Valley Silvertown

Allegation investigated: Facility staff did not provide sufficient incontinence care Facility staff did not provide proper diabetes assistance

At approximately 11:00 a.m. on 07/09/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 12/05/25 and interviewed staff between 2:20 p.m. and 3:30 p.m., obtained pertinent records at 2:45 p.m., toured the facility inside and out at 3:00 p.m., and reviewed video footage of the lobby at 3:30 p.m. LPA obtained video footage of a resident’s room at 1:15 p.m. on 12/23/25. LPA interviewed Staff #1 (S1) at 11:10 a.m. on 04/10/26. LPA conducted a subsequent visit on 06/10/26 and toured the facility at 9:15 a.m., reviewed previously obtained records and video footage, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 10:00 a.m., and interviewed staff and residents between 12:15 p.m. and 4:00 p.m. Today, LPA telephonically interviewed a physician at 2:15 p.m. and toured the facility at 12:15 p.m. Substantiated Regarding the allegation "Facility staff did not provide sufficient incontinence care” it was alleged staff did not assist Resident #1 (R1) with incontinence care on 11/29/25 until around 4:00 p.m. R1 was found in a soiled diaper and wet clothing at that time by Witness #1 (W1). W1 stated Staff #1 (S1) and Staff #2 (S2) then came to assist R1. Interview with R1 at 4:00 p.m. on 12/03/25 revealed they were not assisted by staff and felt unwell after recovering from a Urinary Tract infection (UTI). Telephonic interview with Staff #1 (S1) at 10:45 a.m. today confirmed they began their shift around 2:30 p.m. and found R1 in a soiled diaper and clothing later that afternoon. S2 was unavailable for interview. Interview with Staff #3 (S3) at 9:30 a.m. on 12/02/25 revealed they had found R1 in a soiled diaper and wet clothing another time. Record review of R1’s medical assessment indicated they were incontinent and relied upon staff for toileting assistance. Review of R1’s care plan indicated staff were responsible for assisting R1 with all activities of daily living. Based on interviews and record review, there is sufficient evidence to confirm the allegation. Therefore, the allegation is deemed SUBSTANTIATED at this time. Regarding the allegation "Facility staff did not provide proper diabetes assistance" it was alleged R1’s blood sugar level was too high on the evening of 11/29/25 due to improper staff assistance. Record review of R1’s medication list and Medication Administration Record (MAR) revealed they were prescribed two (02) pills to manage their diabetes, Metformin and Glipizide. Telephonic interview with R1’s physician revealed R1's Glipizide was discontinued, however the facility should have assisted with Metformin. The MAR indicated Staff #4 (S4) did not assist R1 with taking Metformin on the morning of 11/29/25. S4 wrote in the MAR notes that R1 was “physically unable to take” the medication. S4 was unavailable for an interview to explain the notes. Interview with Staff #5 (S5) at 4:00 p.m. on 06/16/26 revealed R1 monitored their blood sugar on their own and depended on staff for medication assistance. S5 could not explain why R1 was not assisted with Metformin on 11/29/25. Based on interviews and record review, the facility did not provide proper diabetes assistance. Therefore, the allegation is deemed SUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 31-AS-20251203164348

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jul 20, 2026

87625 Managed Incontinence (b) ...the licensee shall be responsible for...: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not ensuring Resident #1 (R1) was kept clean and dry which posed a potential risk to the Health, Safety, or Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Licensee will conduct an in-service training on the cited section and submit to LPA by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 20, 2026

87465 Incidental Medical and Dental Care (a) A plan... shall be developed... by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not assisting Resident #1 (R1) with medications which posed a potential risk to the Health, Safety, or Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Licensee will conduct an in-service training on the cited section and submit to LPA by the POC due date.

Allegation investigated: Facility staff did not protect a resident from being threatened Facility staff did not protect a resident from being hit Facility did not follow mandated reporter requirements

At approximately 12:30 p.m. on 06/16/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the assistant administrator and disclosed the reason for the visit. To investigate the allegations above, LPA Antonia Alvizar-Ettima conducted an initial visit on 12/18/25 and reviewed pertinent records, including but not limited to home health notes, a medical assessment, care plan, and staff and client rosters at approximately 11:05 a.m. and toured the facility at 11:25 a.m. LPA Reed conducted a subsequent visit on 04/17/26 and toured the facility at 10:30 a.m., telephonically interviewed Resident #1 (R1) at 11:00 a.m. and Staff #1 (S1) at 11:15 a.m., and interviewed ten percent (10%) of residents, or twelve (12) out of 120 residents between 1:30 p.m. and 4:00 p.m. Today, LPA toured the facility at 12:45 p.m., telephonically interviewed a home health nurse (N1) at 1:30 p.m., and interviewed the administrator at 3:30 p.m. Unsubstantiated Regarding the allegations "Facility staff did not protect a resident from being threatened”, “Facility staff did not protect a resident from being hit", and “Facility did not follow mandated reporter requirements” it was alleged a nurse from an outside agency hit R1 on the shoulder and threatened to kill R1. S1 was present in the room and did not protect R1 or report the abuse properly. Interview with R1 confirmed they were hit and threatened by a home health nurse, not a facility employee. Interview with S1 revealed they witnessed a home health nurse provide care to R1. S1 did not witness any abuse or threats, therefore S1 made no report of abuse. Interview with N1 revealed they did not abuse or threaten R1. R1 told N1 they had shoulder pain, so N1 made sure to stay away from the hurt shoulder. Interviews with twelve (12) out of twelve (12) residents interviewed revealed no residents witnessed or experienced abuse from staff. Interview with the administrator revealed they have not received reports of abuse from any residents. All staff have been trained as mandated reporters to report abuse. Record review of R1’s home health notes revealed no information about abuse or threats made towards R1. During facility tours on 04/17/26 and today, LPA observed staff treating residents respectfully. Based on observations, interviews, and record review, there is insufficient evidence to confirm the validity of the allegations. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 31-AS-20251215130056

Allegation investigated: Facility staff did not provide proper transfer assistance which led to a resident's fall Licensee did not properly train staff

