Valley Pines

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Administrator James Heinan. During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured 6 resident living units. LPA observed each living unit had available bedding and clothing storage areas and working lights. The bathrooms had working lights and available soap and paper towels. LPA observed the water temperatures in the bathroom sinks to be between 111-119 F. LPA toured the outside area and found it to be clear of obstructions. LPA tested two out of two carbon monoxide detectors and found them to function properly when tested. During visit, staff were not able to test the smoke detection system and were not able to provide a copy of the last smoke detection system inspection report. The emergency disaster drill log indicates the last drill occurred on 10/01/2025. See LIC809-C page for more information. Page 1 of 2. LPA reviewed the Centrally Stored Medication and Destruction Record (CSMDR) for 5 residents. Resident R1's CMSDR was missing 2 medications and R2 was missing 1 medication. Staff entered the missing medications into the CMSDR during visit. LPA reviewed 5 resident records. R2's resident record was missing an Appraisal/Needs and Services Plan and R3's resident record was missing an Admission Agreement. LPA reviewed 5 staff records. 4 out of 5 staff were missing a current first aid certification. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. An Advisory Note was issued. See LIC9102 for more information. LPA Marrufo requests that the following documents be updated and copies sent to the department by 12/17/2025: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility Liability Insurance LIC610 Emergency Disaster Plan This report was reviewed with Carolyn Heinan and a copy of this report and appeal rights were provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Dec 10, 2025

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Dec 17, 2025

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by: Licensee did not ensure that 4 out of 5 reviewed staff records did not have a current first aid certification on file, which poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2025

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Dec 17, 2025

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Licensee did not ensure that resident R2's record had an Appraisal/Needs and Services Plan and R3's record had an Admission Agreement, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: by 12/17/2025.

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Dec 17, 2025

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement was not met as evidenced by: Licensee did not ensure that residents R1 and R2's Centrally Stored Medication and Destruction Records did not have missing medications, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2025

Allegation investigated: Facility left resident in soiled diapers for an extended period of time

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegations. LPA met with Licensees James and Carolyn Heinan. On 03/06/2025, the Department received the complaint. On 03/13/2025, the initial complaint investigation was conducted. The following documents were received to include staff timecards, and resident (R1)'s physician's report, preplacement appraisal, appraisal/needs and services plan, identification and emergency contact information, and functional capabilities. It was alleged that the facility left resident in soiled diapers for an extended period of time on 02/28/2025 as R1 was found completely soiled with urine and feces by R1’s private caregiver around 7:00am. Page 1 of 2. Substantiated 7 residents were interviewed. 6 out of 7 residents are independent and are able to care for their own activities of daily living which they denied being left soiled for an extended period of time. 1 out of the 7 residents (R1) states he/she wakes up soiled every morning. R1 stated that there is someone who comes to assist in him/her with changing every morning. Based on interview with the licensee, it was stated that R1 has a private caregiving agency that comes to assist R1 during morning and nighttime care. R1’s private caregivers assist’s R1 with changing, incontinent care, bathing, grooming, and transferring in and out of bed. It was stated that if R1 soiled him/herself through the night, R1 will be changed in the morning when R1’s private caregiver starts around 7:00am. The licensee stated that the facility has an awake night staff, however, the staff does not assist with incontinent care throughout the night because they are unable to lift R1. It was stated that R1’s responsible parties were made aware of this which is the reason they hired a private caregiver from an agency. It was stated that R1 does not have a private caregiver from the hours of 8:00pm – 7:00am. The Department has investigated the above allegation. Based on interview and record review the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Licensees James and Carolyn Heinan and a copy of the report and appeal rights was provided. Page 2 of 2. Based on staff interview, there were no call outs the night of 02/27/2025 – 02/28/2025. It was stated that if the facility staff do call out, they make sure another staff covers the shift. The review of records did not indicate that there was a call out the night of 02/27/2025. The Licensees/owners of the facility, also covers the PM shifts but do not keep record of their timecard because they work 24/7. Staff denied there ever being a time where there were no staff at the facility. Staff stated that R1 has a private caregiving agency who provides R1 morning care and nighttime activities of daily living care to include getting to and from bed, dressing, bathing, and incontinence care. The private caregiving agency starts their shift at 7:00am for morning care and returns from 4:30 – 5:00pm for nighttime care. 7 residents were interviewed. 7 out of 7 residents stated there is always staff available if needed. 7 out of 7 residents did not have any comments or concerns regarding the staffing ratio at the facility. The Department has investigated the above allegations. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensees James and Carolyn Heinan and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Jun 20, 2025 · control 26-AS-20250306164216

