Vine Ridge Senior Living

Allegation investigated: Facility Staff is Yelling at Residents

At approximately 9:05 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegation and met with Resident Care Coordinator (RCC) Alexis Short. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that facility staff yell at residents. Witness W1 stated that on 7/8/2026 at approximately 9:00 AM, staff member S1 had yelled at a resident. According to witness and staff interviews resident R1 was expressing frustration to staff member S3 regarding their morning medication administration. Staff member S1 overheard S3 discussing R1’s frustrations with S2. At that point staff members S1, S2 & S3 went to discuss the matter with R1. Witness 1 stated that at this point S1 yelled at R1. When asked if facility staff have ever yelled at them R1 stated, “No, no one has ever yelled at me.” Continued on 9099-C... Unsubstantiated ...Continued from 9099 When asked how the facility staff treat them R1 stated, “They treat me fine. We have had some disagreements about what time medications are given to me, but the staff are following the doctor’s orders.” Staff member S3 stated that staff member S1 didn’t yell during the exchange with R1. S3 further stated that both S1 and R1 were instead speaking with “raised voices.” During an interview when asked if they ever yelled at residents, S1 stated, “I have never yelled at any resident”. On 7/9/2026, the facility filed an LIC 624 Unusual Incident/Injury Report (IR) regarding the exchange per regulation. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to RCC Short. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 15, 2026 · control 21-AS-20260708152015

Type of visit: Case Management - Incident

At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit to verify the removal of a staff member, S1. LPA met with Resident Care Coordinator Alexis Short and received verification of S1's removal as of 08/21/2026. LPA received the signed Confirmation of removal form signed by the Executive Director Jennifer Hall. LPA requested the facility Guardian roster be updated with the removal of S1. No citations issued during today's visit.the state’s words, verbatim · CDSS document, Aug 26, 2026

Allegation investigated: Resident sustained an injury while in care due to inadequate supervision and lack of a safe environment

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegations and met with facility Executive Director (ED) Carla Lua. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that Resident sustained an injury while in care due to inadequate supervision and lack of a safe environment. On 5/29/2026, Community Care Licensing (CCL) received two anonymous complaints. Both complaints contained the same information. The reporting parties (RPs) stated that resident R1 injured themselves while on a facility outing on 5/26/2026. Three (3) residents went on the outing. The facility submitted an LIC 624 Unusual Incident/Injury Report (IR) on 5/29/2026. The IR was submitted within the required seven (7) day window. Both the RP and the facility IR state that R1 was seated at the rear of the van. Continued on 9099-C... Unsubstantiated ...Continued from 9099 Through interview LPA ascertained that the facility allows ambulatory residents to sit in the rear seats while non-ambulatory residents sit at the seats directly next to the van’s side doors. Resident R1’s LIC 602A Physician’s Report lists R1 as being ambulatory. While exiting the van, resident R1 got their foot caught in the back of the seat next to the side door and hurt their knee. Staff member S1 who was accompanying/driving the residents immediately called the facility to report the incident and emergency services were notified. Facility ED Lua drove to the location where the incident occurred. Emergency services arrived on the scene and recommended that resident R1 be transported to the hospital for further examination. Emergency Services reported that their ambulance was already transporting someone to the hospital. Emergency services suggested that the facility transport R1 to the hospital for expediency. The facility then transported R1 to Providence Healdsburg hospital. Resident R1 was diagnosed with a minor knee injury that did not require any surgery or casting. Resident R1 returned to the facility later the same day. Resident R1 has had no further complications resulting from their injury on 5/26/2026. LPA examined the facility van and found no safety hazards. LPA reviewed staff member S1’s training file and observed that S1 has completed all required annual training including fall prevention. LPA could not find any evidence of a lack of supervision or of an unsafe environment for residents. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 21-AS-20260529081037

