Villa Lorena

Allegation investigated: Licensee did not meet resident's incontinence needs. Facility did not follow food service requirements.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced subsequent visit for a complaint investigation and delivered findings regarding the above mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Business Office Director Denise Nguyen, then Executive Director Nora Garza, who arrived shortly after LPA. On 12/04/2025, the Department received a complaint where it was alleged that the facility left a resident (identified as R1) in a soiled brief for an extended period of time. Additionally, it was alleged that the facility was not following food service requirements, specifically that the facility did not provide a full dinner meal to R1 and that food items in the fridge of R1's unit were not labelled. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099-C 1/3] Unsubstantiated [Continued from LIC 9099] R1 was a resident at the facility residing in the Assisted Living (AL) unit of the facility before transitioning into the Memory Care (MC) unit. R1 did have a diagnosis of Mild Cognitive Impairment (MCI). R1 additionally had an assigned personal companion from an outside agency. In regards to the allegation of having been left in a soiled brief for an extended period of time, per file review of R1's records, R1 was fully incontinent and required assistance with toileting. Per review of R1's assessment dated 10/27/25, R1 only needed stand-by assist for toileting. The complaint alleged that there were only two (2) caregivers scheduled that day and it was unknown how long R1's brief was soiled for. Per review of the staff schedule, there were only 2 caregivers assigned to the AL unit for the 2-10:30pm shift on that date. Interviews with staff revealed that resident briefs are checked at least every two (2) hours, with one staff member specifying that they are changed earlier as needed. Multiple staff members interviewed recalled R1, with two (2) recalling that R1 utilized briefs for incontinence care. None of the staff interviewed shared any issues or concerns regarding R1's incontinence care. One staff member interviewed shared that though there may occasionally be shifts short staffed, staff do all they can to ensure residents needs are met timely and residents do not feel any negative effects of the lack of staff. Interview with an outside source responsible for R1's care shared no concerns regarding R1's care at the facility, including incontinence care. Interview with residents, R1 included, as well as other outside sources, did not reveal any concerns regarding staff attentiveness or care. In regards to the additional allegation regarding the food service requirements, the complaint specified two concerns: 1) that the facility did not provide a full dinner meal to R1 on a specified date as a drink and dessert did was not given with the meal brought to R1's room, and 2) that fruit in R1's unit fridge did not have dates on them. As in-unit fridges are private for residents, there is no specific regulation requiring their contents to be dated. [Continued on LIC 9099-C 2/3] [Continued from LIC 9099-C] Interviews with residents and outside sources revealed no concerns regarding food at the facility. Per staff interviews, R1 was often slow eater, and closer to transitioning to the MC unit, they would sometimes have tray service brought to their room for assistance with feeding. Per review of R1's assessment dated 10/27/25, R1 was independent for meals, aside from needing staff assistance with escort to meals. One staff member interviewed shared that staff, if given permission by residents, checked the unit fridges weekly to toss out any items that have gone bad. In regards to R1, it was shared that R1 didn't utilize their fridge and staff would sometimes store extra items that R1 didn't finish during a meal for the remainder of the day only, should R1 request it later. Additionally, it was shared that in regards to tray service, if it was noted that an item was missing from the prepared meal, staff were to return back to bring it for the resident. Per one staff interview, R1 could be picky about sweets and staff would come to know R1's preferences for desserts and sometimes not add it to the tray depending on what it was that meal. One resident interview shared that residents can get snacks and desserts at anytime, and an interview with administrative staff corroborated this as well. LPA additionally had toured through the main kitchen and inspected refrigerated, frozen, and dry storage food items. LPA noted no concerns during their inspection about the variety, freshness, and safe storage of items inspected. Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Garza to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 08-AS-20251204154407

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Receptionist Armi Bersamin and Executive Director Nora Garza. The facility's license shows a maximum capacity of eighty-five (85) non-ambulatory residents, ten (10) of which may be bedridden. Additionally, the facility is approved for ten (10) hospice waivers. During today’s inspection there were sixty-two (62) residents in care. LPA, Executive Director Garza, and Maintenance Director Vincent Reid toured the interior and exterior of the facility and inspected a sampling of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink was on one end of the building read at 113F and one on the other side read at 119F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. LPA observed a "Town Hall" meeting where staff and residents met for discussion and news, as well as introducing new staff members. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives are stored in the main kitchen and inaccessible to residents. [Continued on LIC 809-C] [Continued from LIC 812] No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Garza, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire panel was last serviced in December 2025. Fire extinguishers were serviced within the last 12 months, dated for January 2026. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Due to time constraints, LPA was unable to complete the file review portion of the inspection. LPA will return on a later date to conduct file review as well as staff and resident interviews. During today's visit, LPA observed residents to be attended to in a timely manner and with respect. LPA also observed residents engaged in a variety of activities during the visit. No deficiencies were cited during today's inspection. An exit interview was conducted with Executive Director Garza to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 26, 2026

Allegation investigated: Resident incurred unexplained bruising while in care. Resident's care needs were not met. Facility did not accord resident with adequate hygiene supplies. Facility did not ensure medical care for resident. Staff did not clean resident's room. Facility staff did not safeguard resident's personal information.

