Vintage Faire Residential

Allegation investigated: Resident inappropriately touched another resident.

On 9/11/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) Lisa Rios arrived unannounced at the facility to conduct a complaint investigation and deliver complaint findings. The LPA met with the Business Office Manager and explained the purpose of the visit. Allegation: That resident inappropriately touched another resident. Licensing Program Analyst (LPA) and Licensing Program Manager (LPM) conducted interviews with eight residents. R1 stated that she has had their private parts groped and that a male resident invited her for a cigarette in a dark corner, showed his private part and asked for a sexual favor. Administrators said they would talk to the resident and it hasn't happened again. R2 stated that a male resident frequently has been seen and reported to management that he inappropriately touches female residents and it keeps happening. Based on interviews, the above allegation is substantiated. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has (Continued on 9099-C) Substantiated been met. This facility is hereby cited, per California Code of Regulations (Title 22, Division 6, Chapter 8),on the attached 9099-D. An exit interview was conducted with the Administrator and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 27-AS-20250717131442

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 25, 2025

87468.1 Personal Rights a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on statements made by R1 and R2, more than one resident has been seen inappropriately touching other residents in care. This poses a potential threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Administrator stated that she will work with Service Center to come up with a plan that will redirect resident in ways that will keep him separate from female residents. Administrator will submit plan to ellen.lindstrom@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 9/11/25 Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) arrived unannounced at the facility to conduct a case management visit. The LPA met with the Administrator and explained the purpose of the visit. During the tour of the facility, LPM Rios was in room 27 and noticed that the call button doesn't work. Residents stated that it hasn't worked in at least a week. Having an inoperable emergency call button can cause a potential risk to residents in care. See deficiency cited on 809D page. Exit interview was conducted and a copy of the report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Sep 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(a)(7)(B) · Plan of correction due date: Sep 25, 2025

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (B) Responding to an individual resident’s needs if the emergency call buttons are inoperable. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above because resident call button did not send an alarm which does not pose an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Administrator stated that she will give the resident s a bell for now and will have the call button fixed by 9/25/25.

Allegation investigated: Staff do not provide resident with housekeeping service Staff speak inappropriately to resident

On 7/23/25 Licensing Program Analyst (LPA) Ellen Lindstrom went to the Vintage Faire Residential facility to deliver the findings on a complaint submitted on 5/08/25. The LPA met with the Business Officer Manager. Allegation: Staff do not provide residents with housekeeping service. On 7/2/25 and 7/8/2025, Licensing Program Analyst (LPA) Lindstrom went to the facility and toured the residential areas, walking up and down the hallways several times. She observed all bedrooms with open doors to be clean, organized, and free from malodors. Additionally, she entered and inspected seven resident bedrooms, which were also clean and malodor-free. During resident interviews, R1, R2 and R3 stated that staff cleaned their room every day. R4 stated that staff cleaned their room and made their bed daily. During staff interviews, S1 stated that rooms are cleaned every day and if there are incontinence issues, rooms are mopped more than once a day. Unsubstantiated Based on observations made and interviews conducted, the Department has concluded that the preponderance of the evidence has not been met to prove the allegation that staff do not provide residents with housekeeping service. Therefore, the allegation that staff do not provide residents with housekeeping service is UNSUBSTANTIATED. Allegation: Staff speak inappropriately to residents On 7/2/2025 and 7/8/25, the Licensing Program Analyst (LPA) toured the facility, spoke to staff and interviewed residents. The LPA did not observe any staff speaking inappropriately to residents. During resident interviews, R1 stated that he feels very supported by staff, R3 stated that the caregivers are great, and R4 stated that staff treated her well. During staff interviews, S1 stated that she had not heard of any complaints recently. Based on observations made and interviews conducted, the Department has concluded that the preponderance of the evidence has not been met to prove the allegation that staff speak inappropriately to residents. Therefore, the allegation that staff speak inappropriately to residents is UNSUBSTANTIATED. There are no citations issued at this time. Exit interview was conducted with the Business Office Manager. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 27-AS-20250508094937

Allegation investigated: Staff did not safeguard resident's cash resources Staff threatened resident

