Valle Verde

Allegation investigated: Staff did not respond to residents calls for assistance timely. Staff did not ensure the door in memory care works properly.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to deliver final findings for the above-stated allegations. During today’s visit, LPA met with Mark Hansen, Executive Director; and Tracie Fairley, Associate Executive Director. LPA explained the purpose of the visit. LPA Kontilis conducted the initial visit on 3/25/2026 from approximately 12:40 pm – 5:30 pm at which time LPA conducted interviews and obtained documents pertaining to the investigation. LPA conducted additional interviews on 7/3/2026, 7/6/2026, and 8/25/2026. On the allegation, staff did not respond to residents’ calls for assistance timely: Reporting Party voiced concern that there was no staff on duty in the independent, assisted living and/or memory care units of the facility on one particular night with no response to emergency pendants throughout the night. Administrator Williams stated residents wear a pendant around their neck as a necklace and when the pendant is pressed, it is a call for assistance and/or help. Administrator Williams stated the care partners wear a pager and care partners are assigned to specific residents. Administrator stated when a resident Please continue to 9099-C, Pg 2. Substantiated presses their pendant, it sends an alarm to the care partner who is assigned to that resident. Administrator stated the pager identifies the resident by the resident’s name, their room number and their location even if the resident is not in their designated room. Administrator stated the time responding to residents’ calls should be within 10 minutes – 15 minutes and if a care partner cannot respond timely, they will call another colleague to assist the incoming call. Records reviewed and interviews conducted revealed on 3/15/2026 a call pendant was pressed at 7:12 pm sending an alarm for assistance to care staff in the Assisted Living area of the community. The call was cleared at 7:40 pm. Records reviewed revealed the duration of time from when the alarm was initiated until it was cleared was 28 minutes, 1 second. The allegation, Staff did not respond to residents’ calls for assistance timely is deemed Substantiated at this time. While the allegation is Substantiated, a deficiency will not be cited as the deficiency has been cited on this day on Complaint Investigation Report #29-AS-202608115226. On the allegation, staff did not ensure the door in Memory Care works properly: Reporting Party voiced concern that the door in Memory Care is not working properly resulting in resident(s) leaving the locked Memory Care facility without supervision. Interviews conducted revealed Resident 1 (R1) left the secured memory care unit unassisted and without supervision and was found in another resident’s room a far distance from the memory care unit. The Memory Support Manager located R1 and brought R1 back to their living area. It was later determined that R1 exited the building through the Memory Care “white door” which leads through the Assisted Living area. Interviews conducted revealed Resident 2 (R2) exited the Memory Care unit through the “white doors”. Interviews conducted revealed R2 was observed walking down the hall of the Assisted Living unit, staff followed R2, and returned R2 to the Memory Care unit. Records reviewed revealed Estimate #2409 for repairs and replacement of the white door leading between Memory Care and Assisted Living. Based on interviews conducted and records reviewed, the staff did not ensure the door in Memory Care works properly allowing residents to leave the Memory Care unit unsupervised is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted. Copy of report issued at the time of the visit. Appeal Rights issued.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 29-AS-20260319092319