At approximately 9:00 a.m. on 06/10/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the assistant administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 12/05/25 and interviewed staff between 2:20 p.m. and 3:30 p.m., obtained pertinent records at 2:45 p.m., toured the facility inside and out at 3:00 p.m., and reviewed video footage of the lobby at 3:30 p.m. LPA obtained video footage of a resident’s room at 1:15 p.m. on 12/23/25. LPA interviewed Staff #1 (S1) at 11:10 a.m. on 04/10/26. Today, LPA toured the facility at 9:15 a.m., reviewed previously obtained records and video footage, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 10:00 a.m., and interviewed staff and residents between 12:15 p.m. and 4:00 p.m. Regarding the allegation "Facility staff did not provide proper transfer assistance which led to a resident's fall" it was alleged S1 transferred R1 improperly which caused them to fall. Substantiated Interview with S1 revealed when they transferred R1 from their reclining chair to their bed, R1’s legs gave out. S1 “helped them to the floor”. R1 was not injured. Interview with Staff #2 (S2) at 9:30 a.m. on 12/02/25 revealed they heard S1 request help from R1’s room. S2 found R1 on the floor and assisted them into bed with S1. S2 told S1 that R1 does not use a walker, only a wheelchair. Review of R1’s medical assessment revealed they are nonambulatory, wheelchair-bound, and require assistance with transferring. Review if R1’s care plan revealed they were at “significant risk for falls”. Review of video footage from R1’s room revealed S1 assisted R1 in standing from their chair at 1:45 p.m. on 11/20/25. S1 placed R1’s walker in front of them and pushed their backside to assist them standing. S1 then walked about five (05) steps with R1. As R1 began falling, S1 held and lifted the back of R1’s pants to ease their fall. R1 then fell to their knees with their hands still on their walker. S2 arrived at 1:47 p.m. S2 informed S1 that R1 only uses their walker once per day and not for transfers. Based on interviews, record review, and video review, staff did not provide proper transfer assistance to R1, resulting in their fall. Therefore, the allegation is deemed SUBSTANTIATED at this time. Regarding the allegation "Licensee did not properly train staff" it was alleged staff were not sufficiently trained to care for R1. Interview with S1 revealed they were not trained on R1’s care plan. S1 was not R1’s regular caregiver and provided care to R1 because of the regular caregiver’s absence. Interview with S2 revealed they “could not remember the last time” the facility provided training. Record review of caregiver files revealed the training provided to all caregivers in 2025 by the facility was insufficient in both hours and content. The facility did not provide caregivers with sufficient training until February 2026. Based on interviews and record review, the licensee did not properly train staff. Therefore, the allegation is deemed SUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided. Regarding the allegation "Licensee yelled at a resident" it was alleged the administrator yelled at Resident #2 (R2) on the afternoon of 12/03/25. Interview with R2 at 11:45 a.m. on 12/05/25 revealed they and the administrator had a disagreement in the lobby. The administrator believed R2 was recording them, so he yelled at R2 to stop. Interview with Resident #3 (R3) at 1:15 p.m. on 12/05/25 revealed they heard the administrator yelling in the lobby in a ‘sharp’ tone. Interview with the administrator at 3:20 p.m. on 12/05/25 revealed they did not yell at R2 but asked them not to record people in the facility without consent. The administrator provided video footage of the incident. Review of the lobby video footage revealed R2 was filming in the lobby. The administrator walked over to R2 and told them not to film. R2 denied filming. The administrator said “Yes you were” in a sharp tone, however the administrator did not yell. Based on interviews and video footage review, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 10, 2026 · control 31-AS-20251203164348

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jun 20, 2026

87464 Basic Services (f) Basic services shall... include: (4) Personal assistance and care as needed by the resident ...with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications. This requirement was not met as evidenced by: Baed on interviews and record and video footage review, the licensee did not comply with the section cited above by staff improperly transferrring Resident #1 (R1) which posed a potential risk to the Health, Safety, or Personal Rights of persons in care.the state’s words, verbatim · CDSS document, Jun 10, 2026

Plan of correction: Licensee to submit an in-service training on the cited section by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1) · Plan of correction due date: Jun 20, 2026

§1569.625 Staff training; legislative findings; contents (b) (1) ... staff members... to receive appropriate training. This training shall consist of 40 hours of training. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in all caregivers receiving insufficient training hours in 2025 which posed a potential risk to the Health, Safety, or Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Jun 10, 2026

Plan of correction: The licensee already issued sufficient training for all staff in February 2026. The licensee will submit an in-service training on the cited section by the POC due date.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure that resident received prescribed medications Staff are using dirty kitchen appliances to prepare meals

At approximately 8:50 a.m. on 04/17/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 11/19/25 and interviewed staff and residents between 11:15 a.m. and 4:15 p.m., toured the facility inside and out at 1:00 p.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, physician’s report, and medical administration record (MAR) at 2:15 p.m. LPA conducted a subsequent visit on 12/02/25 and interviewed staff and residents between 9:00 a.m. and 4:45 p.m. and toured the facility inside and out at 11:00 a.m. On 04/17/26, LPA conducted another record review of a dietitian report at 9:30 a.m. and toured the facility at 10:30 a.m. Substantiated Regarding the allegation "Staff did not ensure that resident received prescribed medications" it was alleged Resident #1 (R1) did not receive their medication for a few days. Interview with the administrator at 2:30 p.m. on 11/19/25 revealed most residents switched to a new pharmacy on 10/01/25. Review of R1’s physician orders revealed their medications were scheduled to be refilled on 09/30/25. Review of R1’s MAR revealed they did not receive two (02) medications on the evening of 09/30/25 and six (06) medications on the morning of 10/01 due to “pending pharmacy delivery”. The administrator also said they drove to the pharmacy at 8:00 p.m. on 10/01/25 for R1’s medication refill. The issue with the pharmacy was worked out. Interviews with Staff #4 (S4) at approximately 10:15 a.m. on 12/02/25 and Staff #5 (S5) at 2:30 p.m. on 01/09/26 confirmed R1 was not assisted with bedtime medications on 09/30/25 and morning medications on 10/01/25 due to running out of supply. Review of R1’s physician report and admission agreement revealed they could not handle their own medications and relied on the facility for medication assistance. Based on interviews and record review, staff did not ensure R1 received prescribed medication for at least two (02) doses. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is cited on the corresponding LIC 9099-D page. Regarding the allegation "Staff are using dirty kitchen appliances to prepare meals" it was alleged the facility prepared toast for R1 on a grill which was used to cook bacon. Interview with the head chef, Staff #3 (S3) at 12:15 p.m. on 11/19/25 revealed the toaster was in disrepair for about one (01) day. S3 confirmed toast was made for all residents on the same grill used to cook bacon. During facility tour on 11/19/25, LPA observed two (02) toasters in the kitchen. Interview with the administrator at 2:30 p.m. on 11/19/25 revealed the facility purchased multiple toasters to resolve the issue. Based on interviews and observations, the facility toaster went into disrepair, so staff cooked toast on the grill and replaced the toaster the next day. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is cited on the corresponding LIC 9099-D page. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 10, 2026 · control 31-AS-20251117123125

