from LIC-9099 On the allegation: Staff mishandled a resident's medications while in care Based on record review and interviews, the facility never lost any of R1’s medications and never missed a dose. R1 had medications that they were taking at the Skilled Nursing Facility that were discontinued prior to moving in. R1 had a procedure on 5/13/25 and was prescribed additional medications at this time. R1 started to sign up with Primer which is a subscription for medications which conflicted with R1’s insurance that caused a delay in getting the prescribed medication. R1 changed pharmacies on 5/20/25 and on 5/21/25 picked up the medication without informing the facility. On 6/2/25 R1 was un-enrolled in the facilities medication management program and is handling their medications on their own. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 15-AS-20250603101418

Type of visit: Office

On 04/23/2025 starting at 2:30 PM, an Informal Meeting was held via video conference with Executive Director, David Clawson. The purpose of this Informal Meeting was to discuss the Change of Ownership transition. The Informal Conference Process was explained to the Executive Director Attendees: Isaac Taggart - Regional Manager Harpreet Humpal - Licensing Program Manager Jill Clancy-Czuleger - Licensing Program Analyst David Clawson – Administrator Issues discussed during the meeting: Change of Ownership Current facility name Admissions Agreements Change of Program David said that he works for Todos Santos Assisted Living and Memory Care. He was informed that since there is no application or License at this time associated with that name, the facility is still operating under the Trevista Concord License. David was then informed that all documents and advertisement should be using the Trevista Concord name LIC809-C LIC809-C Continued.... Stated that to his understanding that company Kalesta who will be the new parent company is in the process of the Change of Ownership (CHOW). David said that they are working with Vanessa Contreras in the Centralized Applications Bureau (CAB). David said that when they do the full CHOW they will be doing a name change at that time. Mr. Clawson confirmed that they are not changing the admissions agreement for the current residents in care, and confirmed that any new admissions arrangements that they are having will still state Trevista Concord as the name of the facility. Mr. Clawson stated that moving forward they intend to operate at their full capacity of 160 residents. Mr. Clawson said that previously the facility has been having a total census around 110 residents between the memory care and assisted living side they intend to increase their census to their max capacity. Currently they have around 25 memory care residents but have the capacity of 42 memory care residents. He describes their plan for double the census of the venerable community including following the guidance of Joseph Dungo the memory care director and adding additional staffing. Exit interview conducted and a copy of this report provided to Licensee via Emailthe state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: Case Management - Other

On 04/09/2025 at 8:50 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with David Clawson, Administrator. On 1/23/25 LPA JCC received a call from Nelson Rodrigues, Executive Director that Trevista Concord was bought out and would be under new management and would be going through the change of ownership process in the future. While at the facility on 03/21/2025, to conducted a complaint investigation (15-AS-20250317123152) LPA was informed that Nelson Rodrigues was no longer the Executive Director and was replaced by David Clawson. David Clawson explained at this time that they would soon be known as Todos Santos Assisted Living and Memory Care. LPA confirmed that that they were in the process of a Change of Ownership (CHOW) and would be under the Trevista Concord License until the CHOW went through. On 04/09/2025 While at the facility to conducted a complaint investigation (15-AS-20250408133937) LPA was informed that they facility is using the Todos Santos facility name on documents provided to residents in care. LPA informed the ED that the facilities license is under the name Trevista Concord and should be operated under that name until the CHOW is completed and Todos Santos has a facility number. LPA requested a copy of David's Administrators Certificate, a copy of ID, the LIC 501 and a Letter from the Licensee stating David is the administrator. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 9, 2025

Type of visit: Case Management - Deficiencies

On 3/21/2025 at 9:15 AM, Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with David Clawson, Adminsitrator. While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20250317123152) on 3/21/2025, LPA observed that S4 was not associated to the facility. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.17 · Plan of correction due date: Mar 24, 2025

Fingerprints and criminal records of individuals in contact with clients...record exemption from the State Department of Social Services before his or her initial presence in a residential care facility for the elderly.the state’s words, verbatim · CDSS document, Mar 21, 2025

Plan of correction: Administrator will read the Regulation and send self certification of understanding to Community Care Licensing (CCL) by POC date. In addition, licensee will not allow any individual to work, reside, or volunteer prior to being finger print cleared and associated. Administrator will also forward a copy of S1 clearance and association to CCLD by POC date.

Type of visit: Required - 1 Year

On 11/20/24 at 9:15 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Executive Director Nelson Rodrigues and explained the purpose of the visit. LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living rooms, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 01/05/2024. Water temperature was measured at 110.3 degrees. At 10:38 am LPA reviewed 10 residents records. At 11:45 am, LPA reviewed 4 staff records and 4 of 4 were fingerprint cleared and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 20, 2024

Type of visit: Case Management - Other

On 6/14/2024 at 12:50 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Stephanie Perez, Wellness Coordinator. The regional office received a death report for R1 that did not have a cause of death listed. LPA spoke with S1 who stated that R1 had moved in that morning and passed at 10 pm that night. R1 had hypernatremia, acute kidney injury, and was being given palliative care. No additional follow up needed at this time. LPA was notified at this time that the ED no longer works at the facility and they are actively hiring for the position. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jun 14, 2024

Allegation investigated: Staff spoke to residents in an inappropriate manner.

