Valley View Retirement Center

Allegation investigated: Resident is not accorded rights to refuse medications. Staff do not ensure residents health care needs are being met.

Licensing Program Analyst (LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegations listed above. The LPA was greeted by the facility staff, and the LPA explained the reason for the visit. The staff contacted the Administrator Judith Montoya on the phone, and the LPA explained the reason for the visit. The Administrator was unable to come to the facility and asked the designated facility staff to provide the LPA with the requested records, and the LPA interviewed the Administrator on the phone. LPA Urena, along with the staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. LPA Urena interviewed the Administrator at approximately 11:37 a.m., staff at approximately 11:55 a.m. and requested records pertinent to the investigation. Additionally, the LPA interviewed R1’s Social Worker with the Veteran’s Administration Office at approximately 12:10 p.m. Continues on LIC 9099C... page 2. Unsubstantiated Pg.2 Resident is not accorded rights to refuse medications. On the allegation that the Resident is not accorded rights to refuse medications; the RP’s concern is that the Resident (R1 refuses to take their medication because R1 does not like how it makes them feel. Furthermore, it is alleged that the medication technicians force R1 to take their medications. However, the RP is unsure whether the staff are physically forcing R1 to take the medication or simply verbally pressuring R1 to comply. To investigate the allegation, LPA Urena conducted record review and interviewed the Administrator, staff, and R1’s assigned Social Worker (SW) with the Veterans’ Administration. R1 was not available for an interview. The record review revealed that R1 has been receiving the prescribed medication as directed by the doctor. No refusal of medication has been recorded. The interview with the Administrator revealed that R1 has been complying with taking their medication. The staff’s interview revealed that R1 has been compliant with the medication. The interview with R1’s SW revealed that R1 has not shared at any time that staff have forced them either physically or verbally pressured them into taking their medication and are aware that R1 is taking their medication as prescribed. Based on the information obtained through record review and interviews, the staff has not violated the R1’s personal rights based on R1’s intake of the medication. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on LIC 9099C...page 3. Pg. 3 Staff do not ensure residents health care needs are being met. On the allegation that Staff do not ensure residents health care needs are being met; the RP’s concern is that the staff are not capable of providing the level of care R1 requires and have resorted to placing R1 in involuntary restraining holds, to stop the behavior displayed by R1. To investigate the allegation, the LPA conducted record review and interviews. Record review of the Incident Reports (LIC 624) sent to the Community Care Licensing (CCL) Office, revealed that the Administrator has followed protocol and regulations by informing the CCL of any incidents involving R1. Record review revealed that R1 has been residing at the facility for about 1.5 years, and during this time R1 has been placed on one involuntary restraining hold. The interview with R1’s SW from the Veteran’s Administration Department (VA) revealed that the facility’s staff proactively communicates with the VA doctors about any changes in R1’s behavior, allowing for VA’s intervention for a positive outcome when R1 becomes combative. Per the SW, there has been one (1) incident of involuntary restraining hold and one (1) voluntary occurrence which occurred on 11/19/2025 when R1 displayed aggressive behavior towards facility staff. The facility Administrator called the VA’s office and the VA’s SW and field support staff arrived at the facility to speak with R1. R1 was advised by the VA staff that R1 needed to be seen by a VA doctor, to which R1 agreed and R1 was transported by car by the VA staff to the VA’s doctor’s office. Based on information obtained through record review and interviews, facility staff are following regulations and protocol to provide the level of care needed to R1, at this time. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted with the facility’s designated staff. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 29-AS-20251124085928