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 28, 2026

Basic Services (f) Basic services shall at a minimum include:(1) Care and supervision as defined ... This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, when R1 exited from the memory care unit of the facility without supervision and R2 wandered from the Memory Care Unit into the Assisted Living area which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: Executive Director/Associate Executive Director state the doors have been repaired and keypads function properly and new keypads will be arriving within the next 14 days. POC cleared at the time of the visit.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20260319092319. The Case Management visit is being conducted to address CCLD’s concerns that were observed during the course of the investigation. LPA Kontilis met with Mark Hansen, Executive Director, Tracie Fairley, Associate Executive Director, and Dania Williams, Manager of Assisted Living. During the complaint investigation, record review revealed Executive Director Hansen has received a criminal background clearance, however, has not been properly associated to the facility. LPA Kontilis reviewed Licensing Information System, Facility Personnel Report Summary. At approximately 4:27 pm, LPA confirmed Executive Director Hansen has not been properly associated to the facility and has been working in the facility since December 8, 2025. During today’s visit, LPA noted the facility’s administrator on record was no longer working at the facility since (on or about) February 6, 2026. LPA Kontilis informed Executive Director that the facility has not received written notification and/or documents naming the new administrator on record. Executive Director stated the facility is currently operating under the Residential Care for the Elderly (RCFE) Certification for Manager of Assisted Living. LPA Kontilis confirmed Manager of Assisted Living’s RCFE certification is current as of 1/31/2025. During today’s visit, the facility will be issued a citation for not meeting the reporting requirements of submitting the documents of change of administrator within 30 days. The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil penalty issued. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.the state’s words, verbatim · CDSS document, Mar 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 26, 2026

87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)… This requirement is not met as evidenced by: Based on interviews conducted and record review, the licensee failed to comply with the section cited above when Executive Director was not properly associated to the facility prior to working, residing and/or volunteering in the facility which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: Administrator agrees to have Executive Director properly associated to the facility no later than POC due date (3/26/2026). Civil Penalty Assessed

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(g) · Plan of correction due date: Mar 30, 2026

87211(g) Reporting Requirements: The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator… This requirement is not met as evidenced by: Based on record review and interviews conducted, the Licensee failed to comply with the section cited above when CCLD was not notified in writing of a change in administrator and proper paperwork was not submitted to the Department within 30 days which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: Administrator agrees to complete and submit change of administrator documents via email to LPA no later than POC due date (3/30/2026).

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Incident visit. LPA Kontilis met with Susie Ponce, Administrator at approximately 11:45 am and explained the purpose of the visit. On 12/17/2025, Community Care Licensing Division (CCLD) received a self-reported LIC624A Death Report pertaining to Resident 1 (R1) who passed away on 12/12/2025 at approximately 3:15 pm. During today’s visit, LPA Kontilis obtained documents pertaining to the investigation and conducted an in-person interviews with Administrator and staff between 12:25 pm and 1:55 pm. During the visit, LPA did not observe any immediate health or safety concerns. Further investigation is needed. The LPA will return at a later date to continue the investigation. No deficiencies noted during today’s visit. Exit interview conducted. Copy of report was issued.the state’s words, verbatim · CDSS document, Dec 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Susan Ponce, Wellness Director and explained the purpose of the visit. The facility is a Continuing Care Retirement Community (CCRC) that consists of Independent Living, Assisted Living, and Memory/Dementia Care. The facility is licensed for a capacity of 547 residents of which there can be 82 non-ambulatory in Independent Living, 29 non-ambulatory in Assisted Living; and 18 non-abulatory residents in Memory/Dementia care. Currently there are 16 residents residing in Memory Care; 27 residents residing in Assisted Living; and 315 residents residing in Independent Living. There are 5 residents currently on hospice. Entrance interview conducted. LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings throughout the facility were checked. The facility was seen to be in good repair inside and outside. LPA observed two fire extinguishers last serviced on 6/26/2025, one fire extinguisher last serviced on 6/3/2025, and four fire extinguishers last serviced on 5/19/2025. There is a fire pull alarm system with pull alarms throughout the facility. The pull alarms ring directly at the local fire department. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Residents participate independently in holiday and birthday celebrations, current event discussions, live entertainment, physical exercise and activities, and outings to parks, restaurants, museums, theaters, sports activities, and other local attractions. Please continue to 809-C, Pg 2. Entrance into the facility is through the Administration building where several offices are located including Executive Director, Wellness Director, Human Resources, Finance, and Chaplain. The Independent Living area is approximately 60 acres with approximately 250 cottages throughout the campus. The Assisted Living area has 26 apartments located adjacent with 17 memory care apartments within the building. There are walkways throughout the residential areas with close proximity to the dining area, salon, a campus store and recreation area. Residents’ apartments have outdoor patios and private bathrooms. LPA observed bathrooms with non-skid flooring and secure grab bars. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs). All persons associated with the facility have criminal record clearance. Administrator certificate is valid. Staff files reviewed had criminal record statements, health screenings, current first aid certificates, and all required training. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Case Management - Other