On 5/14/2024 at 11:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Executive Director, Siobhan Lehman. On the allegation facility Staff spoke to residents in an inappropriate manner. Based on record review and interviews the facility staff was removed from cleaning R1’s room at R1’s request. After S3 was removed S3 confronted R1 about the situation. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited. Exit interview conducted. A copy appeal rights, and this report provided. Substantiated ...Continued from 9099A On the allegation facility Staff did not provide adequate food service to resident. Based on record review and interviews the facility serves meals at regular times each day in the dining room. Residents cans opt in to having there meals delivered to there rooms or if the facility is having a public health situation they will provide meal service to all residents. If the resident opts in the dining or care staff will be notified who needs delivery. if a resident is missed, one the staff are notified they will make a meal for the missed resident. On the allegation facility staff does not ensure facility is kept in good repair at all times. Based on record review and interviews the facility did have a plumbing problem with one of the hallway bathrooms. S1 has been working with the maintenance staff trying to fix this issue. S1 explained that the issue was much deeper in the plumbing and required city work to fix. The work was scheduled and completed. On the allegation facility staff did not provide adequate evacuation assistance for residents. Based on record review and interviews the facility does have an evacuation chair in the stairwell. The facility has regular fire drills that they record. On the allegation facility staff did not respond to resident requests for assistance in a timely manner. Based on record review and interviews the facility does have a call button system that records the calls from the residents, the system is not able to print the logs but LPA observed a low response time in the system. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 14, 2024 · control 15-AS-20240130115751

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 11, 2024

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. Based on LPAs interview licensee did not comply with the section above by the facility staff yelling atthe state’s words, verbatim · CDSS document, May 14, 2024

Plan of correction: The facility agrees to go over resident personal rights in the next staff meeting. A sign in sheet will be sent to CCLD by POC date

Allegation investigated: Staff do not ensure unsafe furniture is removed from the facility. Staff do not ensure the facility is kept in clean, safe, sanitary conditions at all times for residents in care. Staff do not ensure food is properly stored and prepared safely for residents. Staff do not ensure adequate food portions are provided to residents. Staff does not ensure facility is kept in good repair at all times.

On 5/14/2024 at 11:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Executive Director, Siobhan Lehman. On the allegation facility Staff do not ensure the facility is kept in clean, safe, sanitary conditions at all times for residents in care. Based on interviews and observation the facility does appear to be clean. The tables in the dining room are cleaned after each meal. On the allegation facility Staff do not ensure food is properly stored and prepared safely for residents. Based on observation and interviews the facility keep proper food portions for each meal for each resident. Continued on 9099C... Unsubstantiated ....Continued from 9099 On the allegation facility Staff do not ensure adequate food portions are provided to residents. Based on observation and interviews the facility prepares each meal in bulk and keeps it warm in the kitchen on warming trays. The food is then dished up based on the resident’s order. On the allegation facility Staff does not ensure facility is kept in good repair at all times. Based on record review and interviews the facility did have a plumbing problem with one of the hallway bathrooms. S1 has been working with the maintenance staff trying to fix this issue. S1 explained that the issue was much deeper in the plumbing and required city work to fix. The work was scheduled and completed. On the allegation facility Staff do not ensure unsafe furniture is removed from the facility. Based on observation and interviews the facility has a table in the dining room with a glass top where the glass top exceeds several inches past the table. The facility has since removed the glass top. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 14, 2024 · control 15-AS-20231128160340

Allegation investigated: Facility staff did not give a resident notice of change in level of care.

On 5/14/2024 at 11:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Executive Director, Siobhan Lehman. On the allegation facility staff did not give a resident notice of change in level of care. Based on record review and interviews the facility did notify all residents that they were changing the point scale relating to each resident’s care plans. On February 2, 2023, the facility sent out a notice to all residents stating, “Our level of care points and charges are driven by two things - the time needed to complete a care task along with the level of expertise (of the staff member) needed to perform that task.” This notice stated that the increase would be effective April 1, 2023. This point system broken down all the points into eight different levels of care. Continued on 9099C... Unsubstantiated ...Continued from 9099 On May 1, 2023, The facility sent out a second letter giving additional details to the point system and gave the residents an updated timeline of when the increase would be implemented as it was not ready at the previously stated April 1st date. This new notice provided the resident with a table of the point value of each service that is provided. The new notice stated that the changes would be effective July 1, 2023, but in interviews with S1 she explained that each resident would start on the new point system when they had their yearly evaluation, and anyone who had their evaluation prior to July 1, would not be on the new point system until next year. S1 stated that residents had expressed their concern with the new system and the number of levels, and the facility updated it once again on February 1, 2024 to reduce the number of levels from eight to four. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 14, 2024 · control 15-AS-20240124165423

Type of visit: Required - 1 Year

On 12/04/2023 at 09:20 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA met with Executive Director Siobhan Lehman and explained the purpose of the visit. The facility is licensed for 160 non ambulatory residents. The facility has a hospice waiver for Ten (10) residents. LPA inspected the facility inside out. The facility consists of 112 total bedrooms. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. A comfortable temperature is maintained at 74 Degrees Fahrenheit. LPA inspected the living room, theater room, café, dining area, kitchen, bedrooms, hallways, bathrooms, courtyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with walk-in refrigerator and freezer, industrial dishwasher, washers, and dryers. Medications were stored in the medication that was observed locked. Activity supplies were available along with an actives calendar. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 02/20/2023. At 10:25 am LPA reviewed 10 residents’ records. At 12:45 pm, LPA reviewed 5 staff records and 5 of 5 were fingerprint cleared and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 4, 2023