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 10/08/2025. LPA Urena met with the Administrator Judith Montoya and explained the reason for the visit. BEDROOMS: The LPA observed seven (7) resident's bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap, and paper towels. RECORDS: Records review began at 11:45 am. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:35 pm.; medications are centrally stored and locked in the medication room; medications are labeled and checked for expiration dates. The medications are documented properly on the centrally stored medications and destruction record. No errors observed during the medication review. The LPA reviewed the following documents: LIC500 Personnel Report, LIC9020 Client Roster, Certificate of Liability of Insurance, Bond Insurance Certificate, Emergency Drill Logs, Smoke detector(s) and carbon monoxide detector logs. No citations were issued. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with the Administrator, Judith Montoya and explained the reason for the visit. The LPA along and the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. All required posting were observed on the first-floor hallway. The LPA observed the fire extinguishers (12) throughout the facility to be fully charged and last serviced on 10/02/2025. Signs are posted throughout facility to promote hand washing, and cough/sneeze etiquette. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the janitor and laundry room. First aid kits are located in the medication room, and kitchen area. Two (2) television rooms were observed. One on the first floor and one on the second floor. An activity room was observed on the second floor. Activity room was observed to be clean with multiple tables and chairs for activities. A beauty salon was observed on the first floor. The beauty salon was locked at the time of the visit; it is used by facility staff to provide residents with haircuts, nail clipping, etc. A monthly activity calendar was observed to be posted in the hallway of the first floor. LAUNDRY ROOM: Laundry units are located inside laundry room. Continues on LIC 809C... KITCHEN: The kitchen/dining area were observed to be clean. Knives are stored in the inaccessible kitchen. Kitchen appliances appear to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and freezer temperatures were observed to be within the regulation limits (below -0 and 40) degrees. Daily menus were posted inside and outside the dining room. OUTDOOR SPACE: The facility has covered outdoor areas for resident use at the front, and sides of the facility. There is a gate on the side of the facility designated for an emergency exit. There are no bodies of water on the premises. The facility only has a parking lot, no garage nor basement. Due to time constraints, LPA Urena will return on another date to complete the Annual inspection.the state’s words, verbatim · CDSS document, Oct 8, 2025

Allegation investigated: Staff neglected a resident resulting in hypothermia.

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced at the facility to conduct a subsequent visit to investigate the allegation listed above. The LPA met with the Administrator Judith Montoya and informed them of the reason for the visit. The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. During today’s visit, the LPA checked for temperature readings recorded on the temperature thermostats found throughout the hallways of the facility and in a random selection of rooms located on the first and second floor of the facility. Temperatures were observed to be within the allowed temperatures based on regulations. On 06/23/2025, Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility. Continues on LIC 9099C... Unsubstantiated Staff neglected a resident resulting in hypothermia. On the allegation that staff neglected a resident resulting in hypothermia, it is the concern of the reporting party (RP) that upon admission of Resident #1 (R1) to the hospital, R1 exhibited signs of being hypothermic. On 06/15/2025 at approximately 04:01 p.m., per R1’s doctor’s recommendation, R1 was picked up from the facility by the ambulance to be transported to the hospital due to R1 experiencing confusion and being lethargic. However, on route to the hospital, R1 started to experience shortness of breath, and the ambulance personnel routed R1 to the ‘nearest’ hospital to be evaluated. To investigate the allegation, LPA Urena obtained and reviewed records from the transporting ambulance company which transported R1 from the facility to the ‘nearest’ hospital. Furthermore, LPA Urena also obtained and reviewed Admission Records from the ‘nearest’ hospital. Record review of the ambulance ledger revealed that R1’s vital signs were obtained and observed as follows: “Stable, no interventions, nor comfort measures needed on route”. Review of the ‘nearest’ hospital Admission records revealed that R1 was admitted to the Emergency Room (ER) with suspected Sepsis: Pneumonia / Empyema, UTI, or Pyelonephritis. Furthermore, admission records revealed that vital signs were checked as follows: VITAL SIGNS: (Temp. Pulse. RR. BP)-Rate and rhythm Normal, Heart Sounds Normal, Bilateral Breath Sounds Normal, … SKIN EXAM: Skin warm, dry. Although the allegation may have happened or is valid, based on the interviews, and record review, there is not sufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation that staff neglected a resident resulting in hypothermia is deemed Unsubstantiated at this time. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 29-AS-20250616161248

Allegation investigated: Staff did not prevent resident from contracting scabies at the facility