Licensing Program Analyst (LPA) Amy Rodgers met with Administrator Nora Garza to deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit with Administrator Nora Garza and conducted the meeting via phone call. On June 23, 2022, Community Care Licensing (CCL) received a complaint alleging the above-listed allegations. During the investigation, LPA briefly toured the facility, requested records, and interviewed staff and outside sources. Review of R1’s medical assessment records dated March 11, 2022, revealed that Resident #1(R1) had a diagnosis of dementia as well as a visual impairment, was confused and disoriented, had wandering behavior as well as aggressive behavior. R1 resides in the memory care area of the facility. Unsubstantiated (Continued from LIC9099) Regarding the allegation, Resident #1 (R1) incurred unexplained bruising while in care. More specifically, it was noted R1 had a bruise on their right forearm and a bruise on the inside of the wrist. On June 19, 2022 R1 responsibly party noted a bruise on R1 right forearm as well as a bruise on the inside of the wrist. Review of assessment records noted on June 1, 2022 and on June 18,2022, R1 has small discoloration on the right arm with no complaints, and R1 continued to refuse icepacks on several occasions in that time period. Regarding the allegation, R1's care needs were not met and the licensee did not accord the resident with adequate hygiene supplies. More specifically, Licensee did not change R1 wet pants and used the correct size of incontinence briefs. R1 needs and service plan dated March 14, 2022, and September 15, 2021 goals for R1 outline strategies to address hygiene needs and issues related to incontinence and changing R1 brief and clothing. On June 2, 2022, a healthcare provider evaluated R1, including medication adjustments for behavior changes to address concerns, including refusing showers and changing wet clothes. R1 is ambulatory and can freely walk around the memory care unit and participate in activities. Interviews with staff reveal that staff perform two-hour room checks, including incontinence checks on clients, and address incontinence issues as they arise for all residents. In addition, R1 records revealed that throughout 2021 and 2022, no signs of skin issues were noted during incontinence brief changes. Regarding the allegation, the Licensee did not ensure medical care for the resident. More specifically, the R1 ingrown toenail problem was not addressed by the Licensee staff. Records indicated that right toe pain was addressed by a visit from the podiatrist, conducted on April 12, 2022, at the facility. Further review of the records reveals that R1 reported no complaints regarding toe pain or difficulties with ambulation noted during May 2022. A medical professional evaluated R1 on June 2, 2022, and no notes of physical complaints or ambulation issues were noted. (Continued on LIC9099-C) (Continued from LIC9099-C) Regarding the allegation, licensee's staff did not clean R1's room. More specifically, dirty clothes and toilet paper were in R1's drawers and no linens were on R1's bed. Interviews with staff revealed that housekeeping cleans the facility's memory care rooms on a rotating weekly basis and on an as-needed basis. Staff further reports that care staff will alert housekeeping if any malodor is detected. It is not the practice of staff to open residents' drawers for inspection unless malodors are detected. The interviews also indicated that residents' sheets are changed immediately if they become soiled; however, there are instances when new sheets are not replaced right away. Nevertheless, memory care residents are encouraged to participate in activities in the common room and typically do not remain in their rooms during daytime hours. Regarding the allegation, Licensee staff did not safeguard the resident's personal information. More specifically, facility staff disclosed R1's personal information to an outside party. Staff interviews reveal that employees are required to sign non-disclosure agreements and receive training on the proper protocol for sharing residents' personal information with family members or visitors to the facility. Staff interviews deny disclosing any personal information other than to the responsible parties of residents or outside sources with consent forms on file. A review of facility records revealed that staff are provided a Non-Disclosure Agreement, Health Insurance Portability and Accountability Act (HIPAA) Compliance information, and Medical Information Confidentiality Agreement in the Employee Handbook. Interviews with the Responsible party confirm that they did not authorize the resident's personal information to be shared with R1 visitors. Due to a lack of corroborating evidence, the allegation cannot be confirmed or denied. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator Garza, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A reply E-mail or read receipt confirmation was requested from Garza upon receipt of documentsthe state’s words, verbatim · CDSS document, Jul 11, 2025 · control 08-AS-20220623102437

Allegation investigated: Physical abuse to resident by staff.

Licensing Program Analyst (LPA) Amy Rodgers met with Administrator Nora Garza to deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit with Administrator Nora Garza and conducted the meeting via phone call. On November 14, 2024, Community Care Licensing (CCL) received a complaint alleging that the Resident #1(R1) was physically abused by licensee Staff #1(S1) and sustained injuries as a result of the alleged abuse. [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. (Continued on 9099-C) Unsubstantiated [Continued from LIC9099] Review of R1's physician's report revealed that R1 uses a walker to ambulate to help with gait and balance; however, the needs and the service plan revealed that R1 is noncompliant with medical aides. Review of records revealed that R1 was noted to have episodes of increased confusion due to a diagnosis of vascular dementia. Per record review and staff interviews on November 17, 2025, R1 was receiving assistance from S1 while exiting their room. R1 was agitated and expressed a desire to leave their room to get breakfast at approximately 11:30 PM. S1 attempted to assist R1 back into bed, but R1 swung their arms and struck the doorframe. In the process, S1 grasped R1 by the arms, which may have contributed to the bruises and skin tears observed on R1's hands and arms. A medical technician assessed R1 and provided first aid to R1 at the time of the incident. Interview further reveal that S1 denied handling R1 in a rough manner and stated S1 was trying to protect themselves while also ensuring R1’s safety. Further records review and Staff interview reveal that on 11/9/2024 , R1 had a previous fall sustaining two skin tears on their right knee and excoriation on their right back shoulder. Interviews with staff and review of evidence reveal it is unknown if R1 caused the skin tears on R1's arms. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove physical abuse by staff. The allegations were deemed unsubstantiated. An exit interview was conducted with Administrator Garza, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A reply E-mail or read receipt confirmation was requested from Garza upon receipt of documents.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 08-AS-20241119093137

Allegation investigated: Facility did not provide records to resident's responsible party Facility did not notify resident’s responsible party of an incident Facility did not update resident's records

Licensing Program Analyst (LPA) Amy Rodgers conducted a visit to deliver findings regarding the above-mentioned allegation. LPA was allowed entry by the receptionist. LPA identified herself, met with, and disclosed the purpose of the visit to Administrator Nora Garza. On March 25, 2022, Community Care Licensing (CCL) received a complaint alleging that the facility did not provide records to the resident's responsible party, did not notify the resident’s responsible party of an incident, and did not update the resident's records. During the investigation, the department collected resident records, conducted interviews, and reviewed written correspondence. Based on Resident 1 (R1) Physician’s Report dated April 22, 2022, R1 is diagnosed with Alzheimer's Dementia, and R1 has a designated responsible party. Additionally, R1’s Preplacement Appraisal reveals R1 needs assistance with all dressing and prompting. (continued on LIC9099) Substantiated (continued from LIC9099) It is alleged that the Licensee did not provide records to R1's responsible party upon request. Records reviews of written correspondence reveal that R1's responsible party requested R1's medical records, including a wound care document and progress notes, after an incident involving R1 on 2/13/2022. R1's responsible party further reports that after they verbally requested the records, two emails were sent, a few weeks apart, to the executive director requesting copies of R1's records. On 3/18/2022, the executive director provided some documents, but not the requested documents. It was further reported that R1's responsible party contacted the executive director by phone, and they denied having any wound care notes or progress notes for R1. I was also alleged that the Licensee staff did not notify the resident’s responsible party of an incident. The department interviews with staff revealed that R1 was involved in an incident on 2/13/2022 that caused injury to their arms and hands. After the incident, the condition of R1 was not communicated in writing to R1 responsible person. Based on a review of records and multiple interviews with staff, there was sufficient information to determine a written report was not submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. It was also alleged that the licensee staff did not update R1 records to reflect the incident on 2/13/2022. A review of written correspondence dated 3/24/2022 reveals that R1's reporting person requested a file review and was physically shown a file that did not contain documentation for R1's incident on 2/13/2022 or any other relevant documentation. The department requested records for R1 on 2/15/2022 and did not receive records of illness, injury, medical or dental care, or information on R1's function or needs. Based on interviews with staff, records review and written statements to CLL, a preponderance of evidence exists supporting that Licensee staff did not provide records to resident's responsible person, did not notify resident’s responsible person of an incident, and did not update resident's records. The allegation is, therefore, Substantiated. Three (3) deficiencies were cited per the California Code of Regulations, Title 22 (refer to the LIC 9099-D pages). A Plan of Correction was jointly developed with the Licensee and their staff.. An exit interview was conducted with Administrator Nora Garza, to whom a copy of this report, the LIC 9099-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20220325123701

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jun 5, 2025

87468.2(a) In addition to the rights listed in Section 87468.1…personal rights:(19)To have prompt access to review all of their records…2 business days..This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not provide prompt access to review records in 1 of 63 persons in care, which posed a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: LPA had a roundtable discussion with the LIcensee and thier Administration staff on 6/5/2025,regarding regulation 87468.2(a)(19), The licensee and staff agreed they understand the regualtion. .