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Jun 27, 2025

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure that staff checks and changes R1’s throughout the night resulting in R1 being left soiled throughout the night which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 20, 2025

Plan of correction: Licensee will submit a written plan to ensure compliance with the section cited to LPA Kabariti by POC due date.

Allegation investigated: Facility staff neglected resident by leaving resident in soiled diaper all day resulting in a pressure injury Facility has insufficient number of staff to meet the residents needs Facility staff did not report a resident's change of condition to the resident's responsible party

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding regarding the above allegation. LPA met with Licensees James and Carolyn Heinan. On 09/12/2024, the Department received a complaint regarding the above allegations. On 09/16/2024, the initial complaint investigation was conducted. The following documents were obtained to include the resident roster, physician reports, appraisal/needs and services plans, pre-placement appraisals, identification and emergency contact information, centrally stored medication record, incident reports, staff timecards, and police report. Page 1 of 3. Unsubstantiated It was alleged that the facility staff neglect resident by not providing services to include change the resident diapers leaving resident (R1) in soiled diaper all day resulting in a pressure injury. The review of records show that R1 does have history of skin breakdown to include skin breakdown in the sacral. Staff members were interviewed. Based on staff interview, it was stated that the facility had a former caregiver who left the facility on 08/31/2024, who provided all care to R1. Since that caregiver left, the facility staff was having difficulties in providing R1 care. Staff stated that the caregivers do try to assist R1 with changing his/her soiled diapers, however, R1 refuses to be changed most of the time. Staff stated that they cannot force R1 if he/she refuses but will be give the resident space and try again later. Staff stated that they observe the residents very frequently and assist with incontinent care, if needed. It was stated that if a resident's is observed soiled, they would assist the resident right away in changing the resident's diaper. Staff denied leaving any residents soiled. Resident (R1) was interviewed. Based on resident interview, R1 denied being left in soiled diapers for a long time. It was alleged that the facility does not have sufficient number of staff to meet the residents needs. It was alleged that on 09/08/2024, there was only 1 staff at the facility. Staff members were interviewed. Based on staff interview, it was stated that majority of the residents at the facility, besides R1, are are able to take care of their activities of daily living with minimal staff assistance. Staff states that they are able to take care of all the residents’ needs within their shift. The Licensee denied a staffing shortage. It was stated that they have at least 1-2 caregivers for the whole building per shift, as all their residents, besides R1, does not require additional care where they need more caregivers. Page 2 of 3. 3 residents were interviewed. 1 out of 3 residents stated that the facility does not have enough staff. This resident stated that he/she always needs help getting in and out of bed, but because of the staffing sometime they come a little late if the staff are too busy. 2 out of 3 residents did not have any issues or concerns regarding the staffing levels at the facility. These residents stated that they get help from staff when needed. Based on review of the facility’s compliance history, there are no serious incidents reported that resulted from insufficient staffing numbers. It was alleged that the facility did not report R1’s change of condition of a toe infection to the resident’s responsible party. Based on record review, it was found that R1’s alleged toe infection was observed and reported by a vendor who provided manicures and pedicures for the residents. The vendor did not state that R1’s toe was infected but stated to have observed discoloration and advised R1’s family to seek medical advice. Based on interview with the Licensees, they denied the knowledge of R1’s toe being infected. 2 caregivers who were interview, denied the knowledge and observation of R1’s alleged toe infection. 2 staff denied being informed that R1 even had a toe infection. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensees, James and Carolyn Heinan and a copy of the report was provided. Page 3 of 3. It was alleged that facility staff are not treating residents with dignity by belittling and yelling at the residents. 3 residents were interviewed. 3 out of 3 residents denied staff not treating the residents with dignity by belittling and yelling at the residents. 3 witnesses were interviewed. 3 out of 3 witnesses denied the observation of facility staff not treating the residents with dignity by belittling and yelling at the residents. 7 staff members were interviewed. 7 out of 7 staff members denied facility staff not treating residents with dignity by belittling and yelling at the residents. It was alleged that the facility staff violated the resident’s personal rights by forcing them to stay in the room and leave the bedroom door open. 3 residents were interviewed. 3 out of 3 residents denied being forced to leave their bedroom door open. Residents states they voluntarily leave their bedroom door open sometimes. 3 witnesses were interviewed. 3 out of 3 witnesses denied the observation of resident’s being forced to leave their bedroom door open. 7 staff members were interviewed. 7 out of 7 staff members denied forcing the residents to leave their bedroom door open. It was stated that the residents are able to leave their doors open or closed and the facility does not have any rules about that. It was alleged that the facility did not provide R1 with reasonable accommodation to R1’s request of only female caregivers to provide care to R1. Resident (R1) was interviewed. Based on resident interview, R1 prefers women caregivers. R1 denied male caregivers providing care to him/her. R1 states there is a male staff who only assists him/her out of bed but R1 consents to it. The Department has investigated the above allegations. Based on interviews, the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensees, James and Carolyn Heinan and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 26-AS-20240912155005