On 7/23/25 Licensing Program Analyst (LPA) Triel Ellen Lindstrom went to the Vintage Faire Residential facility to deliver the findings on a complaint submitted on 6/25/2025. Allegation: Staff did not safeguard resident's cash resources. On 7/2/25 and 7/8/2025, Licensing Program Analyst (LPA) Lindstrom went to and toured the facility, reviewed documents, and interviewed staff and residents. During staff interviews, S2 stated that some residents keep money in a petty cash account at the facility that staff can use to purchase items that residents request once a week. S3 stated that residents make lists of items they want from the store and give it to S1, who goes shopping for residents once a week and then gives the residents their items along with a receipt. During resident interviews, R1 stated that residents can submit a shopping list every Tuesday. Unsubstantiated R2 stated that S1 shops for residents once a week; R2 gives her a shopping list and S1 gets stuff at various stores. R3 stated that she gives them a list and staff shops once a week; she always gets what she wants. The LPA inspected a binder that contained LIC 405 forms, Clients/Residents Safeguarded Cash Resources. Money spent by facility staff and the store that the purchase was made at was accurately documented. Based on records reviewed and interviews conducted, the Department has concluded that the preponderance of the evidence has not been met to prove the allegation that staff did not safeguard resident’s cash resources. Therefore, the allegation of staff did not safeguard residents' cash resources is UNSUBSTANTIATED. Allegation: Staff threatened residents. On 7/2/25 and 7/8/25, Licensing Program Analyst (LPA) Triel Ellen Lindstrom went to and toured the facility, reviewed documents, and interviewed staff and residents. During resident interviews, R1 stated that she had been asked to transfer from her wheelchair to a dining room chair. She has not been threatened that if she does not comply, she will have to pay more money or be evicted. R3 stated that staff treated her well. During staff interviews, S1 stated that there are no pending evictions. S2 stated that she has never heard staff threaten a resident in any way. Based on observations made and interviews conducted, the Department has concluded that the preponderance of the evidence has not been met to prove the allegation that staff threaten residents. Therefore, the allegation that staff threaten residents is UNSUBSTANTIATED. There are no citations issued at this time. Exit interview was conducted with the Business Office Manager. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 27-AS-20250625081543

Type of visit: Required - 1 Year

On 7/8/24 Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required one year annual inspection. The LPA met with and interviewed Administrator Prithika Singh and explained the purpose of today's visit. The Administrator accompanied the LPA on a tour of the facility. The LPA toured the facility interior, including the lobby, small and large dining rooms, and resident rooms. The lobby is the main common area for residents. Residents were gathered watching a movie and eating ice cream. There were several couches and tables in good repair in this room. Then the LPA toured the small and large dining rooms off the lobby. The dining rooms contained four and six tables respectively, with enough seating for residents. The LPA inspected ten bedrooms. The bedrooms contained the required furniture in good repair and are clean and odor-free. Each bedroom has a private bathroom with grab bars. The LPA measured the temperature of the hot water in a resident bathroom; the water was one hundred and sixteen degrees Fahrenheit. The windows and sliding glass doors were in good repair. The LPA toured the Kitchen. The kitchen was clean, organized, and odor- and -pest free. The LPA inspected the pantry and freezers and observed a seven-day supply of nonperishable food and a two-day supply of perishable food. Food is stored properly and rotated on a weekly basis. The stove hood was last serviced in November 2024 and was clean. The LPA toured the hallways. There were fire extinguishers in several locations in the hallway, as well as the kitchen. There was a smoke detection system that automatically closes several doors in the common areas, sounds an alarm, and indicates which zone a fire is in. There is an overhead sprinkler system. The smoke detectors, sprinkler system, and fire extinguishers were serviced by Jorgensen Co. of Modesto on 11/23/2024. Required notices were posted in the hallways, including personal rights, emergency disaster plan, and ombudsman contact information. The thermostat in the common areas was set at 71 degrees. The LPA toured the locked central medication room. Resident files are kept in this room. Medications were stored in their original packaging with intact labels and organized by resident.. The facility used an electronic medical administration record. The LPA toured the grounds The lawn wasgreen and manicured. The concrete walkways were free of obstruction. There was a shaded seating area outside the small dining room with a pavilion, table and chairs, and large tree. The LPA interviewed six residents. Residents reported that their rooms are cleaned daily and that they appreciate having a private bathroom. The LPA reviewed three resident and three staff files and observed them to be complete. The facility conducted quarterly fire drills in the last year in the AM and PM shifts with all staff. The LPA requested that updated copies of these documents be submitted to Licensing by 5:00 PM on 07/16/2025. These documents can be emailed to LPA at ellen.lindstrom@dss.ca.gov. (1) LIC 308 Designation of Facility Responsibility (2) Copy of a current Administrator Certificate (4) LIC 610 Emergency Disaster Plan (5) Proof of Liability Insurance (6) LIC 500 Personnel Report (7) LIC 309 Administrative Organization As a result of this inspection, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6. An exit interview was conducted with the Administrator, to whom a copy of this LIC809 report was provided. Their signature below confirmed receipt of this document.the state’s words, verbatim · CDSS document, Jul 8, 2025

Allegation investigated: Facility staff are not properly addressing pest infestation Facility staff do not provide adequate food service to residents Licensee does not ensure sufficient number of staff on site to meet the needs of clients in care