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 3, 2025

Reporting Requirements.(a) Each licensee... reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible... within seven days of the occurrence.. This requirement was not met as evidenced by: This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not ensure an incident report was completed forX out of X residents [R1], which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: The Adminsitror agrees to provide appropriate staff with training on mandated reporting requirements. Proof of training is to be provided to Community Care Licensing by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(13) · Plan of correction due date: Aug 5, 2025

Resident records.(b) Each resident’s record .... information:(13)Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. Based on records review and interviews, the licensee did not update records in 1 of 63 persons in care, which posed a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: The Licensee and the resident service director agreed to review all 63 files to ensure files contain regualtion 87506(b)(13) information. The resident service director also agreed to re-train med techs to ensure that accurate and timely charting is completed. Proof of training is to be provided to Community Care Licensing by the POC date.

Allegation investigated: Staff falsified document

Licensing Program Analyst (LPA) Amy Rodgers conducted an visit to deliver findings regarding the above complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Nora Garza. CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews with staff and outside sources. On March 18, 2022, Community Care Licensing (CCL) received a complaint alleging that the licensee's staff falsified documents. More specifically, a PRC COVID-19 test was altered for resident #1(R1). Interviews reveal that R1 developed symptoms of COVID 19 prior to an in-person visit by R1's responsible person on 2/12/2022. Interviews with R1's responsible person further reveal R1 was removed from isolation on 2/14/2022. The department conducted a records review for R1 and the charting records for R1 reflect a gap in chart reporting from 1/12/2022 to 3/25/2022. Therefore, the department could not confirm or deny the isolation time for R1 Substantiated (continued from LIC9099) Records review reveals a COVID-19 RT-PCR test was performed on 2/9/2022 for R1 by the facility staff. The document provided by the licensee staff to R1 responsible person and to the ombudsman revealed the COVID-19 RT-PCR test was negative for R1. However, the scan of the barcode reveals results for another person and the COVID-19 RT PCR test patience name on the document appears to be altered. The Department has investigated the above-mentioned allegation and based on record review and outside source interviews, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations, Title 22, and noted on the attached LIC9099-D page. An exit interview was conducted with Administrator Nora Garza, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy. (continued from LIC9099) Due to facility staff not being able to provide documentation of additional care being provided to R1 than outlined in the care plan and due to contradicting evidence with interviews and records review, this allegation is found to be UNSUBSTANTIATED. An exit interview was conducted with Administrator Nora Garza. A hard copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20220318124522

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Jun 19, 2025

False Claims.No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement.....the services provided by the facility. This requirement was not met as evidenced by: Based on interviews and record reviews, The licensee staff faslified documents for COVID-19 results for R1. This posed a potential personal rights risk to all residents in in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Adminsitrator will have staff review 87207 FALSE CLAIMS and provide signed doumentation that staff reviewed 87207. Licensee to provide documentation to CCL by POC date.

Allegation investigated: Licensee did not assist resident with medication administration Resident was charged for items never provided Licensee did not provide an itemized statement for charges Licensee did not meet resident's transportation needs Housekeeping services did not meet resident's needs License did not meet resident's dining needs

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Nora Garza In February 2022, Community Care Licensing (CCL) received complaints alleging that Licensee staff did not assist a resident with medication administration, the resident was charged for items never provided, Licensee staff did not provide an itemized statement for charges, Licensee did not meet the resident's transportation needs, and License did not meet resident's dining needs. CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews with staff, residents and outside sources. (Contuned on LIC 9099-C) Unsubstantiated (continued form LIC9099) Further review of the written correspondence reveals that during a roundtable discussion with residents and the executive director, R1 specifically requested information from the executive director regarding the laundry service schedule. However, the executive director did not respond to inquiries regarding the laundry service during the roundtable discussion or give a personal response to R1. Based on interviews with residence and records review and written statements to CLLD, a preponderance of evidence exists supporting that Licensee staff did not respond to resident's communication requests. The allegation is, therefore, Substantiated. One (1) deficiency was cited per the California Code of Regulations, Title 22 (refer to the LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Administrator Nora Garza, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (continued from LIC9099) Page 2 of 3 It was alleged that the Licensee did not assist a resident with medication administration. More specifically, Resident #2(R2) wanted to smoke prescribed THC, and the facility refused to allow smoking on campus. Records review reveals that R2 and R2's responsible party were aware of the no-smoking policy before admission to the facility. A records review from the sales director's documentation confirmed that R2 was advised to seek other non-smoking methods of prescribed THC prior to moving to the facility.. It was further alleged that residents were charged for items never provided, and the Licensee did not provide an itemized statement for charges. More specifically, Resident #1(R1) financial advisor has not received an itemized bill for the non-medical charges paid to the facility by R1 account.. Written reports submitted by another Resident responsible party reveal the facility charged the resident services never provided. Further information in the report states that after making a complaint to the facility regarding the services, the facility refunded the questionable charges without presenting an itemized statement. Written reports by another family member reveal that some financial discrepancies were noted, including being charged for services not rendered. However, interviews and records could not provide additional evidence to support the allegation. It was further alleged that the Licensee did not meet the resident's transportation needs. More specifically, Resident #1 (R1) was promised open-ended transportation services provided by the facility. Review of records, more specially the Villa Lorena Flyer- Services and Amenities state: Utilities: Weekly housekeeping and laundry services, maintenance, utilities, basic cable and internet, on staff driver up to 10 miles are all included in rent. A records review of an email from the sales office to a prospective resident as well as a folded advertised flyer state: Monday-Sunday transportation is available (Shopping days every Monday and doctor's appointments on Tuesday through Thursday). A review of records as well as the licensee printed material reveals that the Licensee does not provide open-ended transportation. (continued on LIC9099-C) (continued from LIC9099-C) page 3 of 3 It was further alleged that the Licensee's housekeeping services did not meet the resident's needs, and the Licensee did not meet the resident's dining needs. More specifically, R1 reports they have no idea who is in charge of doing their laundry or how it is to be collected or returned. R1 also reports that there is an increasing amount of prepackaged, pre-prepared food being served. A review of records reveals housekeeping was scheduled for service every Tuesday for R1. The menu collected by the department during the time of the allegations was reviewed, and it included a variety of choices, such as poultry, beef, seafood, salads, sandwiches, and other balanced, healthy options. Based on the Department's investigation, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the allegation are unsubstantiated. An exit interview was conducted with Administrator Nora Garza to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of today's visit.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20220211100740

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Jul 3, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents...shall have... the following personal rights:(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidence in; Based on interviews and records review the licensee did not communicate with residents promptly and appropriately in 3 of of XX persons in care which posed a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: The administrator agrees to provide appropriate staff with customer service training regarding answering inquiries from resdience in a timely manner. Proof of training is to be provided to Community Care Licensing by the POC date.