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 20, 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.... compliance with the following: (1) The licensee shall arrange... medical... care. This requirement was not met as evidenced by: Baed on interviews and record review, the licensee did not comply with the section cited above by not maintaining an ample supply of medication for Resident #1 (R1) which posed a potential risk to the Health, Safety, or Personal Rights of persons in care.the state’s words, verbatim · CDSS document, Jun 10, 2026

Plan of correction: Licensee to submit an in-service training on the cited section by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(29) · Plan of correction due date: Jun 20, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (29) All equipment... shall be kept clean and maintained in good repair. This requirement was not met as evidenced by: Baed on interviews and observations, the licensee did not comply with the section cited above by not maintaining the toaster in good repair which led to staff using a dirty grill which posed a potential risk to the Health, Safety, or Personal Rights of persons in care.the state’s words, verbatim · CDSS document, Jun 10, 2026

Plan of correction: Licensee replaced the broken toaster already. Licensee to submit an in-service training on the cited section by the POC due date.

Allegation investigated: Staff did not respond to resident's call light in a timely manner Staff is serving food that is not of quality to residents in care

At approximately 8:50 a.m. on 04/17/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 11/19/25 and interviewed staff and residents between 11:15 a.m. and 4:15 p.m., toured the facility inside and out at 1:00 p.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, physician’s report, and medical administration record (MAR) at 2:15 p.m. LPA conducted a subsequent visit on 12/02/25 and interviewed staff and residents between 9:00 a.m. and 4:45 p.m. and toured the facility inside and out at 11:00 a.m. Today, LPA conducted another record review of a dietitian report at 9:30 a.m. and toured the facility at 10:30 a.m. Regarding the allegation "Staff did not respond to resident's call light in a timely manner" it was alleged Resident #1 (R1) waited over an hour for staff assistance after pushing their call button. Unsubstantiated Interview with the administrator at 2:30 p.m. on 11/19/25 revealed staff respond to call button requests within ten (10) minutes. Residents are also told to call the front desk if staff have not arrived. LPA and R1 tested their call button at 11:39 a.m. on 11/19/25. Staff responded within six (06) minutes by 11:45 a.m. LPA conducted two (02) more call button tests in Rooms 251 and 253 at 12:30 p.m. and 12:45 p.m. on 11/19/25. Staff responded to the calls within ten (10) minutes. Interview with a receptionist, Staff #1 (S1) at 2:00 p.m. on 11/19/25 revealed they receive all call button requests at the front desk. S1 calls for caregivers on the walkie talkie and relays the room number. Staff usually respond within five (05) minutes. S1 has assisted R1 over the phone as well. Interview with a caregiver, Staff #2 (S2) at 9:30 a.m. on 12/02/25 confirmed they respond to call button requests within fifteen (15) minutes. Interviews with nine (09) out of thirteen (13) residents revealed staff respond to call button requests in a timely manner. Record review of the November 2025 call button logs revealed no residents waited longer than fifteen (15) minutes for staff responses. Based on observations, interviews, and record review, staff respond to call lights in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff is serving food that is not of quality to residents in care" it was alleged the facility served dry and low-quality food. Interviews with nine (09) out of thirteen (13) residents revealed they have no problem with the quality of food served. Record review of the most recent dietitian report revealed “meal quality and appearance” were sufficient. LPA’s observations of the kitchen at 1:30 p.m. on 11/19/25 and resident meals at 2:00 p.m. on 12/04/25 and at 12:00 p.m. on 02/18/26 revealed the facility served food of sufficient quality. Interview with the head chef, Staff #3 (S3) at 12:15 p.m. on 11/19/25 revealed they hold monthly meetings with residents for menu suggestions. They have heard a few complaints about meals served. Kitchen staff address all complaints promptly. Based on observations, interviews, and record review, staff serve food of sufficient quality to residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate heath or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 31-AS-20251117123125

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: Insufficient staffing Licensee did not provide a comfortable temperature in the dining room

At approximately 8:50 a.m. on 04/17/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 11/06/25 and toured the facility at 1:50 p.m., interviewed the administrator at 2:15 p.m., and conducted a record review of pertinent records, including but not limited to staff and client lists, staffing schedules, and employee files at 2:30 p.m. LPA interviewed staff and residents during subsequent visits on 11/13/25 between 1:00 p.m. and 5:10 p.m., 11/19/25 between 11:15 a.m. and 4:15 p.m., and 12/04/25 between 12:50 p.m. and 4:00 p.m. LPA conducted another record review today of employee training records at 9:30 a.m. and toured the facility at 10:30 a.m. Regarding the allegation "Insufficient staffing" it was alleged the kitchen did not have enough servers, causing delays in food service time. Unsubstantiated Interview of the administrator revealed two (02) to three (03) servers assist with each meal service. Review of kitchen schedules for September 2025 revealed there were two (02) servers and one (01) chef per meal service. Interview with the head chef, Staff #1 (S1) at 12:15 p.m. on 11/19/25 confirmed there are at least two (02) servers for each meal service. S1 stated each resident is served within ten (10) minutes of placing their order. Interviews with kitchen servers Staff #2 (S2) and Staff #3 (S3) at 10:00 a.m. and 10:10 a.m. on 12/02/26 confirmed there are at least two (02) servers for each meal service, and residents have not waited long for meals. Observation of meal service at approximately 12:00 p.m. on 02/18/26 revealed three (03) servers were serving residents for lunch. Interviews with twelve (12) out of thirteen (13) residents revealed they had no issue with meal service or wait times. Based on observations, interviews, and record review, the facility has sufficient servers and there is no delay in food service. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Licensee did not provide a comfortable temperature in the dining room" it was alleged the dining room is too cold and the facility refuses to turn up the heat. Interview with the administrator revealed all rooms in the facility are maintained between 68 and 85 degrees at all times. Interviews with S2 and S3 revealed the thermostat in the dining room is never less than 70 degrees. They had not heard of any complaints about the dining room temperature. LPA measured the dining room temperature at 2:30 p.m. on 11/06/25 to be 74 degrees Fahrenheit, at 1:20 p.m. on 11/19/25 to be 71 degrees Fahrenheit, and at 9:15 a.m. on 12/02/25 to be 71 degrees Fahrenheit. Interviews with thirteen (13) out of thirteen (13) residents revealed they had no issue with dining room temperature. Based on observations and interviews, the dining room temperature was maintained within regulations. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate heath or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 31-AS-20251103130636