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Administrator Prithika Singh and explained the reason for the visit. Census: 41 Facility staff are not properly addressing pest infestation- LPA Lund reviewed facility records along with LPA’s observation of the facility, interviewed staff, and residents in care. Based on LPA Lund reviewed facility pest control records from Kingdom IPM Commercial & Residential Pest Control records. The facility records from 10/11/2024 through 4/11/2025 indicate that the facility was addressing any pest control problems. Staff interviewed stated that they have not observed any pest infestation. Resident interviewed stated they have not observed any pest infestation. During LPA’s visits on 12/26/24, 1/8/2025 and annual/one year required visit on 7/9/2024 the facility didn’t have any pest infestation. Unsubstantiated Based on facility records reviewed, LPA’s observation of the facility, interviews with staff, reporting party, and residents in care, on the information provided, it was unclear if facility staff are not properly addressing pest infestation, therefore the allegation was deemed UNSUBSTANTIATED. Facility staff do not provide adequate food service to residents- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on review of the facility six-week menu rotation for the residents in care, reviewed Sysco food services from 10/2/2024 through 12/31/2024 and LPA’s Lund observation of 2- day supply of perishable food and 7- day supply of non-perishable food. Residents interviewed stated that they the facility is providing adequate food for them. Staff interviewed stated that residents have not complained about the food being served at the facility. Based on records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if facility staff do not provide adequate food service to residents, therefore the allegation was deemed UNSUBSTANTIATED. Licensee does not ensure sufficient number of staff on site to meet the needs of clients in care- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on staff schedule from 9/1/24 through 12/31/24 the revealed staff to be on duty consistently residents in care. LPA Lund interviewed residents in care who stated that their needs are being met. Staff interviewed stated that there is adequate staff to meet the needs of the residents in care. Based on records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if licensee does not ensure sufficient number of staff on site to meet the needs of clients in care, therefore the allegation was deemed UNSUBSTANTIATED. As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.the state’s words, verbatim · CDSS document, Apr 17, 2025 · control 27-AS-20241230145929

Allegation investigated: Staff are not ensuring residents take medication Due to lack of supervision, residents are eloping Staff do not ensure residents hygiene needs are met Staff do not treat residents with respect/Dignity

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Administrator Prithika Singh and explained the reason for the visit. Census: 41 Staff are not ensuring residents take medication- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on reviewed Certificate of Completion from Med Techs. Each Med Tech 11 hours of training including Side Effect Adverse Reaction, Medication Order And Working With Pharmacy and Understanding CA Medication Regulations. Staff interviewed stated that they have procedures on how to work with residents regarding medications. Residents interviewed stated that they take the medications that staff provide to them. Unsubstantiated Based on facility records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if staff are not ensuring residents take medication, therefore the allegation was deemed UNSUBSTANTIATED. Due to lack of supervision, residents are eloping- LPA Lund reviewed facility records, and interviewed staff. Based on review of the facility elopement and missing resident procedures. Staff interviewed stated that do two-hour checks on residents in care and would notify management if resident eloped. Management stated that they would notify Modesto PD and CCL if a resident would elope. Based on records reviewed, and interviews with staff, on the information provided, it was unclear if due to lack of supervision, residents are eloping, therefore the allegation was deemed UNSUBSTANTIATED. Staff do not ensure residents hygiene needs are met- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on Morning & Evening shower reviewed. LPA interviewed residents in care stated that the take showers with the help with staff and on their own if they do not need the help of staff. Staff interviewed stated that they have schedule shower days for residents in care and will give a shower to a resident if needed. Based on records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if licensee does not ensure sufficient number of staff on site to meet the needs of clients in care, therefore the allegation was deemed UNSUBSTANTIATED. Staff do not treat residents with respect/Dignity- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on staff training such as Understanding Alzheimers Disease, Abuse, Theft & Loss and Resident Rights. Staff interviewed stated that they have never witnessed any staff mistreating any resident in care, if so, would notify management immediately. Residents in care interviewed stated that they have never been mistreated by staff and never seen any other residents get mistreated. Based on records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if staff do not treat residents with respect/Dignity, therefore the allegation was deemed UNSUBSTANTIATED. As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.the state’s words, verbatim · CDSS document, Apr 17, 2025 · control 27-AS-20241220083914

Type of visit: Case Management - Deficiencies

On 02/20/25, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility regarding a case management for an elopement. LPA Campbell met with Prithika Singh, Administrator and explained the purpose of the visit. This case management is regarding R1 who eloped on 02/17/25. Per the Unusual Incident Report (UIR) submitted on 02/18/2025, R1 was last seen by S1 at 7:40 pm on 02/17/2025. Staff noted he was missing when the door alarm sounded. After searching the facility premises, the Modesto Police Department (MPD) were called at 8:43 pm on 02/17/25 and a report was taken for case #MP25004110. During LPA Campbell's visit, the administrator reported that St. Joseph's Hospital in Stockton contacted the facility to report that R1 had been found and was receiving treatment. Because R1 was now in Stockton, the Stockton Police Department (SPD) was contacted so that they could conduct a visit at the to confirm R1 could be taken off 'Missing Person" status. LPA Campbell asked the Administrator to write a UIR to share R1's current status. Because R1 had missed two of his dialysis appointments, the hospital would be keeping R1 for up to three days. This will provide time for Welba Health, the hospital and the facility to work together to find a new placement or for the facility to create plan to support R1 if he needs to return to the Vintage Faire. Prior to this incident, Administrator Singh submitted several UIR's regarding a change in R1's behavior. LPA Campbell consulted with Administrator Singh regarding steps to avoid future elopements , how the eviction procedure may help when there is a change in condition and the need for reappraisals. LPA Campbell also reminded the administrator that the facility had a responsibility to supervise and care for residents until an more appropriate placement can be found by working with the hospital and Welbe Health (placement agency). Based on LPA Campbell's record reviews and interviews which were conducted, the facility was unable to supervise R1 and be aware of R1's whereabouts. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left.the state’s words, verbatim · CDSS document, Feb 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Feb 20, 2025

