Vacaville Memory Care

Allegation investigated: Staff did not seek medical attention to resident. Staff do not ensure facility is safe, sanitary and in good repair. Staff does not ensure a safe environment for residents. Staff does not ensure resident's needs are being met. Staff are not following food service regulations. Staff are not following reporting requirements. Staff are not following infection control protocols.

At approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to continue a complaint Investigation and delivered the findings regarding the above allegation and met with Executive Director, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff did not seek medical attention to resident, Staff do not ensure facility is safe, sanitary and in good repair, Staff does not ensure a safe environment for residents, Staff does not ensure resident's needs are being met, Staff are not following food service regulations, Staff are not following reporting requirements, and Staff are not following infection control protocols.” The complainant was anonymous, and LPA was unable to obtain additional information regarding the reported concerns. LPA conducted unannounced complaint visits on 04/23/2026, 05/29/2026, and 06/30/2026. Continued on LIC9099-C page... Unsubstantiated Continued from LIC9099-A page... During the investigation, LPA reviewed facility records, including incident reports, medication records, and interviewed staff. The investigation revealed that the facility self-reported two medication errors. On 03/16/2026, the facility submitted an incident report documenting that a resident received the wrong medication. A second self-reported incident dated 05/22/2026 documented another medication administration error in which staff administered an incorrect medication during the medication pass. Based on the facility's self-reported incident reports, staff interviews, and records reviewed, LPA obtained sufficient evidence to support the allegation that staff mismanaged residents' medications. Therefore, this allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents. Continued from LIC9099 page... During the investigation, LPA interviewed staff, reviewed available records, and toured the facility, including resident rooms, common areas, bathrooms, laundry rooms, kitchens, and outdoor areas. LPA observed the facility to be clean, organized, and maintained at a comfortable temperature. The laundry rooms and bathrooms appeared clean and in good repair, and LPA did not observe conditions consistent with the allegations of unsanitary living conditions or infection control concerns. LPA reviewed the facility’s reporting practices related to resident incidents. Administrator stated that emergency medical services are contacted as needed based on the nature and severity of an incident. Regarding the reported resident incident, the facility determined that the event did not meet the criteria for an elopement, as the resident remained within the secured facility grounds and did not exit the facility. The facility documented the event through an internal note, and LPA did not find evidence that the incident resulted in a reportable injury or required additional medical intervention. LPA also reviewed the facility’s practices for meeting residents’ care needs. Staff reported that resident care checks are conducted at least every two hours and additionally as needed, including assistance with personal care and incontinence care. During facility tours, LPA observed residents to be appropriately cared for and did not observe residents who appeared neglected, soiled, or without necessary assistance. LPA did not observe unlabeled food, expired food, or food being improperly stored. Staff explained that all meals are prepared in the facility’s commercial kitchen, delivered to each house at mealtimes, and any leftovers are returned to the main kitchen after meals. Based on interviews, observations, and records reviewed, LPA did not obtain sufficient evidence to support the allegations that staff failed to seek medical attention for residents, maintain a safe and sanitary facility, provide adequate supervision and care, follow food service regulations, comply with reporting requirements, or follow infection control protocols. Therefore, these allegations are Unsubstantiated. A finding of Unsubstantiated means that although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 21-AS-20260417121342

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 17, 2026

87465 Incidental Medical and Dental Care: (a)A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on record reviews facility failed to administer correct medication during the medication pass. This poses immediate health and safety concerns for the residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Executive Director Agrees to conduct in-service training regarding medication pass and submit proof of self-certification to CCL by plan of correction days 07/17 2026.

Allegation investigated: Staff left residents unattended. Lack of staff supervision resulting in resident eloping from the facility.

At approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to continue a complaint Investigation and delivered the findings regarding the above allegations and met with Executive Director, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff left residents unattended and Lack of staff supervision resulting in resident eloping from the facility.” The complaint alleged that the facility left residents unattended and failed to provide adequate staff supervision, resulting in Resident 1 (R1) eloping from the facility during the night shift. LPA conducted an unannounced complaint investigation, interviewed the Executive Director and staff, reviewed facility records, including care notes and the incident report, and toured the facility. Continued on LIC9099-C page... Unsubstantiated Continued from LIC9099 page... Interviews revealed that while the designated caregiver was on a scheduled break, a Medication Technician remained in the facility to provide resident supervision. Staff reported that R1 was found outside Journey House but remained within the facility's secured grounds and did not exit the locked perimeter gate. The Executive Director stated that residents are permitted to access the secured courtyard during the night shift and confirmed that R1 did not have a physician's order requiring one-to-one supervision. LPA's review of records did not reveal any prior elopement by R1. Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegation that the facility left residents unattended or that inadequate staff supervision resulted in R1 eloping from the facility. Therefore, this allegation is Unsubstantiated. A finding of Unsubstantiated means that although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 21-AS-20260406103215

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

On 05/29/2026, Licensing Program Analyst (LPA) Deniz conducted an unannounced case management Legal/Non-Compliance inspection at the facility and was greeted by Executive Director, Camille Brown. LPA conducted the visit as a follow-up to the previous Non-Compliance Conference inspection conducted on 04/23/2025 to assess whether there are any ongoing concerns related to previously identified deficiencies. During today’s inspection, LPA conducted a walkthrough of the facility, reviewed facility operations, and discussed current practices with facility staff and the Administrator. The following areas were reviewed: • Resident supervision • Infection control practices • Incontinence care • Pressure injury prevention • Reporting requirements • Personal rights • Staffing levels • Fire safety and emergency exits LPA observed residents to appear appropriately supervised at the time of the visit. Facility staff were observed providing care and assistance to residents. LPA reviewed staffing schedules and discussed staffing coverage with the Administrator. The Administrator stated that staffing levels remain adequate to meet resident needs. LPA obtained staffing training records in resident rights and incontinence care. The facility has a new complaint allegation that has been still investigated about “Lack of staff supervision” (Complaint number is 21-AS-20260406103215) LPA conducted a walkthrough of the facility and observed that emergency exits were unobstructed at the time of the inspection. Infection control supplies were observed available throughout the facility. Continued on LIC809-C page... Continued from LIC809 page... LPA reviewed incident reporting practices and discussed reporting requirements with the Administrator. The facility continues to submit reports to Community Care Licensing as required. No immediate health and safety concerns were observed during today’s inspection. No citations were issued during today’s inspection. An exit interview was conducted with the Executive Director, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 29, 2026

Type of visit: Case Management - Other

On 04/09/2026, Licensing Program Analyst (LPA) Felias met with Executive Director, Camille Brown, for a Case Management visit to follow up on a substantiated complaint allegation; complaint number 21-AS-20240906144108. On January 3, 2025, the Department concluded an investigation which alleged that neglect resulted in pressure injuries. The licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident. A Non-Compliance Conference was conducted on April 23, 2025, and the licensee was advised an additional civil penalty was under review per Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Welfare and Institutions Code § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation." This is evidenced by the facility not providing care, supervision, and timely medical treatment that resulted in resident sustaining unstageable pressure wounds resulting in hospitalization and surgical debridement. Today, 04/09/2026, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000.00. Exit interview conducted. A copy of the report issued. Appeal rights provided. Executive Director's signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Apr 9, 2026

Allegation investigated: Staff physically abused resident.

At approximately 12:25 PM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Executive Director, Camille Brown. During the course of the investigation, the Department conducted interviews, reviewed documents, and made observations. The following allegation was investigated: “Staff physically abused resident.” The complaint alleged that on 01/27/2026, a staff member physically assaulted a resident by tackling R1 from behind and punching the resident after refused to follow a directive. On 01/28/2026, the facility self-reported the incident by submitting an SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) to Community Care Licensing (CCL). According to the report, staff member S1 and resident R1 were involved in a physical altercation. Another staff member attempted to de-escalate the situation. Continued on LIC9099-C page... Substantiated Continued from LIC9099 page... Management instructed S1 to leave the facility and contacted 911. S1 was terminated on the same day as the incident. Based on interviews conducted, records reviewed, and information obtained, it was determined that staff member S1 used physical force against resident R1, including tackling and striking the resident. Such actions constitute physical abuse. The facility failed to ensure that residents are free from physical abuse and failed to protect the resident from staff misconduct. Based on interviews conducted, records reviewed, and observations made, the facility failed to ensure compliance with Title 22 regulations regarding resident rights and protection from abuse; therefore, this allegation is Substantiated. A finding that the complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 21-AS-20260128150922

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 10, 2026

87468.1(a)(3) Personal Rights of Residents in All Facilities: (a)(3) To be free from punishment,humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’... This requirement was not met as evidenced by: Based on interviews conducted, records reviewed, and observations made, the facility failed to ensure resident’s rights and protection from abuse. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 30, 2026

Plan of correction: Executive Director agrees to provide all staff training regarding abuse, de-escalation and crisis training. ED will submit proof of correction by Plan of Correction (POC )due date 04/10/2026.

Allegation investigated: Staff did not provide adequate supervision of a resident

At approximately 12:25 PM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Executive Director, Camille Brown. During the course of the investigation, the Department conducted interviews, reviewed documents, and made observations. The following allegation was investigated: “Staff did not provide adequate supervision of a resident.” The complaint alleged that staff failed to properly secure the facility’s exterior gate, which allowed a resident to elope from the premises unsupervised and remain missing for an extended period before being located. Per interview conducted with the Executive Director, two (2) separate incidents involving the resident’s exit-seeking behavior were confirmed. The facility submitted the first incident report on 07/15/2025, indicating that despite staff intervention efforts, the resident was able to open the exit door and leave the building. Continued on LIC9099-C page... Unsubstantiated Continued from LIC9099 page... During the incident, staff contacted 911 immediately, and three (3) caregivers followed the resident at a safe distance until emergency responders arrived. The second incident occurred on 11/24/2025. Documentation indicates that staff were closely monitoring the resident due to known exit-seeking behavior. Staff were unable to redirect the resident at the main gate and contacted paramedics for assistance. During both incidents, staff maintained visual contact with the resident and continued to follow at a safe distance. LPA conducted interviews with the Executive Director and the resident’s spouse; however, there was insufficient evidence to determine that the resident was left unsupervised for an extended period of time. Based on interviews conducted and records reviewed, the facility followed its established protocols and remained in compliance with Title 22 regulations; therefore, the allegation is Unsubstantiated. A finding that the complaint allegation is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 21-AS-20260203110945

Type of visit: Case Management - Other

On 03/19/2026 LPA Ali Deniz conducted case management visit at the facility regarding the additional policy information requested by Community Care Licensing (CCL) and met with administrator Camille Brown. LPA requested facility records and documentation, including policies related to staffing, supervision, documentation practices, reporting requirements, and emergency procedures. LPA also requested a facility layout/diagram. No citations were issued during today’s visit. Exit interview conducted with the Administrator, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 19, 2026

Allegation investigated: Staff do not ensure faucets used by residents for personal care deliver hot water Staff do not ensure resident’s care needs are met Staff do not dispense medications as prescribed Staff do not keep accurate resident records Staff do not safeguard resident's belongings Staff do not ensure facility is maintained clean Staff do not maintain facility free of odors Staff do not provide planned activities