Type of visit: Case Management - Annual Continuation

At approximately 11:00 am. on 04/10/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the administrator and disclosed the reason for the visit. Today’s annual visit is a continuation of yesterday’s annual visit. Today, LPA toured the facility at 11:05 a.m., interviewed staff and residents between 11:10 a.m. and 12:30 p.m., and reviewed pertinent records including but not limited to admission agreements, medical assessments, care plans, and hospice and home health files at 12:35 p.m. Files were complete and available for audit, though two (02) home health binders were missing plans of care. The residents were recently admitted, so LPA provided a Technical Violation and consulted the licensee on maintaining complete documentation for outside agencies. Interview with the administrator at 3:00 p.m. on 04/09/26 revealed a dietitian had not reviewed the facility’s menu and food service program within the last six (06) months. Therefore, a deficiency is cited on the corresponding LIC 809-D page. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555 · Plan of correction due date: Apr 20, 2026

87555 General Food Service Requirements (b) The following... shall apply: (17)...consultation services shall be provided... during at least one meal. A written record... shall be... kept on file in the facility. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in not providing dietitian services which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 10, 2026

Plan of correction: Licensee to provide proof of a scheduled appointment for dietitian services by the POC due date.

Type of visit: Required - 1 Year

At approximately 9:00 a.m. on 04/09/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the licensee and disclosed the reason for the visit. A file review was conducted prior to today’s visit. The facility was last visited on 02/18/26 for a complaint visit. It is a two-story building with assisted living and memory care units, shared and private rooms, common areas, offices, beauty salon, theatre room, medication room, and outdoor areas. It has an approved fire clearance for one hundred eighty three (183) non-ambulatory residents of which eight (08) may bedridden. Approved hospice waivers for twenty-five (25). A Change of Management to include Valley Silvertown LLC as a partial manager was approved on 09/23/25. Facility postings at the main entrance included the facility license, Ombudsman contact, confidential complaint contact, Emergency Disaster Plan, personal rights in English and Korean, monthly and daily activity calendar, and the facility sketch with evacuation routes clearly labelled. Sprinkler systems and fire alarms are located throughout the building. Sign-in sheets are available for residents, agencies, and other visitors at the reception area. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. Linen closets with adequate supplies of fresh linens, locked janitorial and electrical closets, and public restrooms were located on the first and second floor. The upstairs activity room contained card games, art supplies, reading materials, seating in good condition, and adequate space. Between 9:00 a.m. and 9:30 a.m. today, LPA observed the activity director providing a physical exercise routine for about seven (07) residents. At 10:30 a.m., LPA observed church services provided in the upstairs activity room. At approximately 10:35 a.m. LPA observed the room temperature to be 72 degrees Fahrenheit. Evacuation chairs were observed at the top of each stairway. LPA and the licensee inspected rooms on the first and second floors. The pull cord system in Room #106 was tested at 12:06 p.m., and staff responded by 12:08 p.m. At 12:10 p.m. the hot water in the bathroom was measured to be 112.5 degrees Fahrenheit. The pull cord system in #114 was tested at 12:12 p.m. and staff responded by 12:13 p.m. The hot water in the bathroom was measured to be 113.0 degrees Fahrenheit. Business offices and a staff training room were located on the first floor near the main entrance. At 12:15 p.m., LPA observed fully charged fire extinguishers on the first and second floor hallways which were last inspected on 05/22/25. Two (02) emergency exits on the southern perimeter of the building were unlocked and alarmed. The alarms were tested to be operational at 12:25 p.m. Emergency exit paths were unobstructed and free of debris. At 12:30 p.m. and 12:35 p.m., LPA measured the hot water in room #237 and the upstairs public restroom to be 109.6 degrees Fahrenheit. At 12:40 p.m. the memory care portion was surveyed. The memory care unit is equipped with 15-second delayed egresses at four (04) locations. The activity room in memory care contained art supplies, exercise equipment, and furniture in good repair. Resident bedrooms contained a chair, nightstand, appropriate lighting, storage, and bedding in good condition. At 12:45 p.m. LPA tested a delayed egress door to be operational. The patio area in the middle and rear of the facility contained maintained lawn areas, a smoking area, and shaded seating with furniture in good repair. Two (02) storage sheds near the parking lot were locked and contained chemicals and tools. The laundry area contained three (03) washers and three (03) dryers. Detergents were made inaccessible in an adjacent storage room. The facility elevator was functional. The dining room contained adequate seating. Daily and alternative menus were posted at each table. The kitchen area contained functional equipment and sanitary surfaces. Resident specialized diets were posted on the wall along with temperature logs. The pantry, refrigerator and freezer contained adequate supplies of perishable, non-perishable, and emergency foods. At 3:10 p.m. LPA measured the walk-in refrigerator and freezer temperatures to be 39 degrees and -11 degrees Fahrenheit, respectively. Due to time constraints, LPA to return to the facility tomorrow, 04/10/25 for an ANNUAL – CONTINUATION visit to complete the annual inspection. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 9, 2026

Allegation investigated: Financial abuse

At approximately 12:45 p.m. on 01/28/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA toured the facility inside and out at 12:45 p.m. today, interviewed staff and residents between 12:50 p.m. and 3:45 p.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, rent balances, and client roster at 1:30 p.m. Regarding the allegation "Financial abuse" it was alleged the facility withdrew funds from the account of Resident #1 (R1) without their expressed written consent. Interview with the administrator at 1:00 p.m. today revealed they had received no payment from R1 since November 2025. The administrator showed LPA account records which confirmed R1 had made no payments since 11/28/25. Interview with the licensee at 1:20 p.m. today confirmed the facility had not received payment from R1 since November. Unsubstantiated The facility had no record of an increase notice from $3559 to $3859. Interview with the licensee at 1:20 p.m. today revealed no residents have been issued rent increase notices since the Change of Management in September 2025. Based on interviews and record review, the facility increased R1’s rent without providing sufficient notice, and the previous rent increase issued was given only 60 days prior to the increase. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is issued on the corresponding LIC 9099-D page. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided. Record review of R1’s file at 1:30 p.m. revealed the latest payment issued to the facility was a check payment from R1 in November 2025. Interview with a representative from R1’s bank at 2:00 p.m. today revealed R1 set up automatic payments to the facility on 11/21/25. Interview with R1 at 2:10 p.m. today revealed that was unintentional. Based on interviews and record review, the facility did not financially abuse R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 31-AS-20260128104745

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655 · Plan of correction due date: Feb 7, 2026

§1569.655 Increase in fee rates... 90 days’ written notice... (a) If a licensee... increases the rates of fees for residents... the licensee shall provide no less than 90 days’ prior written notice to the residents. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not providing a rent increase notice to Resident #1 (R1) at least 90 days prior to issuing a rent increase, which posed a potential risk to the Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Licensee will conduct an in-service training on the cited section and submit to the LPA by the POC due date.