1569.312 Basic services requirements. Every facility ... shall provide ... the following basic services:(d) Being aware of the resident's ..whereabouts...(e) Monitoring . activities of the residents...to ensure their general health... This requirement is not met as evidence by: Based on documents reviews and interviews, the facility was not aware of the residents whereabouts and could not monitor activities of the resident to ensure their general health.the state’s words, verbatim · CDSS document, Feb 20, 2025

Plan of correction: The Licensee/Administrator shall create a supervision plan for clients who have a change in condition and need a higher level of care and how staff shall ensure that residents do not AWOL. The plan will be sent to LPA Campbell at renee.campbell@dss.ca.gov

Type of visit: Required - 1 Year

On 7/9/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual inspection. LPA Jensen met with Administrator Prithika Singh and explained the purpose of today's visit. The Administrator holds a current certification # 7009678740 good through 10/20/2024. LPA Jensen toured the grounds and observed all paths to be free of obstruction. There are shaded areas and patio furniture available for resident use. All window screens appeared to be in good repair. A large branch that had fallen from a tree on the property was on the ground near resident rooms. The branch was not creating a hazard. LPA Jensen provided technical assistance to the Administrator regarding monitoring the health of the tree as it is in proximity to resident rooms. LPA Jensen toured the facility interior including the common areas, resident rooms and kitchen. The fire extinguisher and Ansul system was last serviced on October of 2023 and is in compliance. The facility maintains a first aid kit that is complete. No medications or toxins were observed to be accessible to residents in care. The kitchen appeared sanitary. A 2 day supply of perishable food and 7 day supply of non-perishable food was available. LPA Jensen observed numerous food items in the pantry that is ordered in bulk to be missing expiration dates including canned fruit and vegetables, ketchup and dry good such as flour. Technical assistance regarding food storage was provided. LPA Jensen toured 10 resident rooms and observed all to have the required furniture. LPA Jensen observed a dresser that was broken, a bed spread that was torn, a chair that was torn and some carpet stains. Technical assistance was provided. The water temperature was measured in a resident bathroom at 118 degrees Fahrenheit which falls within the required range of 105-120 degrees. LPA Jensen interviewed 5 residents, all of whom stated they are satisfied with the care they are receiving. LPA Jensen reviewed 5 resident files and observed them to be complete. The needs and service plans for residents were observed to be updated and in compliance. LPA Jensen reviewed 5 staff files and determined them to be complete. The facility admits residents participating in the P.A.C.E. program through WellBe health and as such is subject to the Home and Community Based Services final rule. Technical assistance was provided. The inspection tool was used during the course of this visit. LPA Jensen left the facility from 12pm to 1pm for a meal period. The Licensee will email LPA Jensen an updated LIC 500 and current liability insurance. No deficiencies are being cited. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 9, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff do not assist resident in a timely manner. Staff do not adequately supervise memory care residents. Staff do not provide resident with a safe environment.

On 6/24/2024 at approximately 10:00am Licensing Program Analyst (LPA) Jensen arrived at facility to deliver findings in relation to the above listed allegations. LPA Jensen met with Administrator Prithika Singh and explained the purpose of today’s visit. Staff do not assist resident in a timely manner During the course of the investigation LPA Jensen made 4 site visits during which the interaction between residents and staff were observed. During all 4 visits staff appeared attentive and no residents with unmet needs were observed. LPA Jensen also tested the call signal system which appeared to be in good working order. LPA Jensen also interviewed 5 residents and a hospice nurse that cares for 2 of the residents and none of the interviewees complained about quality or timeliness of care. Based on site observations, the call signal system being in good repair and interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Unsubstantiated Staff do not adequately supervise memory care residents During the course of the investigation LPA Jensen made 4 site visits during which the interaction between residents and staff were observed. During all 4 visits staff appeared to adequately supervise residents in care. LPA Jensen verified with the Modesto Police Department that there have been no call outs to this location this year for issues with residents. LPA Jensen interviewed 5 residents and a hospice nurse that cares for 2 of the residents and none of the interviewees stated they are aware of an occasion where residents were not adequately supervised. LPA Jensen reviewed 4 resident files and found no documentation to support a lack of supervision. Based on observations, records reviewed and interviews conducted, the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Staff do not provide resident with a safe environment. During the course of the investigation LPA Jensen made 4 site visits and no safety hazards were observed. LPA Jensen verified with the Modesto Police Department that there have been no call outs to this location this year. LPA Jensen interviewed 5 residents and a hospice nurse that cares for 2 of the residents and none of the interviewees stated they felt the environment was unsafe. While there may have been an occasion wherein an unsafe environment existed, based on observations, records reviewed and interviews conducted, the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 24, 2024 · control 27-AS-20240318103436

Allegation investigated: Staff mismanages resident's medications.