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 10:31 AM. LPA met with facility Administrator Judith Montoya entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a physical plant tour, reviewed one (1) resident file, and conducted interviews with the Administrator, three (3) witnesses, and seven (7) residents between 10:35 AM and 02:15 PM. Continued on LIC-9099C Unsubstantiated The allegation of “Staff did not prevent resident from contracting scabies at the facility” alleges that the facility did not take appropriate precautions to prevent Resident #1 (R1) from contracting scabies while residing at the facility. Interviews with the Administrator, staff #1 (S1) and Witness #1 (W1) revealed that R1 has a skin condition that results in itching and a rash similar to scabies. The Administrator and S1 stated that R1 was admitted to the facility with this condition and was receiving care for the condition while they resided at the facility. W1 confirmed that R1 was diagnosed with this condition around the time they moved to the facility. Additionally, W1 confirmed that R1 has been tested for scabies on multiple occasions and each test returned negative results. LPA interviewed Witness #2 (W2) who stated that R1 has not been confirmed to be diagnosed with scabies but received treatment as a precautionary measure. LPA reviewed R1’s file. LPA observed R1’s admission appraisal needs and services plan dated 02/17/2025 which stated that R1 had a “Skin condition but being treated.” All current residents interviewed stated that the facility staff maintain a clean facility and conduct room cleanings/bath towel changes daily with bedsheets being changed weekly. No current residents had concerns with the cleanliness of the facility. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not prevent resident from contracting scabies at the facility.” Therefore, the allegation is deemed Unsubstantiated at this time. A copy of the report was printed and exit interview was conducted.the state’s words, verbatim · CDSS document, Jun 23, 2025 · control 29-AS-20250616161248

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

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with the Administrator, Judith Montoya and explained the reason for the visit. The LPA along and the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. All required posting were observed on the first-floor hallway. The LPA observed the fire extinguishers (12) throughout the facility to be fully charged and last serviced on 10/10/2024. Signs are posted throughout facility to promote hand washing, and cough/sneeze etiquette. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the janitor and laundry room. First aid kits are located in the medication room, and kitchen area. Two (2) television rooms were observed. One on the first floor and one on the second floor. An activity room was observed on the second floor. Activity room was observed to be clean with multiple tables and chairs for activities. A beauty salon was observed on the first floor. The beauty salon was locked at the time of the visit; it is used by facility staff to provide residents with haircuts, nail clipping, etc. A monthly activity calendar was observed to be posted in the hallway of the first floor. LAUNDRY ROOM: Laundry units are located inside laundry room. Continues on LIC 809C... KITCHEN: The kitchen/dining area were observed to be clean. Knives are stored in the inaccessible kitchen. Kitchen appliances appear to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and freezer temperatures were observed to be within the regulation limits (below -0 and 40) degrees. Daily menus were posted inside and outside the dining room. OUTDOOR SPACE: The facility has covered outdoor areas for resident use at the front, and sides of the facility. There is a gate on the side of the facility designated for an emergency exit. There are no bodies of water on the premises. The facility only has a parking lot, no garage nor basement. Due to time constraints, LPA Urena will return on another date to complete the Annual inspection.the state’s words, verbatim · CDSS document, Oct 14, 2024