At approximately 02:15 PM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Executive Director, Camille Brown. During the course of the investigation, the Department conducted interviews, reviewed documents, and made observations. The following allegations were investigated: “Staff do not ensure faucets used by residents for personal care deliver hot water, Staff do not ensure resident’s care needs are met, Staff do not dispense medications as prescribed, Staff do not keep accurate resident records, Staff do not safeguard resident's belongings, Staff do not ensure facility is maintained clean, Staff do not maintain facility free of odors, and Staff do not provide planned activities.” “Staff do not ensure faucets used by residents for personal care deliver hot water” – The complaint alleged that faucets in the resident’s room did not provide hot water for personal care, preventing the resident from bathing properly. Continued on LIC9099-C page... Unsubstantiated Continued from LIC9099 page... During the investigation, LPA reviewed facility records and documentation. On 11/06/2025, the facility notified Community Care Licensing that one of the five houses experienced a hot water system failure. The facility reported that residents’ hot water needs, including those in the kitchen, would be mitigated by implementing safety measures. An outside maintenance vendor was contacted immediately, and repairs were scheduled. LPA attempted to obtain additional information from the complainant but did not receive a response. No additional evidence or documentation was provided to support the allegation. Based on interviews conducted and documents reviewed, this allegation is Unsubstantiated. -------- “Staff do not ensure resident’s care needs are met” - The complaint alleged that staff do not assist the resident with showering, mobility using a walker, or other personal care needs. During the investigation, LPA conducted interviews with facility staff and reviewed resident records, including the resident’s care plan and service records. Staff reported that residents receive assistance with activities of daily living in accordance with their assessed needs and care plans. Documentation reviewed by LPA indicated that the resident receives assistance with personal care and mobility support as needed. LPA conducted observations of the facility during the visit. No concerns were observed regarding staff providing assistance to residents with mobility or personal care needs at the time of the visit. LPA attempted to obtain additional information from the complainant but did not receive a response. No additional documentation or evidence was provided to support the allegation. Based on interviews conducted, records reviewed, and observations made, this allegation is Unsubstantiated. ------- “Staff do not dispense medications as prescribed” - The complaint alleged that staff hand medications to the resident and leave without confirming ingestion; pills are sometimes found on the floor or in drawers. During the investigation, LPA interviewed facility staff responsible for medication administration and reviewed medication administration records (MARs). Staff reported that the resident sometimes refuses taking medications. Record reviews did not indicate irregularities related to medication administration for the resident. LPA attempted to obtain additional information from the complainant but did not receive a response. No additional information or evidence was obtained to corroborate the allegation. Based on interviews conducted and records reviewed, the allegation is Unsubstantiated. Continued on LIC9099-C page... Continued from LIC9099-C page... ------- “Staff do not keep accurate resident records” - The complaint alleged that medication refusals and administration were not properly recorded in facility logs. During the investigation, LPA reviewed facility records including medication administration records and resident documentation. Records reviewed by LPA appeared to be maintained and included documentation of medication administration. LPA attempted to obtain additional information from the complainant but did not receive a response. No additional evidence was provided to support the allegation. Based on records reviewed and information obtained during the investigation, this allegation is Unsubstantiated. ------- “Staff do not safeguard resident's belongings” - The complaint alleged that resident’s food and personal items have gone missing, including repeated loss of food provided by the reporting party. During the investigation, LPA interviewed staff regarding procedures for safeguarding resident belongings. Staff reported that residents maintain personal belongings in their rooms and that staff do not have information regarding missing items belonging to the resident. LPA attempted to obtain additional information from the complainant but did not receive a response. No supporting documentation or evidence was obtained. Based on interviews conducted and documentation reviewed, this allegation is Unsubstantiated. ------- “Staff do not ensure facility is maintained clean” - The complaint alleged that resident’s room and Memory Care unit are cleaned only once weekly, resulting in unsanitary conditions by the end of the week. During the investigation, LPA conducted observations of the facility, including common areas. At the time of the visit, the areas observed appeared to be maintained in a clean and sanitary condition. LPA interviewed staff regarding housekeeping schedules. Staff reported that housekeeping services are conducted once a week, with additional cleaning performed as needed. LPA attempted to obtain additional information from the complainant but did not receive a response. No additional evidence was obtained to support the allegation. Based on observations made and interviews conducted, this allegation is Unsubstantiated. --------- “Staff do not maintain facility free of odors” - The complaint alleged that unit smells of urine and feces, indicating poor odor control. Continued on LIC9099-C page Continued from LIC9099-C page... During the investigation, LPA conducted observations of the facility including the Memory Care unit and common areas. At the time of the visit, LPA did not observe strong or persistent odors indicating unsanitary conditions. Staff reported that routine housekeeping and resident care practices are conducted to maintain the facility in a sanitary condition. LPA attempted to obtain additional information from the complainant but did not receive a response. No additional evidence was obtained to corroborate the allegation. Based on observations made during the visit and information obtained, this allegation is Unsubstantiated. ----------- “Staff do not provide planned activities” - The complaint alleged that Residents do not participate in structured activities; only watch TV. During the facility visit on 12/12/2025, LPA observed residents participating in a Christmas decoration activity alongside care staff members. Staff were observed engaging with residents and providing support during the activity. Residents appeared involved and actively participating. LPA attempted to obtain additional information from the complainant but did not receive a response. No additional information or documentation was provided to support the allegation. Based on interviews conducted and observations made during the investigation, this allegation is Unsubstantiated. Based on interviews conducted, documents gathered these allegations are Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 21-AS-20251106091142

Allegation investigated: Residents/responsible parties were not provided notice of change of ownership

At approximately 11:45AM, Licensing Program Analysts (LPA) Deniz arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. Residents/responsible parties were not provided notice of change of ownership – Complaint alleges that the executive director told a family member that the facility was owned and operated by Heritage Resource Group LLC. During a non-compliance conference conducted April 23, 2025 with representatives of the facility and CCL, it was confirmed that the facility has been operating under the management group, Heritage Resource Group since October 2024. Facility representative was unable to provide proof that facility residents were notified of the change of management group. Continued on LIC9099-C page... Substantiated Continued from LIC9099 page... Based on interviews conducted and documentation provided, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents. Continued from LIC9099-A page... Therefore, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 21-AS-20250404122536

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Feb 20, 2026

Plan of Operation 87208(a) Licensee shall have and maintain a current, written definitive plan of operation for the facilit…Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met as evidenced by: Licensee failed to submit Admissions Agreement for review to ensure changes were not made that required approval by CCL. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Licensee to submit Admission Agreement currently being used by the facility for department review by POC Due Date of 02/20/2026.

Allegation investigated: Facility did not follow resident's special diet

At approximately 09:30 AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Executive Director, Camille Brown. During the course of the investigation, the Department conducted interviews, reviewed records, and made observations. The following allegation was investigated: “Facility did not follow resident’s special diet.” The complaint alleged that Resident 1 (R1) experienced an allergic reaction after consuming food at the facility. The Reporting Party (RP) stated that on 11/18/2025, the facility notified them that R1’s lips were swollen. The RP transported R1 to the hospital, where a doctor reportedly stated R1 had an allergic reaction to something ingested. The RP stated that a staff member mentioned apple pie was served and believed cinnamon may have caused the reaction, as R1 is allergic to cinnamon. Continued on LIC9099-C page... Unsubstantiated Continued from LIC9099-A page... LPA interviewed the RP, who reported a visible unknown black substance around the edges of a water bottle. LPA reviewed the evidence and confirmed the presence of the unknown substance. The RP stated that they were confident the bottle had not been properly sanitized by staff. Based on the evidence provided by the RP and interviews conducted, the preponderance of evidence supports that the facility failed to ensure that R1’s drinking container was clean and sanitary. Based on interviews and evidence reviewed, this allegation is Substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs). Failure to correct the cited deficiencies by the Plan of Correction (POC) due date may result in civil penalties. Exit interview conducted. A copy of the report, LIC 9099D (Deficiency Page), Plan of Correction, and Appeal Rights were discussed and provided to the Administrator. Signature on form confirms receipt of documents. Continued from LIC9099 page... LPA reviewed the facility menu for the date in question and found no food items listed that contained cinnamon. LPA also reviewed the facility’s diet and allergy boards, which documented R1’s allergy information. Interviews with facility staff did not confirm that cinnamon-containing foods were prepared or served to R1. During a follow-up interview, the RP stated they did not have evidence to support the allegation and acknowledged R1 was assuming. The RP further stated that R1 has dementia and may not recall events clearly. Based on interviews and record review, there was insufficient evidence to support that the facility failed to follow R1’s special diet. Therefore, this allegation is UNSUBSTANTIATED. An unsubstantiated finding means there is not enough evidence to prove or disprove the allegation. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 21-AS-20251203140207

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(29) · Plan of correction due date: Feb 10, 2026

87555(b)(29) - General Food Service Requirements, (b)The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement was not met as evidenced by: Based on interviews and LPA observation of records, it was determined that resident R1’s water bottle contained unknown black substance, that indicating it was not properly cleaned or sanitized. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: Administrator agrees to provide in-service training to all direct care staff on proper cleaning and sanitizing of resident drinking containers and implement a routine cleaning schedule to ensure all containers remain clean and sanitary. Administrator will submit proof of correction by Plan of Correction(POC )due date 02/10/2026.

Allegation investigated: Staff not following care plan when assisting resident with ADLs. Staff violated residents personal rights.

At approximately 09:35 AM, on 01/14/2026, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to continue a complaint investigation and deliver findings regarding the above allegations. LPA met with the facility Administrator, Camille Brown. During the course of the investigation, the Department conducted interviews, reviewed records, and made observations. The following allegations were investigated, "Staff did not follow care plan when assisting a resident with Activities of Daily Living (ADLs) and staff violated a resident’s personal rights." The complaint alleged that during the PM shift, a staff member attempted to transfer a resident using a Hoyer lift without the requuested two-person assist, resulting in a staff injury and raising concerns regarding the resident’s safety. LPA interviewed the Administrator and facility staff, who stated that no residents require the use of a Hoyer lift and that while some residents require a two-person assist, none require Hoyer lift transfers. Staff denied knowledge of any incident or staff injury involving a Hoyer lift. Contiued on LIC9099-C... Unfounded Continued from LIC9099... Facility representatives stated that no staff member by the name referenced in the complaint is employed at the facility and that the facility does not use three-digit room numbers; no resident was identified as occupying the room number referenced. LPA reviewed facility records, including resident care plans and incident reports. Record review did not identify any resident documented as requiring a Hoyer lift, nor did records reflect any reported incident or injury related to Hoyer lift usage on or around 01/05/2026. Based on record review, interviews conducted, and observations made, there was insufficient evidence to support the allegations that staff failed to follow a resident’s care plan when assisting with ADLs or that staff violated a resident’s personal rights. Therefore, the allegation is UNFOUNDED means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview was conducted and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 21-AS-20260107110256

Type of visit: Case Management - Incident

On 01/14/2026, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct an investigation and met with facility administrator, Camille Brown. Community Care Licensing (CCL) conducted an investigation regarding an allegation of sexual abuse. The facility reported that staff member S1 sexually abused a resident while providing incontinence care. The facility reported the allegation to local law enforcement, Community Care Licensing, and the Long-Term Care Ombudsman, as required of mandated reporters. Staff member S1 was arrested and later pled guilty to a misdemeanor charge of assault and battery. No deficiencies were cited as a result of this investigation.the state’s words, verbatim · CDSS document, Jan 14, 2026

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

On 01/14/2026, Licensing Program Analysts (LPA) Deniz conducted an unannounced case management Legal/Non-Compliance inspection at the facility and were greeted by Executive Director Camille Brown. LPA conducted the visit to follow up on items identified during the Non-Compliance Conference dated 04/23/2025. The following areas were reviewed during the inspection: • Neglect resulting in pressure injuries • Incontinence care • Staff not adequately supervising residents in care • Lack of supervision resulting in resident injuries • Infection control protocols • Personal rights • Reporting requirements • Changes to LLC/Management Company without notifying the Department • Fire clearance – blocked doors LPA requested and reviewed documentation regarding staffing ratios. Review of facility records indicated the facility has adequate staffing. One (1) out of the five (5) houses on the facility was closed due to low census. Staff members provide coverage across the remaining houses as needed. The Administrator stated that staffing levels are currently adequate. Facility in-service trainings have been completed in the following areas: observation of residents, pressure injuries, incontinence care, and personal rights. The following concerns—staff not adequately supervising residents in care, lack of supervision resulting in resident injuries, infection control protocols, and changes to LLC/Management Company without notifying the Department—are currently being addressed through Complaint Investigations 21-AS-20250501124124, 21-AS-20250516100242, 21-AS-20250520084631, 21-AS-20250701124101, and 21-AS-20250404122536. Citations were issued where applicable under the identified complaints. Plans of Correction have been completed. Continued on LIC809-C page... Continued from LIC809 page... Reporting Requirements: Review of incident reports indicated the facility has been submitting reports to Community Care Licensing in accordance with regulations. Fire Clearance: LPA conducted a walkthrough of the facility and observed that all emergency exits were unobstructed at the time of the inspection. No citations were issued during today’s inspection. An exit interview was conducted with the Administrator, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 14, 2026