On 6/24/24 at approximately 11:00 am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Prithika Singh and explained the purpose of today's visit. During the course of the investigation LPA Jensen inspected the medication room and interviewed the Administrator, a medication technician (S1) and housekeeping staff (S2). The Administrator advised that the medication technicians are required to watch residents take their medication in order to ensure they are taking them when administered. The medication technician interviewed stated that some resdients are watched to ensure that they take their medication and housekeeping staff stated that she found medication in a resident room last month when cleaning. Based on the interviews conducted staff are not following medication administration protocol as required by facility policy resuting in some resdients not taking medication as prescribed therefore the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Substantiated A citation is being issued pursuant to the California Code of Regulations (CCR) Title 22, Division 6. A civil penalty is also being assessed for repeat violations. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 24, 2024 · control 27-AS-20240610115421

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 25, 2024

Incidental Medical and Dental Care ... The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews conducted staff are not following facility policy on medication administration which has resulted in medication not being taken as prescribed. This poses an immediate risk to the health, welfare and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2024

Plan of correction: The Administrator agrees to develop a plan to come in to compliance with regulatory requirements related to medication administration and send the plan to LPA Jensen by 6/25/24.

Allegation investigated: Staff do not meet resident's dietary needs.

On 5/23/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Administrator Prithika Singh and explained the purpose of today's visit. During the course of this investigation LPA Jensen reviewed 5 resident files. 1 of 5 resident files contained a physician report that states Resident 1 (R1) requires a soft mechanical diet. LPA Jensen interviewed the kitchen manager who stated they were not aware of any dietary restrictions for R1. LPA Jensen inspected the kitchen and observed postings in the kitchen that consisted of lists of residents who require chopped food, diabetic diet and foods specific people would like to avoid. According to kitchen staff those are the only dietary restrictions. Based on record reviews, interviews and LPA Jensen's kitchen observations, the allegation of "staff do no meet resident's dietary needs" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. A deficiency is being cited pursuant to the California Code of Regulations (CCR). An exit interview was conducted and this report, appeal rights and a confidential names list was given Substantiatedthe state’s words, verbatim · CDSS document, May 23, 2024 · control 27-AS-20240318103436

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: May 24, 2024

Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not as evidenced by: Based on LPA Jensen's interview with kicthen manager and record review, R1 was not receiving a soft mechanical diet as ordered by the physician. This poses an immediate risk to the health, safety and personal rights of residents in carethe state’s words, verbatim · CDSS document, May 23, 2024

Plan of correction: Facility kitchen staff was immediately informed that R1 requires a modified diet. The Licensee agreed to audit all resident files to ensure any dietary restrictions are being adhered to.

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

Allegation investigated: Staff are not replacing the residents sleeping materials Staff do not allow the residents to have access to fluids Staff interrupt the residents while sleeping Staff mishandled the residents personal belongings