Allegation investigated: Licensee allowed a volunteer to perform staff duties

At 12:45 p.m. on 12/04/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 11/06/25 and toured the facility inside and out at 1:50 p.m., interviewed staff and residents between 2:00 p.m. and 4:00 pm., and conducted a record review of pertinent records, including but not limited to staff records and a staff roster at 2:30 p.m. Another subsequent visit was conducted on 11/13/25 in which LPA interviewed staff, family, and residents between 1:00 p.m. and 5:10 p.m. and toured the facility inside and out at 1:30 p.m. Another subsequent visit was conducted on 11/19/25 in which LPA interviewed staff and residents between 11:15 a.m. and 4:15 p.m., toured the facility inside and out at 1:00 p.m., and conducted a record review of pertinent records at 2:15 p.m. Today, LPA interviewed staff and residents between 12:50 p.m. and 4:00 p.m., toured the facility at 1:00 p.m., and conducted a record review at approximately 3:00 p.m. Substantiated Regarding the allegation "Licensee allowed a volunteer to perform staff duties" it was alleged Volunteer #1 (V1) performed staff duties and without supervision. Record review of the staff roster and V1’s facility file revealed V1 was listed as a volunteer and not yet 18 years old. Record review of the facility program plan revealed the job description for ‘Receptionist’ required the individual to be at least 18 years old. LPA called the facility prior to the investigation at 4:45 p.m. on 10/06/25 and V1 answered and directed LPA’s call. Interview with the administrator at 2:15 p.m. on 11/06/25 revealed V1 mainly answers phones in the reception area and does not interact directly with residents. Interviews with four (04) out of seven (07) staff revealed they have seen V1 perform staff duties without supervision. Interviews with four (04) out of eleven (11) residents revealed they have seen V1 perform staff duties without supervision. Six (06) out of eleven (11) residents were unsure. Based on observations, interviews, and record review, V1 has performed receptionist duties without sufficient supervision. Therefore, the allegation is deemed SUBSTANTIATED at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 31-AS-20251103130636

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(b) · Plan of correction due date: Dec 12, 2025

87411 (b) Personnel Requirements -General - All persons who supervise employees or who supervise or care for residents shall be at least eighteen (18) years of age. Based on record review and interviews, the licensee did not comply with the above section through leaving Volunteer #1 (V1) to supervise residents without supervision which posed a potential risk to the Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee has removed V1 from the staffing schedule and confirmed that V1 only works in the office and no longer works behind the front desk. Deficiency cleared.

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.

Type of visit: Case Management - Deficiencies

At 12:45 p.m. on Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. During the course of investigation of complaint #31-AS-20251203164348 today and complaint #31-AS-20251117123125 on 12/02/25, LPA discovered deficiencies in the facility. At approximately 9:40 a.m. on 12/02/25 during a facility tour, LPA observed the northern exit gate was locked with a padlock. Review of the facility sketch revealed that was an emergency exit leading to a designated assembly point. A deficiency is issued on the corresponding LIC 9099-D page for locking an emergency exit path. At approximately 9:50 a.m., LPA observed the roof entrance above the dining room to be unlocked with no auditory alarm installed. The roof was therefore accessible to residents. No staff were supervising the area, although it was the Assisted Living portion of the facility. LPA conducted a record review at approximately 11:00 a.m. and interviewed the administrator at the same time. Record review and interview revealed at least one (01) resident in the Assisted Living side has dementia, and therefore the roof should not be accessible to residents with dementia. Deficiency is cited on the corresponding LIC 9099-D page. Record review of the medical assessment of Resident #1 (R1) around 11:30 a.m. on 12/02/25 revealed they were bedridden. An incident report submitted on 11/30/25 confirmed R1 was “bedbound”. Review of the facility’s fire clearance revealed the facility can admit eight (08) bedridden residents in Rooms 103-108, 129, 130, 189 or 190. R1 did not reside in a room designated for bedridden residents. A deficiency is cited on the corresponding LIC 9099-D page for violating the facility’s fire clearance. The administrator sent an eviction notice on 11/30/25 for Resident #2 (R2). The notice did not contain certain required elements such as contact information of the Licensing Department, the ability to investigate the eviction, or the statement about the need to file an unlawful detainer. A deficiency is issued on the corresponding LIC 9099-D page for an unlawful eviction. At approximately 2:00 p.m. today, LPA reviewed a notice issued to residents from management. The notice stated “you will be responsible for managing your own medications, including medication storing, administration, and refills” if residents did not provide an updated medical assessment. Interview with licensee Nick today at approximately 2:30 p.m. revealed it was written incorrectly. A resident’s ability to manage and store medications is determined by a medical professional and not based on facility policies. A deficiency is issued on the corresponding LIC 9099-D page for a lack of understanding of Title 22 regulations. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Dec 5, 2025

87705 Care of Persons with Dementia - (d) The licensee shall ensure that the facility has an auditory device... to monitor exits on exterior doors... accessible to those residents who may be at risk for elopement This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above in leaving the roof accesible and unlocked which posed an immediate risk to the Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee installed a lock during today's visit. Deficiency cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(6) · Plan of correction due date: Dec 5, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents... shall have... the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above in locking the northern emergency exit to the assembly point which posed an immediate risk to the Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee removed the lock on the emergency exit during today's visit. Deficiency cleared.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.72(c) · Plan of correction due date: Dec 5, 2025

§1569.72 Bedridden residents - (c) ... bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance. This requirement was not as evidenced by: Based on record review and interviews, the licensee did not comply with the above section in allowing Resident #1 (R1) to reside in a room not designated for bedridden residents which posed an immediate risk to the Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee acquired a new LIC 602 for Resident #1 (R1) showing they are non-ambulatory. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.683(a) · Plan of correction due date: Dec 12, 2025

§1569.683 Eviction notices... (a) In addition... (4) The following statement: "In order to evict a resident ...the... facility... must file an unlawful detainer action in superior court and receive a written judgment. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above in the eviction notice of Resident #2 (R2) which posed a potential risk to the Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee has revoked the eviction notice and will review the cited sectio and re-submit the eviction properly.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(2) · Plan of correction due date: Dec 12, 2025

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above in issuing a misleading notice to residents which posed a potential risk to the Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee reviewed the cited section and issued a written statement confirming understanding of the deficient area. Deficiency cleared.

