Valley Comfort #5

Allegation investigated: Staff did not ensure medical treatment was provided to resident in a timely manner

**This report is a copy of the previous report, but with attached D-Page.** Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to deliver findings of a complaint investigation, LPA Met with Administrator (ADM) Nick Gaither to explain the purpose of the visit. During the investigation LPA conducted interviews and reviewed hospital records and R1s facility file. Interview with S1 and the ADM revealed that on 2/26/26 R1had an unwitnessed fall and was discovered on the ground with a laceration on the cheek. According to interview with S1, they contacted the Responsible Party whom is identified by the faclility as having Durable Power for medical decisions (DPoA) whom refused the facilities suggestion to seek medical assessment such as calling 911. On 02/27/26 per the Unusual Incident Report submitted to CCL, and interview with S2, S2 and the administrator chose to send the R1 out for evaluation of the previous day's injury in response to a complaint of pain by R1. R1s LIC602 documents resident is unable to make needs known. Interview with the Reporting Party revealed that suture care would have been applied if R1 had come in to the hospital the previous day. Continued on c Page Substantiated **This report is a copy of the previous report, but with attached D-Page.** Additionally in record review of the DPOA agreement from the time of the incident, the DPoA was not signed by a doctor indicating it was active. DPOA should not be presumed active, and needs a doctors written order following an assessment of the client to become active. PIN 25-07ASC AUTHORITY OF CONSERVATORS AND AGENTS UNDER POWERS OF ATTORNEY RELATED TO CLIENTS’ RIGHTS and PIN 25-06 ASC CALLING 9-1-1 IN RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE) were provided during todays visit as reference. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations is being cited on the seperately attached 9099, LIC 9099D. Licensee expressed that the is a Dr's Note that would explain the DPOA being estaablished, and that the facility did act appropriately in supplying timely medical attention, such as with offering medical transport assistance, and were it not for the DPOA's resistance to the care, would have reached an outcome where timely medical attention was delivered. A copy of the report was read and given to the administrator, a copy of the appeal rights were provided. an exit interview conducted.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 27-AS-20260227144413

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87645(a)(1,2) · Plan of correction due date: Jul 9, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement was not followed as evidenced by: Based record review and interviews with administrator and 1 staff that the presumed DPOA refused ER services for the client, and the facility sought medical attention the following day when R1 complained of pain. Not following this requirement poses an immediate risk to the health and safey and personal rights of a client in carethe state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: No Immedate, POC. Licensee will put the 2 pins on quaterly staff training for communicating the need for send out for evaluation/radiology to the family, that will be taking place in two weeks. 7/22/26

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility unannounced to deliver an ammendement to a report, a copy of that report with attached d page, appeal rights, and two pins. LPA met with the administrator nick gaither to explain the purpose of the visit LPA discussed the above items with the administrator, left his information for further questions. noel.wolfpetersen@dss.ca.gov facility is in good repair, clean at the time of the visit. A copy of the report was read and given to the administrator. no citations were attached to this visit, 1 citation was issued with the previous report. exit interview was conducted.the state’s words, verbatim · CDSS document, Jul 8, 2026

Allegation investigated: Staff did not ensure medical treatment was provided to resident in a timely manner

**This report is amended to include details and reasoning for a substantiated finding, rather than an unsubstantiated finding, meaning that the evidence collected suggests, more likely than not, that the facility failed to provide timely medical treatment to a client in care.** Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to deliver findings of a complaint investigation, LPA Met with Administrator (ADM) Nick Gaither to explain the purpose of the visit. During the investigation LPA conducted interviews and reviewed hospital records and R1s facility file. Interview with S1 and the ADM revealed that on 2/26/26 R1had an unwitnessed fall and was discovered on the ground with a laceration on the cheek. According to interview with S1, they contacted the Responsible Party whom is identified by the faclility as having Durable Power for medical decisions (DPoA) whom refused the facilities suggestion to seek medical assessment such as calling 911. On 02/27/26 per the Unusual Incident Report submitted to CCL, and interview with S2, S2 and the administrator chose to send the R1 out for evaluation of the previous day's injury in response to a complaint of pain by R1. R1s LIC602 documents resident is unable to make needs known. Interview with the Reporting Party revealed that suture care would have been applied if R1 had come in to the hospital the previous day. Continued on c Page Substantiated **This report is amended to include details and reasoning for a substantiated finding, rather than an unsubstantiated finding, meaning that the evidence collected suggests, more likely than not, that the facility failed to provide timely medical treatment to a client in care.** Additionally in record review of the DPOA agreement from the time of the incident, the DPoA was not signed by a doctor indicating it was active. DPOA should not be presumed active, and needs a doctors written order following an assessment of the client to become active. PIN 25-07ASC AUTHORITY OF CONSERVATORS AND AGENTS UNDER POWERS OF ATTORNEY RELATED TO CLIENTS’ RIGHTS and PIN 25-06 ASC CALLING 9-1-1 IN RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE) were provided during todays visit as reference. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations is being cited on the seperately attached 9099, LIC 9099D. Licensee expressed that the is a Dr's Note that would explain the DPOA being estaablished, and that the facility did act appropriately in supplying timely medical attention, such as with offering medical transport assistance, and were it not for the DPOA's resistance to the care, would have reached an outcome where timely medical attention was delivered. A copy of the report was read and given to the administrator, a copy of the appeal rights were provided. an exit interview conducted.the state’s words, verbatim · CDSS document, May 21, 2026 · control 27-AS-20260227144413