Allegation investigated: Facility did not follow infection control plan

At approximately 01:15PM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to continue a complaint Investigation and delivered the findings regarding the above allegation and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Facility did not follow infection control plan”. The complaint alleged that the facility failed to follow its infection control plan by allowing residents with suspected scabies, COVID-19 exposure, or other contagious conditions to move freely throughout the facility without appropriate isolation or precautions. LPA conducted an unannounced visit, interviewed staff, reviewed resident records, and assessed the facility’s infection control practices. The Administrator reported that the facility had no confirmed scabies cases. Continued on LIC9099-C... Unsubstantiated Continued from LIC9099... One resident (R1) was discharged from the hospital on 09/03/2025 with documentation indicating only a possible exposure to scabies. No diagnosis was confirmed. The facility reported that upon the resident’s return from the emergency department, isolation precautions were initiated immediately, Personal Protective Equipment (PPE) was made available, and staff were notified of the precautionary measures. LPA observed that the facility maintained sufficient PPE supplies and that staff were aware of proper usage. During the facility tour, LPA did not observe any residents with visible rashes or symptoms consistent with scabies, nor did LPA observe lapses in infection control practices. No evidence was provided to indicate that symptomatic residents were permitted to wander throughout the facility without precautions. Staff interviews were consistent in reporting that no residents were diagnosed with or treated for scabies, and no active outbreak was present. Based on the interviews, observations, and documentation reviewed, there is insufficient evidence to support the allegation that the facility failed to follow its infection control plan. Therefore, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 21-AS-20250909141835

Type of visit: Required - 1 Year

On 11/12/2025 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Executive Director, Camille Brown. Facility has an approved fire clearance and capacity for 75 non-ambulatory residents of which 10 can be bedridden. Facility has an approved hospice waiver for 15 individuals and has approval for a secured perimeter. Upon arrival, LPA was informed that there were 45 Residents in care and 22 staff members on-site. At approximately 10:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 11:05AM, LPA and Executive Director toured the building and grounds. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is comprised of 5 separate houses for residents which 1 out of 5 house closed temporarily, 1 office building, and facility kitchen. Each house has 13 resident rooms, 3 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to Residents. Staff were in the process of cleaning bathrooms at the time of this inspection. Water temperature measured 110.6 degrees F and 112.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. LPA also observed activity supply for residents use and residents were in planned activity during the inspection. Continued on LIC809-C Continued from LIC809... Facility's fire extinguishers, smoke and carbon monoxide detectors and sprinkler system were last inspected June 2025. Facility smoke detectors are hard wired and connect directly to the local fire station. Facility's last emergency/disaster drill was conducted October 16, 2025. Fire Extinguishers found to be last charged on 08/07/2025 at the time of visit. Medication is centrally stored and secure. At approximately 2:05PM, LPA reviewed 5 resident records and found 5 of 5 residents have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contained physician's orders for each resident. At approximately 2:25PM, LPA reviewed 6 staff records. 6 of 6 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of certifications. 2 out of 6 staff members did not have Health Screening (LIC503) results and 1 out of 6 staff members TB test result wasn’t in file. (Technical Violation Given). Executive Director agrees to share Health Screening and TB test results with by due date 11/30/2025. Administrator Certificate is for Camille Browm expires 07/24/2026. LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 06/10/2025. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 11/30/2025: LIC 308 Designation of Facility Responsibility LIC 610 Emergency Disaster Plan (If Changed) Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 12, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Resident incontinence care needs are not being met Facility staff not following resident care plans

At approximately 09:40AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegations “Resident incontinence care needs are not being met and Facility staff not following resident care plans.” Complaint alleged that Staff Member 1 (S1) leaves residents soiled for extended periods during their shift, delays doing their job tasks until bedtime and takes multiple breaks throughout their shift leaving residents unsupervised. Multiple attempts to contact Complainant for more information were unsuccessful. The Department was unable to obtain additional information such as which residents were being left soiled, which residents were being left unattended, and what job tasks were not being completed. Continued on LIC9099-C... Unsubstantiated Continued from LIC9099... LPAs conducted staff interviews. Interview with S1 denied the allegation that they leave residents unattended. S1 also stated that they complete their job duties and if a task was not completed, it would be relayed to the next shift to complete. S1 stated that they are to check residents every 2 hours or more frequently if the resident requires it. 8 of 12 staff interviews reported seeing an improvement of incontinence care or did not have concerns about resident incontinence care while 4 of 12 staff interviews reported concerns about how often residents were being changed. 10 of 12 staff interviews stated that they haven’t observed or seen S1 or other facility staff leaving the residents unattended while 3 of 12 interviews stated that they have seen or heard of facility staff leaving residents unattended but only 1 of 12 interviews identified S1. 4 of 12 staff interviews reported that certain job tasks such as taking out the garbage or doing the dishes were sometimes not completed while 1 of 12 interviews reported that there were multiple times that they came to work to find that beds were not made, residents not changed, and laundry was not completed. This interview revealed that while these issues did occur before, it was addressed by management and were no longer a concern. None of the interviews conducted identified S1 as being the staff member to not provide incontinence care to residents. 8 of 12 staff interviews reported that they had no concerns with job duties being completed from shift to shift. Interviews further revealed that if a job task was not completed during a shift, it would be relayed to the oncoming shift and it would be the oncoming shift’s responsibility to complete. Based on interviews conducted, these allegations are Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 12, 2025 · control 21-AS-20250520084631

Allegation investigated: Staff neglect resulted in residents being hospitalized Staff inappropriately touches the residents while in care Staff leaves the residents unattended

At approximately 09:40AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegations “Staff neglect resulted in residents being hospitalized, Staff inappropriately touches the residents while in care, and Staff leaves the residents unattended.” Complaint alleged that Staff Member 1 (S1) leaves the residents unattended to hang out with other staff members, that residents have fallen and have gone to the ER due to S1 leaving them unattended, and that S1 grooms male residents’ private areas. Additional report received stated that Staff Member 2 (S2) also grooms male residents’ private areas. Multiple attempts to contact Complainant for more information were unsuccessful. The Department was unable to obtain additional information such as which residents were left unattended, which residents fell, when these residents were sent to the ER and which residents were having their private areas groomed. Continued on LIC9099-C... Unsubstantiated Continued from LIC9099... Due to lack of information provided by the Complainant, the Department was unable to determine if staff neglect due to being left unattended resulted in residents being hospitalized. Interview with S1 denied the allegation that they leave residents unattended. 9 of 13 staff interviews stated that they haven’t observed or seen S1 or other facility staff leaving the residents unattended. 4 of 13 interviews stated that they have seen or heard of facility staff leaving residents unattended but only 1 of 13 interviews identified S1. Interviews conducted revealed that there are usually two staff members in each house as well as two medication technicians available each shift. During staff breaks, facility staff members will stagger their time to ensure that there is always 1 staff member in the house to supervise the residents. Interviews conducted with S1 and S2 denied the allegations that they groom or shave the private areas of male residents. 10 staff interviews stated that they haven’t observed or heard of facility staff grooming or shaving the private areas of male residents. Based on interviews conducted these allegations are Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 12, 2025 · control 21-AS-20250516100242

Allegation investigated: Facility did not meet resident's incontinence care needs Facility does not have sufficient staff to provide care and supervision to residents

At approximately 09:40AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Facility did not meet resident's incontinence care needs.” Facility does not have sufficient staff to provide care and supervision to residents.” “Facility did not meet resident’s incontinence care needs” – Complaint alleged that night staff leave residents “soaked” in their incontinence briefs. Complainant also stated that R1 was observed to have a puddle of urine underneath them and wasn’t changed by Staff Member 1 (S1) when R1 was taken to the bathroom. Complainant stated that the incident was witnessed by Staff Member 2 (S2). LPAs spoke with S1who recalled the incident. Continued on LIC9099-C... Substantiated Continued from LIC9099... Per S1, they changed R1’s depends in the bathroom but put R1’s pants back on because they couldn’t find any clean clothes in R1’s closet. LPAs spoke with S2, who was unable to recall details of the incident. Based on interview conducted, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. Continued from LIC9099-A... they had seen improvement in staffing and felt that there was enough staffing available to meet residents’ needs. Review of facility documents indicated that as of June 2025, the facility had 12 residents requiring 2-person assistance for care needs such as transferring. Review of facility schedules indicated that the facility had at least 2 staff members in each house to meet the needs of residents. During visit conducted on 08/14/2025, LPAs observed that each house had two caregivers assigned. Based record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 12, 2025 · control 21-AS-20250501124124

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 15, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a)In addition to the rights listed in Section 87468.1,... shall have all of the following personal rights: (4) to care, supervision, and...This requirement was not met as evidenced by: Based on interviews conducted and observations made, Licensee did not ensure residents' personal rights and incontinence care needs were met. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 12, 2025

Plan of correction: Licensee to schedule training with approved outside vendor for all care staff regarding personal rights of residents and incontinence care . Licensee to provide scheduled training date to CCL by POC due date of 09/15/2025. Training to include: Staff Names and Signatures. Training to be submitted by POC due date of 09/25/2025.

Type of visit: Case Management - Incident

On 09/12/2025 at approximately 9:40AM Licensing Program Analyst (LPA) Ali Deniz conducted a case management- incident visit regards to allegation of abuse and met with Executive Director, Camille Brown. LPA is conducting a case management visit to obtain more information and conduct a safety and wellness check regarding incident report and a SOC341, dated and received by the Department on 09/11/2025, involving Resident 1 (R1) which were self-reported by the facility Executive Director. LPA interviewed administrator and reviewed R1's records, and obtained copies of documents including a personnel report, LIC602, and Appraisal. The Department will follow up for further details. No deficiencies were cited during today’s visit. Exit interview was conducted with Executive Director, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Sep 12, 2025

Allegation investigated: Staff do not maintain facility in safe, sanitary and good repair

At approximately 11:40AM/PM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff do not maintain facility in safe, sanitary and good repair.” Complainant alleged that “facility staff do not clean the bathrooms, that there is poop on the bathroom floors and that facility staff wipe the tables with the same towels used to wipe the chairs which is unsanitary.” The Department found that these concerns listed by the Complainant were not a violation of Title 22 regulations. During visits conducted on 05/06/2025, 06/04/2025, and 06/19/2025, LPAs observed that facility bathrooms were clean and did not have feces on the floor. Continued on LIC9099... Substantiated Continued from LIC9099... However, LPAs also observed the following items to be in disrepair: • Paper towel dispenser was removed from the bathroom wall • Toilet paper holder was broken • Facility shower bathroom had a “out of order” sign for the toilet • Soap dispensers was broken • Utility sink in facility laundry room was clogged Based on these observations, the allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. *During visit on 07/23/2025, LPAs observed that all items identified to be in disrepair were fixed. Deficiency cited today has been cleared. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, Plan of Corrections Letter and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 21-AS-20250530124825

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 4, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observations made, Licensee did not comply with the section cited above and did not ensure that bathrooms were in good operating condition. LPAs observed the following to be broken or in disrepair: paper towel dispenser, toilet paper holder, toilet out of order, soap dispenser, and utility sink. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: During visit on 07/23/2025, LPAs observed that facility has fixed all items that were in disrepair. Deficiency Cleared.