Allegation investigated: Gate Door in Memory Care Yard is Not Locking

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegations and met with facility Administrator Carla Lua. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that the emergency egress Gate Door in Memory Care (MC) Yard is Not Locking. The MC Garden egress doors are locked in place with electromagnets. When the fire alarm is activated, the magnets will release allowing egress from the doors. On 6/19/2026 LPA inspected the facility’s Memory Care unit garden fire egress doors. The garden has three (3) emergency egress doors. The doors are located in the North-East (door #1) section, the North-West (door #2) section and the South corner (door #3) of the MC garden. LPA observed that doors #1 and #2 were not locking as designed. The wooden gate doors had warped. As a result of the warping the electromagnets were unable to connect and keep the doors locked. Continued on 9099-C... Unsubstantiated ...Continued from 9099 Instead, door #1 and door #2 were being held shut by rocks placed on the outside of the gates. The rocks holding the doors shut were small and the doors were easily able to be pushed open. As such, the emergency egress pathways were not blocked. When asked about the doors not operating as designed facility Executive Director (ED) Carla Lua stated that the doors were functioning and that the facility landscapers had turned off the electromagnetic locks the previous day so that they could access the MC garden for up-keeping and had failed to turn them back on. ED Lua then confirmed that the power to the locks was turned on. ED Lua then contacted facility maintenance who immediately adjusted the doors so that they would remain locked using the electromagnets. LPA returned to the facility on 7/9/2026. LPA observed that the three (3) MC garden gates were properly locked by the electromagnets as designed. However on the same day, 7/9/2026 LPA observed that the egress door at the South-West end of the MC interior corridor was unlocked and that it was being blocked by a large ottoman. The facility was cited separately for this deficiency on a Case Management inspection. During today’s 8/11/2026 visit, LPA observed all three (3) MC Garden gates to be properly locked. Additionally, LPA observed the egress door at the South-West (SW) end of the MC interior corridor to be secured. LPA tested the delayed egress door at the SW end of the MC interior corridor and LPA observed the delayed egress function to be working as designed. Although the MC units delayed egress doors and locking garden gate doors were not functioning as designed, they were able to be opened in the event of an emergency evacuation. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Copy of LIC-9099 and LIC-9099C discussed and provided to ED Lua. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 21-AS-20260617095856

Type of visit: Case Management - Other

At approximately 10:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to initiate complaint investigations for complaints 21-AS-20260703103248 and 21-AS-20260708152015 and to continue the investigation for complaints 21-AS-20260529081037 and 21-AS-20260617095856. During the course of the inspection, LPA observed a large ottoman blocking the Emergency Exit door at the South-West end of the memory care unit. All emergency egress pathways and exit doors shall be clear and unobstructed. This deficiency will be cited. As this deficiency poses an immediate safety risk to persons in care an immediate Civil Penalty of $500 will be issued. Photographs of the ottoman blocking the exit door were taken. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, LIC-421IM and Appeal Rights discussed and provided to Executive Director Lua. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Jul 10, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. ... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in a large ottoman was observed to be blocking the Emergency Exit door at the South-West end of the memory care unit which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Licensee or Administrator to submit an LIC 9098 Self Certification stating that going forward all exit doors and pathways will be clear and unobstructed to Community Care Licensing by POC due date of 7/10/2026.

Allegation investigated: Facility is Not Maintaining Medication Records Correctly

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegation and met with facility Administrator Carla Lua. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that the Facility is Not Maintaining Medication Records Correctly. LPA reviewed the facility’s Centrally Stored Medication and Destruction Records and observed all medications to be centrally stored and secure. LPA also reviewed Medication Administration Records (MARs) for a sample of facility residents. LPA did observe multiple instances of staff not entering their initials in the MARs to indicate that the medication has been administered. For resident R1, the MARS for medication R1M1 was not initialed on the following dates: 9/1/2025, 9/3/2025, 9/4/2025, 9/5/2025, 9/7/2025, 9/11/2025, 9/14/2025, 9/15/2025, 9/16/2025, 9/18/2025, 9/24/2025, 9/25/2025, 9/26/2025 and 9/29/2025. Continued on 9099-C... Substantiated ...Continued from 9099 For resident R2, the MARS for medication R2M1 was not initialed on the following dates: 1/5/2026, 1/6/2026, 1/7/2026, 1/8/2026, 1/15/2026, 1/29/2026, 1/30/2026, and 1/31/2026. For resident R2, the MARS for medication R2M2 was not initialed on the following dates: 9:00 AM medication pass – 1/5/2026, 1/6/2026, 1/7/2026, 1/8/2026, 1/15/2026, 1/29/2026, 1/30/2026 and 1/31/2026. 5:00 PM medication pass - 1/29/2026, 1/30/2026 and 1/31/2026. For resident R3, the MARS for medication R3M1 was not initialed on the following dates: 1/8/2026, 1/30/2026 and 1/31/2026. For resident R3, the MARS for medication R2M2 was not initialed on the following dates: 1/8/2026, 1/30/2026 and 1/31/2026. California Health and Safety Code (HSC) 1569.69 (g) states that Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility's medication management program and procedures at least twice a year. Consonus Pharmacy conducted reviews of the facility’s medication management program on 9/15/2025 and 12/17/2025. Both reviews noted that there are a “High Number of Holes” in the MARs for the quarter under review. “Holes” indicate that staff initials have not be entered when medications are administered. Based on LPA’s 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. ...Continued from 9099-A In reference to resident R2, witness W1 stated that on 1/20/2026 they received their morning medications late. LPA reviewed Medication Administration Records (MARs) for resident R2 for 1/20/2026 and observed nothing to indicate that R2’s medications were not administered at the prescribed times. In reference to resident R3, witness W1 stated that the facility is swapping out resident R3’s medication and replacing them with an over the counter (OTC) medication. A photograph of pills in a bottle was provided by witness W1. The photograph did not show prescription labels or any evidence that could tie the photograph to resident R3’s prescribed medications. In reference to resident R4, witness W1 stated that R4’s medication was being kept in a black lock box in staff member S2’s office. LPA inspected S2’s office and found no evidence of a black lock box containing medications. LPA observed the PRN medication in question to be centrally stored, secure and with proper documentation. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges that the Facility Staff are Not Properly Trained in Medication Management. During the course of the investigation there were six (6) staff members designated as Med Aids who were responsible for administering medication to residents. California Health and Safety Code (HSC) 1569.69 states that in facilities with sixteen (16) or more residents, each employee of the facility who assists residents with the self-administration of medications shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction. Additionally, employees who continue to assist with the self-administration of medications shall also complete eight hours of in-service training on medication related issues in each succeeding 12-month period. LPA reviewed training documentation and course materials for the facility’s six (6) Med Aides. LPA observed that the Med Aides had taken all required initial training and continuing training. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Copy of LIC 9099, LIC 9099D, LIC 9099S and Appeal Rights discussed and provided to Administrator Lua. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 21-AS-20260126110939