Allegation investigated: Facility staff handled resident roughly resulting in bruises.

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA was allowed entry by the receptionist and met with Administrator Nora Garza. LPA identified herself and discussed the purpose of the visit. Investigation was conducted by the Community Care Licensing (CCLD) Investigative Branch (IB) Investigator. The Department’s investigation included a tour of the facility, observations, records reviews, and interviews with staff and outside sources. Prior to the investigation, the CDSS/CCLD/Investigations Branch Investigator interviewed the reporting party and reviewed the facility file. On February 15, 2022, Community Care Licensing (CCL) received a complaint alleging facility staff handled resident roughly resulting in bruises. More specially, that an altercation occurred between Resident #1 (R1) and Staff #1 (S1) that resulted in bruising of R1. (Continued on LIC 9099-C) Substantiated (continued from 9099) Page 2 of 3 Interviews reveal on 02/13/2022, S1 reportedly attempted to help Resident#2(R2) change their incontinence brief. Resident #1(R1) began to hit S1 in the back, while S1 was helping R2, and was reported to have attempted to put S1 in a choke hold while yelling at S1 to “leave [R2] alone”. S1 admittedly grabbed R1’s wrists to try to remove R1’s arm from around S1’s neck. When that did not work, S1 reported they began to strike at R1’s hand with a closed right fist until R1 let go and S1 could free themselves. S1 reported the incident to Staff #2 (S2). The altercation resulted in bruising and skin tears of R1’s hands and wrists on both the right and left limbs. Staff interviews corroborated the details of the incident. When a staff member asked R1 what happened, R1 pointed to S1 and confirmed that they had caused the injury. Due to R1 diagnosis of dementia they could not provide any other statements about what happened. R2 is also diagnosed with dementia and could not provide a statement about the incident. S2 reported this incident to their supervisor, Staff #3 (S3), who also reported the incident to their supervisor, Staff #4 (S4). In addition to S1 causing bruising to R1, the Licensee did not report this incident to the licensing agency. [See LIC 811 Confidential Names List for a description of R1, R2 S1, S2, S3 and S4] Staff interviews and resident family interviews reveal other incidents where S1 has been inappropriately rough with residents in care or verbally abusive with residents in care. Department Interview with the executive director reveal S1 is no longer working at the facility. (continued on LIC 9099) (continued from LIC9099-C) Page 3 of 3 Based on S1’s own account of events, interviews with staff and outside sources, records review, and photographs evidence of bruising healing over time, a preponderance of evidence exists supporting that facility staff handled resident roughly, resulting in bruising. The allegation is, therefore, Substantiated. One (1) deficiency was cited per the California Code of Regulations, Title 22 (refer to the LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee and the licensee staff. An exit interview was conducted with Administrator Nora Garza, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (continued from 9099) Records review reveal resident #1 (R1) moved into the facility on 06/02/2021. A review of records also reveal while R1’s assessment documented the need for stand-by assist for showing upon move-in, R1’s plan of care indicated that R1 was independent for showers and R1 only needed assistance with dressing and prompting. Dressing and prompting were described as assistance with selecting an outfit for the day, prompting to shower, and checking back later to see if the shower was taken. Staff interviews supported that R1 was not receiving stand-by assist but rather that R1 was receiving services as outlined in the care plan of dressing and prompting assistance. A service plan log for recording daily care by staff indicated that stand-by assist was indeed provided in the months of July and August through the period in time at which a reassessment was done on 08/26/2021. The department records review of daily logs initialed by staff show that stand-by assist was provided for July and August. Facility staff could not produce a service plan log for June as there was a change in staffing and records for June could not be located. A review of R1's reassessment at the end of August 2021 deemed R1 independent for showering. Therefore, according to records stand-by assist was provided and was a higher level of care than indicated on the care plan. Records review showed that more care was provided not less than was outlined in the care plan. An interview was attempted with R1 but due to dementia diagnosis, no pertinent information was obtained. Due to facility staff being able to provide documentation of more care being provided to R1 than outlined in the care plan and due to contradicting evidence with interviews and records review, this allegation is found to be UNSUBSTANTIATED. An exit interview was conducted with Administrator Nora Garza. A hard copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20220215101301

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Apr 21, 2025

87468.2 (a)(8) Additional Personal Rights of Residents in Privately Operated Facilities (a)(8) In addition to rights listed in Section 87468.1, Residents shall have the following personal rights…to be free from physical abuse. This requirement was not met as evidenced by: Based on interviews with staff and outside sources, records review, and photographs, Facility staff handled resident roughly resulting in bruises. Licensee did not comply with regulation for 1 of 69 residents. This caused an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: S1, who was involved with incident was terminated by the facility. The administrator agreed to attend and have memory care staff attend personal rights training regarding proper handling of residents who are comabtive as well as proper protocol for residents who are being physically agressive with staff. Proof of training is to be provided to Community Care Licensing by the POC date..

Allegation investigated: Licensee did not follow COVID-19 guidance Facility was in disrepair Staff spoke inappropriately to residents