Allegation investigated: Staff are not mitigating the spread of infectious outbreaks in the facility

At approximately 11:40AM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff are not mitigating the spread of infectious outbreaks in the facility.” Complainant alleged that the facility has several residents with scabies and the facility was unable to provide a protocol for laundry or sanitization. Per interview conducted with Executive Director, in May 2025, the facility had three suspected cases of scabies and contacted local public health. Continued on LIC9099C... Substantiated Continued from LIC9099C... During visit conducted on 07/11/2025, the Department was informed by the Executive Director that the facility currently has seven suspected cases of scabies. Interview conducted with Executive Director revealed that many residents with suspected scabies are receiving hospice services and have been receiving preventative treatment from their assigned hospice care team without a confirmed diagnosis. Per Executive Director, it would be the Hospice Agency’s responsibility to initiate a dermatologist appointment to confirm a scabies diagnosis. Interview further revealed that facility staff were only donning and doffing PPE if it was specifically instructed to do so by a resident’s hospice care team and were not implementing this portion of their infection control plan universally or throughout the whole facility. Based on interview conducted and observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 21-AS-20250701124101

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b) · Plan of correction due date: Jul 24, 2025

87470 Infection Control Requirements (b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: This requirement was not met as evidenced by: Based on interviews and observations, Licensee did not comply with the section cited above and did not ensure that facility staff were following infection control protocol. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: Licensee agrees to submit self-certification that all staff will be trained in PPE by POC due date of 7/24/2025. Proof of training will be complete by POC due date of 8/04/2025

Allegation investigated: Facility did not follow infection control plan

At approximately 11:45AM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Facility did not follow infection control plan.” The complaint alleged that there is an outbreak of scabies and multiple residents are infected. Interview conducted with Executive Director indicated that the facility had 3 suspected cases of scabies in May 2025. Review of incident report submitted to Community Care Licensing on 05/29/2025 showed that per their infection control protocols, facility contacted their Local Public Health to inform them of the suspected cases. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Incident report also stated that facility increased their cleaning protocols and provided training to facility staff on the topic of Hand Hygiene, Infection Control, and Standard Precautions on 05/27/2025. Per Executive Director, the houses were being cleaned twice per week. Review of Housekeeping schedule indicated that homes were cleaned twice per week with alternating schedules. Based on record review and interviews conducted, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 21-AS-20250501124124

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

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

On 07/23/2025 Licensing Program Analysts (LPAs) Deniz and Felias conducted an unannounced case management Legal/ Non-compliance inspection to this facility and was greeted by Executive Director Camille Brown. LPAs are following up on items identified during a non-compliance conference dated 04/23/2025: · Observation of a resident · Neglect resulting in pressure injuries · Incontinence Care · Staff not adequately supervising residents in care · Lack of supervision resulting in resident injuries · Infection control protocols · Personal rights · Reporting Requirements · Changes to LLC/Management Company without notifying the Department · Fire Clearance - Blocked Doors LPAs requested and reviewed documents for all employees hired from May 2025 to July 2025. Review of facility records indicated that 16 individuals have been hired. LPAs reviewed a sample size of 8 staff records. Record Review indicated that training has been conducted or has been scheduled for the following areas: Observation of a resident, Pressure Injuries, Incontinence Care, and Personal Rights. Continued on LIC809C Continued from LIC809 The following concerns "Staff not adequately supervising residents in care, Lack of supervision resulting in resident injuries, Infection control protocols, and Changes to LLC/Management Company without notifying the Department" are currently being addressed in Complaint Investigations 21-AS-20250501124124, 21-AS-20250516100242, 21-AS-20250520084631, 21-AS-20250701124101, and 21-AS-20250404122536. Citations have been issued where needed under identified complaints. Reporting Requirements: Review of Incident Reports showed that facility has been submitting reports to Community Care Licensing per regulation. Fire Clearance - Blocked Doors. LPAs conducted a walkthrough of the facility and observed that all emergency exits were unobstructed. No citations were issued during today's inspection. Exit interview conducted with Administrator and copy of the report was given.the state’s words, verbatim · CDSS document, Jul 23, 2025

Allegation investigated: Facility did not provide sufficient staffing to intervene when a resident physically assaulted another resident

At approximately 1:00PM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation of “Facility did not provide sufficient staffing to intervene when a resident physically assaulted another resident.” Complaint alleges that Resident 1 (R1) was physically assaulted by Resident 2 (R2) resulting in R1 receiving bruises on their head, neck, chest, and their right eye being “swollen shut.” Pictures and video of the bruises were provided showing bruising as described by the complainant. Per complainant, R2 has exhibited this behavior towards other residents, however, interview with Executive Director, Camille Brown indicated that resident had been observed grabbing other residents but had not exhibited behavior this severe. Review of Special Incident Reports do Continued on LIC9099C Unsubstantiated Continued from LIC9099 not show any other incidents involving R2 with other residents. Per interview with staff involved, R2 walked into R1’s room three to four times but staff was able to be verbally redirect R2. The fourth time, while staff was in the room, R2 punched R1 in the eye and then left. Staff did not observe R2 hit R1 in any other part of their body. Staff requested assistance by the Medication Technician and R1 was assessed approximately an hour later by a hospice nurse and was treated for their eye. Per interview with the Executive Director, R2 has had medication changes and increased supervision due to their behaviors since this incident. Witnesses have reported seeing R2 the facility without staff, however, LPAs observed R2 with supervision during visits on 5/6/2025, 6/4/2025, and 07/11/2025. Based on document review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 21-AS-20250501124124

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not distribute resident's medication as prescribed Staff do not provide residents with toiletry supplies

At approximately 1:00PM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff do not provide residents with toiletry supplies, and Staff did not distribute resident's medication as prescribed.” “Staff do not provide residents with toiletry supplies,” – Complainant alleged that facility staff do not ensure residents are supplied with toilet paper, paper towels, and soap, and further stated that the bathrooms are always out of an item or are never fully stocked. During visit on 06/04/2025, it was observed that 14 out of 15 bathrooms were missing items such as toilet paper, paper towels, or soap. During visit conducted on Continued on LIC9099C Substantiated Continued from LIC9099 06/19/2025, it was observed that 12 out of 15 bathrooms were missing items such as toilet paper, paper towels, or soap. During visit conducted on 07/11/2025, it was observed that 7 out of 15 bathrooms were missing items such as toilet paper, paper towels, or soap. Based on observations made, this allegation is Substantiated. “Staff did not distribute resident's medication as prescribed,” – Complainant alleged that R1 was not provided their medication timely, stating that they had to wait 18 hours for their medication. Interview conducted with Staff Member 1 (S1) revealed that there are usually two medication technicians each shift. On 05/15/2025, R1’s medication was delivered to the wrong house. Per S1, if a medication is received for a resident that is in a different home, it should be given to the medication technician that oversees that house and the medication technicians coming in for the next shift are to be informed of any medication received prior to their shift. S1 further stated that they found R1’s medication at the end of their shift on 05/16/2025 and therefore was able to start the medication once the medication was located. Review of R1’s file showed that their medication arrived on 05/15/2025 with instructions to be given three times a day. Review of R1’s Electronic Medication Authorization Record (EMAR) showed that R1 missed their morning dose of medication but received their afternoon and evening dosage on 05/16/2025. Based on observations made and interviews conducted, this allegation is Substantiated. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 21-AS-20250530124825

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 12, 2025

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: based on interviews and record review, Licensee did not comply with the section cited above and did not ensure that Resident 1’s medication was administered per physician’s orders. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: Licensee to submit self certification that training will be conducted for all staff that administer medication by POC due date of 07/12/2025. Training to include the following: Trainer, Date, Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 07/21/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Jul 21, 2025

87307 Personal Accommodations and Services:(a)...The following provisions shall apply:(3)Equipment and supplies... for personal care and...adequate hygiene practice shall be readily available...:(D) Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by: based on observations amde, Licensee did not comply with the section cited above and did not ensure that facility bathrooms were supplied with general hygiene items such as toilet paper, soap, and paper towels. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: Licensee to submit In-service training on replenishing house bathroom supplies. Training to include the following: Trainer, Date, Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 07/21/2025.

Allegation investigated: Staff do not maintain a comfortable temperature inside of the facility

At approximately 12:20PM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to initate a Complaint Investigation regarding the above allegation and met with Administrator, Camille Brown. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation that "Staff do not maintain a comfortable temperature inside of the facility." Complainant alleged that during a visit to the facility, it was extremely hot inside one of the homes and the outside temperature was 95F. Complainant also stated that the air conditioner has been broken for one year, so facility has placed fans on the floors to blow air however it was still very hot inside and residents complained of being hot, uncomfortable and sleepy due to the heat. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Facility reported to Community Care Licensing (CCL) that one of their homes, Clark House, did not have their main air conditioning (AC) unit working. CCL Staff conducted a visit on 05/31/2025, where it was observed that the inside of Clark House was 77F. It was observed that each resident in Clark House had an individual AC unit that was operational and functioning. Clark House residents were observed to not be in distress (exhibiting red faces and/or sweating). The other 4 houses were also observed and found to have operating AC units. During visit conducted on 06/04/2025, it was observed that all 5 houses were at a comfortable temperature and none of the residents were observed to be in distress. Based on observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 21-AS-20250530124825

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Manager Bertozzi arrived unannounced to conduct a Case Management inspection to ensure heath and safety and was greeted by Joe Rosario, the Maintenance Director. Sales Manager, Rosa Graciea arrived later. Administrator, Camille Brown was available by phone and gave permission for staff to sign report. LPM is following up regarding a recent report that the facility's air conditioner was not working. LPM confirmed with Executive Director Camille Brown via phone on May 31, 2025 and with Maintenance Director, Joe Rosario during this visit that one of five buildings had the air conditioner not working (Clark House). When LPM arrived the temperature outside was approximately 100 degrees F. The thermostat inside of Clark House read at 77 degrees F. Per conversation with Joe, the central air conditioner in Clark House is not working, however, each resident room has an individual air conditioner. In an attempt to keep the main areas of the facility cool, two vacant rooms have the air conditioners running with the doors open. LPM conducted a walk through and observed two vacant rooms with the room air conditioner on and a fan directing air outside of the room into the main area. LPM confirmed that each resident room in Clark House had their room air conditioner on. Residents appeared comfortable and were not exhibiting sign of distress, like red faces and/or sweating. LPM confirmed through observation that the other four houses had functional air conditioner. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, May 31, 2025

Type of visit: Case Management - Incident

At approximately 9:25AM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Camille Brown. The purpose of the visit was to follow up on an incident report/SOC341 that was self-submitted to Community Care Licensing (CCL). Incident Report 1/SOC341: CCL received an incident report and SOC341 on 04/18/2025. Reports stated that on 04/15/2025, facility management became aware of an incident that occurred on the evening of 04/14/2025. Per reports, Staff Member 1 (S1) witnessed Staff Member 2 (S2) make open-hand contact with Resident 1's (R1's) cheek. Facility made all notifications per Title 22 Regulations. Reports stated that S2 was currently suspended pending internal investigation. During visit, LPAs were informed that S2 is no longer employed at the facility. LPAs obtained additional documentation related to the incident. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 6, 2025

Allegation investigated: Facility staff not meeting hygiene needs of residents

During the Office Meeting, Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Victoria Bertozzi, and Licensing Program Analysts (LPAs) Caitlynn Felias and Ali Deniz delivered findings for this Complaint Investigation regarding the above allegation and met with Executive Director, Camille Brown, and Regional Director of Operations, Karen Enciso. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Facility staff not meeting hygiene needs of residents.” Complainant alleged that they visited the facility and observed residents that smelled of urine and had food on their faces or food on their clothes. Complainant stated that it was obvious residents had not been changed or bathed in a long time. Continued on LIC9099C Unsubstantiated Continued from LIC9099 LPAs contacted Complainant who stated they observed these residents at various events where some events occurred right after mealtime. Complainant was unable to provide additional details or information such photos depicting their observations or resident names. LPAs conducted staff interviews. Staff interviews conducted stated that the number of showers a resident receives is based on their shower schedule. Most residents receive 2 showers per week but that other residents receive 3 showers per week, or daily if it a part of their care plan. Resident laundry is also done twice a week or daily if it is found to be soiled. Interviews conducted also stated that residents will sometimes refuse care or refuse to leave an activity to receive care from facility staff until after the activity is over. On 04/14/2025, LPAs conducted a facility walkthrough of all 5 homes and the courtyard. LPAs observed the following: residents in each home were observed to be clean and presentable. LPAs did not observe any food on residents or residents to be in dirty clothing. There were no strong odors observed in common areas or bathrooms. Based on interviews conducted and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 21-AS-20250327135736