From the deficiency page — Deficiency type: Type B · Section cited: CCR 877506(a) · Plan of correction due date: May 28, 2026

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location... and to licensing agency staff. This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that three (3) of three (3) residents (R1, R2, R3) MARs were not initialed by staff on dates noted in findings which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Licensee or Administrator to provide training in Medication Management record keeping for all staff currently administering medications. Additionally, the facility will provide it’s most recent Medication Management audit to Community Care Licensing (CCL). Proof of training to include training materials and signatures of staff members attending training to be sent to CCL by POC due date of 5/28/2026.

Type of visit: Office

An Office meeting was conducted today, 04/15/2026, in the Santa Rosa Regional Office. The following individuals were present at the meeting: Victoria Bertozzi, Licensing Program Manager; Robert Frank, Licensing Program Analyst; Larona Farnum, Chief Operating Officer of Western Living Concepts and Carla Lua, Executive Director. The purpose of the office meeting was to hold an Informal discussion to address the following areas of concern identified by the Department. Reporting Requirements: Submitting Incident Reports (IRs); Missing IRs from 2025; Submitting IRs with complete information. Seeking Timely Medical Care for Residents. IRs received by Community Care Licensing (CCL) state that facility staff called residents’ family members for direction regarding notification of Emergency Services. Facility Medication Management: Staff training in new medication policies received by Community Care Licensing on 3/19/2026. Fire Safety issues and Personal Rights concerns regarding Assisted Living Waiver (ALW) residents sharing rooms. Medical Renewals for residents on ALW. On 1/9/2026 during a facility visit to initiate a complaint investigation (complaint 21-AS-20260102134135), LPA Frank observed an After Visit Summary from Providence Healdsburg Hospital Emergency Center for the date of 10/20/2025 for resident R1 in R1’s facility file. Continued on 809-C... ,,,Continued from 809 The After Visit Summary stated that R1 had suffered an injury. On 10/20/2025 resident R1 was a resident of the facility. Community Care Licensing did not receive an IR for this injury. Under California Code of Regulations, Title 22, Division 6, Chapter 8, Article 4 Operating Requirements, 87211 Reporting Requirements (a)(1)(B) state that a written report shall be submitted to the Licensing Agency for any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. As no IR was submitted to CCL for this event, the facility will be cited for this deficiency. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Executive Director Lua. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: May 13, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency...(B) Any serious injury...while the resident is under facility supervision. This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that an Incident Report was not Submitted for R1 for an injury sustained at the facility which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Licensee or Administrator will submit facility policies and processes for submitting Incident Reports to Community Care Licensing within the regulated time frame. Additionally, the facility will train all staff members on these policies and processes. These policies and processes and proof of staff training are to be submitted to Community Care Licensing by POC due date of 5/13/2026.

Type of visit: Case Management - Incident

At approximately 12:30 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection and met with Executive Director (ED) Carla Lua. The facility submitted one (1) Incident Report (IR) for Resident 1 (R1) for a medication error. On 3/8/2026, at approximately 1:30 PM during the afternoon medication pass, medications were being delivered to residents directly in their rooms. During this medication pass Medication Aid MA1 mistakenly gave medications intended for resident R2 to resident R1. Medication aide MA1 immediately realized their error and called emergency services and notified ED Lua. Resident R1 was transported to the Kaiser Permanent Emergency Department for evaluation. Resident R1 returned to the facility later the same day. Resident R1 suffered no adverse effects of the medications given to them in error. Resident R1's after visit summary stated they should skip taking a specific medication the following morning on 3/9/2026. The facility did inadvertently give the medication that was to be skipped to resident R1. Resident R1 suffered no adverse effects of not skipping the noted medication. The facility has immediately changed its procedures so that three (3) staff members are reviewing residents After Visit Summaries when residents are seen in Emergency Departments or seen by their primary care physicians. The facility will be cited for this deficiency. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Executive Director Lua. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 12, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 13, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical... shall be developed...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that on 3/8/2026 medication prescribed for resident R2 was given to resident R1 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2026

Plan of correction: Licensee or Administrator will submit proof that all of the facility's Medication Aids have retaken "Hour 3" training as shown in the facility's Medication Training Program to Community Care Licensing by POC due date of 3/13/2026. Additionally, the facility will develop and submit Procedures for Medication Errors to Community Care Licensing by POC due date of 3/13/2026.