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Nora Garza OIn February 2022, Community Care Licensing (CCL) received complaints alleging that Licensee staff did not follow COVID-19 guidance, Resident #1(R1) room was in disrepair and licensee staff spoke inappropriately to R1. CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews with staff, residents and outside sources. [CONTINUED ON LIC 9099-C] Substantiated Continued from LIC 9099-A) It was alleged staff retaliated against a resident. More specifically it was alleged Staff #1 (S1) spoke of retaliating against resident #1 (R1) by stating they are trying to move R1 from the facility. Although the reported party stated they observed S1 speaking about retaliation. Staff interviews and interviews with residents did not corroborate the allegation, as staff consistently denied witnessing any form of retaliation by S1 to residents. Resident interviews, including R1, denied witnessing any form of retaliation by S1 to residents. It was also alleged staff did not meet residents needs and staff did not meet resident's incontinence needs. More specially, licensee staff did not help with R1 for over an hour after R1 request with incontinent needs, clothing changing and providing breakfast service. A review of R1 needs and service (dated 11/26/2021) reveals toileting and grooming as independent. Additionally resident will remain as much independence as possible with bathing and showering. The report further states the R1 will retain ability to partially dress self and staff will help with balance while dressing. R1 was interviewed around the time of the complaint and no evidence could be found in the interview to support the allegation. Records review as well as interviews with the licensee, staff, and medical personnel, were conducted and revealed that although some residents required more incontinence and toileting care, there wasn’t any documentation of concern for neglect, abuse, or non-accidental injuries were noted. Based on the Department's investigation, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted with Administrator Nora Garza to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of today's visit. ( Continued from LIC9099) (Pages 2 of 3) According to records review R1's physician report reveals they can communicate and have no issues with confusion or depression. R1's needs and service plan (dated 1/14/2022) states they have stand-by assistance, with bathing, hair care and personal hygiene. It was alleged that facility staff was not following COVID-19 protocol. More specifically, licensee management team kept positive COVID-19 cases from care giving staff, residents, and families of residents . Care giving staff and resident were interviewed around the time of the complaint and revealed that residents and staff had tested positive for COVID-19 and stated that the facility did follow the COVID-19 protocol by not informing care staff or residents of positive COVID-19 cases. Records review revealed COVID-19 related incident reports were not submitted to CCL from 12-21-2020 to 2-8-2021. Information gathered during staff and resident interviews indicated that staff facility-wide policy, supported by CCLD PIN recommendations, was to communicated to families in writing, report infection disease outbreaks to CCL, and adhere to infection control personal protective equipment guidelines. Records review, staff interviews and resident interviews gave corroborating evidence that Licensee management staff did not follow CCL infection protocols. It was further alleged staff spoke inappropriately to resident. More specifically Staff #1 (S1) yelled at R1 while standing outside their room entrance. A written statement by R1 and resident #2(R2) reveal S1 used statements towards R1 that were hurtful. R1 statement revealed when S1 discovered R1 had hired an outside agency to conduct mold testing, S1 approached R1 at their door (#106). S1 was angry and accused R1 of not reporting mold issues to maintenance. R1 then rebutted and tried to explain they reported the mold to maintenance three (3) different times yet the mold was not removed only covered up. R2 written statement revealed they witnessed R1 crying while S1 was yelling " this is my house and they (R1) have no rights here" Interview with current Administrator confirm S1 is no longer working at the facility. (continued on LIC9099-C) ( Continued from LIC9099-C) (Page 3 of 3) It was further alleged the facility was in disrepair. More specifically, R1's two living spaces within a two story building (room 106) had flood soaked walls and carpet, that was not addressed by facility and caused mold. A written statement sent to CCL by R1 reveals they reported the flooding to the facility and the facility had not addressed the flooding for weeks. Musty odor was observed by residents and an independent mold inspection was performed on 1/2/2022 in room #106. Inspection yielded high levels of mold and mold growth was present. According to Outside Source #1(OS1) they witnessed the facilities director and executive director speaking of the mold in room #106. According to the Centers for Disease Control, indoor mold has been proven to cause upper respiratory infections (www.cdc.gov). Therefore, the present mold is a health and safety concern for the clients in care. Based on interviews, written correspondence record review and outside source reports the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The allegation is, therefore, Substantiated. Three (3) deficiencies were cited per the California Code of Regulations, Title 22 (refer to the LIC 9099-D pages). A Plan of Correction was jointly developed with the Licensee.An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator Nora Garza whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20220210154600

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 5, 2025

87303 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidence in; Based on observations and interviews the licensee did not treat for mold in 1 of XX (GET CENSUS) persons in care which posed a potential Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee staff will provide documentation of rehab inspections for unit 106 by POC date. LPA provide the mold report for unit #106 for reference..

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jul 3, 2025

87468.2 – Additional Personal Rights...(a)(8) In addition… residents… shall… be free from... intimidation, and verbal, mental, physical, or sexual abuse This requirement was not met as evidenced by: Based on records review and interviews, S1 used language that was intimidating to (R1). This posed a potential personal rights and safety risk to 1 of xx residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Administrator agreed to provide LPA with documentation of training for all for personal rights and provide documentation by POC date. S1 was no longer works at the facily as of 9/27/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a) · Plan of correction due date: Jul 3, 2025

87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: This requirement was not mer as evidenced by: Based on interviews, the licensee did not ensure staff followed COVID-19 guidance, which posed a potential Health, Safety, and Personal Rights risk to all persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Administrator agreed to provide LPA with documentation of training on infection control for all staff by POC date.

Allegation investigated: Licensee did not allow resident to have visitors. Licensee did not safeguard resident's belongings.

Licensing Program Analyst (LPA) Amy Rodgers made an unannounced visit to deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit with Administrator Nora Garza. On June 6, 2022, Community Care Licensing (CCL) received a complaint alleging that the Licensee did not allow Resident #1(R1) visitors and that the Licensee did not safeguard R1's belongings. During the investigation, LPA briefly toured the facility, requested records, and interviewed staff and outside sources. The review of the physicians report (dated 7/14/2021) reveals R1 has some impairment in hearing and is legally blind. R1 was an assisted living resident. Records review indicate R1 has a history of paranoia and distrust. Interview with staff indicate that R1 has a history of confusion and disorientation. (Continued on 9099-C) Unsubstantiated (Continued from 9099) Regarding the allegation, the Licensee did not allow R1 visitors. More specifically, staff denied visitation to R1 on their birthday, despite proof of vaccination provided. Outside Source #1(OS1) stated they tried to visit R1 on their birthday but were denied entry and recalls it was due to COVID-19 screening issues with the facility. OS1 interview further reveals they were allowed entry in the facility to visit to R1 during previous visits. Interviews with the Manager on Duty during the time period states R1 was showing signs of agitation that day, and they did ask R1 if they wanted visitors. Interview further reveal R1 stated they did not want visitors that day. Outside Source #2(OS2) and outside source #3(OS3) interviews reveal they never observed any visitors being denied entry nor have heard any complaints about visitors not being able to visit the residents of the facility. Regarding the allegation, the Licensee did not safeguard the R1's belongings. More specifically, R1's passport and two purses are missing. Interviews with the Former Business Office Director reveal the facility discourages any valuables brought to facility. They also state they do not recall R1 having valuables or passports. Emergency Personnel report (dated 6/6/2022) can not confirm or deny any items were taken from R1’s room. However, during the search, the officer was able to locate one purse under the bed and three missing glasses, but was unable to locate a beaded and purse that was one of the items R1 reported missing. The officer also noted that, while speaking with R1, they would have mood alterations and become argumentative. Based on evidence obtained from interviews, observations and records reviewed, no corroborating evidence was obtained to indicate the facility failed to safeguard a client’s belongings. Based on the Department's investigation, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted with Executive Director Nora Garza to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of today's visit.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 08-AS-20220608130716