Allegation investigated: Licensee using an Admission Agreement that is not lawful

During the Office Meeting, Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Victoria Bertozzi, and Licensing Program Analysts (LPAs) Caitlynn Felias and Ali Deniz delivered findings for this Complaint Investigation regarding the above allegations and met with Executive Director, Camille Brown, and Regional Director of Operations, Karen Enciso. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Licensee using an Admission Agreement that is not lawful.” Complainant alleged that the facility residency application for Pacifica Senior Living in Vacaville requires family to accept financial liability which is a violation of 42 CFR 483.15(a)(3). Continued on LIC9099C Unfounded Continued from LIC9099C LPAs Felias and Deniz conducted an investigation into the allegation of “Licensee using an Admission Agreement that is not lawful” specifically related to Title 42 regulation section 486.15(a)(3) which states “42 CFR 483.15(a)(3), the facility must not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may request and require a resident representative who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources.” Vacaville Senior Living is a Community Care Licensed facility, and the oversight is under Title 22 Regulations not Title 42. In reviewing Title 22 regulations there is not language that coincides with the section cited above. This allegation is Unfounded. A finding that the complaint is Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 21-AS-20250321091423

Allegation investigated: Staff do not respect residents privacy by posting pictures online without consent Facility has insufficient staffing to meet the needs of residents in care Facility is obstructing facility exit

During the Office Meeting, Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Victoria Bertozzi, Licensing Program Analysts (LPAs) Caitlynn Felias and Ali Deniz delivered findings for this Complaint Investigation regarding the above allegations and met with Executive Director, Camille Brown, and Regional Director of Operations, Karen Enciso. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff do not respect residents privacy by posting pictures online without consent, Facility has insufficient staffing to meet the needs of residents in care, and Facility is obstructing facility exit.” Continued on LIC9099C Substantiated Continued from LIC9099 “Staff do not respect residents privacy by posting pictures online without consent” – Complainant alleged that Staff Member 1 (S1) violated residents’ privacy by posting pictures of residents on their personal social media account. LPAs were provided with photos, a video, and resident names. Review of S1’s file showed that they received a write up for posting activity events with residents on their personal social media account. Interview with prior Executive Director stated that S1 was given verbal permission to post events by a different Director since they did not have access to the business account. LPAs reviewed a sample size of 6 resident agreements. 5 of 6 files did not have signed social media consent forms or “model release agreements.” Per interview with Community Relations Director, all agreements were signed electronically and the consent forms could have missed during signing. LPAs identified that the residents provided in the photos did not have signed social media consent forms. Based on interviews conducted, document review, and observations made, this allegation is Substantiated. “Facility has insufficient staffing to meet the needs of residents in care” – Complainant alleged that facility management is allowing one care staff member in each house and refuses to help when they are short-staffed. LPAs conducted interviews. Per interview with prior Executive Director, facility has not had adequate staffing to meet resident care needs. Interview with current Executive Director stated that 4 of the 5 facility houses require at least 2 staff members based on resident care needs such as transferring or bathing. Review of facility documents indicated that at least 6 residents in the community require 2-person assistance with care. Based on interviews conducted and document review, this allegation is Substantiated. “Facility is obstructing facility exit” – Complainant alleged that facility management is instructing staff members to block the exit door to prevent residents from escaping. LPAs were provided with a photo during the investigation. Photo provided showed that a facility exit door was obstructed by a gray couch. Based on observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents. Continued from LIC9099 LPAs were provided with a photo which showed S1 standing next to a male resident wearing gloves. The male resident is sitting down at a table. From the photo provided, it is unclear what S1 is doing in the photo as their hands are obstructed by items on the table. Review of facility’s Clinical Policy and Procedure Manual for Podiatry and Nail Care states the following: “Policy: The Community will arrange or make available to residents foot and nail care. Procedure: Personal Care Assistants will not trim toenails, smooth corns, calluses, etc. The Resident Care Director will schedule podiatry appointments for all foot and/or nail care other than cleaning and moisturizing…” Review of S1’s file showed that they did not have training to provide nail care. Interview conducted with S1 stated that they provided an activity called “Nail Spa” which included placing warm towels over resident nails, filing and painting them. S1 denied cutting or trimming resident nails. Interviews conducted with other facility staff provided conflicting information. 4 of 8 interviews stated that S1 has not been seen cutting or trimming resident nails, while 4 of 8 interviews stated that S1 has been seen cutting or trimming nails. Based on interviews conducted, document review, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 21-AS-20250221084248

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

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met as evidenced by: based on interviews conducted and document review, Licensee did not comply with the section cited above and ensure that all 5 homes at facility had adequate staffing to meet resident care needs. Licensee has at least 6 residents that require two staff member assistance. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2025

Plan of correction: Licensee to submit written plan to ensure staffing is sufficient to meet resident care needs by POC Due Date of 04/25/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Apr 25, 2025

87468.2Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...(1)To have a reasonable level of personal privacy accommodations...personal care & assistance...use of the Internet...this requirement was not met as evidenced by: based on interviews conducted & document review, Licensee did not comply with the section cited above & Residents did not have signed social media consent forms prior to being on social media. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2025

Plan of correction: Licensee to conduct training on the facility's social media policy, cell phones, and personal rights of residents. Training to include the following: Date, Topic, Name/Job Role, and Staff Signatures. Training to be submitted by POC Due Date of 04/25/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Apr 23, 2025

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...this requirement was not met as evidenced by: based on observsations made, Licensee did not comply with the section cited above and ensure that all facility exits were unobstructed in the event of emergency. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2025

Plan of correction: Licensee to conduct training on keeping all facility exits clear and unobstructed, such as a fire drill, for all shifts (AM, PM, NOC). Training to include the following: Date, Topic, Name/Job Role, and Staff Signatures. Training to be submitted by POC Due Date of 04/25/2025.

Type of visit: Office

A Non-Compliance Conference was conducted today in the Santa Rosa Regional Office. Present in the meeting were, Regional Manager, Carla Nuti-Martinez, Licensing Program Manager (LPM) Victoria Bertozzi, Licensing Program Analysts (LPAs) Caitlynn Felias and Ali Deniz, Executive Director, Camille Brown, and Regional Director of Operations, Karen Enciso. The purpose of today’s Non-Compliance (NCC) meeting was to address areas of concern identified by the Department. The following areas were discussed: · Observation of a resident · Neglect resulting in pressure injuries · Incontinence Care · Staff not adequately supervising residents in care · Lack of supervision resulting in resident injuries · Infection control protocols · Personal rights · Reporting Requirements · Changes to LLC/Management Company without notifying the Department · Fire Clearance - Blocked Doors Continued on LIC809C Continued from LIC809 Parties discussed Admission Agreements. As of October 2024, Facility has been under the management group, Heritage Resource Group. It was found that the Licensee did not submit a new Admissions Agreement to Community Care Licensing for review and approval. Facility’s Admission Agreements were provided to the Centralized Application Bureau (CAB) for review. A copy of CAB’s review and revision recommendations were provided to Licensee during office meeting (deficiency cited, see 809D, Regulation 87209(a)). Facility's Non Compliance Plan will be in place for 2 years. Department will review compliance plan after 1 year to review progress. The Department discussed the Technical Support Program (TSP) should the facility be open to having TSP work with them on concerns listed. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. The issuance of a Civil Penalty is under review. The Licensee is being informed that a Civil Penalty might be assessed based on a violation that the Department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 23, 2025

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

87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation...plan & related materials shall be on file in the facility & shall be submitted to the licensing agency with the license application. Any significant changes...which would affect the services to residents shall be submitted...for approval. This requirement was not met as evidenced by: Licensee failed to submit Admissions Agreement for review to ensure changes were not made that required approval by CCL. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2025

Plan of correction: Licensee to submit proof of revised Admission Agreements to Centralized Application Bureau (CAB) by POC Due Date of 05/02/2025 for review and approval.

Type of visit: Case Management - Deficiencies

At approximately 9:20AM, Licensing Program Analysts (LPAs) Felias and Deniz arrived unannounced to conduct a Case Management - Deficiencies Visit and met with Executive Director, Camille Brown. The purpose of the visit was to follow up self-reported incidents that were submitted to Community Care Licensing (CCL). The Santa Rosa Regional Office (SRRO) received 3 late incident/death reports from the facility. Review of reports showed that the incidents occurred on the following dates: 03/17/2025 and 03/24/2025. Reports were received by the SRRO on the following dates: 03/27/2025 and 04/01/2025. Per Title 22 Regulations, incident reports must be submitted to CCL within seven (7) days of the incident occurring (deficiency cited, LIC809D, Regulation 87211(a)(1)). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 24, 2025

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...below. This requirement was not met as evidenced by: Licensee did not comply with section cited above. Per record review, Licensee did not submit incident reports timely. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2025

Plan of correction: Licensee to submit Inservice Training on the topics of Incident Reporting and Documentation. Training to include the following: Date, Topic, Name/Job Role, and Signatures. Training to be submitted to CCL by POC due date of 04/24/2025.

Type of visit: Office

On April 4, 2025 at 11am, a meeting was conducted by Assistant Program Administrator (APA) Stacy Barlow to verify Chapter 7 Bankruptcy Report filed by the Pacifica Senior Living as reported by the media. Present during the meeting are: Shelley Grace - Assistant Branch Chief, CCLD Craig Lundgren - Legal Counsel, CCLD Carl Knepler - Chief Executive Officer, Marlene Nelson - Director, Quality Assurance and Risk Management APA Barlow verified with Knepler information received by CCL from the media as follows: • $25M lawsuit against the community located in Bakersfield • Photography lawsuit against one of the properties • lawsuit against a Skilled Nursing Facility (SNF) in the Healdsburg location Knepler states that despite the lawsuits, there is no financial impact to any of the properties, residents or staff of the company. Knepler added there are no vendor issues as well. continuation on LIC 809C Knepler also states that management communicates with the staff and residents to make them aware of the changes. Signages have been changed. Knepler added that the bankruptcy did not affect any of the communities because Pacifica Senior Living Management was no longer the management company for any of the Pacifica Communities, that the communities had given notice to the department and residents back in October or November of last year of the changes in management companies. He said that the judgment in Bakersfield did not involve the operating entity, only the management company. He said there were no other suits pending against any of the Pacifica entities. APA requested the following documents be provided to CCL by today: • Spread sheet of all facilities whose management company was/is Pacifica Senior Living Management Company • management companies for each location • letter provided to the residents notifying them of the changes At the conclusion of the meeting, APA emphasized to Knepler the importance of communicating with CCL any lawsuits that the company may have in the future. Knepler agreed with APA. A copy of this report was provided to Knepler.the state’s words, verbatim · CDSS document, Apr 14, 2025

Allegation investigated: An adult at the facility is forcing a resident to eat

At approximately 11:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegation and met with Executive Director, Juliet McGranahan. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, "An adult at the facility is forcing a resident to eat.” Report received on 02/11/2025 alleged that an adult at the facility is forcing a resident to eat. Report received also included a photograph that showed an female individual dressed in scrubs. The individual was shown to be holding a piece of food on a fork and was being held in front of a female resident's mouth. Per photograph, it does not appear that the resident is in distress. LPA was unable to receive additional details about the photograph provided such as date, time of day, or resident's name. Based on interviews, LPA identified that there are residents at the facility who require assistance with eating/feeding. Continued on LIC9099C Unsubstantiated Continued from LIC9099 LPA was informed that facility staff will help residents eat through verbal prompting or by guiding the utensil to a resident's mouth. Per interviews, there are 4 residents that require help with feeding. Review of resident files indicated that none of these residents were the resident shown in the photograph. Interviews conducted also indicated that they have not observed residents to be force fed by staff. During visit conducted on 02/20/2025, LPA observed lunch being served to the residents. LPA observed that some residents were being verbally prompted to eat. LPA did not observe any resident being hand-fed but was informed that some of the residents were sleeping and would be provided their meal when they woke up. Based on document review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 21-AS-20250211151605