Allegation investigated: Staff did not provide requested records to resident’s representative in a timely manner.

At approximately 8:50 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to initiate and deliver a finding for a Complaint Investigation regarding the above allegation and met with facility Executive Director (ED), Carla Lua. During the course of the investigation LPA conducted a facility visit, conducted interviews, collected and reviewed documents. Complaint alleges facility staff did not provide requested records to a resident’s representative in a timely manner. On 1/23/2026, a request was emailed to facility ED Carla Lua by a resident’s representative asking for copies of resident R1’s record including Medical Records, R1’s Care Plan, all incident reports (including in house reports) and a phone log of all calls related to R1. Continued on 9099-C Substantiated ...Continued from 9099 Later in the same day, 1/23/2026, ED Lua responded to the document request stating, “We will follow up once the documentation is compiled and ready for release.” On 1/26/2026 LPA Frank spoke with ED Lua via telephone. ED Lua asked if internal incident reports needed to be provided to residents’ representatives if requested. LPA advised ED Lua to check with their legal counsel. During today's facility visit a copy of California Code of Regulations (CCR) 87211 Reporting Requirements was provided ED Lua. On 1/27/2026, the resident’s representative email ED Lua requesting an update and, “if you were gonna have the documents available for me to pick up today before you leave.” On 1/30/2026 ED Lua sent an email to the resident’s representative stating, “This email is to formally clarify our position regarding your request for records from R1’s file. Pursuant to California RCFE regulations (Title 22) and upon advice of legal counsel, we will not release any resident records unless and until we receive a certified written request that clearly identifies: 1. The specific documents being requested. Once a compliant certified request and proper authorization are received, we will review and release only those records that are legally permissible under state regulations. Until that time, no documents will be released. Any further requests should be submitted in writing and in compliance with the above requirements,”. Title 22, Division 6, Chapter 8, Article 08. 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(19) states: (a) 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: (19)To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. The documents requested were not provided within the regulated time. 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 LIC9099D. Exit interview conducted. Copy of LIC9099, LIC9099C, LIC9099D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to ED Lua. LPA also provided ED Lua copies of California Code of Regulations (CCR) 87211 Reporting Requirements, CCR 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities and CCR 87506 Resident records for future reference. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 21-AS-20260130113942

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Feb 6, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed...(19)To have prompt access to review all of their records and to purchase photocopies...shall be provided within two (2) business days... This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that R1's representatives were not provided copies of documents in R1's file within the regulated time frame which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: Licensee or Administrator to provide all requested documents to R1's representatives by POC due date of 2/6/2026. Additionally, Licensee or Administrator will submit an LIC 9098 Self Certifying that they have reviewed California Code of Regulations 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities and California Code of Regulations 87506 Resident Records to Community Care Licensing by POC due date of 2/6/2026.

Allegation investigated: Unlawful Eviction

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegations and met with facility Executive Director Carla Lua. During the course of the investigation LPA conducted a facility visit, conducted interviews, collected and reviewed documents. Complaint alleges that facility is attempting to unlawfully evict Resident R1. A witness reported that on 12/30/2025 the facility Executive Director (ED) Carla Lua conducted a meeting with resident R1. R1’s representative attended the meeting via telephone. During the meeting ED Lua stated that the facility was going to terminate the residency agreement with resident R1. The Facility did not provide the required eviction notice to resident R1 at the meeting. As the facility did not provide an Eviction Notice, no eviction has taken place. At the current time, resident R1 still resides at the facility. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Copy of report discussed and provided to Executive Director Lua. Signature on form confirms receipt of documents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 29, 2026 · control 21-AS-20260102134135

Allegation investigated: Facility left resident at the hospital

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegation and met with facility Executive Director Carla Lua. During the course of the investigation LPA conducted a facility visit, conducted interviews, collected and reviewed documents. Complaint alleges facility left a resident at the hospital. On 11/13/2025 resident R1 was transported to Healdsburg Providence Hospital Emergency Center. When the hospital contacted the facility to arrange discharging R1 back to the facility a witness states that a staff member at the facility stated, “we will not be taking the patient back and we are on the phone with the State right now. You guys have to keep them.” Witnesses stated that in a later conversation, a staff member of the facility stated, “facility will accept the patient back if they are prescribed medication.” Later in the same day (11/13/2025) resident R1 was transported back to the facility. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Copy of report discussed and provided to Executive Director Lua. Signature on form confirms receipt of documents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 29, 2026 · control 21-AS-20251113161000

Allegation investigated: Insufficient staffing Facility staff did not meet resident’s care needs