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers were granted entry into the facility by Executive Director Nora Garza. after identifying herself and stating the purpose of the inspection. The facility serves elderly residents, age 60 and over, 85 non-ambulatory of which 10 may be bedridden. The facility is approved for delayed egress. LPA was accompanied by Executive Director Garza for a tour of the facility which was conducted inside and out and included a sample of resident units, the dining area and recreation rooms. There is a fire signal system in place and operational. The last disaster drill was conducted on April 2025. Exterior and interior passageways were free from obstructions. Pull cords and pendants are present in the facility. Resident and facility room temperatures were within a comfortable range. The facility is approved for delayed egress doors in the memory care area. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] [Continued from 809] Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. The medication carts were locked and stored in the medication rooms. Medications were labeled and kept in compliance with label instructions. LPA interview confirmed the licensee provides assistance in meeting medical and dental needs. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA also conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were sited at the time of visit. A final exit interview and a copy of this report, Licensee/Appeal Rights - LIC 9058 (rev. 01/16), were provided to,Executive Director Garza. whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced visit to commence a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Nora Garza. During today’s visit, LPA toured the facility, reviewed client records, and interviewed staff and clients. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with the Garza, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Mar 20, 2025

Allegation investigated: Licensee did not ensure residents are assessed for proper care placement Lack of supervision resulted in residents eloping Licensee staff did not meet personal care needs for residents

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannouced visit to deliver findings regarding the above-mentioned allegations. LPA introduced themselves and disclosed the purpose of the visit to Resident Service Director Maureen Manzon. On 10/7/2024 it was alleged that Licensee did not ensure residents are assessed for proper care placement and lack of supervision resulted in residents eloping, and licensee staff did not meet personal care needs for residents. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents and outside sources, records review, and LPA observations. It was alleged that Licensee did not ensure residents are assessed for proper care placement for four residents (R1-R4). [See LIC 811 Confidential Names List for a description of R1.] and they should be placed in the memory care unit. A review of facility records reveals there are currently four residents (R1-R4) that reside in the assisted living portion of the facility with a diagnosis of dementia, and they are unable to leave the facility unassisted. A review of physician’s reports and care plans for [R1-R4] reveal all care plans as well as medical assessments are up to date. Records review indicate residents [R1-R4] are regularly observed for changes in physical, mental, emotional, and social functioning and these changes are brought to the attention of the responsible parties. (continued on 9099] Unsubstantiated [Continued form 9099] It was alleged that lack of supervision resulted in residents [R1-R3] eloping from the Assisted living unit of the facility as well as residents from the memory care facility. A review of facility records reveals there are currently four residents (R1-R4) that reside in the assisted living portion of the facility with a diagnosis of dementia, and they are unable to leave the facility unassisted. Interviews with staff reveal inconsistent accounts of elopement in the assisted living wing of the facility, regarding R1. Interviews with staff reveal (R2-R4) do not have exit seeking behavior and staff has not observed exit seeking behaviors. Record reviewed showed that internal investigation of a recent elopement incident was conducted, and LPA interviews and record reviews revealed the facility had in place an Absentee Notification Plan/Policy and followed the policy procedure. LPA toured the facility four times over the last three months and observed the delayed egress alarm system in the memory care unit of the facility. The annual inspection visit conducted in February 2024 also indicate delayed egress alarms working. LPA observed the alarm is operational and interviews reveal staff respond appropriately to the alarms when triggered. It was alleged that the Licensee did not meet personal care needs for residents in the memory care unit by not receiving bathing assistance from staff which resulted in residents smelling bad. LPA conducted observations on four (4) visits in the past three (3) months in the memory care area of the facility. LPA did not notice any malodorous in the memory care unit nor did the residents in the memory care unit have a smell of incontinence. LPA observed residents were sitting in the memory care unit common room, and all looked clean and well taken care of. LPA was accompanied by S1, who toured the facility. LPA also interviewed two outside sources that frequent the unit and confirmed they have not witnessed residents smelling bad and have observed frequent bathing for all residents. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations were deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) was provided to Resident Service Director Maureen Manzon whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 08-AS-20241007110409

Allegation investigated: Facility showers do not dispense hot water Facility has insufficient staffing to meet the needs of residents Staff use objects to obstruct the doorway in the memory care unit The alarm in the memory care unit is in disrepair The facility Administrator is not available a sufficient amount of time to manage the daily operations of the facility Staff are not adequately trained. Lack of supervision resulting in resident eloping from the facility

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA introduced themselves and disclosed the purpose of the visit to Resident Service Director Maureen Manzon. On 8/20/2024 it was alleged that Licensee did not ensure showers in memory care unit were at complaint temperatures, there is not enough staffing in memory care which resulted in the licensee not meeting the residents needs, the delayed egress alarm in the memory care unit is not working, the memory care director does not respond to help from staff which effects the daily operations of the facility, staff are not properly trained and lack of supervision resulted in a resident in memory care unit eloping from the facility. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff and outside sources, records review, and LPA observations. (continued on 9099-C] Unsubstantiated [continued from 9099] Regarding the allegation, facility showers do not dispense hot water in the memory care unit. LPA toured the facility and took water temperatures of showers and facets in the memory care unit on three separate visits in the last three months, as well as the annual visit conducted in February 2024. All faucets used by residents for personal care delivered hot water and were operational. The hot water was complaint with CCLD regulations. Interview with three outside sources also confirm they have not observed any issues with the water temperature in the showers of the residents in the memory care unit. Regarding the allegations, facility has insufficient staffing to meet the needs of residents which results with memory care residents being placed on the floor. Record reviews of staff shift schedules as well as interviews with outside sources and the resident care directory for the memory care unit reveal there is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. LPA observations during unannounced visits and interviews with outside sources reveal no witness to the residents being placed on floor due to lack of supervision. Regarding the allegation, licensee staff use objects to obstruct the doorway in the memory care unit. Interviews with four outside sources in the memory care unit of the facility as well as the assisted living unit reveal all outdoor and indoor passageways and stairways were kept free of obstruction. Regarding the alarm in the memory care unit is in disrepair. LPA observed on three visits in three months the fire department approved delayed egress alarm system was working inside as well as the perimeter of the care unit. Interview with outside sources as well as staff reveal no observation of delayed egress not working or in disrepair. [continued on 9099-C page 2] [continued form 9099-C] Regarding the allegation of staff are not adequately trained. Records reveal licensee conducted required title 22 training to staff before staff could work alone with residents. Records reveal monthly in service training to all staff including working with dementia residents, hand washing, residents rights, fall awareness/prevention,ect. The records also indicate drills are conducted for elopement procedure and fire safety. Regarding the allegations, the facility Administrator is not available a sufficient amount of time to manage the daily operations of the facility. Records reveal administrator staff is scheduled in the memory care unit as well as the assisted living portion of the facility for a sufficient amount of time to satisfy staffing needs. Interviews with staff confirm they are able to reach out to supervising staff when needed. Regarding the allegation, Lack of supervision resulted in resident elopement from the memory care unit, it was alleged that a resident eloped from the facility due to staff not providing adequate supervision. Record reviewed showed that internal investigation of the incident was conducted, and LPA interviews and record reviews revealed the facility had in place an Absentee Notification Plan/Policy and followed the policy procedure when the elopement took place. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations were deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) was provided to Resident Service Director Maureen Manzon whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 08-AS-20240820121327