Allegation investigated: Personal Rights. Facility staff did not assist resident with showering as needed.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to deliver findings for the allegations listed above. The LPA arrived at the facility and met with Administrator Judith Montoya and explained the reason for the visit. On 06/26/2024, Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit for the allegations listed above. Upon arrival LPA met with staff and explained reason for the visit. Administrator Judith Montoya arrived shortly after. At approximately 09:45am, LPA conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. Continues on LIC 9099C… Unsubstantiated Personal Rights. On the allegation of personal rights violation, the Reporting Party (RP) alleges that the staff were neglectful, consequently Resident #1(R1) sustaining multiple fractures due to a fall. To investigate the allegation the LPA conducted record review pertinent to the investigation. LPA Urena was unable to interview R1 due to R1 is no longer residing at the facility. LPA Urena attempted to interview the reporting party and responsible party; however, was unable to reach them. The LPA interviewed Staff (S1) on 09/12/2024 at approximately 12:49 p.m. S1 stated that on 05/28/2023 at around 7:30 a.m., they found R1 sitting on the floor when they made the morning rounds to assist with breakfast. S1 asked R1 what happened, but R1 did not remember. S1 assisted R1 to stand up, but R1 could not put pressure on the left foot due to pain. Left foot appeared slightly swollen. S1 alerted the med tech and administrator to the fall and R1’s condition. The med tech contacted R1’s physician. The administrator contacted R1’s responsible party. The administrator contacted an ambulance to take R1 to the hospital for further assessment. The LPA interviewed the administrator on 09/12/2024 at approximately 12:35 p.m. The administrator stated that they stayed in touch with the hospital and were informed that R1 would be transferred to a Skilled Nursing Facility (SNF) after being discharged by the hospital. Medical records indicate that R1 was discharged to the SNF on 05/31/2023. R1 did not return to the facility after being discharged by the SNF. The record review of R1’s physician’s report dated 02/12/2023, and R1’s Resident Appraisal/Needs Service Plan assessment dated 02/13/2023 revealed that R1 was ambulatory while residing at the facility which was from 02/13/2023 through 05/28/2023, and R1 did not have a history of falls. Furthermore, the LPA reviewed the medical records pertinent to the allegation of fractures. The medical records indicate on 05/29/2023 that R1 was admitted to the hospital due to pain and slight swelling of the left foot after a fall, and X-rays of the left foot were taken. The X-rays showed nondisplaced fracture of the third metatarsal (toe), and a subtle fracture through the distal fibula. Additionally, medical records indicate that R1 was awake, but disoriented to place time and events at time of admission; however, R1 was able to follow commands, and speech was clear. No other fractures or injuries were noted due to the fall. Although R1 did sustain fractures to the left foot due to the fall; at the time of the fall, R1 was ambulatory and did not have a history of falling. The staff also followed protocol to assist R1 once staff found that R1 had fallen. Staff notified the R1’s responsible party, R1’s physician and got help for R1 in timely manner. Based on the information obtained through record review and interviews; the allegation that staff was neglectful, is deemed Unsubstantiated at this time. Pg. 3 Facility staff did not assist resident with showering as needed. On the allegation that Resident 1 (R1) was not assisted with showers as needed, the Reporting Party (RP) alleges that R1 was only showered once a month. To investigate the allegation, the LPA interviewed the administrator, and Staff #1 (S1). LPA Urena was unable to interview R1 due to R1 is no longer residing at the facility. LPA Urena attempted to interview the reporting party, and responsible party; however, was unable to reach them. The administrator’s interview revealed that although, R1 could shower themselves, the administrator stated that R1 was assisted with showers two times a week. The administrator stated that the responsible party was specific about the days they wanted R1 to receive assistance with their showers. The S1’s interview revealed that in addition to the showers, S1 would assist R1 with shaving, nail clipping, etc. The S1 provided the LPA with a schedule followed by S1 for the services provided to residents in care at the facility. LPA Urena conducted residents’ interviews related to showers, and residents revealed that they could either shower independently or were assisted twice a week by staff if needed. Based on the information obtained through record review and interviews, the allegation that Facility staff did not assist resident with showering as needed, is deemed Unsubstantiated at this time. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 29-AS-20240624163635