Allegation investigated: Questionable Death

At approximately 11:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Executive Director/Administrator, Juliet McGranahan. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Questionable Death." Report received on 12/03/2024 alleged that facility staff were not properly providing incontinence care to residents which resulted in a resident’s bed sore getting infected and causing the resident to pass away. Based on interviews, LPA was able to identify the resident and discovered that an investigation was completed for a previous complaint involving this resident. That investigation substantiated the allegation that Resident 1 (R1) was neglected Continued on LIC9099C Substantiated Continued from LIC9099 resulting in pressure injuries. The investigation revealed that R1 required surgery for the sacral decubitus ulcer they obtained while being isolated for Covid-19. Resident passed away approximately one month later from End Stage Parkinson’s Disease with significant contributing conditions including Decubitus Sacral Ulcer, Malnutrition, Dementia and Bilateral Heel Ulcers. Based on interviews conducted, document review, and observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. Continued from LIC9099 During visit conducted on 02/20/2025, LPA observed that there were a total of 12 direct care staff clocked in and on-site. LPA conducted a walkthrough of the facility with Resident Care Coordinator and observed the residents' being served lunch. LPA observed at least 1 to 2 staff members in all five homes. LPA observed that residents appeared to be clean. Homes did not have any strong odors during the walkthrough. Based on interviews conducted and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 21-AS-20241203111210

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 21, 2025

87466 Observation of the Resident: Licensee shall ensure...residents are regularly observed for changes...& that appropriate assistance is provided...Licensee shall ensure...changes are documented & brought to the attention of the resident's physician & responsible person, if any. Requirement was not met as evidenced by: based on interviews, records & observations, Licensee did not ensure that facility staff responded appropriately to observations of R1's wound resulting in an unstageable injury. This is an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 20, 2025

Plan of correction: Licensee to schedule training for all care staff regarding observation of a resident. Licensee to provide scheduled training date to CCL by POC due date of 02/21/2025. Training to include: Trainer, Date of Training, Topics, Job Role, Staff Names and Signatures. Proof of Training to be submitted by POC due date of 03/03/2025.

Allegation investigated: Licensee did not ensure staff followed proper infection control protocols.

Licensing Program Analyst (LPA) Nakagawa arrived unannounced and met with Juliet McGranahan, Administrator to open this complaint investigation and deliver findings. During the course of this investigation the facility was toured, records and photos were reviewed and interviews conducted. It is alleged that Licensee did not ensure staff followed proper infection control protocols. During the course of the investigation, photographs were reviewed and interviews were conducted showing that used PPE was not properly doffed by staff; nor was it properly discarded, stored or removed during an active case of Covid-19, therefore this allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. Substantiatedthe state’s words, verbatim · CDSS document, Feb 4, 2025 · control 21-AS-20250131121829

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(2)( · Plan of correction due date: Feb 4, 2025

87470 Infection Control Requirements (b) (2)All staff...providing direct care to resident who has a communicable disease shall wear appropriate... PPE ...(B)PPE shall be...discarded in the nearest... receptacle with... immediately upon completing a task. This requirement has not been met as evidence by: Based on photos, observation, interviews and record review Licensee did not follow mandated guidance of infection control plan and failed to discard PPE in a tightly-lidded container as required which poses a potential health, safety, and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: Licensee to submit proof of training of staff on proper PPE donning, doffing and the proper disposal of used PPE following Infection Control Plan. Proof to be submitted to CCL by 2/5/2025.

Allegation investigated: Personal Rights

At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Resident Care Director, Lorena Madrigal. During the investigation, the Department conducted interviews. The following allegation was investigated, “Personal Rights." Report received on 10/09/2024 alleged that the Activities Director speaks Spanish to residents that do not understand Spanish and makes residents uncomfortable. Report stated that the Activities Director has been asked many times to not speak Spanish but continues to do so. LPA was unable to contact Complainant for additional information regarding allegation. LPA conducted staff interviews. Interview with Executive Director revealed that the facility has Spanish and English-speaking residents. The facility employs facility staff who can speak English and Spanish in order to help residents feel comfortable and accomodate their care needs. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Interview conducted with Activities Director revealed that they speak both English and Spanish. When facilitating a group activity, they will address their audience in only English, as that is the main language the majority of their residents speak. Per Activities Director, they will speak Spanish to their Spanish-speaking residents, but in a large group setting, they will respond to questions in English. Based on interviews conducted, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Resident Care Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 3, 2025 · control 21-AS-20241009095052

Allegation investigated: Facility staff handles residents in a rough manner

At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Resident Care Director, Lorena Madrigal. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Facility staff handles residents in a rough manner.” Report received on 11/01/2024 alleged that facility staff have been observed to handle residents in a rough manner, and stated that facility staff have been seen squeezing residents’ arms to get them to stop doing something. LPA conducted staff interviews. 4 of 6 staff interviews conducted stated that they have seen residents be handled in a rough manner and/or spoken to disrepectfully. Continued on LIC9099C Substantiated Continued from LIC9099 Interview conducted with Executive Director stated that they have not observed or witnessed these incidents firsthand but had multiple staff members report incidents to management. Based on interviews conducted, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report,LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Resident Care Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 3, 2025 · control 21-AS-20241101083738

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 4, 2025

87468.1 Personal Rights of Residents in All Facilities: (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: based on interviews conducted, Licensee did not ensure residents' personal rights. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 3, 2025

Plan of correction: Licensee to schedule training with approved outside vendor for all care staff regarding personal rights of residents. Licensee to provide scheduled training date to CCL by POC due date of 01/04/2024. Training to include: Staff Names and Signatures. Training to be submitted by POC due date of 01/13/2024.

Allegation investigated: Staff are inappropriately posting the residents on social media

At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Resident Care Director, Lorena Madrigal. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, "Staff are inappropriately posting the residents on social media." Report received on 11/22/2024 alleged that facility management took personal photographs of residents without their consent or knowledge and posted the photographs to their private social media page instead of posting on the Pacifica Senior Living website or the Pacifica Senior Living Facebook page. LPA conducted staff interviews. Interview with Executive Director revealed that the facility's outside vendors have tagged facility management's personal social media pages along with the Pacifica Senior Living Facebook page during events such as outings, holiday parties, and other resident activities. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Interview conducted with Facility's Marketing Director revealed that they would use Facebook Live during public events to show events and activities occurring at the facility. Per Marketing Director, the content of the videos and photos did not include any private or medical information and was solely to promote the community. The photos and videos posted to Facebook were for parties or events such as Cinco de Mayo, Chili and Cornbread Day, or Grandparents' Day, and showed residents' participation. LPA was informed that all videos and photos have been deleted off their personal social media page. Interview with Marketing Director also revealed that at this time all residents have signed consent forms regarding photography and social media. LPA was provided with a copy of the Admissions Agreement which included the consent form for social media and photography. Based on interviews conducted and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Resident Care Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 3, 2025 · control 21-AS-20241122093505

Allegation investigated: Neglect resulting in pressure injuries

At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Resident Care Director, Lorena Madrigal. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, "Neglect resulting in pressure injuries." Report received on 09/06/2024 stated that Resident 1 (R1) was isolated for COVID-19 from 08/25/2024 to 09/02/2024. On 09/01/2024, facility staff reported a smell and R1 was sent to the ER on 09/02/2024 where they were diagnosed with an unstageable wound on their sacrum. LPA conducted staff interviews. 1 out of 8 staff interviews conducted revealed that on 08/29/2024, redness was observed by facility staff who notified the medication technician on duty. Continued on LIC9099C Substantiated Continued from LIC9099 The medication technician on duty provided facility staff with topical barrier cream to apply to R1 on 08/29/2024. Review of R1’s medication authorization record (MAR) showed that R1 had an ointment prescribed “as needed” for redness but the record did not indicate or show that an ointment was administered for R1 on 08/29/2024. Subsequently, there was no additional written documentation notated on R1’s MAR or progress notes to indicate that a change in skin condition was observed and that barrier cream was applied. Additional interviews also revealed that on 08/31/2024, another facility staff observed R1 to have a dark spot that was purple, brown, and leaking. This facility staff notified the medication technician on duty who stated they would notify management. Review of facility documents showed that on 09/01/2024, R1's nurse practitioner was faxed to notify them of the observation. Review of incident report dated 09/02/2024 stated that facility staff notified R1’s doctor of the wound on 09/01/2024 and that R1’s nurse practitioner called the facility on 09/02/2024 to request for R1 to be sent out to the hospital for an unstageable pressure wound on the coccyx area. Review of progress notes did not show any documentation or notification of a sore being observed for R1 by facility staff. Review of documentation also showed that seven staff were written up for failing to notice the wound on R1’s back. Based on interviews conducted, document review, and observations made, this allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An informal meeting will be scheduled at a later date between the Facility and the Department to be held at the Santa Rosa Regional Office.** Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Resident Care Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 3, 2025 · control 21-AS-20240906144108

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 4, 2025

87466 Observation of the Resident: Licensee shall ensure...residents are regularly observed for changes...& that appropriate assistance is provided...Licensee shall ensure...changes are documented & brought to the attention of the resident's physician & responsible person, if any. Requirement was not met as evidenced by: based on interviews, records & observations, Licensee did not ensure that facility staff responded appropriately to observations of R1's wound resulting in an unstageable injury. This is an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 3, 2025

Plan of correction: Licensee to schedule training with approved outside vendor for all care staff regarding observation of a resident and proper documentation. Licensee to provide scheduled training date to CCL by POC due date of 01/04/2024. Training to include: Trainer, Date of Training, Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 01/13/2024.

Allegation investigated: Staff did not ensure resident’s incontinence needs were met

At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Resident Care Director, Lorena Madrigal. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff did not ensure resident’s incontinence needs were met." Report received on 09/23/2024 stated that facility staff has shown neglect by double briefing residents to save time when working on the floor. LPA conducted staff interviews. 4 of 6 staff interviews conducted stated that residents have been observed to be double briefed or to be wearing two incontinence briefs at a time. Photos provided to LPA showed residents wearing two incontinence briefs at a time. Continued on LIC9099C Substantiated Continued from LIC9099 Facility correspondence between management and facility staff showed that double briefing had occurred at the facility. LPA was provided with copies of incontinence care in-service training that was conducted for all direct care staff on 10/10/2024. Based on interviews conducted and observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Resident Care Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 3, 2025 · control 21-AS-20240923174728

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

87468.2 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... shall have all of the following personal rights: (4) to care, supervision, and services that meet their individual needs...This requirement was not met as evidenced by: Based on interviews conducted and observations made, Licensee did not ensure residents' personal rights and incontincence care needs were met. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 3, 2025

Plan of correction: Licensee to schedule training with approved outside vendor for all care staff regarding personal rights of residents. Licensee to provide scheduled training date to CCL by POC due date of 01/04/2024. Training to include: Staff Names and Signatures. Training to be submitted by POC due date of 01/13/2024.