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by and identified herself to Resident Service Director Maureen Manzon. LPA then met and discussed the purpose of the visit with Resident Service Director Maureen Manzon and Licensee Lorraine Black. Today's visit was in response to an Incident Report reported to CCLD on 9/27/2024. According to the report Staff #1 (S1) recently left the property and did not return. According to the licensee, S1 no longer works at the facility. LPA Rodgers investigated the circumstances surrounding the departure of S1. The investigation included gathering evidence and interviews with staff and Licensee. No deficiencies were cited for the above incident. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Licensee Lorraine Black , to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 1, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by and identified herself to Executive Director Joey Collado Jr.. LPA then met and discussed the purpose of the visit with Memory Care Director Marie Lou Fikingas. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 8/19/2024). According to the LIC624: on 8/18/2024, Resident #1 (R1) went AWOL (absent without leave) from the facility. [See LIC 811 Confidential Names List for a description of R1.] As of today’s (08/28/2024) licensing visit, R1 is living in the memory care unit of the facility. LPA observed R1 is safe and unharmed. LPA also reviewed pertinent records and interviewed relevant staff. According to R1’s latest LIC602 Physician’s Report (dated 1/26/2024): R1’s primary diagnoses is Dementia with behavioral disturbances. Doctor determined that R1 is not able to safely leave the facility unassisted. Records and interviews revealed: R1 had lived at the facility for around two (2) years, and this was R1’s first AWOL incident since moving in. According to the facility’s Absentee Notification Plan/Policy: When a client such as R1 is AWOL from the facility, staff are to search the “surrounding area.” After the unsuccessful search, staff are to notify the administrator or the Resident Service Director. Immediately contact and then law enforcement. The procedure was followed. [Continued 809-C] [Continued form 809] CCLD concluded: Facility staff provided needed supervision to R1 leading up to the AWOL. Licensee had a written Absentee Notification Plan as part of R1’s record of care, and staff followed this plan. No deficiencies were cited for the above incident. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Executive Director Joey Collado Jr., to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 28, 2024

Allegation investigated: Staff tampered with resident's personal belongings. Resident was not provided with safe equipment.

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA met with Executive Director, Jose Collado Jr. and Memory Care Director, Marie Lou Fikingas. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff and outside sources. It was alleged that staff tampered with Resident #1’s (R1) personal belongings, involving their laptop. R1 had a laptop in their room with an active camera, which was used for Zoom calls with their family. One day a medication technician went to R1’s room to dispense medications and observed themselves on the camera as though it was being recorded. The medication technician left the room and reported the camera to the Executive Director (ED). The ED went to R1’s room to verify if the camera was in use. The ED confirmed the facility does not have cameras in the building as they prefer staff and residents to have privacy. When the ED arrived at R1’s room they saw themselves on the camera as well as being recorded. The ED’s interview revealed that he asked R1 if it was okay to cover the camera for privacy, as there was a sticky note hanging on the laptop near the camera. Continued on an LIC 9099C. Substantiated The ED used the sticky note and covered the camera with R1’s permission. R1’s Physician Report dated 11/22/01 indicated a diagnosis of Major Neurocognitive Disorder, and was confused and disoriented, and unable to leave the facility unassisted. Due to R1’s diagnosis it’s unknown if R1 understood the camera was being covered. Outside source interviews confirmed R1 did not know how to operate the laptop due to their medical diagnosis. Outside sources stated the camera was always on so that the family could contact R1, since R1 didn’t know how to operate it. Additional outside sources revealed the facility did not have consent to cover the camera on the laptop, as that was how the family communicated with R1. When the family tried to contact R1 via camera on the laptop they were unable, due to the camera being covered. Therefore, the family member went to the facility and discovered a piece of tape was placed over the camera. Due to R1’s medical diagnosis and not being able to provide consent, the facility needed to discuss the issue with the responsible party prior to covering the camera. The ED explained the staff were uncomfortable being recorded and didn’t want to provide medications. Therefore, he asked R1 for consent to ensure staff felt their privacy was protected. It was also alleged, a resident was not provided with safe equipment. R1 was provided with a wander guard bracelet that alarms if R1 exits the building. The safety feature was in place due to R1’s medical diagnosis and not residing in the locked memory care unit. The wander guard does not prevent a resident from eloping but alerts staff so they may intervene. According to staff, if R1 exited the building, a notification was sent to the staff’s iPad, a notification to the concierge, and a loud sounding alarm for all to hear. Staff interviews confirmed R1’s wander guard was inoperable but for an unknown time. A review of correspondences indicated the facility was made aware of the inoperable equipment on 02/12/22 and the facility responded on 02/14/22 stating a new wander guard was requested, and being programmed, they will cut the existing one off and replace it. On 02/15/22, R1’s family member was visiting R1 when a staff member entered the room to replace the inoperable wander guard. The wander guard was inoperable for approximately three (3) days, which was unsafe for R1 due to their medical diagnosis. Based on 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 LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Memory Care Director, Marie Lou Fikingaswhose signature below confirms receipt of these rights. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) was provided to Memory Care Director, Marie Lou Fikingas whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 26, 2024 · control 08-AS-20220831154817

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 9, 2024

Personal Rights of Residents in All Facilities. Residents in...facilities...shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews the licensee did not accord dignity to 1 out of 71 residents [R1] when they covered R1’s laptop camera, which posed a potential safety and/or personal rights to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2024

Plan of correction: Executive Director agreed to attend Personal Rights training regarding treating residents with dignity and provide proof of training by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 9, 2024

Personal Rights of Residents in All Facilities. Residents...facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on interviews the licensee did not ensure resident’s safety equipment was operable for 1 out of 71 residents [R1] due to the wander guard being inoperable for approximately three days, which posed a potential safety and/or personal rights to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2024

Plan of correction: Executive Director agreed to attend Personal Rights training regarding safe equipment for residents and provide proof of training by POC due date.

