Villa Capri

Allegation investigated: Staff did not follow the doctor's orders for resident in care

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on the above allegation. LPA met with Administrator Brooke Patterson. Complaint alleges staff did not follow the doctor's orders for resident in care. Complainant states that resident was prescribed fentanyl patches for end-of-life comfort care but facility denied resident use of patches. During investigation, LPA conducted interview with facility’s corporate RN nurse, Kari Miller (RN) who reported that as of February 2026, she developed a “RCFE Hospice Coordination Checklist for Administrators,” which states in bold font that fentanyl patches are not allowed for pain management. Per interview with RN, the facility has not provided any disclosure to prospective residents or current residents indicating the no fentanyl patches policy and does not currently have a written policy disclosing to residents the denial of fentanyl patches used for comfort care. Continued on 9099C... Substantiated Continued from 9099... During investigation, LPA conducted interviews. Three (3) out of three (3) witnesses report that R1 was denied use of fentanyl patches by RN. Per interview, after prolonged discussion with R1’s physician, RN eventually approved the use of the patches for R1. Fentanyl patches were prescribed to R1 for comfort care on 3/19/26 at 11:36am and according to Villa Capri Observations notes were administered at 10:03pm. Additionally, three (3) out of three (3) witnesses report subsequent resident (R2) was prescribed comfort care fentanyl patches and was also denied the use of the patches. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 21-AS-20260416084717

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jul 3, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: Based on LPA interview and record review, the licensee did not comply with the section cited above in that facility refused to adminsiter R1's physician prescribed medication which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Facility to submit written policy indicating how the facility will meet the requirements of following physicians' medication orders to meet the necessary medical needs of residents.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso conducted a Required - 1 Year visit, on 5/28/26 at approximately 2:00pm, and met with the newly hired Administrator Brooke Patterson. Fire clearance is approved for 80 non-ambulatory residents, which includes 4 bedridden. Facility has a required infection control plan, and a required emergency disaster plan. Hospice care waiver approved for thirteen(13) residents. Facility has a dementia plan of operation. LPA requested thirteen (13) resident files. LPA started file reviews. LPA requested thirteen (13) staff files for review. LPA started reviewing staff training. LPA discussed, with Brooke Patterson, the needed paperwork/documents and signatures of the CEO regarding the change the facility administrator. Brooke stated their understanding of the above, including the required board resolution regarding the hired/designated administrator, representing the managing Licensee/GSL MGMT LIVING LLC. LPA is requesting the following documents be updated and submitted by 6/28/26: LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working LIC610E (9-pages)-Emergency Disaster Plan (ensure to review and update as needed/required) Infection Control Plan (ensure to review and update as needed/required) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all facilities Copy of Current Liability Insurance Copy of current Administrator Certificate The LPA will continue the annual at a later date. No deficiencies cited during today's inspection. Exit interview conducted with Administrator Brooke Patterson.the state’s words, verbatim · CDSS document, May 28, 2026

Allegation investigated: Facility staff did not appropriately address resident's change in condition, and seek medical attention in a timely manner Required partiy (s) not notified timely of resident's change in condition