At approximately 8:50 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegations and met with Alexis Short, Resident Care Coordinator. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges the facility did not have sufficient staffing and that the facility did not meet the resident’s care needs. Resident R1 resides in the facility’s Memory Care unit. Resident R1 has been admitted to hospice services. Upon viewing resident R1’s Care Plan prepared by the facility, LPA observed that R1 requires a one (1) person assist for most daily activities. Continued on 9099-C... Unsubstantiated ...Continued from 9099 Resident R1’s Care Plan prepared by the hospice program was also observed to state that R1 requires assistance with most daily activities. LPA reviewed facility staff time sheets for the period of 8/1/2025 through 8/30/2025. The facility has three (3) defined shifts. The AM shift is 6:00AM-2:30PM. The PM shift is 2:00PM-10:30PM. The Night (NOC/Nocturnal) shift is 10:00PM-6:30AM. During the time frame noted the AM shift was observed to typically have four (4) to five (5) staff members providing care. There were several AM shifts that were observed to have six (6) or seven (7) staff members providing care. During the time frame noted the PM shift was observed to typically have four (4) staff members providing care. The PM shift was observed to typically have three (3) to four (4) staff members providing care. The NOC shift was observed to have three (3) staff members providing care. During the time frame observed (8/1/2025-8/30/2025) there was adequate staffing levels to help R1 with their daily care needs. LPA interviewed R1’s Hospice Case Manager with Sutter’s Care at Home program. The case manager stated they think the facility is meeting the care needs of their hospice residents and that the facility cares about the level of care they provide. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to Resident Care Coordinator Short. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 7, 2025 · control 21-AS-20250903150111

Type of visit: Case Management - Annual Continuation

At approximately 8:45 AM, Licensing Program Analyst (LPA) Frank arrived unannounced to continue a Required 1 Year visit and met with Facility Administrator Carla Lau. LPA was informed that there are currently thirty six (36) residents in care. LPA conducted a sample file review of seven (7) staff members. LPA observed that one (1) staff member (staff member S1) did not have any proof of annual training in their file. LPA also observed that one (1) staff member (staff member S3) only had 9.75 hours of the required twenty (20) hours of annual training. These deficiencies will be cited. All other staff members had appropriate documentation, proof of training and current 1st Aid and CPR certification on file. LPA also conducted a sample file review for seven (7) residents. Upon review, LPA observed all resident files to have appropriate documentation including current Service Plans and Physician's Reports. LPA spot checked Medication for seven (7) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items. Carla Lua’s Administrator Certification 6072212740 is current with an expiration date of 9/12/2026. Continued on 809-C... ...Continued from 809 LPA is requesting the following documents submitted to CCLD by 11/31/2025: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Proof of Liability Insurance Current Admissions Agreement Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Lua. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 31, 2025

Allegation investigated: Physical plant in disrepair

At approximately 8:50 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to initiate and deliver a finding for a Complaint Investigation regarding the above allegation and met with facility Administrator Carla Lau. Complaint alleges that the floor in the memory care dining/common area is in disrepair. A witness stated that it is dangerous to the residents as the damaged floor is a trip hazard. During LPA's inspection of the memory care dining/common area LPA observed a large portion of the floor in disrepair. The synthetic flooring strips were bubbled and loose. The ends of the flooring strips were observed to be raised. LPA further observed that it appeared that tape was at one point used to secure the flooring. Facility administrator Lau stated the floor had been in disrepair for approximately three (3) months. LPA obtained photographs of the damaged floor area. The facility is planning to replace the damaged flooring during the weekend of 9/19/2025 to 9/21/2025. Continued on 9099-C... Substantiated ...Continued from 9099 Based on LPA’s observation and interviews, 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. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099, 9099C, 9099D, Plan of Corrections and Appeal Rights discussed and provided to ED Lau. Signature on form confirms receipt of documentsthe state’s words, verbatim · CDSS document, Sep 5, 2025 · control 21-AS-20250903150111