Allegation investigated: Facility staff are not trained

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Licensee, Carolyn Heinan. On 09/17/2024, the Department received the complaint. On 09/24/2024, the initial complaint investigation was conducted. The following documents were obtained to include the resident shower schedules and 3 residents physician’s report and appraisal/needs and services plan. It was alleged that the facility staff are not trained. On 09/24/2024, 2 new staff member’s (S1 & S2) training records were requested. Based on interview and record review, the licensee was unable to produce S1 & S2’s training documentation. The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. This report was reviewed with Licensee, Carolyn Heinan and a copy of the report and appeal rights were provided. Substantiated 3 staff members were interviewed. Based on staff interview, 3 out of 3 staff stated that the residents bedsheets are changed out weekly, unless there is an accident. If there is an accident, then the sheets will be washed immediately upon noticing. 3 residents were interviewed. Based on resident interview, 3 out of 3 residents stated that resident’s laundry is done weekly. 2 out of 3 residents stated that bedsheets are washed weekly, and 1 out of 3 residents stated their bedsheets are washed every 2 weeks. None of the residents had any issues or complaints regarding the laundry schedule. Based on observation, 3 out of 3 residents bedrooms were observed clean with no foul odor. It was alleged that the facility food is not served in a safe and healthful manner. It was alleged that the facility serves residents expired food such a bread and fruits and reuses coffee from the day before. 3 staff members were interviewed. Based on interview, 3 out of 3 staff denied reusing coffee from the day before and serving it to the residents. Staff stated that they make fresh coffee every morning for the residents. It was stated that if there is left over coffee from breakfast, they will reheat the coffee for lunch, however, they do not reuse coffee from the day before. Based on observation of the facility’s food supplies on 09/24/2024, the breads and fruits were observed in good quality and not expired or rotten. LPA observed expired can foods and perishable items inside the pantry and refrigerator. Licensee states the staff and resident’s share the same pantry and refrigerator, which the expired items were the staff’s food and not for the residents. 3 residents were interviewed. 3 out of 3 residents did not have any complaints about the food being served at the facility. 3 out of 3 residents denied being served expired food. It was stated that the fruits being serve are of good quality. Page 2 of 3. It was alleged that the facility did not ensure residents bathing needs were met as the licensee does not let the staff use soap during showers. It was alleged that the licensee instructed the staff to only use water. 3 staff were interviewed. Based on staff interview, 3 out of 3 staff stated that the residents are provided showers based on a shower schedule. It was stated that the residents have their own hygiene products to include soap and shampoo, and if needed, the facility also has hygiene products they can use for the residents. Staff denied being told to shower the residents using only water. 3 residents were interviewed. Based on resident interview, 3 out of 3 residents stated that they have their own hygiene products to use for showers. 3 out of 3 residents denied only using water for showers. It was stated the residents have a shower schedule and if they want more shower they just have to ask the staff. Based on observation, the residents hygiene items are either stored safely in their room (if able) or locked in the shower room where they are assisted by the staff. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded, meaning, the allegations are false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee, Carolyn Heinan and a copy of the report was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 26-AS-20240917152938