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/3/2025 at approximately 9:50am, and met with Gao Yang, Memory Care Director. RP alleges that "facility staff did not appropriately address resident's change in condition and seek medical attention in a timely manner, and required partiy (s) not notified timely of resident's change in condition". LPA requested resident (R1) records, including care plan, medical assessment, medications, progress notes, and all communication documents regarding resident's change in condition, including notification to required parties, Physician, and responsible party, LPA obtained copies of requested records. LPA interviewed staff/S1, Kaiser Physician, Home Health Nurse, and other related parties, regarding allegations. Per LPA record reviews, and interviews conducted, the investigation revealed that R1 was observed to have a change in condition, more confusion and not at thier baseline, on 8/18/25. The staff faxed a notification to R1's medical physician's office, of R1's change in condition, on 8/18/25. Continued on LIC9099C.... Substantiated Per interviews and medical records, a Dr's Order was placed for R1 to obtain lab work, to see if there was anything that could be causing the resident's change in condition. Facility staff, S1, stated they don't have and/or never received a Dr's Order for R1 to obtain lab work. S1 stated that there was a never a response from the Physician/medical office on the faxed notification on 8/18/25. Staff S1 was not able to provide any follow-up to the resident R1's Physician regarding the 8/18/25 notification of change in condition, from 8/18/25 through to 8/24/25,10:20am. Per record review, there was a fax document regarding R1's change in condition dated 8/24/25, faxed at 10:20am to resident R1's Physician. R1 continued to be declined with confusion from their baseline as known, per review of records. Before 8/24/25 at 10:20am, there was no follow-up contact made by the facility to the Physician regarding R1's change in condition of 8/18/25. Per file reviews and interviews, Home Health Nurse (HHN) contacted Physician's office and notified them of R1's change in condition, and crackles in lungs, on 8/26/25. Per record reviews, HHN was told by staff on 8/25/25 when seeing R1, that R1 was more confused than their baseline. Per record reviews, there was no documentation of resident's responsible party (RP) being notified of resident R1's change in condition back on 8/18/25 or the next day, on 4/19/25; There was a mention of responsible party being aware when resident R1 was sent out 911 due to Physician's request, on 8/28/25. Per interviews and obtained documentation, reporting party was notified on 8/28/25 the need of R1 to be seen for lab work related to change of condition since 8/18/25, R1 needed to be evaluated by a medical professional regarding change in condition, including Home Health Nurse hearing crackles in resident's lungs. Per interviews, RP and reviewed obtained documentation, RP was notified by the facility on 8/27/25 that resident had a change of condition; Rp had no notification/information regarding 8/18/25, when Physician was faxed about change in R1's condition. There was sufficient information obtained to support violations had occurred regarding the allegations, "facility staff did not appropriately address resident's change in condition and seek medical attention in a timely manner, and required partiy (s) not notified timely of resident's change in condition". Deficiency will be cited, 87466 Observation of the Resident, see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with Gao Yang, Memory Care Director. Appeal Rights Provided.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 21-AS-20250829102706

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Sep 15, 2025

87466 Observation of the Resident, The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: LPA's investigation, R1 was observed to have a change in condition, on 8/18/25, Physician was faxed about R1's changes observed, but there was no follow-up after this date till 8/24/25 at 10:20am, per record reviews. RP was not notified per file reviews, obtained information, and interviews, until 8/27/25 that resident had a change of condition. This is a personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Licensee to ensure all observed changes in residents are followed-up on when notifying resident's Physician, until the resident changes have been addressed. Ensure responsible parties are notified as required by regulation when changes are observed. Hold an in-service training with your staff regarding this requirement by regulation, "Observation of the Resident" Ensure staff understand the policy of observations of the resident, including documenting what has been done on notifications, what is being done, any changes in monitoring of the resident/care plan updates, and any follow-up needed. Submit proof of training and facility's future compliance by 9/15/25.

Allegation investigated: Facility staff are not providing resident's medication dosage as prescribed Facility staff have not requested required medication refills

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 7/1/2025 at approximately 10:20am, and met with Administrator Maria Cortes. Reporting party alleges that facility staff are not providing resident's medication dosage as prescribed, and facility staff have not requested required medication refills. The LPA conducted interviews with staff, S1, S2, and interviews with other related parties regarding allegations. LPA reviewed R1's records. including care plan, medical assessment, medication records, including eye drop medication records, medical documentation/appointment records, and admission documents. The investigation revealed that resident R1's medications have been provided to R1 as prescribed, and ordered by the Physician, per review of records and staff interviews. Continued on LIC9099C.. Unsubstantiated The medication refills for R1 have been provided to the facility as required by care plan agreements, and recorded as received by facility staff, per medication record reviews. There was differing information obtained during the investigation regarding allegations; There was no information obtained to support that violations had occurred. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "facility staff are not providing resident's medication dosage as prescribed, and facility staff have not requested required medication refills” are Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Maria Cortes.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 21-AS-20250407104217

Allegation investigated: Staff do not ensure that resident's bathing needs are met Staff do not ensure resident has access to assistive devices