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 9, 2025

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance...for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation & interview, the licensee did not comply with the section cited above in that a large portion of the floor in the memory care dining/common area floor was in disrepair. The flooring strips were bubbled and loose which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee to provide plans on what is being done mitigate the trip hazard in the memory care dining/common area floor to Community Care Licensing by POC due date of 9/9/2025. Licensee will also provide photographs of the repaired floor as soon the floor repair is completed.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 8:50 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection and was greeted by Administrator/Executive Director (ED), Carla Lau. Vine Ridge Senior Living serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for ninety-nine (99) ambulatory and non-ambulatory residents. Facility has an approved hospice waiver for eight (8) residents. The facility consists of a multi-level building with multiple outside patio areas. The Memory Care unit has it's own dedicated patio and garden area. Upon arrival, LPA was informed that there were twenty-three (23) residents in assisted living and fifteen (15) residents in Memory Care for a total of thirty-eight (38) Residents in care. At approximately 9:25 AM, LPA reviewed Facility Staff Roster and found that staff member S1 had not been cleared in the Guardian Background check system. A citation will be issued for this deficiency. A Civil Penalty of $100 will be assessed for this deficiency. All other staff members on site were background cleared and associated to the facility per regulation. At approximately 10:25 AM LPA toured the facility with Resident Care Coordinator, Alexis Short. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offers a variety of menu options for the residents at each meal. There is also a variety of fresh fruit and other snacks available for residents at all times. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Continued on 809-C... ...Continued from 809 Hot water temperatures for a sample size of nine (9) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. All stairwells had evacuation chairs per regulation. The building's smoke and carbon monoxide detectors and sprinkler system were last inspected in 2/2025. All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged in 10/2024. The facility conducts disaster drills quarterly. The last disaster drill was conducted on 6/25/2025. During inspection of memory care unit LPA observed the flooring in the common area/dinning area to be in disrepair. This deficiency will be cited on complaint 21-AS-20250903150111. The facility is planning to replace the damaged flooring during the weekend of 9/19/2025 to 9/21/2025. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, LIC421BG, LIC811 Confidential Names and Appeal Rights discussed and provided to ED Lau. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso conducted a Required - 1 Year visit, on 10/28/24 at approximately 9:45am, and met with Resident Care Coordinator (RCC) Alexis Short. The facility is a licensed assisted living, community, which includes a memory care unit. Hospice care waiver approved for eight (8) 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 ninety-nine (99) non-ambulatory of which eight (8) may be bedridden; Bedridden is fire cleared for the first floor only. The facility is holding required emergency disaster drills, last two were held on April 19, and July 15, 2024. LPA discussed with RCC that the emergency disaster drills are to be held quarterly, and to ensure one is an evacuation drill; The quarterly emergency disaster drills are to be held on each shift. LPA reviewed five (5) resident records. All records were complete. The LPA reviewed five (5) staff records. All staff have criminal record clearance as required by regulation. Staff have first aid and CPR certification as required. LPA reviewed staff training; LPA discussed with RCC organizing proof of training, ensuring all staff are meeting the training requirements by H&S Code. LPA discussed ensuring administration staff have a plan on who is able to access the training information when the Licensee and/or the Administrator are not on-site. LPA toured the facility with RCC Alexis. 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, expires 10/11/25. Combination smoke/carbon monoxide detectors were present and in working order. Facility is fire sprinkled throughout. Common areas, hallways, and bathrooms observed by the LPA had sufficient lighting available to residents in care. All notices that are required to be posted have been posted and are in a highly visible area. Continued on LIC809C... 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. LPA observed that each stairwell, two (2) had required evacuation chairs, and the large open staircase from the second floor down, also has an evacuation chair to the side of it. Facility had a sufficient supply of cleaners/disinfectants, paper products, hygiene products, and personal protective equipment (PPE). All disinfectants/cleaners were stored and secured, inaccessible to residents in care. Medications were observed and reviewed; All medications were stored in compliance with State and Federal requirements. All outside courtyards were clean, orderly, and had outside furnishings, and shaded areas for resident use. LPA is requesting the following documents be updated and submitted by 11/28/24: 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 Current Liability Insurance Copy of current Administrator Certificate There are no deficiencies cited during today's visit. Exit interview conducted with RCC Alexis Short.the state’s words, verbatim · CDSS document, Oct 28, 2024