Type of visit: Case Management - Annual Continuation

At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a 1-Year Required Visit and met with Executive Director/Administrator, Juliet McGranahan, and Resident Care Director, Lorena Madrigal Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 75 non-ambulatory residents of which 10 can be bedridden. Facility has an approved hospice waiver for 15 individuals and has approval for a secured perimeter. Upon arrival, LPA was informed that there were 63 Residents in care and 20 staff members on-site. LPA conducted a walk-though of the facility with Resident Care Director. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is comprised of 5 separate houses for residents, 1 office building, and facility kitchen. Each house has 13 resident rooms, 3 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to Residents. LPA observed that 4 of 10 sinks accessible to residents were out of compliance with Title 22 Regulations, measuring at 147.2F, 128.6F, 125.7F, and 138.2F (deficiency cited, LIC809D, regulation 87303(e)(2)). LPA reviewed staff files, resident files and resident medication. During staff file review, LPA observed 6 of 8 staff files had current First Aid and CPR certification (Technical Violation issued, LIC9102, Regulation 87411(c)(1)). LPA also observed that 8 of 8 staff files did not have annual 2024 training conducted as required by Health and Safety Code (deficiency cited, LIC809D, H&S Code 1569.625(b)(2)). During resident file review, LPA observed that 1 of 5 residents did not have an updated Physician's Report (LIC602) as required (technical violation issued, LIC9102, regulation 87705(c)(5)). During medication review, LPA observed that 4 of 10 resident medication was not centrally stored and logged as required (deficiency cited, LIC809D, regulation 87465(h)). Continued on LIC809C Continued from LIC809 Administrator's Certificate for Juliet McGranahan (6071164740) was current with an expiration date of 07/10/2026. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610E) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 12/06/2024. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director and Resident Care Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 5, 2024

The state marks this report as 13 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Executive Director/Administrator, Juliet McGranahan Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 75 non-ambulatory residents of which 10 can be bedridden. Facility has an approved hospice waiver for 15 individuals and has approval for a secured perimeter. Upon arrival, LPA was informed that there were 59 Residents in care and 23 staff members on-site. LPA reviewed the Facility's Staff Roster and found that Staff Member 1 (S1) were not fingerprint cleared or associated to the facility as required. Executive Director notified S1 to leave the premises during visit (deficiency cited and civil penalty issued, see LIC809D and LIC421BG, Health and Safety Code 1569.17(c)(1)(A)). Facility's fire extinguishers, smoke and carbon monoxide detectors and sprinkler system were last inspected July 2024. Facility smoke detectors are hard wired and connect directly to the local fire station. Facility's last emergency/disaster drill was conducted September 2024. LPA, Executive Director, and Memory Care Director reviewed Guardian requirements, Title 22 Regulations, and Licensing expectations.the state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: POC

LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 09/11/2024 to conduct an inspection to clear a Plan of Correction regarding toxins being accessible to residents in care. LPA inspected 4 out of 4 kitchens and found locks were in place to keep toxins/soaps/hazardous materials/sharps inaccessible to residents. Staff training has taken place and AM staff was observed putting the training into practice. LPA discussed the quality of the locks and the proper use with the Administrator. Administrator and Memory Care Director, Lorraina Madrigal, agreed to monitor the proper use of the locks and that staff continue safe practices and protocols. No deficiencies were cited during this visit. LPA conducted exit interview with Administrator.the state’s words, verbatim · CDSS document, Sep 11, 2024

Type of visit: Case Management - Deficiencies

On 08/26/2024, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced for the purpose of conducting a case management inspection. LPA was greeted by Juliet McGranahan, Administrator. LPA and Administrator toured the facility and made observations during the inspection. The facility was found to be clean and a comfortable temperature, however LPA found the facility did not have safeguards in place to protect the residents from hazards kept in the kitchen. CCL received an incident report on 8/1/2024 stating that resident R1 accidentally ingested dish soap after accessing the kitchen while caregiver was busy with another resident. R1’s Physician’s Report states that R1 is at risk of allowed direct access to personal grooming and hygiene products and R1 is in a Dementia Care Unit where soaps should be safely secured. Per Title 22 regulation 87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. The facility did not store toxic substances so that they were inaccessible to R1. Deficiency cited (see 809-D) per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Continued on 809-Dthe state’s words, verbatim · CDSS document, Aug 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Aug 26, 2024

87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: Based on self-reported incident report, the licensee did not comply with the section cited above in that soap in kitchen area was accessible to residents, which poses/posed an imminent health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2024

Plan of correction: Facility to submit plan for conducting staff training on how to properly store toxic materials and items that could en danger residents by 08/27/2024 and training to take place no later than 08/30/2024 with a copy of training materials and sign in sheet of participants submitted to CCL by 09/03/2024.

Allegation investigated: Reporting requirements not met

On 4/26/2024, Licensing Program Analysts (LPA's) Tobola and Mutilau arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Acting Administrator, Juliet McGranahan (AD). LPA toured the facility, interviewed staff and outside parties, reviewed resident facility and medical records and made observations during the course of the investigation. Complaint alleges reporting requirements not met. Upon a review of incident reports submitted to Community Care Licensing (CCLD), the facility failed to properly submit incident report involving resident (R1) sustaining a fall in the facility courtyard during overnight hours. LPA and AD found that the facility did not properly complete and submit a Special Incident Report LIC624 to CCLD or reporting parties for the incident involving R1 on 1/6/2024. Allegation, facility failed to follow reporting requirements is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given Substantiated Complaint alleges, Neglect/Lack of Supervision resulted in resident sustaining a severe injury. Based on upon review of R1's medical and facility records it was found that on 1/6/2024, R1 had sustained a laceration to their shoulder and arm. Based on review of medical records, an additional wound assessment was conducted. In the assessment there are no indications of areolar tissue violation, no fascia violation, no foreign bodies/materials, no muscle damage, no underlying fracture and no vascular damage noted. In addition, R1's family member agreed that they did not wish for R1 to undergo significant interventions, only wound and comfort care. Due to contradicting information gathered and a lack of corroborating evidence the allegation is found to be unsubstantiated. LPA's Tobola & Mutialu conducted a separate case management to address the general neglect/lack of supervision. A finding that the complaint allegations, complaint alleges staff did not seek resident timely medical attention and neglect/lack of supervision resulted in resident sustaining a severe injury are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 21-AS-20240122094705

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 3, 2024

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.. This requirement was not met as evidence by:** Based upon review of facility and CCLD records, it was found that the facility failed to properly complete and report an Unusual Incident Report LIC624 regarding resident R1 sustaining unwitnessed fall located in facility courtyard. This serves as a potential healthy and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Administrator failed to follow proper reporting requirements for incidents. Administrator agrees to conduct an in-service training for all staff on reporting protocols and incident report review to clear deficiency. Signed training to be submitted to CCLD by POC date 5/3/2024.

Type of visit: Case Management - Other

On 4/26/2024, LPA's Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Acting Administrator, Juliet McGranahan. On 1/6/2024, resident (R1) had sustained lacerations to their shoulder and arm after an unwitnessed fall located in the facility courtyard during evening hours. During the complaint investigation, LPA's found that although it was undetermined whether resident R1 had sustained a severe injury, the facility still failed to ensure R1 was provided adequate supervision resulting in R1 injured and found outside of their designated living quarters in facility courtyard. LPA's issued citation under Health & Safety Code "Enumerated Rights; Severability" 1569.269. Deficiency cited from the California Health & Safety Code, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Civil Penalty issued for a total of $250 for repeat violation.the state’s words, verbatim · CDSS document, Apr 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269 · Plan of correction due date: Apr 27, 2024

Enumerated rights; severability(a(6) - ..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 was not met as evidence by** Based on interviews with Administrator and a review of resident R1 medical and facility records, it was found that facility failed to ensure proper supervision resulting in R1 left unsupervised, causing unwitnessed fall and injury in the facility courtyard. This serves as an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Facility failed to ensure that proper care and supervision were provided to resident R1. Administrator agrees to submit updated plan of action on how staff are to provide adequate supervision for all residents during evening hours. Written statement to be submitted to CCLD by POC date 4/28/2024. Civil Penalty issued for a total of $250 for repeat violation.

Type of visit: Case Management - Other

On 2/13/2024, Licensing Program Analyst, Tobola arrived unannounced for the purpose of a case management for additional updates on facility plan of corrections and to amend a report from a previous visit and was greeted by Acting Administrator, Juliet McGranahan. LPA will need to conduct a visit at a later date to finalized amended report. LPA and Acting Administrator held a discussion with the company clinician and Health Services Director. The party discussed the current plan of developing improved practices for medication assistance and record keeping. The facility was informed that to provide documentation to CCLD for any changes to the facility program plan and protocols. In addition, LPA provide an update on the delivery for new laundry machines to replace the current ones. Lastly, Administrator stated that the facility corporation will not be moving forward with the Technical Support Services at this time. No deficiencies cited.the state’s words, verbatim · CDSS document, Feb 13, 2024

Allegation investigated: Lack of supervision Staff did not safeguard residents' belongings

On 1/24/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Acting Administrator, Juliet McGranahan. LPA toured the facility, interviewed staff, reviewed resident records, reviewed medication records and made observations during the course of the investigation. Complaint alleges lack of supervision regarding staff sleeping while on duty. LPA was provided photos of what appears to be a caregiving staff sitting in a chair with their arms crossed. However, it is undetermined if staff's eye were closed or sleeping while on duty. Upon interviews with staff (S1, S3 & S4), LPA found that several staff have witnessed other caregiving staff to be sleeping while on duty during both afternoon and overnight shifts. Based on statements consistent with photo evidence pertaining to concerns, the allegations is found to be substantiated. Continued onto LIC9099-C Substantiated Complaint alleges facility did not safeguard residents' belongings. Based on interviews with multiple staff (S1, S3 & S4) it was consistently indicated that residents clothing are often shared due to soiled clothing in need of cleaning. This ultimately resulted in the facility being unable to properly maintain and safeguard resident belongings, therefore the allegation is found to be substantiated. Allegations, lack of supervision and staff did not safeguard residents' belongings are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Complaint alleges staff did not ensure that residents were appropriately dressed for hot weather. Based on a tour of the facility and LPA observations, residents under care were found to have appropriate clothing on and appear to be comfortable. Based on interviews with staff (S1, S2, S3 & S4) there was no indication of residents being dressed inappropriately based on weather conditions and temperatures, therefore the allegation is unsubstantiated. Complaint alleges staff did not seek a resident medical attention for resident with a resident (R2) who was observed by Reporting Party to have skin picking behaviors resulting in R2 bleeding. Based on a review of records, the facility has documented and is aware of R2 behavior, indicating changes of condition and clearly documenting progress notes for when R2 was observed to be bleeding from skin picking. In addition, staff are documented to have provided 1st aid and cleaning to tend to R2's scratches. Due to a lack of corroborating evidence the allegation is unsubstantiated. Complaint alleges facility violated residents' personal rights regarding staff yelling or speaking inappropriately to residents in care. Based on interviews with staff (S1, S2, S3 & S4) and Reporting Party, there is not enough corroborating evidence supporting the allegation. Based on LPA observations and tours of the facility, there were no observed occurrences of this behavior from staff, therefore the allegation is unsubstantiated. A finding that the complaint allegations, general food requirements not met, staff did not ensure that residents were appropriately dressed for hot weather, staff did not seek a resident medical attention & facility violated resident personal rights are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jan 24, 2024 · control 21-AS-20231113154439

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 31, 2024

87411 (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This was not met as evidence by: Based on photo evidence and interviews with multiple staff, LPA found that caregiving staff have been witnessed to be asleep during their shifts which serves as a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Facility agrees to submit plan of action on how to ensure staffing is sufficient and providing adequate supervision for residents in care. Plan of action to be submitted to CCLD by POC date 1/31/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Feb 29, 2024

Safeguards for Resident Cash, Personal Property and Valuables: Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables.. This was not met as evidence by: Based on interviews with multiple staff, LPA received consistent information regarding resident clothing being shared amongst each other due to inaccessible clothing (soiled or requiring replacement). This serves as a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Facility agrees to submit plan of action on how to ensure resident personal clothing items are sufficient and maintained. Plan of action to be submitted to CCLD by POC date 1/31/2024. In addition, facility is to ensure all laundry machines pending repair or replacement have been resolved. Proof of Corrections Form LIC9098 confirming laundry machines for each cottage are functioning by POC due date 2/21/2024.