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 5/21/2025 at approximately 9:45am, and met with Administrator Maria Cortez, and Gao Yang Memory Care Director. Reporting party alleges that staff do not ensure that resident's bathing needs are met, staff do not ensure resident has access to assistive devices, facility staff are not providing resident's medication dosage as prescribed, and facility staff have not requested required medication refills. LPA toured the facility memory care. LPA reviewed R1's records. including care plan, medical assessment, medication records, and admission documents. The LPA conducted interviews with staff, S1, S2, S4, S5, S6, S7, and interviews with other related parties. The investigation revealed that resident, R1 has refused to be bathed by care staff at times; Per interviews, and record reviews, staff would offer bathing to the resident more than once, and if the resident still refuses the staff try again the next day. R1 gets one (1) shower a week per care plan, and if there is an incident and/or accident requiring bathing of R1, this is provided by the staff, as needed. Continued on LIC9099C.. Unsubstantiated Responsible party (s) is notified, if R1 refuses bathing as scheduled/as needed, per review of records and interviews. R1’s responsible party (RP) has been notified of resident’s refusal to bathe, and RP has come in to help assist with R1 being bathed. Per record review, on one occasion, R1 refused bathing assistance by RP, but the next day R1 agreed to being bathed by RP. Per interviews, review of records, and observations, staff offer R1 the use of their walker when R1 is observed ambulating without the walker. Staff will offer R1’s glasses to the resident if they observe the resident without them, per interviews. Residents in memory care can move around freely, and staff monitor groups of residents, and check on residents as needed and/or required, per interviews. R1 is not a one-to-one staffed resident and/or assessed as needing one to one staffing at this time. There was differing information obtained during the investigation regarding allegations; There was no information obtained to support that violations had occurred. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "staff do not ensure that resident's bathing needs are met, and staff do not ensure resident has access to assistive devices” are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Maria Cortes.the state’s words, verbatim · CDSS document, May 21, 2025 · control 21-AS-20250407104217

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 Analysts (LPAs) Alviso and Contreras conducted a Required - 1 Year visit, on 4/2/25 at approximately 9:00am, and met with Gao Yang-Journey Director. Facility has a required infection control plan, and a required emergency disaster plan. Hospice care waiver approved for thirteen(13) residents. Facility has an approved dementia plan of operation. Fire clearance is approved for 80 non-ambulatory residents, which includes 4 bedridden. Per LPAs file reviews, the facility is conducting required emergency disaster drills; On 3/17/25 fire drill, 2/13/25 fire drill, and 12/9/24 fire drill/evacuation training. On 3/27/25 the staff had an elopement drill. Training drills are done to cover staff on all shifts. LPAs reviewed ten (10) resident records. All records were complete. LPA reviewed resident (R11) medication records; LPA was provided copies of requested records. LPA obtained additional information regarding current medication orders and how medications are being provided. The LPAs reviewed ten (10) staff records. All staff have criminal record clearance as required by regulation. LPA reviewed staff training records. All staff had required training. Staff have First Aid and CPR certification as required. LPAs toured the facility with the Gao Yang-Journey Director, and Jose Moreno-Maintenance Director. Facility was observed to be clean, orderly, and at a comfortable temperature. LPA observed all exits free and clear from obstruction. LPA observed random fire extinguishers which were serviced and tagged as required. Common areas, hallways, and bathrooms observed by the LPA had sufficient lighting available to residents in care. Continued on LIC809C... The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility had a sufficient supply of food, water, and other emergency supplies to meet the seventy-two (72) hour shelter in place requirements. The storage lock box with master keys to rooms and facility vehicles to be used in facility emergencies is in the mail/fax room on the first floor. LPA observed that each stairwell, two (2), had required evacuation chairs, with instructions posted up. The facility has three generators, and emergency disaster supplies stored in case of an emergency. Hot water was measured at 119.8 degrees Fahrenheit in memory care on the 1st floor, and 114.4 degrees Fahrenheit on facility's 2nd floor; Both hot water measurements were within regulation. Facility had a sufficient supply of cleaners/disinfectants, paper products, hygiene products, and personal protective equipment (PPE). Cleaners/disinfectants were locked up and inaccessible to residents in care. Medication rooms, in assisted living and in memory care were locked and inaccessible to residents in care. There are small refrigerators in the medication rooms which are used for any medications needing to be stored and refrigerated. Medications were stored in compliance with State and Federal requirements. LPAs observed the beauty salon to be in operation during the inspection; The salon's door has a lock to secure the beauty salon as needed/required when not staffed. All outside courtyards were clean, pathways were clear of obstructions, and had outside furnishings and shaded areas for resident use. LPA is requesting the following documents be updated and submitted by 5/2/25. LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Infection Control Plan (ensure to review and update as needed/required) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all facilities Copy of Current Liability Insurance Copy of current Administrator Certificate No deficiencies cited during today's inspection. Exit interview conducted with Journey Director Gao Yang.the state’s words, verbatim · CDSS document, Apr 2, 2025