Allegation investigated: Resident sustained an injury while in care as a result of an un-witnessed fall Staff did not ensure reporting requirements were followed

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a complaint investigation into the above allegations, met with the administrator Nick Gaither to explain the purpose of the visit. Resident had a fall with a neck/femur fracture from before admission 2/6/26, however the recent 602, does have elements checked that do not support a resident need related to transferring and they are also noted as "supervised". Discharge documents have indepenedant and amulatory checked on a report from 2/6/26. interviews with the staff doing observation of the resident don't comport with a high fall risk prior to the 2/26/26 fall. Resident was not a monitoring system for the time of the fall, now staff observations and 1:1 walking assistance from a staff 2-3 times a day, staff get trained once a year with inservice(July) about fall type risks/ambulating for care and supervision. Supplemental trainings as needed are provided. Resident reported in interview a weakness in the legs, but overall not concerned with unmet mobility needs as she has staff assistance. Resident did sustain an injury as a result of an unwitnessed fall, its not strongly supported that the fall risk was something known or should have been known to the facility prior to the fall. continued on c page. Unsubstantiated CCLD was notified on 3/4/26, which would be within 7 days of the initial occurrence. Residents family was notified same day. Both notifications are within the timelines in regulation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. LPA gave guidance that if the needs and services of the client have changed(leg weakness/ ambulation assistance), it is time to get an updated 602 for the client. probably a conversation with the doctor about medical devices, walkers/alarms. A copy of the report was given to the administrator, no citations were given, an exit interview was conducted.the state’s words, verbatim · CDSS document, May 14, 2026 · control 27-AS-20260227144413

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: Required - 1 Year

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct one year required annual visit. LPA Lund met with Administrator Nick Gaither and explained the purpose of the visit. Census: 63 LPA Lund and Administrator Nick Gaither inspected the physical plant including assisted living unit, memory care unit, resident bedrooms, resident bathrooms, medication room, medication cart, dining area, kitchen, laundry room and outside perimeter of the care community. The common areas of the community to be free of odor and clean. The rooms in assisted living unit and rooms in the memory care unit were in compliance. The facility had sufficient furniture and lighting throughout the facility and inside resident rooms. There are no bodies of water present in the facility. The kitchen and dining room area were observed along with 7- day non-perishable and 2-day perishable food on hand, while proper food preparation and storage was observed as well. Smoke detectors are hard wired, and fire extinguishers (5/7/2025) are current and in compliance with the fire safety code. Facility has a built-in sprinkler system and has yearly inspections and tests. The medications were centrally stored. The toxins, knives, and sharp objects are kept locked and inaccessible to clients. LPA Lund reviewed four staff and four residents’ files and were in compliance. No deficiencies cited during this visit. Exit interview copy report left.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a case management visit. LPA met with Administrator Nick Gaither and explained the reason for the visit. Census: 62 LPA Lund and spoke Administrator Nick Gaither regarding staff (S1) has not worked at the facilities since December 2023. No deficiencies were cited during the visit. An exit interview and report left.the state’s words, verbatim · CDSS document, Jul 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct one year required visit. LPA Lund met with Administrator, Nick Gaither and explained the purpose of the visit. Census: 58 LPA Lund and Administrator Nick Gaither toured/inspected the physical plant including assisted living unit, memory care unit, resident bedrooms, resident bathrooms, medication room, medication cart, dining area, kitchen, laundry room and outside perimeter of the care community. LPA Lund observed the common areas of the community to be free of odor and clean. LPA Lund inspected rooms in assisted living unit and rooms in the in the memory care unit. Sufficient furniture and lighting was observed throughout the facility and inside resident rooms. There are no bodies of water present in the facility. LPA Lund inspected the kitchen and dining room area and observed 7- day non-perishable and 2-day perishable food on hand, while proper food preparation and storage was observed as well. Smoke detectors are hard wired, and fire extinguishers (6/11/2024) are current and in compliance with the fire safety code. Facility has a built-in sprinkler system and has yearly inspections and tests. LPA Lund observed that centrally stored medications, toxins, knives, and sharp objects are kept locked and inaccessible to clients. LPA Lund reviewed three staff and five residents’ files and were in compliance. No deficiencies cited during this visit. Exit interview copy report left.the state’s words, verbatim · CDSS document, Jan 22, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct annual/required visit. LPA Lund met with Administrator, Nick Gaither and explained the purpose of the visit. Census:61 LPA Lund and Administrator Nick Gaither toured/inspected the physical plant including assisted living unit, memory care unit, resident bedrooms, resident bathrooms, medication room, medication cart, dining area, kitchen, laundry room and outside perimeter of the care community. LPA Lund observed the common areas of the community to be free of odor and clean. LPA Lund inspected rooms in assisted living unit and rooms in the in the memory care unit. Sufficient furniture and lighting was observed throughout the facility and inside resident rooms. There are no bodies of water present in the facility. LPA Lund inspected the kitchen and dining room area and observed 7- day non-perishable and 2-day perishable food on hand, while proper food preparation and storage was observed as well. Smoke detectors are hard wired, and fire extinguishers are current and in compliance with the fire safety code. Facility has a built-in sprinkler system and has yearly inspections and tests. LPA Lund observed that centrally stored medications, toxins, knives, and sharp objects are kept locked and inaccessible to clients. LPA Lund reviewed four staff and four residents’ files and were in compliance. No deficiencies cited during this visit. Exit interview held with Administrator, Nick Gaither, and a copy of this report given.the state’s words, verbatim · CDSS document, Dec 27, 2023