Type of visit: Case Management - Incident

At approximately 1:45 p.m. on 11/06/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the administrator and disclosed the reason for the visit. Today’s case management visit was conducted because of an incident report submitted by the facility which indicated Resident #1 (R1) left the facility around 6:00 a.m. on 10/20/25. Interview with the Administrator at 2:15 p.m. today revealed the facility has followed up with the police every few days and heard no updates on R1’s whereabouts. Record review of R1’s medical assessment and emergency contacts revealed R1 is self-responsible, able to follow instructions, and had no mental or developmental health diagnoses. Also, R1’s physician did not indicate that they could not leave the facility without assistance. Based on interviews and record review, the facility provided sufficient supervision to R1 based on their care needs. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 6, 2025

Allegation investigated: Insufficient care and supervision provided to residents Facility is unsanitary

At approximately 9:30 a.m. on 10/02/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted a file review at 4:00 p.m. on 10/01/25, interviewed staff and residents between 9:40 a.m. and 2:00 p.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and client roster at 10:00 a.m., and toured the facility inside and out at 10:15 a.m. Regarding the allegation "Insufficient care and supervision provided to residents" it was alleged a resident exposed themselves and urinated in a common area. File review revealed the facility submitted an incident report in which Resident #1 (R1) had urinated in the courtyard on 09/20/25. Interview with Staff #1 (S1) at 9:40 a.m. today confirmed the details of the report and noted only Staff #2 (S2) witnessed the event. Unsubstantiated ***This report was amended to correct an error*** - LPA NR 05/15/26 Interview with Staff #2 (S2) at approximately 11:30 a.m. revealed they reported the incident to Staff #3 (S3). Interview with S3 at approximately 12:15 p.m. today revealed they were aware of the issue and spoke with R1 and their family about additional assistance and facility rules. Record review of R1’s reassessment from 03/15/25 indicated that R1 did not need assistance with toileting. Review of R1’s medical assessment also indicated that they were able to follow instructions and handle their toileting needs without staff assistance. Interview with the administrator at 12:20 p.m. today revealed it may have been an episode of confusion, and staff are monitoring R1’s behaviors for the next two (02) to three (03) weeks to ensure they and other residents are afforded a safe and comfortable setting. Based on interviews and record review, although R1 used a common area to urinate, staff appropriately supervised R1 and reported the issue to all appropriate parties. Furthermore, the facility has increased supervision of R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Facility is unsanitary" it was alleged Resident #2 (R2) disposed of their toenails and urine from their catheter bag in a common area. During facility tour, LPA observed the facility was sanitary and free from debris. Information received revealed that both incidents happened few days after R1 was admitted to the facility. Staff #1 (S1) who witnessed both incidents revealed that they immediately cleaned common areas and made sure to eliminate urine odor. The incidents were reported to the staff #3 (S3). S3 stated they spoke with R2 about the incident and made clear that they are to use their room and restrooms for catheter care and dispos the toenails in the trashcan. S3 also spoke with R3’s home health agency about increased assistance. Interview with R2 at approximately 11:45 a.m. today revealed they no longer empty their catheter in common areas after speaking with S3. R2 verified that they can care for their catheter independently. A review of R2’s facility records confirmed that R2 can independently care for their catheter and empty urine bag. Review of R2’s care plan revealed R2 needed “time to adjust [to a] new environment”, and care staff were to “monitor… and report difficulties”. Overall investigation revealed that although alleged incidents did happen, staff immediately cleaned the common areas to ensure that residents are not exposed to unsanitary conditions. Therefore, based on interviews observation and record review, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 31-AS-20250926092430

Type of visit: Case Management - Health Checks

At approximately 2:00 p.m. on 08/21/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the administrator and disclosed the reason for the visit. Today’s case management visit was conducted to ensure the health and safety of two (02) newly admitted residents, Resident #1 (R1) and Resident #2 (R2). LPA and the administrator toured the facility around 2:30 p.m. and met with and interviewed R1 at 2:45 p.m. and R2 at 3:00 p.m. today. LPA observed both R1 and R2 were in good condition. Their rooms were sanitary and accommodations were comfortable. Both residents reported that their needs are being met. Neither R1 nor R2 had any concerns at this time. Based on interviews with R1 and R2, today’s wellness check is complete. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 21, 2025

Type of visit: Case Management - Incident

At 1:30 p.m. on 07/11/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the administrator and disclosed the reason for the visit. Today’s case management visit came about after the facility submitted two (02) reports detailing resident falls in which staff may have not responded in a timely manner. The first incident happened on 06/30/25. Resident #1 (R1) fell near their bathroom around 5:00 a.m. R1 yelled for help. Resident #2 (R2) overheard R1 yelling for help around 5:00 a.m. The report noted that R1 did not use the call system and refused medical treatment when staff came to assist R1 around 7:15 a.m. The administrator was interviewed at 1:40 p.m. today and noted that they were nearby at the time of the fall and did not hear R1 yelling for help. The second incident happened on 07/04/25. Around 4:00 a.m., Resident #3 (R3) fell and waited two (02) hours for staff assistance. The administrator stated that the two (02) staff on shift at the time were interviewed and claimed that they responded to assist R3 quickly, but they did not reset the timer on the call system, so it showed that the response did take approximately two (02) hours. Due to the need for more information, LPA will continue the investigation at a future date to determine if residents were assisted in a timely manner after falling. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 11, 2025

Allegation investigated: Facility is advertising miselading statements on its brochure