Type of visit: Case Management - Incident

Licensing Prigram Analyst (LPA) Alviso conducted a case management inspection, on 3/18/25 at approximately 3:55pm, and met with Administrator Maria Cortes. LPA met with Gao Yang, Journey Director. The case management is being conducted to review a resident incident that the facility Administrator reported to the Department. LPA reviewed records on the resident (R1) and on staff (S4, S5). LPA obtained additional information on the resident incident, and obtained copies of documentation/records. Required reports were completed, submitted to all required parties. Per interviews and documentation provided by the administration staff, Administrator and Journey Director, stated training has been provided to staff regarding mandating reporter, and training in providing care to the residents; Proof of the training was provided to the LPA. Per review of records, interviews with staff, S1 and S2, and interviews with other related parties, it was identified that staff (S4, S5) inappropriately handled (R1) when trying to provide incontinent care to them, and R1 was refusing care from the staff. (R1) reacted by screaming and kicking at staff when they handled R1 inappropriately. Staff didn't use a different approach and/or stepping away and allowing some time to the resident to be agreeable to the incontinent care needed. The following deficiency will be cited regarding the reported resident (R1) incident and information obtained during today's inspection, 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, see LIC809D. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Exit interview conducted with the Administrator Maria Cortes. Appeal Rights Provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 31, 2025

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Per review of records, interviews with staff, S1 and S2, and interviews with other related parties, it was identified that staff (S4, S5) inappropriately handled (R1) when trying to provide incontinent care to them, and R1 was refusing care from the staff. (R1) reacted by screaming and kicking at staff when they handled R1 inappropriately. Staff didn't use a different approach and/or stepping away and allowing some time to the resident to be agreeable to the incontinent care needed. This is a risk to residents personal rights.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: Licensee/Administrator to ensure all caregiving staff in memory care/journey care unit have "Resident Rightd/Personal Rights" training, ensure both staff, S4 & S5 are included. Submit proof of training, include attendees, date/time spent, topics covered, and qualified trainer's name/title. POC due 3/31/25.

Allegation investigated: Medications are not provided to the resident as prescribed

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/28/24 at approximately 10:15am, and met with Administrator Maria Cortes. LPA also met with Memory Care Director Gao Yang. Health & Wellness Director Jennifer Haney was unavailable to meet with the LPA during the inspection. Reporting party alleges that "medications are not provided to the resident as prescribed". LPA reviewed resident (R1) records, including medication orders/medications records. The LPA obtained copies of records requested. The LPA conducted interviews with staff (S1, S2), and other related parties. The investigation revealed that R1's medications, two (2) medications, one routine order and one PRN order, were identified as not having been provided to the resident as ordered by the Physician. The routine medication order, medication order #1, is to be provided to the resident twice daily, an am dose and a pm dose. R1's routine medication ran out on 1/18/25, and the refill hadn't been requested by staff to be ordered until the medication ran out. R1 missed a total of eight (8) doses of the medication, a pm dose on 1/18, two doses on 1/19, 1/20/ and on 1/21, and an am dose on 1/22. The medication was delivered to the facility on 1/22/25, and the resident, R1,was provided a pm dose of the medication. Continued on LIC9099C... Substantiated Continued from LIC9099... R1's PRN medication, medication order #2, is to be provided as needed at "bedtime".This medication was prescribed for psychosis, agitation, and anxiety as needed at bedtime on 12/6/2023, per Doctor's Order. On 10/1/24, the Doctor prescribed the medication order as needed in the evening for psychosis, agitation, and anxiety only. In review of PRN records, "PRN Given Report", the medication has been provided outside of "bedtime" hours, listed were some of the following hours observed, 9:51am, 1:13am, 2:03am, and 12:42am. LPA also observed that some of the entries listed this medication being provided to R1 for sleep and insomnia, which it is not prescribed for, per Doctor's Order. Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that Representative is to be notified when medications need to be filled, minimum of two weeks advance notice to R1's Representative. This was not done regarding medication order #1. There is sufficient information obtained to support that a violation has occurred regarding the reported allegation of "medications are not provided to the resident as prescribed". This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed, see LIC9099D. Civil Penalty assessed at $250 for repeat violation within 12 months, see LIC421FC. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator Maria Cortes. Appeal Rights Provided.the state’s words, verbatim · CDSS document, Jan 28, 2025 · control 21-AS-20250127143918