On 08/06/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced case management visit to follow up on an immediate exclusion order issued 07/11/2024 for Staff #1 (S1). LPA met with Director of Human Resources Jenny Firth and explained the purpose of the visit. LPA reviewed the facility’s fingerprint clearance roster and observed S1 was still associated to this facility as of the date of this visit. S1 had been originally associated to with the facility on 05/30/2024, and remained associated according to multiple Licensing Agency background check system(s). Director of Human Resources Jenny Firth disassociated S1 from the facility fingerprint roster during this Confirmation of Removal Case Management visit. The Director of Human Resources stated S1 had not been physically present in the facility since 07/16/2024, the date when the exclusion order was received by the Licensee. LPA interviewed other staff in the facility who confirmed S1 had not been present recently. LPA reminded the Director of Human Resources that any further presence of S1 in the facility or interacting with clients violates the exclusion order and the facility could be subject to deficiencies and civil penalties if they do not abide by the order. Exit interview conducted. Copy of report provided to the facility.the state’s words, verbatim · CDSS document, Aug 6, 2024

Type of visit: Required - 1 Year

On 08/06/2024 Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct a required annual facility site inspection visit at the facility above. When the LPA arrived, they were greeted by DIrector of Human Resources Jenny Firth as the facility administrator was not available, and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This facility is a Continuing Care Retirement Community (CCRC) that consists of assisted living segment, memory care/dementia unit, and independent living segment. The facility has waivers for Hospice and Dementia, housing both non-ambulatory and ambulatory residents. KITCHEN(S): The facility has a main kitchen for residents of the facility in the main kitchen/dining room building. The main kitchen serves residents in the assisted living and memory care segments of the facility, as those areas have dining rooms, but no full kitchens. There is a separate kitchen in a facility restaurant building connected to the resident pool area. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in the kitchen are inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last up to a week or longer as observed by the LPA. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. Heating devices such as stoves are inaccessible to residents, as are sharps/other items that could constitute a danger to residents. The kitchen was clean and sanitary, with covered trash cans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. Continued on 809-C COMMON AREAS: At the time of the visit, the main lounge(s) and dining room(s) were observed to be appropriately furnished, with all furniture in good condition. There are lounge areas/breakout areas for residents in the different facets of the facility including assisted living, independent living, memory care, and dementia care that are appropriately furnished, with all furniture being in good condition. There are multiple fireplaces on the premises, which were all covered and inaccessible. There are pianos in the common areas of the facility in good repair and operating condition. There are operating aquariums in different portions of the facility that are in good operating condition. The facility maintains a resident mail room, resident operated thrift store open to the public, a resident convenience store, fitness center for residents, and resident clinic. The facility maintained a comfortable temperature in all individual buildings inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit in each of the buildings inspected. The fire extinguishers in all buildings inspected were fully charged and are observed by LPA to be serviced annually. The LPA observed required postings throughout all common spaces including Resident Personal Rights, Resident Council Rights, and Residential Care Facility for the Elderly (RCFE) Complaint Poster(s). There are activity supplies and equipment, including reading materials for the residents in all common areas inspected. All window screens were in good repair in all of the buildings comprising the facility. There is appropriate lighting in all of the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all stairways are well-lit with sturdy hand railings/stair chair accessibility devices. As the facility has more than 16 residents with multiple buildings and multiple stories, there is a signal system in place which was functional at the time of the inspection by the LPA. This required annual facility site inspection cannot be completed on the initial inspection date of 08/06/2024. A Case Management – Annual Continuation will need to be completed at a later date. Exit interview conducted. A copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Aug 6, 2024