At approximately 12:30 p.m. on 06/26/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA interviewed staff and (07) residents [which was at least 10% of the community] between 12:40 p.m. and 3:00 p.m. today, toured the facility inside and out at 1:00 p.m., and conducted a record review of pertinent records, including but not limited to staff and client rosters at 3:30 p.m. Regarding the allegation "Facility is advertising misleading statements on its brochure" it was alleged the facility produced a brochure which advertised services which were not offered. The Department also received photographs of the brochure showing the facility offered “24-hour nursing care”, skilled nursing care, and physical therapy services. Interview with the administrator at 12:40 p.m. today confirmed the brochure was available in the facility about one (01) month ago. Substantiated Interview with Staff #1 (S1) at 3:15 p.m. today revealed beverages are always offered, and snacks are kept in the kitchen and provided upon request. The memory care unit also has a designated snack cart. Interview with Staff #2 (S2) at 1:30 p.m. today revealed snacks are available in the kitchen and memory care snack cart, and all snacks are provided upon request. Interview with kitchen staff, Staff #3 (S3) at 1:10 p.m. today revealed that residents often approach the kitchen for snacks without any issue. Interviews with seven (07) out of seven (07) residents today revealed no residents have been denied snack or beverages, though at least three (03) were unaware of how to get snacks. Based on observations and interviews, the facility offers snacks and beverages to residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided. All brochures were removed due to confusion about the services offered. The administrator further noted that there is no nurse on site, and the facility does not offer skilled nursing or physical therapy directly. During the facility tour, LPA did not observe any brochures. Interviews with seven (07) out of seven (07) residents confirmed the brochures were formerly available and have since been removed. Interview with Staff #1 (S1) at 3:15 p.m. today confirmed the brochures offered skilled nursing, and the facility removed the brochures several weeks ago. Based on observations, record review, and interviews, the facility was advertising misleading statements. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is issued on the corresponding LIC 9099-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 31-AS-20250624150337

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Jul 3, 2025

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above by offering services on its brochure which it did not provide which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 26, 2025

Plan of correction: The facility has removed all misleading brochures and will consult with LPA prior to producing another brochure. Deficiency is cleared at this time.

Type of visit: Case Management - Other

At 3:00 p.m. on 05/15/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. Today’s case management visit was conducted to collect records and information about a staff member. LPA conducted a records review of the staff list at 3:05 p.m. and interviewed Staff #1 (S1) at 3:15 p.m. Due to the need for more information, LPA will return at a later date for further investigation. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 15, 2025

Type of visit: Required - 1 Year

At 8:50 a.m. on 01/17/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later the administrator and disclosed the reason for the visit. A file review was conducted prior to today’s visit. The facility was last visited on 01/07/2025 for a case management visit. It is a two-story building with assisted living and memory care units, shared and private rooms, common areas, offices, beauty salon, theatre room, medication room, and outdoor areas. It has an approved fire clearance for 183 non-ambulatory residents of which 8 may bedridden. Approved hospice waivers for 25. Facility postings at the main entrance included the facility license, Ombudsman contact, confidential complaint contact, Emergency Disaster Plan, personal rights, monthly and daily activity calendar, and the facility sketch with evacuation routes clearly labelled. Sprinkler systems and fire alarms are located throughout the building. Surveillance cameras are located in common areas and exterior areas. Sign in sheets are available for residents and visitors at the reception area. Ramps and handrails at the front were secure. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. Linen closets with adequate supplies of fresh linens were located on both floors. At 9:10 a.m. LPAs observed the room temperature to be 72 degrees Fahrenheit. The upstairs activity room contained card games, art supplies, reading materials, seating in good condition, and adequate space. At 9:15 a.m. LPA observed two (02) residents engaged in activities. At 9:30 a.m., LPA observed residents gathering for church services in the Theatre Room. The Theatre Room contained reading material, comfortable seating, and a massage chair. Business offices were located near the main entrance. At 10:15 a.m., the house phone was used to call out and deemed operational. At 10:20 a.m., LPA observed fully charged fire extinguishers on the first and second floor hallways which were last inspected on 05/16/24. The southeast and southwest emergency exits were unlocked. Emergency exit paths were unobstructed and free of debris. At approximately 10:30 a.m., LPA observed minor repairs needed to the drywall in the first floor stairwell by the kitchen and on the second floor at the northwest corner. A Technical Violation is issued for the repairs. The patio area in the middle and rear of the facility contained maintained lawn areas, a smoking area, a television, a piano, and shaded seating with furniture in good repair. Two (02) storage sheds near the parking lot were locked and contained chemicals and tools. The laundry area contained two (02) washers and two (02) dryers. At 10:40 a.m. today, LPA observed one (01) out of two (02) washers was inoperable. Interview with the administrator at approximately 1:15 p.m. today revealed the facility has scheduled maintenance to repair the appliance. Detergents were made inaccessible in an adjacent storage room. The facility elevator was functional. The dining room contained adequate seating. Daily and alternative menus were posted at each table. The kitchen area contained functional equipment and sanitary surfaces. Resident specialized diets were posted on the wall along with temperature logs. The pantry, refrigerator and freezer contained adequate supplies of perishable, non-perishable, and emergency foods. At 10:50 a.m. LPA measured the walk-in refrigerator and freezer temperatures to be 33 degrees and -13 degrees Fahrenheit, respectively. The memory care unit is equipped with 15-second delayed egresses at four (04) locations. The activity room in memory care contained art supplies, exercise equipment, and furniture in good repair. Resident bedrooms contained a chair, nightstand, appropriate lighting, storage, and bedding in good condition. At 11:05 a.m. and 11:10 a.m., LPA tested the call systems in Room #115 and Room #118 of the memory care unit. Staff responded to the call within one (01) minute. At 11:15 a.m. LPA measured the water temperature in Room #115 to be 113.7 degrees Fahrenheit. Exit signs were illuminated and displayed exit routes. Fire sprinklers were observed throughout the unit. Three (03) out of three (03) storage rooms were locked. An outdoor area contained shaded patio with furniture in good condition. The medication room near the main entrance was attended and contained a refrigerator and cabinets for medications, medical files, a complete first aid kit, and disposal devices. LPA conducted a medication review at 11:25 a.m. Three (03) out of three (03) resident medications reviewed contained accurate medications counts. Evacuation chairs were observed at the top of each stairway. All public bathrooms contained liquid soap, paper towels, trash cans. At 3:45 p.m., LPA tested the smoke and carbon monoxide detector in Room 107 and determined both to be operational. LPAs conducted a record review of resident and personnel files at 1:20 p.m. Most employee and resident files were available for audit. However, the licensee did not have a complete file available for audit. Therefore, a deficiency is issued and noted on the corresponding LIC 809-D page. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 17, 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.