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 28, 2025

87465(a)(4) Incidental Medical and Dental Care- The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by: LPAs record reviews, interviews, and observations, Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that R1's Representative is to be notified a, minimum of two weeks in advance for refills. R1 missed 8 doses of Medication Order #1, and has been provided medication order #2 outside of dosage hours, and given for sleep/insomnia which is not per the Dr's Order. This is a risk to residents rights & health&safety. Civil Penalty assessed at $250 for repeat violation within 12 months, LIC421FC.the state’s words, verbatim · CDSS document, Jan 28, 2025

Plan of correction: Licensee/Administrator to ensure all residents receive their medications as prescribed by the Physician. Submit a plan on how the facility will ensure that R1's medications are ordered/filled in a timely manner, and that PRN medications are provided to the resident per dosage instructions on Doctor's Orders, including time frame given, and reason for giving the medication. Hold an in-service training with all medication staff regarding refills/orders in a timely manner, record keeping, and Dr's instruction Orders on PRNs. Submit plan regarding medications as stated above and on plan regarding facility's future compliance. POC due 1/28/25. *Submit proof of training by 2/7/25.

Allegation investigated: Medications are not provided to the resident as prescribed

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/17/24 at approximately 10:00am, and met with Administrator Maria Cortez. LPA also met with Memory Care Director Gao Yang, and Health & Wellness Director Jennifer Haney. LPA reviewed resident (R1) records, including medication orders/medications. The LPA requested copies of resident (R1) records, and facility records. Administration staff provided the requested copies to the LPA. The LPA conducted interviews with staff (S1, S2, S3), and other related parties. The investigation revealed that R1's medications are filled by the responsible party (RP) of R1, and brought into the facility to be centrally stored for R1. Per review of records and interviews, there was no documentation and/or date of when R1's medications were provided by the RP to the facility. The facility medication staff didn't document how many bottles of R1's eye medications were provided by RP, there are three (3) different type of eye drops prescribed; No documentation of how many containers of the prescribed powder mix medication was delivered by RP. Continued on LIC9099C.. Substantiated It is unknown by review of information/record reviews/interviews that eye drop medications were not provided to R1 as prescribed. Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that RP is to be notified when medications need to be filled, minimum of two weeks in advance notice to RP. Staff were not able to provide proof of a two week in advance request to RP to order R1's powder mix medication. R1 missed the AM dose and will miss the PM dose due to the medication ran out, and is just now on order, R1 will continue to miss the dose till the order is received by RP. There is sufficient information obtained to support that a violation has occurred regarding the reported allegation of "medications are not provided to the resident as prescribed". This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed, see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator Maria Cortes. Appeal Rights Provided.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 21-AS-20241212113741