Allegation investigated: Neglect/Lack of supervision of resident's incontinence care resulting in pressure injury

On 1/24/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Acting Administrator, Juliet McGranahan. LPA Tobola toured the facility, interviewed staff and outside parties, reviewed resident records and made observations during the course of the investigation. Complaint alleges neglect/Lack of supervision of resident's incontinence care resulting in pressure injury. Based on a review of resident (R1) records, LPA found that R1 had a history of skin breakdown and entered the facility with wounds on R1's heel and groin area as noted on R1's assessment for admission. R1 was found to be admitted on 10/13/2023. Upon review of R1's progress notes it was indicated that on 11/11/2023, staff observed a wound on R1's coccyx area. The wound in this area was not present prior to R1's admission. Continued onto LIC9099-C Substantiated Based on interviews with Reporting Party, and multiple outside parties (I2, I3 & I4) LPA found statements to be consistent with observations regarding resident R1 being left in soiled continence care products. In addition, (I4) indicated concerns of R1 being left in bed a majority of the time while in the facility, with staff not properly equipped to use hoyer lift for R1's mobility and repositioning. I4 also stated having observed a lack of repositioning, encouraging mobility and continence care not properly provided, resulting in R1 developing additional pressure sore while under the facility's care. Allegation, neglect/lack of supervision of resident's incontinence care resulting in pressure injury is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. This is an amendment of the original report to indicate civil penalty language and amount correction** LPA issued Civil Penalty at a total amount of $250 for repeat violation within a 12 month period for regulation 1569.625(b)(2).the state’s words, verbatim · CDSS document, Jan 24, 2024 · control 21-AS-20231120113822

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269 · Plan of correction due date: Feb 25, 2024

Enumerated rights; severability-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 was not met as evidence by: Based on observation, records review & interviews, the licensee did not comply with the section cited above involving resident R1's needs not being met resulting in development of pressure sore while under facility care which poses an immediate health & safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Facility failed to ensure staff were sufficient and competent to provide necessary services to meet resident needs. Administrator is to implement a vendorized training for all staff that provide resident care on continuous bedridden care, continence care and other topics pertaining to meeting resident physical care requirements. Training date is to be submitted to CCLD by POC date 1/25/2024. Completed training log signed by all staff is to be submitted to CCLD by POC date 2/8/2024. This is an amendment of the original report to indicate civil penalty language and amount correction** Civil penalty of $250 issued for repeat violation within a 12 month period for regulation 1569.625(b)(2).

Allegation investigated: Staff do not follow infection control protocols.

On 1/9/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating complaint investigation and was greeted by Regional Director of Operation, Julie Mason and Acting Executive Director Juliet McGranahan. LPA toured the facility, interviewed staff, reviewed facility protocol records and made observations. Complaint alleges staff do not follow infection control protocols allowing COVID positive staff to work, as well as allowing COVID positive residents to move around facility openly. Based on a review of facility COVID protocol records, it is indicated that essential staff can return to work before 5 days of isolation with a negative test within 24 hours of returning, at least 24 hours passed since last fever or if other symptoms have improved. COVID positive staff can provide care for COVID+ residents. LPA unable to find any corroborating evidence of facility acting against the staffing COVID protocol in place. Continued onto LIC9099-C Unsubstantiated In addition, facility COVID protocols indicate that, if an individual tests positive for COVID-19 they must isolate with transmission-based precautions and staff providing care must wear appropriate PPE. It also states that isolation can end after day 5 if: - Symptoms are not present, or are mild and improving; AND - Individual is fever-free for 24 hours Interviews with lead medtech and nursing staff (S1, S2 & S3) were found to be consistent indicating that staff followed protocol to isolate COVID positive residents as well as encourage the use of masking. However, based on residents' diagnoses of Alzheimer's or Dementia as the facility is a full memory care unit, resident were often unable to follow or refused guidance or isolation techniques. S1, S2 & S3 stated that additional protocols of adjusting meal and activity times for better mitigation were implemented. Due to a lack of corroborating evidence and conflicting information, the allegation is found to be unsubstantiated. A finding that the complaint allegation staff do not follow infection control protocols is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiency cited.the state’s words, verbatim · CDSS document, Jan 9, 2024 · control 21-AS-20231205102935

Allegation investigated: Lack of supervision resulted in resident sustaining injuries

On 1/9/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating complaint investigation and was greeted by Regional Director of Operation, Julie Mason and Acting Executive Directer Juliet McGranahan. LPA toured the facility, interviewed staff, reviewed facility records and made observations. Complaint alleges lack of supervision resulted in resident sustaining injuries. Based on review of facility records and interview with Acting Administrator, it was found that resident (R1) residing in the Wilson House had sustained injuries after an unwitnessed inicident. R1 was observed by staff (S1) to have fallen out of their wheelchair causing slight bleeding to R1's forehead. Upon interviews with multiple staff (S1, S2 & S6) it was confirmed that S1 was the only staff present at the time the incident. S1 was found to be assisitng another resident, without additional staffing support or supervision for several other residents in the Wilson House due to shift changes and meal break conflicts. Continued onto LIC9099-C Substantiated Allegation, lack of supervision resulted in resident sustaining injuries is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. A finding that the complaint allegation facility has inadequate supplies is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED No deficiency cited.the state’s words, verbatim · CDSS document, Jan 9, 2024 · control 21-AS-20240102083909

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269 · Plan of correction due date: Jan 10, 2024

Enumerated rights; severability-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 was not met as evidence by:** Based on LPA interviews with Acting Administrator, staff, review of records and observations, it was found that resident R1 sustained an unexplained injury on 12/31/2023 due to several residents not properly supervised. This is an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2024

Plan of correction: Facility agrees to provide written plan on how they will remain in compliance with the regulations and H&S Codes and meeting staffing expectations. Plan to be submitted to CCLD with LIC9098 Plan of Corrections by POC date 1/10/2024.

Allegation investigated: Staff did not properly manage residents medications Staff failed to keep facility clean, safe, and sanitary Residents hygiene needs are not being met

On 12/20/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by the Resident Service Director, Rolinda Noquillo. LPA toured the facility, interviewed staff and outside parties, reviewed outside agency medication reports and made observations. Complaint alleges staff did not properly manage residents' medication. Based on LPA observations and medication audit report review and interview with Omnicare Pharmacy Nurse (N1) it was found that medical technician staff are not properly following protocol for medication management. N1 indicated that staff (S2) was observed directly administering medication to residents' tongue/mouth where resident's are to be self-administered. In addition, There were several medications were observed to be expired and not properly disposed. Lastly, staff were observed pre-pouring medications when protocols listed in medication rooms indicate requirement for live dispensing and prohibits pre-pouring. Continued onto LIC9099-C Substantiated Staff failed to keep facility clean, safe, and sanitary. Based on a tour of the facility, photo evidence and LPA observations, it was found that resident living areas are not properly cleaned or maintained. LPA observed urine on resident bedroom floor next to bed and commode. Urine was observed on multiple resident communal toilet seats uncleaned by staff (photos taken). In addition, LPA received photo evidence of feces on the floor of resident living areas and on resident toilet seats. Complaint alleges residents hygiene needs are not being met. Based on interview with home health agency staff (H1) it was indicated that staff had left resident (R2) soiled on multiple occasions. In addition, LPA received photo of evidence of several instances where resident (R1) was left in urine soiled clothing while resident common areas. Allegations, staff did not properly manage residents medications, staff failed to keep facility clean, safe, and sanitary & residents hygiene needs are not being met are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Dec 20, 2023 · control 21-AS-20231113154439

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 21, 2023

The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by:** Based on review of Omnicare Pharmacy medication audit conducted 12/20/2023 and interview with Omnicare Nurse (N1) it was found that staff (S2) was observed inappropriately administering medications directly into residents' mouths/tongue when staff are to only provide assistance with self-administering. This serves as an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Licensee failed to ensure staff are completing medication protocol in compliance with Title 22 regulations. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023. In addition, Licensee is to conduct medication administration training for all medtech staff. Completed and signed training to be submitted to CCLD by POC date 1/4/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Dec 20, 2023

Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This was not met as evidence by:** Based on Omnicare Pharmacy audit it was found that the facility staff have not properly processed or disposed of several expired medication. This serves as potential health & safety risk.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: License failed to ensure resident medication is properly maintained. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023. In addition, Licensee is to submit a LIC9099 Proof of Corrections Form self-certifying that all expired or discontinued medications are disposed of in a proper manner. LIC9099 to be submitted to CCLD by POC date 1/4/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f) · Plan of correction due date: Dec 20, 2023

87464(f) - Basic services shall at a minimum include care and supervision as described in Health and Safety Code section 1569.2(c). These requirements were not met as evidenced by:** Based on interview with home health agency (H1) it was found that H1 had observed resident R2 left in soiled continence care on multiple occasions. In addition, based on photo evidence, resident R1 was observed to be left in soiled clothing on multiple occasions. This serves as an immediate health & safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Licensee failed to ensure residents were provided proper basic services. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87393(a) · Plan of correction due date: Jan 4, 2024

87303(a)-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidence by:** Based on tour of the facility, LPA observation and photo evidence it was found that the facility was not in safe or sanitary condition. Urine was observed uncleaned on resident bedroom floors, bathrooms as well as photo evidence indicating feces in common areas. This serves as a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Licensee failed to ensure facility was in a clean, safe and sanitary condition. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023.

Allegation investigated: Staff do not ensure that residents are provided care in a timely manner. Staff do not ensure that residents receive their medication(s) as prescribed.

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pacifica Senior Living Vacaville for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Noel Factor, and was granted access into the facility. During the course of the investigation, LPA Sarangi interviewed staff and a sample of residents. LPA reviewed a sample of Medication Administration Record (MAR) for 5 residents in care and reviewed facility documents. LPA conducted a tour of the facility on October 10, 2023. Complaint alleges that Staff do not ensure that residents are provided care in a timely manner. Based on the interviews that were conducted, LPA could not prove or disprove the allegation. LPA reviewed the staff and resident roster and found those to be appropriate. (Report continued on LIC 9099C) Unsubstantiated LPA reviewed the Staff Schedule and found that to be appropriate. LPA interviewed staff members that care for residents which yielded no additional information to corroborate the allegation. LPA conducted a tour of the facility on October 10, 2023 and found staff caring for the residents in a timely manner. Furthermore, activities were being conducted on said date. Complaint alleges that Staff do not ensure that residents receive their medication(s) as prescribed. Based on a Medication Administration Record (MAR) review of a sample of resident medications, LPA could not corroborate the allegation. In addition, LPA could not prove or disprove the allegation. A finding that the complaint allegation of Staff do not ensure that residents are provided care in a timely manner and staff do not ensure that residents receive their medication(s) as prescribed are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Nov 17, 2023 · control 21-AS-20230918111148

Allegation investigated: Staff does not ensure facility has sufficient lighting for residents in care.

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pacifica Senior Living Vacaville for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Noel Factor, and was granted access into the facility. During the course of the investigation, LPA Sarangi interviewed staff and a sample of residents. LPA conducted a tour of the facility on October 10, 2023. Complaint alleges that Staff does not ensure facility has sufficient lighting for residents in care. Based on interviews that were conducted, LPA could not prove or disprove the allegation. LPA conducted a tour of the facility on October 10, 2023, and found that the facility was well lit. Furthermore, LPA reviewed the electricity bill for the facility and found that the facility is up to date with the billing. (Report continued on LIC 9099C) Unsubstantiated A finding that the complaint allegation of Staff does not ensure facility has sufficient lighting for residents in care is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Nov 17, 2023 · control 21-AS-20230920100813

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the Annual Inspection at Pacifica Senior Living on 11/09/2023. LPA and Administrator Noel Factor inspected the facility and found the facility clean and odor-free. Residents were engaged in different activities throughout the community: arts and crafts, gardening, games, walking and socializing in each of the cottage great rooms. Snacks were being enjoyed in the courtyard during LPA's visit, and 50's music was being played. Kitchens were inspected and found to be clean and well-organized. Sharps were locked and inaccessible to residents. 4 of the 5 kitchens were having maintenance on kitchen sinks, but did not impact the residents. Shower rooms were equipped with shower chairs, non-skid mats and shower curtains for privacy. Living rooms were decorated attractively and clean, providing a homey feel to the facility. At the time of visit, LPA found the staff cheerful and interactive with residents. LPA reviewed 5 staff files and found them to be complete. No citations issued.the state’s words, verbatim · CDSS document, Nov 9, 2023

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct an Annual Required inspection and was greeted by Administrator Noel Factor. LPA and Administrator toured the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents' rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. There were fire extinguishers throughout the facility, all that were inspected were fully charged and tested 07/24/2023. Fire Dept. conducted inspection on 11/7/2023. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Administrator Certificate #6039807740 for Noel Factor expires on 08/16/2024. Medications were reviewed, centrally stored and locked. LPA reviewed five residents' files, all residents files have a current medical assessment and care plans updated within the last 12 months. LPA will continue Annual Inspection to review personnel files at a later date. Exit interview was conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 7, 2023