Allegation investigated: -Resident sustained an injury while in care. -Staff do not ensure adequate care and supervision is provided to residents. -Staff leave residents in soiled clothing for extended periods of time. -Staff do not ensure a safe environment is provided for clients in care. -Staff do not ensure safe transfer methods are used for residents in care.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with acting Administrator, Carla Lua. Resident sustained an injury while in care. Per Reporting party, staff would leave spills on the floor, causing residents to slip and fall in the facility. The Reporting party stated that three weeks ago a resident (R1) had a bad fall in the bathroom due to one of the staff leaving them in the bathroom alone. R1 lost their balance and hit their head. The Reporting party acknowledged that medical treatment was provided immediately, and the resident was taken to the emergency room. Based on records review, on 6/24/24 the facility submitted an incident report notifying to the Department that on 6/20/24 at approximate 2pm, R1 had an unwitnessed fall and injury. Per incident report, staff found R1 on the restroom floor, they have notified 911 immediately and R1’s responsible party, R1 was transported to the hospital for further evaluation. Continue on LIC9099C... Unsubstantiated Continued from LIC9099... Discharge documents for R1 confirmed that R1 was discharged the same day with a diagnosis of facial laceration and closed head injury. R1’s care plan dated 6/23/23 indicates that due to their memory challenges, it was determined that staff will escort resident to the bathroom, give verbal prompts/cues with toileting tasks. However, R1’s physician report dated 9/25/23 revealed that R1 is capable for self-care including toileting needs. Although R1 had a fall, the investigation did not reveal information that injury while in care was due to any lack of supervision. A finding that the complaint allegation of resident sustained an injury while in care is 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, therefore the allegation is UNSUBSTANTIATED. Staff do not ensure adequate care and supervision is provided to residents. The Reporting party stated that they noticed residents in the memory care unit with bumps on their heads that weren't there before due to staff do not check on residents as often as they should do, the staff are supposed to be checking on residents every two hours to repositioning or taking them to the bathrooms, but they are just logging into the paperwork that they did, but it is not happening. During LPA’s interviews with reporting party, LPA requested names of staff or residents, but complainant could not provide any further details. Based on records review of facility records, staff are assigned tasks that are documented into the assignment sheet/ADL’s checklist/NOC memory care round checks sheet. Upon reviewing facility logs as follow: assignment sheet for the month of August 2024 indicates at least two staff need to be present in memory care unit to assist residents in care. ADL’s checklist for the month of August 2024 indicates that staff have ensured that each resident’s care plan and needs are being met daily. NOC memory care round check sheet information details continence status as well as how each resident was found including on recliner, sleeping, etc. during checks performed at 10pm, 12 am, 2am, 4am and 6am respectively. Staff schedule and staff timesheet for the month of August 2024 confirmed that there is an average of two caregivers, med-technician/aide per morning and afternoon shift, two caregivers at night shift to provide care and supervision for nine residents in memory care unit. Continue on LIC9099C... Continued from LIC9099C... Also, physician’s report and care plans of residents (R1, R2, R3, R4, R5, R6, R7 & R8) in the memory care unit indicates that they are not required to have two-person assist to help them to meet their needs. A finding that the complaint allegation facility staff did not ensure adequate care and supervision is provided to residents is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff leave residents in soiled clothing for extended periods of time. Per Reporting party, staff would neglect residents incontinent care needs. The Reporting party stated that several staff would just leave residents in their soiled clothing for extended periods of time and not taking them to the restroom. Based on records review, the facility has an assignment shift where staff are documenting rounds and times of task performed. According to facility records, staff are assisting residents timely with their continence needs every two hours or as needed. Based on interviews conducted by LPA with facility staff (S1, S2, S3, S4, S5 & S6) acting administrator or resident care coordinator will communicate with them regarding any changes of condition of any resident. Supplies of incontinence care are provided by the facility, unless that resident have any special preference/needs of supplies, they will be brought by hospice or their responsible parties. However, during the investigation there was no information or supporting evidence that could indicate that any of the incidents above mentioned have happened at a prior date. A finding that the complaint allegation of staff leave residents in soiled clothing for extended periods of time is 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, therefore the allegation is UNSUBSTANTIATED. Staff do not ensure a safe environment is provided for clients in care. The Reporting party have noticed that memory care residents would often leave their recliners open and then trip and fall on them, because many staff would not check on residents to make sure the recliners were closed. During LPA’s interviews conducted with the reporting party, they have explained to LPA that they were referring to the strong smell of urine that could be perceived in the morning when anybody enters the memory care unit area. Continue on LIC9099C... Continued from LIC9099C... On 8/9/24 LPA toured the memory care unit and observed that there were recliners available in the common area/dining room. Based on interviews conducted by LPA with staff (S1, S2, S3, S4, S5 & S6) and residents (R1, R2 & R3) indicates that staff helps them to use the recliners, they revealed that at times there are recliners located in the common area that had been found open, but they close them to prevent a further fall hazard issue. Also, staff indicates that they have observed other co-workers to closed them as well as a safety measure. but there no concerns raised that could indicate that they are left open causing an unsafe environment for residents in care. LPA toured the memory care unit and observed closed recliners in a couple of resident’s rooms. A finding that the complaint allegation of staff does not ensure a safe environment is provided for clients in care is 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, therefore the allegation is UNSUBSTANTIATED. Staff do not ensure safe transfer methods are used for residents in care. Per Reporting party, it has been observed staff would practice unsafe transfers with the residents by not using the belt assist device. On 8/9/24, LPA conducted interviews with staff (S1, S2, S3, S4, S5 & S6) to have them explain the current protocol of transferring residents from their wheelchairs to their bed. Interviews with staff indicated that they do have a protocol in place where they will assess if resident is one or two people assist, they will call another staff (if needed), place wheelchairs close to resident’s beds, they will put the brakes on to ensure safety of the transfer, then they will lift slowly the resident, but not aggressively, some of them will stand up a little bit, and get them transferred to their bed. After finishing their transfer, they will put the wheelchair aside where they won’t represent a hazard trip issue. Based on records review of staff training on file, they are following training protocols regarding transfer of residents from their wheelchairs to their beds. A finding that the complaint allegation of staff does not ensure safe transfer methods are used for residents in care is 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, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during today's visit. Exit interview conducted with acting administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 21-AS-20240710150350

Allegation investigated: -Facility did not have a certified administrator. -Staff are not properly trained .