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 18, 2024

87465(a)(4) Incidental Medical and Dental Care-A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by: LPAs record reviews, interviews, and observations, Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that RP is to be notified when medications need to be filled, minimum of two weeks in advance. R1's last dose of their powdered mix medication was 12/16/24, and today, 12/17, R1 missed the AM dose and will miss the pm dose due to the medication is out, and is just now on order, waiting to be filled, per interviews with staff and other related parties. This is a risk to residents health & safety and personal rights.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Licensee/Administrator to ensure all residents receive their medications as prescribed by the Physician. Submit a plan on how the facility will ensure that R1's medications are ordered/filled in a timely manner, ensuring the two week notice is sent out to the RP of R1, and maintaining necessary records to ensure compliance with regulations. Maintain all medication records accurately and keep them up to date. Hold an in-service training with all medication staff regarding refills/orders in a timely manner, and record keeping. Submit plan regarding medications as stated above and discussion of facility's future compliance. POC due 12/18/24. *Submit proof of training by 12/23/24.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Other Visit, and met with Executive Director, Maria Cortes. The purpose of this Case Management Visit is to follow up on a SOC341 report dated 7/23/24 along with an incident report notifying Community Care Licensing (CCL) about a suspected physical abuse incident that happened on 7/17/24 at 3am. Per incident report, on 7/22/24 at approximately 2:30pm, staff (S2) reported to the Executive Director about an incident that occurred on 7/17/24 around 3am resident (R1) was in another resident's apartment. S2 was attempting to redirect them back to their apartment, but R1 was exhibiting aggressive behaviors. At that time, S2 called for assistance from another staff (S1), while S1 was trying to redirect them R1 walked towards S1 by speaking out loud and S1 pushed R1 that R1 almost fell. Upon reported to Executive Director, the facility contacted law enforcement on 7/22/24. The police report incident #SR-242050248 and case number #24-8824. On 7/23/24 at 10am, the facility staff performed a skin assessment of R1 with no injuries found. Responsible parties were notified. Per facility policy, S1 was suspended pending further investigation. On 7/24/24, in-service training to the staff was conducted regarding elder abuse/mandated reporter. During today's visit, the facility provided LPA, S1's resignation letter dated 7/25/24 indicating that they are resigning due to them feeling disappointed with the facility regarding this incident by sending law enforcement to their residence. Based on records review, the facility conducted an internal investigation, where the findings including resignation letter received was a concern for the facility. However, internal investigation results were unsubstantiated. LPA reviewed staff (S1 & S2) training records including the in-service conducted on 7/24/24 with other staff excluding S1, who was suspended at that time. The facility provided staff contact information to LPA. The Department will review information obtained to determine if further action is needed. No deficiencies cited during today's inspection. Exit interview was conducted with Executive Director and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 1, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso conducted a Required - 1 Year visit, on 5/21/24 at approximately 12:35pm, and met with Administrator Maria Cortes. Hospice care waiver approved for thirteen(13) residents. Facility has an approved dementia plan of operation. Facility has a required infection control plan, and a required emergency disaster plan. Fire clearance approval is for 80 non-ambulatory residents, which includes 4 bedridden. The facility is holding monthly emergency drills, including an evacuation drill; On 3/13/24 an evacuation drill was completed on each shift; Facility understands quarterly drills are to be held, one an evacuation drill, and all drills held on each shift. LPA reviewed eight (8) resident records. All records were complete. The LPA reviewed seven (7) staff records. All staff have criminal record clearance as required by regulation. LPA reviewed staff training records. All staff had required training. Staff have First Aid and CPR certification as required. In review of staff records, LPA observed that the facility hired a staff person that has a class B driver's license, and they can legally drive the facility's vehicle/bus to use for resident activities and/or scheduled transportation, per facility's plan of operation. LPA toured the facility with the Administrator Maria Cortes, and Maintenance Director Jose Moreno. Facility was observed to be clean, orderly, and at a comfortable temperature. LPA observed exits free from obstruction. LPA observed random fire extinguishers which were serviced and tagged. Common areas, hallways, and bathrooms observed by the LPA had sufficient lighting available to residents in care. The LPA observed some residents having their lunchtime meal in the dining room. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility had sufficient supply of food, water, and other emergency supplies to meet the seventy-two (72) hour shelter in place requirements. The facility has three generators, and emergency disaster supplies stored in case of an emergency. Continued on LIC809C... The storage lock box with master keys to rooms and facility vehicles to be used in facility emergencies is in the mail/fax room on the first floor. LPA observed that each stairwell, two (2) had required evacuation chairs, with instruction posted up. Facility had a sufficient supply of cleaners/disinfectants, paper products, hygiene products, and personal protective equipment (PPE). Hot water was checked at 119. degrees Fahrenheit which is within regulation. Laundry rooms had no cleaners/toxins accessible to residents in care, and the rooms were clean and orderly. Medication rooms, in assisted living and in memory care were locked and inaccessible to residents in care. All medications were stored in compliance with State and Federal requirements. There are refrigerators in medication rooms, for any medications needing to be stored refrigerated. LPA observed the beauty salon to be locked, ensuring toxins are not accessible to residents in care. Cleaners/toxins were locked up and inaccessible to residents in care. All outside courtyards were clean, orderly, and had lots of outside furnishings, and shaded areas for resident use. LPA is requesting the following documents be updated and submitted by 6/21/24. LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Infection Control Plan (ensure to review and update as needed/required) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed Copy of Current Liability Insurance Copy of current Administrator Certificate There are no deficiencies cited during today's visit. Exit interview conducted with Administrator Maria Cortes.the state’s words, verbatim · CDSS document, May 21, 2024