Allegation investigated: Staff do not prevent resident from being harassed by other resident(s). Staff do not ensure that resident's personal possessions are safeguarded.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to investigate the allegations listed above. The LPA arrived at the facility and met with Judith Montoya and explained the reason for the visit. On 06/06/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegations listed above. The LPA arrived and met with Med Tech-Supervisor Rosalba Monarrez and explained the reason for the visit. The Administrator Judith Montoya, arrive after at approximately 1:40p.m. and the LPA explained the reason for the visit. LPA Urena interviewed staff, residents, and the administrator between 12:30 p.m. and 2:30p.m. The LPA requested documents pertinent to the investigation. Continues on LIC9099C... Unsubstantiated Pg.2 Staff do not prevent resident from being harassed by other resident(s). On the allegation that staff are not preventing residents from harassing fellow roommates, it is the concern of the Reporting Party (RP) that resident 1(R1) has been threatened by other residents with comments about actions that they may take against R1. To investigate the allegation LPA Urena interview residents and staff. The LPA attempted to interview the RP but was unable to reach them on the phone. The LPA interviewed R1 about the alleged harassment by other residents, and R1 stated that some residents make comments while R1 is in the dining room, in the hallway or when R1 leaves their room door open; R1 could not provide dates or times of the alleged incidents. However, R1 stated that the harassment started a couple of years back. LPA asked if R1 had asked the other residents to stop, and R1 stated yes, but they continue the alleged harassment. LPA asked if they had brought up the incidents to staff, and R1 said, 'yes'. The LPA interviewed residents about the alleged threats of residents against other residents in the facility. The residents interviewed stated that they have not witnessed, experienced, heard or made any threats directed to R1, or to anyone else. LPA Urena interviewed the dining area staff and caregiver staff about the allegation, and staff stated that they have not witnessed or heard any residents making threats to other residents, and if they did, they would bring it up to the administrator. Staff interviews revealed that if residents are arguing or have issues with one and other, staff intervene and de-escalate the situation. The LPA interviewed the administrator about the alleged threats and harassment, and the administrator stated that they are not aware of anyone being harassed. The administrator added that a similar allegation was brought up back in November of 2022, however that was resolved, and no other incidents have been brought up to their attention. Although the allegation may have happened or is valid, based on the interviews, and record review there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Pg. 3 Staff do not ensure that resident's personal possessions are safeguarded. On the allegation that staff do not ensure that residents belongings are safeguarded, the RP’s concern is that R1 alleges that personal items have gone missing from their room. The LPA interviewed R1 about the items missing from their room, and the R1 stated that there was a specific item that they had purchased and kept in their room and a couple of other items. R1 stated that they have not been able to find it. When the LPA asked if they remembered the last time they saw the item(s), R1 could not remember. LPA asked R1 if they informed the administrator about the missing items, and R1 stated that they had not, 'because they don’t do anything about it'. The LPA interviewed residents about missing any personal items from their room, and the residents stated that they have not lost or missed any personal items. The LPA interviewed staff about the protocol that is followed if a resident informs them of missing personal items from their room, and the staff stated that they try to assist residents in looking for the missing items, and also inform the administrator. The administrator stated that residents do inform them if they happen to be missing something, the staff will help them look for the item(s), and usually the items are found in their rooms. Although the allegation may have happened or is valid, based on the interviews there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 29-AS-20240604100921

Allegation investigated: Failure to observe resident Failture to seek timely medical attention

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. LPA met with the Administrator and explained the reason for the visit. During the initial visit on 6/21/2022, between 12:30 p.m. and 4:40 p.m., LPA Peraldi conducted a facility tour and reviewed records and obtained copies of pertinent documents. The LPA also conducted interviews with the Administrator, residents, and staff. On 06/11/2024, the LPA conducted a file review of Resident #1 (R1’s) documents such as but not limited to, admission agreement, and medical records. Regarding the allegations: Failure to observe resident. Failure to seek timely medical attention. It was alleged that the facility did not properly observe Resident #1’s (R1’s) condition and failed to seek timely medical attention by not following up on R1’s doctor’s appointments and lab work and not communicating with R1’s responsible party. Substantiated Per record review, R1’s admission agreement, dated and signed 01/02/2020 stated that resident requires or desires assistance in meeting medical and dental needs. Interview conducted with the Administrator from another complaint relating to R1, dated 03/04/2022 stated that R1 went to doctor’s appointments by themselves and R1 did not communicate with facility staff regarding R1’s doctor’s appointments or aftercare. Administrator stated that R1 was independent and dealt with medical care by themselves. However, it was revealed during a record review that R1 had a California Advance Health Care Directive and a Power of Attorney (POA) and in the document R1 stated that R1 wants R1’s agent to make health care decisions now even though R1 currently had the mental capacity to make own health care decisions; document signed and dated 02/25/2016. Interview conducted with the Administrator from another complaint relating to R1, dated 03/04/2022 stated that the facility did not have a copy of R1’s POA paperwork stating that R1 had a medical POA. Additionally, R1 was enrolled in the Assisted Living Waiver Program (ALW) and it was documented on R1’s Individual Service Plan (ISP) dated 06/26/2020 that R1 does not understand all medical appointment necessary to manage R1’s multiple medical diagnoses. The ISP continues stating, “Under medical supervision, participant’s active diagnosis will remain under control with no disease progression. RCFE and participant will work together to identify all medical specialists required to address all active diagnoses. RCFE will assist participant with scheduling all follow up appointments and lab work ordered by MD.” Although facility staff believed R1 was independent and was capable of caring for R1’s own medical care, R1 did need assistance with arranging medical care and the facility staff should have communicated with R1’s POA/ responsible person regarding R1’s medical care and needs. Furthermore, facility staff should have maintained proper paperwork that was essential to observing R1 and ensuring that R1’s medical needs would be met. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are deemed Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Conduct inimical. It was alleged that facility staff purposely ignored R1’s medical care and needs. Although facility staff did not have proper documents such as California Advance Health Care Directive and a Power of Attorney (POA) for R1 in order to provide proper care and supervision, the LPA could not determine that the facility staff purposely ignored R1’s medical care needs. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Failure to report Covid-19 outbreak. It was alleged that the facility had a Coronavirus Disease 2019 (COVID-19) outbreak during November 2020 and failed to report to appropriate agencies. The complainant alleged that the facility was on lock down during the month of November 2020. Record review revealed that COVID-19 was reported to Community Care Licensing on December 10, 2020. It was reported that the initial COVID-19 test were conducted on December 6, 2020, and results came in on December 8, 2020. There was no further documentation of an outbreak prior to December 2020. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 26, 2024 · control 29-NP-20220613164253