Type of visit: Case Management - Other

At approximately 2:00 p.m. on 01/07/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the administrator and disclosed the reason for the visit. Today’s case management was conducted to provide guidance and inspect the facility to ensure compliance with Title 22 regulations. LPA interviewed Resident #1 (R1) at 2:10 p.m. and the administrator at 3:30 p.m. and toured the facility at 3:15 p.m. During today’s visit, no immediate health or safety concerns were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 7, 2025

Allegation investigated: Unassociated staff providing care Staff sleeping while on duty

At 8:30 a.m. on 05/15/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 05/08/24 and interviewed the ED at 8:40 a.m., conducted a record review at 8:50 a.m., toured the facility at 9:00 a.m., and interviewed Resident #1 (R1) at 9:10 a.m. Today, LPA interviewed the ED, five (05) staff members, and four (04) out of forty (40) residents, which was 10% of the population between 8:35 a.m. and 11:00 a.m., conducted a record review at 10:30 a.m., and toured the facility at 10:45 a.m. Regarding the allegation “Unassociated staff providing care” it was alleged S1 was working in the facility before obtaining a criminal background clearance. Interview with R1 revealed they saw S1 in the building in April 2024 and asked staff who S1 was. R1 was told that multiple staff were not aware of S1’s identity. Substantiated File review prior to the investigation revealed S1 received their criminal background clearance on 05/06/24. Record review revealed S1 began employment on 04/02/24. Interview with S1 at 11:00 a.m. today confirmed they started their employment around 04/02/24. Based on record review and interview, S1 began working at least 5 days prior to obtaining a criminal background clearance. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 9099-D page. A civil penalty in the amount of $500 ($100 per day for 5 days, $100 x 5 = $500) is issued. Regarding the allegation “Staff sleeping while on duty” it was alleged Staff #2 (S2) was asleep during their shift. Interview with Staff #3 (S3) at 10:00 a.m. today revealed S2 was recently fired for sleeping on the job. Interview with the ED at 10:15 a.m. today confirmed S2 was fired on 05/12/24 for sleeping on the job, however S2 was only in training at the time and was not in charge of caring for residents. The ED ensured sufficient care and supervision were provided to residents by qualified staff during S2's training. Record review today revealed S2 received a corrective action notice on 05/08/24 for sleeping on the job and was witnessed by two (02) staff members. LPA was unable to contact either of the two (02) staff witnesses. Based on interviews and record review, S2 was asleep during their shift. Since S2’s actions did not affect the residents in care, the allegation is deemed SUBSTANTIATED at this time and a Technical Violation is issued. No immediate health and safety risks were observed. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, May 15, 2024 · control 31-AS-20240503095800

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: May 15, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ... shall prior to working... in a licensed facility: (1) Obtain a California clearance... as required by the Department. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section citedd above in one (01) staff member which poses an immediate Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: On 05/06/24, the criminal record clearance of the staff member in violation was approved by the Department. Deficiency cleared.

Type of visit: Prelicensing

At 9:15 a.m. on 02/13/2024, Licensing Program Analysts (LPAs) Nicholas Reed, Perchui Melina Khurshudyan, Ray Comer conducted an unannounced prelicensing visit. LPAs met with the administrator and disclosed the reason for the visit. LPAs and Administrator toured the facility inside and out at 9:30 a.m. A file review was conducted prior to the visit. Today’s inspection was conducted due to a Change of Owner ship with residents in care. The facility was last visited on 11/29/2023 for an annual visit. It is a two-story building with assisted living and memory care units, shared and private rooms, common areas, offices, beauty salon, theatre room, medication room, and outdoor areas. It has an approved fire clearance for 175 non-ambulatory residents and 8 may bedridden residents. Facility postings included the facility license, Ombudsman contact, confidential complaint contact, Emergency Disaster Plan, theft policy, personal rights, activity calendar, facility sketch with evacuation routes clearly labelled, and a blank copy of an admission agreement. Sprinkler systems and fire alarms were located throughout the building. Surveillance cameras are located in common areas and exterior areas. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. Linen closets with adequate supplies of fresh linens were located on both floors. At 9:20 a.m. LPAs observed the room temperature to be 78.5 degrees Fahrenheit. The memory care unit was equipped with 15 second delayed egresses at four (04) locations. The activity room contained art supplies, exercise equipment, music equipment, and furniture in good repair. Resident bedrooms contained a chair, nightstand, appropriate lighting, storage, and bedding in good condition. At 9:35 a.m., five (05) fire extinguishers were observed to be fully charged and last inspected on 08/29/2023. At 9:37 a.m., LPAs tested the call system in Room #125 of the memory care unit. By 9:39 a.m. staff responded to the call. Exit signs were illuminated and displayed exit routes. Fire sprinklers were observed throughout the unit. Two storage rooms were locked and contained hygiene supplies and resident files. An outdoor area contained shaded patio with furniture in good condition. At 1:45 p.m. LPAs tested the hot water temperature in Rooms 115 and 125 to be 119.0 degrees Fahrenheit. The courtyard contained a gas grill, patio furniture in good condition, walkways free of obstructions, a designated smoking area, a backup generator, and unlocked exit gates. Two locked sheds contained maintenance supplies and extra bedroom supplies. The laundry area contained two industrial washers and dryers. At 10:10 a.m. LPAs observed one (01) of the two (02) washers to be out of order. The administrator confirmed a work order was submitted to fix the washer. Detergents were made inaccessible in an adjacent storage room. The dining room contained adequate seating. Daily menus and alternative menus were posted at each table. The kitchen area contained appropriate equipment and sanitary surfaces. Resident specialized diets were posted on the wall along with temperature logs. The pantry, refrigerator and freezer contained adequate supplies of perishable, non-perishable, and emergency foods. A hot box was used to transport memory care resident meals and maintain at safe temperatures. At 10:15 a.m. LPAs measured the walk-in refrigerator and freezer temperatures to be 30 degrees and -25 degrees Fahrenheit, respectively. A first aid kit was observed in the kitchen manger’s office. LPAs toured Room #186, #108, and #205, and #254 in the assisted living unit. Resident rooms contained appropriate furnishings which were in good repair. At 10:35 a.m. LPAs tested the house telephone to be operational. The locked medication room near the main entrance contained a refrigerator and cabinets for medications, medical files, and disposal devices. LPAs conducted a medication review at 11:15 a.m. Evacuation chairs were observed at the top of each stairway. At 11:37 a.m. LPAs tested the dual functioning smoke and carbon monoxide detectors to be functional. All public and resident bathrooms contained liquid soap, paper towels, trash cans, grab bars near the toilet and shower, and non-skid mats or surfaces in the shower. Some bathrooms contained commodes. LPAs and the administrator reviewed Component III at approximately 1:00 p.m. LPAs conducted a record review of resident and personnel files at 1:30 p.m. At 2:40 p.m. LPAs and Administrator discussed plans for future facility renovations. The Administrator agreed to notify the Department and obtain all necessary permits prior to any construction. During today's inspection, the facility was in compliance with Title 22 regulations. Prelicensing is complete and the facility has no deficiencies. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 13, 2024

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Facility Type: RCFE Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Dec 21, 2023