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Mar 28, 2025

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure to provide staff (S1) and (S2) with training which poses/posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 21, 2025

Plan of correction: Licensee states to have provided training for S1 and S2. During visit, LPA obtained the training records for S1. Licensee will fax S2's training records to the Department by POC due date.

Allegation investigated: Facility staff did not follow the resident's care plan Facility staff mentally abuses a resident

Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to deliver the finding regarding the above allegation. LPA met with Licensee / Administrator Carolyn Heinan and James Heinan. On 09/10/2024, the Department received the complaint. On 09/16/2024, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1)’s admission agreement, physician’s report, appraisal/needs and services plan, preplacement appraisal, identification and emergency contact information, centrally stored medication record, incident report, and LIC500. It was alleged that the facility staff did not follow the resident’s care plan as the licensee stated to R1’s private caregiver that R1 needed a 2-person assist for transfers, when during the assessment a 2-person assist transfer was not indicated. Page 1 of 4. Unsubstantiated Based on interview and record review, R1’s care plan was not updated prior to LPAs visit on 09/16/2024, to indicate that R1 required a 2-person assist. It was stated that the Licensee was not part of the assessment with R1’s family member and home health agency on 09/06/2024 and was unsure of their discussion / care plan developed. On 09/09/2024, R1’s private caregiver through a home health agency, started services at the facility to help with R1’s care needs. Based on interview with the private caregiver (W1), it was stated that W1 was trying to put R1 to bed but was unable to transfer R1 from wheelchair to bed by him/herself and needed a second person for assistance. W1 described themselves as a small and petite individual who did not receive any training from the home health agency nor have any caregiving experience prior to providing care to R1. W1 states that he/she called the Licensee for assistance, but the Licensee was unable to assist with the transfer due to back pain. W1 stated that the Licensee advised W1 to call 911 for a “lift-and-assist” as the facility staff were unable to provide secondary assistance to transfer R1 from the wheelchair to bed. W1 stated to have called the lift-and-assist who shortly arrived at the facility. On 09/16/2024, 4 staff members were interviewed. The Licensee stated that there was a caregiver who left the facility on 08/31/2024, who knew how to care for R1. This caregiver provided training to a facility staff before departure, however, this facility staff stated that due to back pain and safety reasons, the staff was unable to transfer R1 by him/herself. Based on staff interview, 4 out of 4 staff members stated that due to safety reasons, R1 requires a 2-person assist to get R1 in and out of bed. It was stated that R1 is in a lot of pain and is unable to bear weight during transfers making it difficult for one person to assist R1. The licensee stated that upon departure of the staff who was providing care to R1, they had spoken with R1’s family member regarding the inability to assist with transferring R1 due to the lack of capable staff, back pain and the licensees age. The licensee stated to have advised family to find R1 a new placement who can better meet R1’s needs. Page 2 of 4. It was alleged that the licensee mentally abuses R1 by putting it into R1’s mind that R1 has dementia and would deny R1’s reality of the actual events. It was alleged that on 09/09/2024 the fire fighters, paramedics and police were at the facility and when R1 asked the licensee if the police were there, it was alleged that the licensee would deny the reality and put it into R1’s mind that R1 has dementia. Based on record review, R1 is diagnosed with mild cognitive impairment. Based on R1’s service plan, its indicated that R1 has mild forgetfulness. 4 witnesses were interviewed. Based on interview, 3 out of 4 witnesses denied the observation of the licensee stating R1 has dementia. 3 out of 4 witnesses denied the observation of the licensee confusing R1’s reality. 