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with acting administrator Carla Lua. An allegation was received by the Department regarding facility did not have a certified administrator. Per Reporting Party, acting administrator was hired in December 2023 as the facility administrator and admitted to reporting party of not having an administrator certificate. The reporting party states acting administrator began taking their administrator classes earlier this year and is not sure if they have applied for the certificate. Based on records review, prior administrator has resigned in December 2023, new administrator’s first date was March 17, 2024. Although, the acting administrator do not have a current administrator certificate and is currently in the administrator certification section pending review list of the Department as of March 28, 2024, and application was received on April 2, 2024. Continue on LIC9099C... Unsubstantiated Continued from LIC9099... However, LPA was provided with interim certified administrator Larona K Farnum certificate #6020540740 expires on 10/1/24, who confirmed during interviews conducted with LPA, that they were present in the facility in average of 15-20 hours per week depending on administrator’s duties needed, during the last two weeks of December 2023 through March 2024. LPA will address reporting requirements on a case management due to the licensee did not notify the Department in writing within thirty (30) days of the hiring of a new administrator. On April 29, 2024, the Department received pertinent documentation dated April 29, 2024, from the Board of Directors Western Living Concepts, Inc appointing new administrator and requesting the Department to change administrator’s name on file. The Department received an allegation of facility staff are not properly trained. Reporting Party states housekeeping staff have been now assigned to provide care giving services to the residents without having trainings. Per the reporting party, current acting administrator gives some staff special treatment and does not let some staff take their break or lunch. The reporting party did not have further details to provide. Based on visits conducted on 5/16/24, 6/5/24 and 6/11/24 staff were present and appeared to be sufficient staff to meet resident’s needs. Based on records review, LPA obtained staff schedule for the month of May 2023, where it was determined that there are an average of two caregivers and a medication technician assigned to the morning and afternoon shift. The night shift usually has two caregivers for a census of 20 residents in care. Based on review of staff (S1, S2, S3, S4, S5, S6, S7, S8, S9 & S10) training records, six out of six staff who assist in the administration of medications have the required training per regulation. Four out of six caregiver staff who assist residents with a diagnosis of dementia have at least twenty hours average of training hours required per regulation. LPA was provided with assignment sheet designed for two groups (Group A & Group B) of caregivers, which revealed that caregivers are supposed to take staggered lunches to always ensure coverage. LPA conducted on 6/5/24 and 6/11/24 confidential interviews with staff (S1-S10) including kitchen staff revealed that some staff assist residents when they are at the dining room and at times, they do escort them to their room, but they do not necessarily assist residents with toileting, medication, etc. LPA learned based on records review and interviews with staff, information was not provided to support that violation occurred regarding facility staff are not properly trained. A finding that the complaint allegation of facility staff is not properly trained is 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, therefore the allegation is UNSUBSTANTIATED. No citations during today's visit. Exit interview was conducted with acting administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 21-AS-20240507093626

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with acting Administrator, Carla Lua. LPA learned through records review that the licensee did not notify the Department of the change of administrator in writing within thirty (30) days of the hiring of a new administrator back in December 2023. During the investigation it was revealed that prior administrator has resigned in December 2023, interim administrator covered administrator’s duties during the last two weeks of December through March 2024, new administrator’s first date was March 17, 2024. On April 29, 2024, the Department received pertinent documentation dated April 29, 2024, from the Board of Directors Western Living Concepts, Inc appointing new administrator and requesting the Department to change administrator’s name on file. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. 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 acting administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(g) · Plan of correction due date: Jul 19, 2024

87211 (g) Reporting Requirements: The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. This requirement is not met as evidenced by: Based on records review, the licensee did not notify the Department of the change of administrator in writing within thirty (30) days of the hiring of a new administrator back in December 2023, which is a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: Licensee agrees to ensure that any changes to the facility will be reported as required by Title 22 Regulations # 87211. Licensee will submit LIC9098 self-certification form that they understand and compliance with regulation to CCL by POC due date.

Type of visit: Required - 1 Year

At approximately 8:30AM, Licensing Program Analyst (LPAs) Chris Arnhold and Christi Coppo made an unannounced annual required inspection of the facility. LPAs met with Executive Director Angie Smith. At approximately 9:00AM, LPAs and Executive Director toured the building and grounds which was found to be clean and in good repair. LPAs observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPAs observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Combination smoke/carbon monoxide detectors were present and found to be in working order. Facility has fire sprinklers throughout and were inspected 10/12/2023. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 11:30AM, LPAs reviewed 5 resident records and found all records have current physician's reports (LIC 602) and Appraisal Needs and Services Plans, as well as current and signed admission agreements. At approximately 1:05PM, LPAs reviewed 5 staff records. Five out of five records did not contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. Continued on 809C At approximately 2:30PM, LPAs reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has the required evacuation stair chairs in place. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts and documents disaster drills quarterly. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308 Designation of Facility Responsibility Evidence of current Liability Insurance received during visit Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Executive Director Angie Smith and Appeal rights were given.the state’s words, verbatim · CDSS document, Oct 12, 2023