Allegation investigated: -Facility does not have adequate staffing to meet resident's needs -Facility is malodorous

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the investigation regarding the above-mentioned allegations. LPA met with Executive Director, Jose Collado Jr. and Memory Care Director, Marie Lou Fikingas. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the facility does not have adequate staffing to meet the residents’ needs in the memory care unit. A review of staffing schedules indicated sufficient staffing. Staff interviews confirmed the facility had sufficient staffing. Staff also stated if a staff member calls out then the existing staff will work over one (1)-two (2) hours or a manager will assist. The facility will also use staff from their assisted living portion of the facility when necessary. The Executive Director’s (ED) interview confirmed the facility had sufficient staffing. ED also stated the facility does not use a registry for staffing, even though they have one on file to call if needed. ED stated if staff call out three (3) hours prior to their shift then a manager will cover the shift. Continued on an LIC 9099C. Unsubstantiated If staff call out for less than three (3) hours, then the staff already working will stay over for approximately one (1) to two (2) hours as needed. ED expressed staff have not complained and they all work together as family. The ED explained there were a couple of unforeseen circumstances that came about with staff not being present due to family emergencies. However, all shifts were covered. Resident interviews expressed their needs are met and when they call for assistance, it’s received. The Resident Service Director (RSD) also confirmed the facility has sufficient staffing. The RSD explained the memory care unit has one (1) lead; four (4) caregivers; one (1) med tech; one (1) activity director. The Memory Care Director (MCD) also confirmed the memory care unit has sufficient staffing. Outside source interviews revealed the facility had insufficient staffing and addressed the issue with the MCD. On 10/29/22 the MDC responded to the outside source in writing and explained during this time a Medication Technician had a medical emergency and another care staff had a death in their family. However, services were not interrupted for the residents. The facility always ensured sufficient staff were present to meet the residents’ needs. It was also alleged the facility was malodorous in the memory care unit. On 11/08/22, LPA observed the memory care unit, it was clean and odor free. Later in the visit, LPA was out in the common area and observed a strong feces odor. There was a resident sitting in a chair in the common area that fell asleep, sitting up in the chair. The resident had a bowel movement in their incontinent briefs. Staff interviews confirmed that residents were unable to alert staff when they have a bowel movement due to their Major Neurocognitive Disorder. Staff interviews revealed they check the residents every two (2) hours but if they smell the resident, they change their briefs immediately. The MCD also confirmed a specific resident likes to fall asleep in the common area and they have bowel movements, while in the common area. The MCD also stated staff check residents every two (2) hours or sooner if a smell was observed. The ED, RSD, and MCD all confirmed there were no odors in the memory care unit. The Maintenance Director’s interview confirmed there were no odors, and the carpets were shampooed every two (2) weeks. The housekeeper’s interview also confirmed there were no odors but sometimes a resident has a bowel movement on themselves and that can cause the common area to smell. However, once observed, the caregivers change the residents. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) was provided to Memory Care Director, Marie Lou Fikingas whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 26, 2024 · control 08-AS-20221031133222

Allegation investigated: Resident eloped Staff not following resident's care plan Staff did not notice resident's change in condition

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close out the complaint investigation regarding the above-mentioned allegations. LPA identified herself and met with Jose "Joey" Collado,Executive Director & Amy Salvador Resident Service Director, to discuss the purpose of the visit and elements of the complaint. On or around February 2022, it was alleged that the resident eloped. Interviews revealed Resident 1 (R1) usually takes walks around the facility. Interviews revealed that R1 walks along the perimeter of the facility a few times a day. R1 has not eloped from the facility. The facility is surrounded by a large gate and R1 does walk outside of the facilty and there is a sitting area out there that R1 will go sit at. Interviews revealed if R1 does walk any further staff are close behind. R1 loves to walk/exercise and will walk back and forth. There are no incident reports of R1 eloping from the facility. There were no witness statements to support the allegation of resident eloped. Unsubstantiated It was alleged that staff not following resident's care plan. Interviews revealed there were no documentation of the care plan being changed. R1's care plan shows that they will conduct their own showers on Monday, Wednesday and Fridays. After a records review, there was no documentation that showed the facility was not following the care plan. The care plan and physicians report dated 11/22/2021 stated that R1 was able to bathe and dress and handle toileting needs. There were no witness statements to support the allegation that staff not following resident's care plan. It was alleged that staff did not notice resident's change in condition. Interviews revealed that R2 was sick. Interviews revealed that R2 was tested for Covid and received a negative test. R2's condition did not change, R2 had a cold and the staff followed all protocols and made sure the resident was taken care of and tested. The resident received meals in their room and although they were not positive for covid they treated this incident as such and R2 was isolated as if they were covid positive. There were no witness statements to support the allegation that staff did not notice resident's change in condition. The allegations of resident eloped, staff not following resident's care plan and staff did not notice resident's change in condition were therefore determined to be unsubstantiated, since the preponderance of evidence standard was not met. An exit interview was conducted with Jose "Joey" Collado, Executive Director & Amy Salvador Resident Service Director A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Mar 12, 2024 · control 08-AS-20220317135636

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers were granted entry into the facility by Executive Director Joey Collado Jr. after identifying herself and stating the purpose of the inspection. The facility serves elderly residents, age 60 and over, 85 non-ambulatory of which 10 may be bedridden. The facility is approved for delayed egress. LPA was accompanied by Executive Director Collado for a tour of the facility which was conducted inside and out and included a sample of resident units, the dining area and recreation rooms. There is a fire signal system in place and operational. The last disaster drill was conducted on February 2024. Exterior and interior passageways were free from obstructions. Pull cords and pendants are present in the facility. Resident and facility room temperatures were within a comfortable range. The facility is approved for delayed egress however appropriate signs were not provided on delayed egress doors. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] [Continued from 809] Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. The medication carts were locked and stored in the medication rooms. Medications were labeled and kept in compliance with label instructions. LPA interview confirmed the licensee provides assistance in meeting medical and dental needs. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA also conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were sited at the time of visit however, a technical violation issued. A final exit interview and a copy of this report, LIC 9102, Licensee/Appeal Rights - LIC 9058 (rev. 01/16), were provided to, Executive Director Collado Jr. whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Feb 20, 2024

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: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Joey Collado and Resident Services Director Amy Salvador. Today's visit was in response to two (2) LIC624 Incident Reports, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/14/2023 and 08/18/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a facility tour and welfare check on R1, finding they were safe. LPA also collected copies of pertinent facility and hospital records and interviewed pertinent staff. No deficiencies were observed or cited during today's visit. One (1) Technical Violation (TV) was issued regarding Reporting Requirements. An exit interview was conducted with Collado and Salvador, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Nov 15, 2023