1 out of 4 witnesses stated that the licensee has told R1 that he/she has dementia and denies R1’s reality that is causing R1 to become confused. W4 states that R1 questioned if the firemen and paramedics were real, in which W4 confirmed the reality. W4 stated that the licensee has commented to R1’s face stating that R1 does not know what he/she is talking about, is too much trouble, and threatened to put R1 into the streets. On 09/16/2024, 7 staff members were interviewed to include the licensee. The licensee denied the allegation and denied stating that R1 has dementia to his/her face. Licensee stated that R1 has forgetfulness. The Licensee denied intentionally yelling or hurting R1’s feelings and denied threatening to put R1 into the streets. The licensee states that R1 and the licensee jokes in German, which the tone can be heard as loud, but the conversations were always friendly. The Licensee stated that he/she does not remember R1 asking about the incident that occurred the night of 09/09/2024. The remainder of the staff interviewed denied the observation of the licensee mentally abusing R1 and other residents in care. Page 3 of 4. On 09/16/2024, R1 was interviewed. Based on interview, R1 stated that the staff treat him/her nicely. R1 stated that the licensee treats him/her nicely and had no complaints about the licensee. R1 states that he/she likes to speak German with the licensee and states to have playful conversations with the licensee. R1 denied the licensee saying mean things or confusing R1. When LPA asked R1 about the night the paramedics arrived to assist R1 to bed, R1 stated that nothing happened that day and did not elaborate further about the incident. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee / Administrator Carolyn Heinan and and James Heinan and a copy of the report was provided. Page 4 of 4. On 09/09/2024, R1’s private caregiver through a home health agency, started services at the facility to help with R1’s care needs. Based on interview with the private caregiver (W1), it was stated that W1 did not receive any training from the home health agency nor have any caregiving experience prior to providing care to R1. W1 states that he/she was unable to transfer R1 from the wheelchair to bed alone and asked the licensee for assistance, which the licensee was unable to provide due to back pain. W1 was instructed by the licensee to call for a “lift-and-assist”. W1 stated that the fire fighters arrived and was unable to move R1 to bed because R1 would scream anytime they tried to lift him/her. W1 stated that because R1 refused to be moved, the fire fighters left and stated that they could not force R1. Based on interview with the licensees, it was stated that the fire department showed up at the facility around 7:30pm but because R1 refused to be moved from the wheelchair to bed, the fire department left. The licensee stated to have checked in on R1 around 10pm, however, R1 still refused to go to bed. R1’s family member was informed of the situation. Around 12am, the licensee called 911 and paramedics were able to assist R1 to bed. The licensee states the reason for the delay was because they did not want to upset R1’s family members and they were waiting for a response from the family members on what to do, as R1 was refusing to be lifted to bed. The licensees denied impeding in the transfer. Based on interview with W1, W1 denied the licensees impeding in the transfer between the fire fighters. W1 stated that all parties were trying to get R1 to bed, but R1 was refusing. W1 denied the licensee impeding in R1’s transfer and stated that R1 needed secondary assistance to move R1 from wheelchair to bed. It was alleged that the facility does not have an awake night staff or security checking the residents throughout the night. Page 2 of 3. Based on interview with the licensees, it was stated the staff are consistent and know their hours of work, in which they do not write a staffing schedule. It was stated that one of the licensees covers the night shift and the licensee’s do not clock in and out of work as they are the owners of the business. On 09/16/2024, 7 staff members were interviewed. Based on interview, 7 out of 7 staff stated that the facility has an awake night staff and live-in staff available on-call. It was stated that one of the licensee covers the night shift. Based on record review of the facility's staffing record that was submitted to the Department, the facility has a night shift staff scheduled to cover from 9:00pm - 7:00am. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee / Administrator Carolyn Heinan and and James Heinan and a copy of the report was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Jan 10, 2025 · control 26-AS-20240910121029