Allegation investigated: Staff are not following Physicians orders

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 3/5/24 at approximately 9:20am, and met with Administrator Maria Cortez. LPA reviewed resident (R1) records and facility records.The LPA reviewed MAR records that document medications residents are assisted with; The MARs also shows days medications were provided, including any refusal of medications and/or why a medication was not provided to a resident. The LPA reviewed resident R1's care plan, medication records, including Dr's Orders. The LPA conducted interviews with staff, and other related parties regarding the allegation. The Investigation revealed that medication orders are provided as prescribed by the Physician to the resident. There is a supplement shake that per review of records, R1 refused at times, and this is documented in records. Continued on LIC9099C... Unsubstantiated Per review of records and interviews, there are times R1 is out of the community with POA and/or other family member(s), and may miss their supplement shake being provided to them, this is documented in records. Required parties are notified of R1's missed medication order, per record reviews. There is differing information obtained in the investigation regarding the allegation that "staff are not following Physicians orders". There was no information obtained that supported that a violation had occurred. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "staff are not following Physicians orders" is Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Maria Cortes.the state’s words, verbatim · CDSS document, Mar 5, 2024 · control 21-AS-20240129083327

Allegation investigated: Staff are not changing the resident timely

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/31/24 at approximately 3:15pm, and met with Administrator Maria Cortez. LPA reviewed resident (R1) records; The LPA requested copies of resident records, and facility records. Administrator provided the requested copies to the LPA. The LPA conducted interviews with staff, and other related parties. The investigation revealed that R1 is receiving incontinent care by the facility, it's part of resident's care plan. Health & Wellness (H&W) Director Jennifer Haney stated that facility caregivers are to check on the resident every two hours, and change the resident as needed; The resident has a companion with them for part-time hours, and some of the facility caregivers checked a couple times on the resident, to find the companion had already changed R1. Some of the facility caregivers had stopped checking on R1 due to thinking the resident was being provided incontinent care by the resident's private companion. The LPA discussed the responsibility of the facility staff providing the care plan services, which include incontinent care needs. The private companion is not responsible for the resident's care plan services, and shouldn't provide the care services. Substantiated Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of "staff are not changing the resident timely" has been substantiated. Due to the substantiation of the allegation, a citation will be cited today, 87625 Managed Incontinence-(b)(1)(2)(3)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered.Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, see LIC9099D The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Appeal Rights Given. Exit interview conducted with the Administrator Maria Cortez.the state’s words, verbatim · CDSS document, Jan 31, 2024 · control 21-AS-20240129083327

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625 · Plan of correction due date: Feb 15, 2024

87625 (b)(1)(2)(3 Managed Incontinence-)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. Health & Wellness (H&W) Director Jennifer Haney stated that facility caregivers are to check on the resident every two hours, and change the resident as needed; The resident has a companion with them for part-time hours, and some of the facility caregivers checked a couple times on the resident, to find the companion had already changed R1. Some of the facility caregivers had stopped checking on R1 due to thinking the resident was being provided incontinent care by the resident's private companion. This is a risk to resident's personal rights.the state’s words, verbatim · CDSS document, Jan 31, 2024

Plan of correction: Licensee to ensure an inservice is conducted with all staff regarding incontinent care services to residents. Submit plan of future compliance with this regulation, ensuring staff are checking on resident and changing resident timely. Submit proof of training. All POC documentation is due 2/15/24.

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.