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jun 27, 2024

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided when such observation reveals unmet needs...responsible person, if any. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not ensuring R1’s medical care being arranged and followed which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2024

Plan of correction: Administrator stated that she will submit a plan on how to ensure staff monitor residents for any change in condition and ensure that arrangement of medical care is proper and submit a plan of staff training regarding above regulation

Allegation investigated: Facility staff lock(ed) resident outside of the facility. Resident is not being accorded dignity in their personal relationships with staff.

Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent visit to this facility today to deliver findings. At 9:30 a.m., the LPA met with the Administrator, Judith Montoya and explained the reason for the visit. During the time of the visit, the Administrator left the facility and authorized staff, Rosalba "Rosie" Monarrez to sign the report. During the initial visit on 03/29/2023 between 8:15 a.m. and 10:30 a.m., LPA Brian Balisi conducted a brief physical plant tour and conducted an interview with Staff #1 (S1) and Resident #1 (R1). During today’s visit, at 9:35 a.m., LPA Peraldi conducted an interview with the Administrator. Between 9:44 a.m. and 2:31 p.m., the LPA conducted interviews seven (7) out of seventy (70) residents and two (2) staff. At 2:35 p.m., the LPA along with S1, conducted a physical plant tour. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Facility staff lock(ed) resident outside of the facility. It was alleged that Resident #1 (R1) was locked out of the facility and was pressing the call button for a while. Interview with R1 revealed that R1 has a car and leaves the facility daily. R1 explained that R1 parks inside the facility parking lot and enters the parking lot with a controller but sometimes the controller does not work and must press the call button/ buzzer to get in. R1 explained that their controller for the parking lot is currently working. R1 stated that there has not been issues with getting inside the facility ever since facility staff gave R1 a new controller earlier this year. Interview with the Administrator revealed that the front gate is always open during the day and at nighttime the gate locks on the outside but remains unlocked from the inside. The Administrator explained that the parking lot gate is locked but that there is a call button/ buzzer that can be pressed to reach a staff member that will open the gate. The Administrator said that R1 drives their own car and has their own controller for opening the parking lot gate. Interviews with multiple residents did not reveal any concerns regarding being locked out of the facility. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Resident is not being accorded dignity in their personal relationships with staff. It was alleged that a staff member is being disrespectful to Resident #1 (R1). During the interview with R1, R1 explained that there is a staff member who is rude to R1, however R1 does not recall the staff member’s name. Interviews with multiple residents revealed that staff treat residents with respect and dignity. Furthermore, interviews with multiple residents did not reveal any concerns regarding staff. Interviews with the Administrator revealed that there have not been any issues between staff and residents. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 29-AS-20230320151242