Type of visit: Required - 1 Year

On 12/30/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Carolyn Heinan and explained the purpose of the visit. LPA toured the facility inside and outside including a random sample of resident rooms, common areas, activity room and kitchen area. While touring the facility it was observed that the temperature was at 72 deg F. Hot water was also tested in the resident rooms and the temperature was 112 deg F. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floor. Resident call buttons are functioning. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. Five resident records and three staff records were reviewed. Resident records are updated, complete and signed. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA requested the following to be emailed: Liability Insurance. LPA received a copy of Deed.. No deficiencies are cited at this time. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Dec 30, 2024

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin arrived unannounced to conduct a case management visit to deliver an immediate exclusion letter for staff (S1). LPA met with Administrator/Licensee James Heinan. LPAs provided a letter "Order to Licensee/Facility of Immediate Exclusion From Facility" that the department determine that S1 engaged in conduct inimical as a staff in a facility. ADM was informed to remove S1 from any contact with residents and S1 may not be physically present in any facility. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator/Licensee James Heinan and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct an unannounced case management – deficiencies. LPA met with Licensees Carolyn and James Heinan. On 09/16/2024, LPA Dolores arrived to the facility to open the initial complaint investigations for complaint control numbers 26-AS-20240910121029 and 26-AS-20240912155005. During the complaint investigations, Title 22 violations were observed. On 09/16/2024, LPA Dolores was informed of a resident (R1) who passed away in March 2024. LPA Dolores reviewed the facility’s file and did not observe an incident report and death report was received by the licensing department. Licensee produced the incident report from R1's file from March 2024 stating R1 was sent to the hospital. Licensee was unable to produce documentation to show the incident report or death report was submitted to the licensing department. On 09/16/2024, LPA Dolores obtained records for 2 complaint investigations. Based on interview, the Licensee's observed resident (R2) had a change of condition from ambulatory to bedridden. It was stated that the resident also required a two-person assist during transfers. The review of R2’s records show the physician’s report was last updated on 09/16/2022, which does not indicate the change of condition and updated ambulatory status. R2’s appraisal/needs and services plan was last developed during admission on 09/18/2022. PAGE 1 OF 2. The Licensee updated R2's appraisal/needs and services plan on 09/10/2024 stating the resident is bedridden, but the appraisal/needs and services plan was not reviewed and acknowledged by R2 and/or R2's responsible party. There was also no indication that R2 required a two-person assist. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809D. This report was reviewed with Licensees Carolyn and James Heinan and a copy of the report and appeal rights were provided. PAGE 2 OF 2.the state’s words, verbatim · CDSS document, Sep 24, 2024

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

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to submit a written incident report and death report to the licensing Department for R1 during an incident that occurred in March 2024 which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee states they will submit a statement of understanding of the section cited. Licensee will also submit a plan in writing to ensure all fax cover sheets will be attached to incident reports and death reports. Licensee will submit the plan of correction to LPA Dolores via fax by 10/01/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87505 · Plan of correction due date: Oct 1, 2024

Each facility shall document in writing the findings of the pre-admission appraisal and any reappraisal or assessment which was necessary in accordance with Sections 87457, Pre-admission Appraisal, and 87463, Reappraisals. If supporting documentation from a physician is required, this input shall also be obtained and may be the same assessment as required in Section 87458, Medical Assessment. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure to update R2's reappraisal and physician's report upon a change on condition based on the licensee's observations which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee will submit R2's updated physician's report and appraisal/needs and services plan that will be reviewed by R2's responsible party to LPA Dolores via fax by 10/01/2024.