On 5/9/24 at approximately 10:00am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility to continue an investigation in to the above listed allegations. LPA Jensen met with Business Office Manager, Joyce Prasad, and explained the purpose of the visit. Staff are not replacing the residents sleeping materials LPA Jensen conducted interviews with 10 residents and 10 of 10 residents stated that they have sufficient bedding. Several residents utilized a combination of their own blankets plus facility bedding by choice. During a site visit, LPA Jensen observed the facility supply of bedding and determined it to be adequate. Based on LPA Jensen’s observation of the facility’s bedding supply, LPA Jensen’s observation of bedding in individual rooms and the interviews conducted with residents the allegation of "staff are not replacing the residents sleeping materials" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Unsubstantiated Based on the lack of a cohesive policy regarding washing resident’s personal drinking cups that aligns with general food service sanitation practices and LPA’s observation of an unsanitary cup the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Staff are mishandling the residents medications During the course of the investigation LPA Jensen inspected the medication room. LPA Jensen observed 2 plastic cups containing multiple pills. Each cup had the number 12 on it and a resident’s first name only. LPA Jensen interviewed the Medication Technician on duty and inquired why the medication was there. The Medication Technician stated that it appears the Medication Technician attempted to administer the medication at noon the prior day but was unsuccessful for some unknown reason. LPA Jensen reviewed the Medication Administration Record (MAR) for the residents in question and determined that the medication was signed off on as having been administered. LPA Jensen’s findings were verified by a physical count of the medications. In addition, the facility submitted an incident report to advise that all of the February 2024 MAR had gone missing without explanation. It should be noted that the records went missing at approximately the same time that 2 employees were facing disciplinary action and were subsequently separated from employment with the organization. Based on the inaccurate MARs, missing MARs and medication not administered without explanation the allegation of staff mishandled resident’s medications is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Staff do not provide a comfortable temperature for the residents LPA Jensen interviewed a resident that stated the room is very cold in the mornings and that there is no thermostat in this particular unit. The resident further stated that this issue has been brought to the attention of staff and for this reason the resident has extra blankets. LPA Jensen interviewed the Maintenance Director who stated there was previously an issue with the heat but was addressed immediately and repaired within a week. The Maintenance Director also stated that there is currently a problem with the air conditioner and the repair is pending management approval. LPA Jensen reviewed maintenance records and invoices and determine that on 3/22/24 an invoice from a mechanical vendor states “While performing your routine maintenance, Lakeside technician found the following: Swamp cooler needs a new motor which has been shorted to the ground.” Based on the resident interview and maintenance invoice reviewed the allegation that staff do not provide a comfortable temperature for residents is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Facility is not reassessing residents to ensure needs are met During the course of the investigation LPA Jensen reviewed 8 of 34 resident files. 2 of 8 resident files did not have any Needs and Service Plan. Resident 7 was admitted on 3/13/23 and did not have a Needs and Service Plan and Resident 8 was admitted on 8/24/23 and did not have a Needs and Service Plan. Based on LPA Jensen's review of the resident files lacking a Needs and Service Plan the allegation of "Facility is not reassessing residents to ensure needs are met" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. While the residents may have had a pre-placement appraisal. Deficiencies are being cited pursuant to the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, appeal rights and a confidential names list was given. Staff do not allow the residents to have access to fluids LPA Jensen was working in the facility TV room which is in proximity of the kitchen. LPA Jensen overheard a resident go to the kitchen and request “just a little red juice”. The kitchen staff told the resident, no, you can’t have that. You have ice water in your room. LPA Jensen went to the kitchen and asked staff 1 (S1) if the resident can have juice. S1 advised LPA Jensen she was told no because she has ice water in her room and because of the sugar content as she is diabetic. S1 went on to explain that residents can have juice in the morning at breakfast but not throughout the rest of the day to bring to their room as that is the policy. LPA Jensen asked to see the modified diet list to verify whether or not the resident’s name was on the diabetic list. The kitchen manager (S2) interjected and said she is not diabetic. LPA Jensen asked if she can have juice. The kitchen manager said yes but in the dining room, just not in the bedroom. LPA Jensen asked why the resident was told no as opposed to offering her juice to have in the common area. The kitchen manager stated S1 should have offered and it was a mistake not to. LPA Jensen conducted interviews with 10 residents and 10 of 10 residents deny that there access to fluids is restricted. LPA Jensen observed bedside drinking cups in every resident room in the facility. Based on LPA Jensen’s interviews conducted and LPA Jensen’s observations of drinking water in the bedrooms, the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. However, based on the interaction between kitchen staff and the resident that asked for juice a personal rights violation did occur and is being addressed on a separate case management. Staff interrupt the residents while sleeping LPA Jensen conducted interviews with 10 residents and 10 of 10 residents deny that staff interrupt their sleep. LPA Jensen interviewed a former NOC shift staff member who stated that she did not awaken residents unless necessary. The NOC shift staff stated that if a resident had a closed door the protocol was to knock and wait for a response. If there was no response the room was entered for a health and safety check and the resident would be awoken only if necessary for example if incontinence care was required. All residents interviewed were satisfied with the care they are receiving and none stated that staff disturb them . Based on the interviews conducted and a review of facility policies the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it Staff mishandled the residents personal belongings LPA Jensen interviewed 10 residents and 1 resident family member. The majority of residents stated they have had no issues with their personal belongings being mishandled. 1 of 10 residents stated that his clothing disappears and reappears. 1 of 10 residents stated that her door remains locked to prevent any items from disappearing due to a resident that has a habit of wandering in to other client’s rooms. LPA Jensen interviewed a housekeeping staff member who explained that only a single resident's laundry is washed per load. All clothing that can labeled is labeled. After clothing is washed and dried it is hung up and organized based on room number. LPA Jensen reviewed facility training and staff are trained on housekeeping and the theft policy annually. While it is possible that at some point an item was inadvertently misplaced the allegation of staff mishandled the residents personal belongings is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 9, 2024 · control 27-AS-20240226113502

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(30) · Plan of correction due date: Jun 6, 2024

General Food Service Requirements All utensils used for eating and drinking and in preparation of food and drink, shall be cleaned and sanitized after each usage. This requirement was not met as evidenced by: Based on LPA Jensen's observation and interviews with staff and residents, the facility does not sanitize drinking cups after each use. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: The Licensee shall develop a policy and provide training on the policy for kitchen staff and submit proof to the department by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Jun 6, 2024

Personal Accomodations The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by: Based on interviews as well as review of a service invoice showing repairs needed but not yet completed the facility has a swamp cooler out of order. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: The Licensee will submit proof of repair of the swamp cooler and proof that the HVAC is in good working order by the Plan of Correction of due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 6, 2024

Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on LPA Jensen's observation medication for 2 residents that was not administered despite a MAR that showed it was and based on the missing MAR for all residents for February 2024. This poses an immediate risk to the health, safety and personal rights of residents in carethe state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: The Licensee conducted an investigation nad an in-service training on proper MAR securing satifying the need to take immediate action regarding missing documentation. The Licensee also agrees to conduct a medication training with an outside vendor and send proof of completion to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 97467(a) · Plan of correction due date: Jun 6, 2024

Resident Participation in Decision Making rior to, or within two weeks of the resident’s admission, the licensee shall a... prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This requirement was not met as evidenced by: Based on LPA Jensen's review of resident files in which 2 of 8 were missing a Needs and Service Plan. This poses a potential risk to the health, safety adn personal rights of residents in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: The Licensee agrees to submit an attestation that all needs and service plans have been updated by the POC due date.

Allegation investigated: Staff did not ensure facility was kept free of pests Staff did not safeguard resident's personal items

On 5/9/24 at approximately 10:00am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility to continue an investigation in to the above listed allegations. LPA Jensen met with Business Office Manager, Joyce Prasad, and explained the purpose of the visit. Staff did not ensure facility was kept free of pests On 10/19/23, the facility was cited for “repeated observations and treatments for active bed bugs in the facility” with a plan of correction that required the facility, in part, to “create a policy specific to the elimination of bedbugs and the maintenance of a bed bug free facility.” After this citation was issued, the facility has had pest control treatments based on the service records reviewed. LPA Jensen also interviewed 10 residents and 9 staff members. All residents stated bed bugs are not a problem or no longer a problem. All current staff members also stated that bed bugs are not a problem or no longer a problem and 1 former staff member stated that the facility has bed bugs. Based on the pest control service invoices reviewed and the interviews conducted the allegation UNSUBSTATIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Unsubstantiated Staff did not safeguard resident's personal items LPA Jensen interviewed 10 residents and 1 resident family member. The majority of residents stated they have had no issues with their personal items missing or not safeguarded. 1 of 10 residents stated that his clothing disappears and reappears on occasion. 1 of 10 residents stated that her door remains locked to prevent any items from disappearing due to a resident that has a habit of wandering into other client’s rooms. LPA Jensen interviewed a housekeeping staff member who explained that only a single resident’s laundry is washed per load. All clothing that can labeled is labeled. After clothing is washed and dried it is hung up and organized based on room number. LPA Jensen reviewed facility theft and loss policy as well as the facility training records for theft and loss which state staff are trained on the theft policy annually. The theft and loss policy states that upon admission, an inventory of personal property will be completed. The list must be verified by the resident or responsible party. Items on the list will be engraved or marked for identification and the facility is not liable for items not on the list and that the facility will provide a locked drawer at the request of and at the expense of the resident. While it is possible that at some point an item was inadvertently misplaced the allegation of “staff did not safeguard resident’s personal items” is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were provided. LPA Jensen returned on the morning of 5/10/24 to provide report due to technical difficulties with printerthe state’s words, verbatim · CDSS document, May 9, 2024 · control 27-AS-20240226102140

Allegation investigated: Staff hit residents Staff handle residents in a rough manner Staff curse at residents

On 5/9/24 at approximately 10:00am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility to continue an investigation in to the above listed allegations. LPA Jensen met with Business Office Manager, Joyce Prasad, and explained the purpose of the visit. LPA Jensen conducted site visits at the facility while engaging with residents and observing staff interacting with residents on no less than 6 seperate occassions. LPA Jensen did not see any evidence of physical or verbal abuse during any site visit. Allegation 1: Staff hit residents LPA Jensen interviewed a total of 9 staff members, 1 hospice nurse, 1 family member of a resident and 10 residents. All deny having ever witnessed or experienced staff hitting a resident. 10 of 10 residents interviewed stated they are treated well by staff. Based on the interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Unsubstantiated Allegation 2: Staff handle residents in a rough manner LPA Jensen interviewed a total of 9 staff members, 1 hospice nurse, 1 family member of a resident and 10 residents. All deny having ever witnessed or experienced staff being rough with a resident. 10 of 10 residents interviewed stated they are treated well by staff. Based on the interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Allegation 3: Staff curse at residents LPA Jensen interviewed a total of 9 staff members, 1 hospice nurse, 1 family member of a resident and 10 residents. All deny having ever witnessed or experienced staff cursing at a resident. 10 of 10 residents interviewed stated they are treated well by staff. Based on the interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. No deficiencies were cited. An exit interview was conducted and a copy of this report and appeal rights were provided. LPA Jensen returned on the morning of 5/10/24 to provide report due to technical difficulties with printerthe state’s words, verbatim · CDSS document, May 9, 2024 · control 27-AS-20240228102945

Allegation investigated: Staff caused injuries to residents while in care Staff do not meet the residents hygiene needs Staff are not addressing the resident dental needs Staff are unable to communicate effectively with the residents Staff allow the residents to have access to fumigated rooms Staff yell at the residents