Allegation investigated: Facility staff are not ensuring that resident takes their medications while in care.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced 10-day initial complaint visit to this facility. At 9:30 a.m., the LPA met with the Administrator, Judith Montoya and explained the reason for the visit. During the time of the visit, the Administrator left the facility and authorized staff, Rosalba "Rosie" Monarrez to sign the report. At 9:35 a.m., the LPA conducted an interview with the Administrator. At 9:50 a.m., the LPA reviewed records and obtained copies of pertinent documents. Between 9:44 a.m. and 2:31 p.m., the LPA conducted interviews seven (7) out of seventy (70) residents and two (2) staff. At 2:35 p.m., the LPA along with staff, conducted a physical plant tour. Additionally, on 12/01/2023, the LPA conducted an interview with a resident’s therapist. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Facility staff are not ensuring that resident takes their medications while in care. It was alleged that due to facility staff not properly assisting Resident #1 (R1) with their self-administration of medication, led to R1 not taking their medications. Interview with the Administrator revealed that R1 has been having feeling depressed and R1 disclosed to the Administrator that R1 in the past has spit out R1’s medication instead of ingesting it. The Administrator explained that immediately after hearing R1’s statement, the Administrator informed R1’s responsible person and R1’s primary health clinic. The Administrator stated that she also informed R1’s therapist and R1’s case manager regarding the incident. The Administrator explained that staff dispense R1’s medication and hand it to R1 in a small cup, along with a cup of water and staff stay to supervise R1 until R1 takes their medication. The Administrator stated that staff have not witnessed R1 spit out medication. Interview with Staff #1 (S1) revealed that staff do stay with R1 to supervise R1 take their medication. Interview with R1 did not reveal any concerns regarding staff not properly assisting with R1’s self-administration of R1’s medication. R1 did not voice any concerns regarding staff and stated that staff supervise R1 when taking medication. Additionally, interview with R1’s therapist on 12/01/2023, revealed that the facility staff and Administrator are constantly in contact with R1’s health clinic and psychologist. R1’s therapist stated that facility staff and Administrator have been cooperative and helpful regarding R1’s care and supervision. During the time of the visit, R1, R1’s family member, R1’s therapist, S1 and the Administrator held a meeting regarding R1’s care and current medication, and no additional issues were raised during the meeting. Interviews with multiple residents did not reveal issues regarding staff not properly assisting with residents’ medication. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 29-AS-20231201085402

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Emily Peraldi and Brian Balisi arrived at the facility unannounced to conduct a required annual visit. At 10:15 a.m., the LPAs met with the Administrator and explained the reason for the visit. At 10:42 a.m., the LPAs along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPAs observed the kitchen/dining area. Knives are stored in the inaccessible kitchen. Kitchen appliances appear to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:52 a.m., hot water measured at 117.1-degree Fahrenheit. BEDROOMS: The LPAs observed nine (9) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Between 10:48 a.m. and 11:30 a.m., hot water measured between 105.4 and 117.1-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. OUTDOOR SPACE: At 10:53 a.m., the LPAs observed the back and front of the facility which has a covered outdoor area for resident use. There is a gate on the side of the facility designated for an emergency exit. There are no bodies of water on the premises. The facility only has a parking lot, no garage nor basement. Continued on LIC 809-C. COMMON AREAS: The LPAs observed common area to be relatively clean and properly furnished. The LPAs observed the fire extinguisher to be fully charged and last serviced on 10/05/2023. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. Fire alarm, fire sprinklers and fire doors were observed and passed by the Fire Department. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the janitor closets and storage. Medications and first aid kits are located in a locked medication room. Laundry units and additional linens are located inside laundry room. RECORD REVIEW: Starting at 11:30 a.m., the LPA conducted a file review for all residents and staff. Staff records were reviewed for documents including, but not limited to health screening, TB test, staff training records, and fingerprint clearance. All files were in order. The Administrator’s Certificate expires 01/31/2024. The LPA reviewed resident records for nine (9) out of sixty-nine (69) residents. Resident’s records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. All files were in order. Additionally, the LPAs received a copy of valid liability insurance and Facility Disaster Emergency Plan. Between 11:19 a.m. and 11:46 a.m., the LPA conducted interviews with six (6) staff and eight (8) residents. Between 1:50 p.m. and 2:15 p.m., the LPA conducted a review of medication and medication documentation with Medication Technician for six (6) residents and observed all medications were properly documented and assisted with as prescribed. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 12, 2023

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.