On 5/6/24 at approximately 9:50 am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with business office manager, Joyce Prasad and explained the purpose of today's visit. During the course fhe investigation, LPA Jensen reviewed facility records, resident records, made site observations and interviewed residents, staff, responsible parties and outside medical providers. Allegation 1: Staff caused injuries to residents while in care LPA Jensen interviewed a total of 9 staff members, 1 hospice nurse, 1 family member of a resident and 10 residents. All deny having ever witnessed or expienced staff causing injuries to a resident. 10 of 10 residents interviewed stated they are treated well by staff. Based on the interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Unsubstantiated Allegation 2: Staff do not meet the residents hygiene needs LPA Jensen observed residents at the facility on 6 separate occasions over the course of the past 4 months. LPA Jensen did not observe any residents that appeared to have their hygiene needs neglected. In addition, LPA Jensen interviewed 10 residents who state they handle their own hygiene needs or state that they have never had a problem getting staff to assist with hygiene needs. A resident family member that was interviewed and a hospice nurse that was interviewed both denied having any concerns regarding resident hygiene therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Allegation 3: Staff are not addressing the resident dental needs LPA Jensen interviewed 10 residents and 1 family member of a resident. All state that staff would assist them if they had any dental needs or that they would solicit the help of family members if they needed to be taken to appointments. LPA Jensen interviewed staff that state they would assist with transportation or make arrangements for dental care when and if needed. Based on the interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Allegation 4: Staff are unable to communicate effectively with the residents LPA Jensen interviewed 10 residents and 1 family member of a resident. All state they have never had a problem communicating with staff. During the last 4 months, LPA Jensen has visited the facility 6 times and never encountered a staff member that she was unable to communicate with therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Allegation 5: Staff allow the residents to have access to fumigated rooms LPA Jensen conducted an interview with the Administrator Prithika Singh. She advised that pest control treatments were done which required the residents to leave the room for several hours. The facility made arrangements with the pest control company to fumigate in the morning as soon as the residents were taken out of there room for breakfast. The facility then initiated several activities for resident engagement to keep the residents out of their rooms until it was safe to return. LPA Jensen interviewed 10 residents who all deny being given access to fumigated rooms. Based on the interviews conducted the allegation UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Allegation 6: Staff yell at the residents LPA Jensen interviewed a total of 9 staff members, 1 hospice nurse, 1 family member of a resident and 10 residents. All deny having ever witnessed or experienced staff yelling at a resident. 10 of 10 residents interviewed stated they are treated well by staff. Based on the interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 6, 2024 · control 27-AS-20240226113502

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

Type of visit: Case Management - Health Checks

On 2/21/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for the purpose of a health and safety check. LPA Jensen met with Administrator Prithika Singh and explained the purpose of today's visit. The Department is conducting health and safety checks to monitor the facility in the areas of care and supervision, staffing, buildings and grounds and resident hygiene. The Administrator handed LPA Jensen a request for a hospice waiver increase for review. LPA Jensen requested the staff schedule as well as records documenting hours worked. LPA Jensen also requested pest control service records. LPA Jensen toured the facility including the kitchen, reading room, a resident room, common areas and hallways. No deficiencies were observed. LPA Jensen viewed the supply of linens and bedding and determined it to be sufficient. LPA Jensen toured the grounds and observed the grounds to be maintained with all pathways to be free of obstruction. There was outdoor furniture available to clients. LPA Jensen engaged with several clients during the course of the visit. The clients observed during the course of this visit appear have had their grooming needs met. LPA Jensen interviewed the Administrator who advised the facility is currently fully staffed and they have extra staffing available if there are call outs. The Administrator advised they have been experiencing issues with the company email system through Covenant Care California Inc. and also with faxing. LPA Jensen is requesting incident reports be sent by regular mail through United States Post Office (USPS) until the issue is resolved. Technical assistance is being provided on reporting requirements. LPA Jensen and the Administrator discussed emergency plans and disaster protocol. There is a resident roster in the disaster binder. The facility is planning to conduct a disaster training refresher in the near future. No citations were issued. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 21, 2024

Type of visit: Case Management - Health Checks

On 2/14/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a health and safety visit. LPA Jensen met with Joyce Prasad and explained the purpose of the visit. Joyce explained that the Administrator was out due to illness and that she was in charge however she was unable to stay due to having a prior commitment. LPA Jensen was referred to the Medication Technician who was temporarily in charge. LPA Jensen interviewed 2 staff members and 1 resident. LPA Jensen toured a double occupancy resident room and the facility dining room. Technical assistance is being provided in the area of Administrator Qualifications and Duties. LPA Jensen did not have access to all facility records such as personnel files or building and maintenance records. LPA Jensen will return at a later date when there is an Administrator or designee present. An exit interview was conducted and a copy of this report was provided to the Medication Technician.the state’s words, verbatim · CDSS document, Feb 14, 2024

Allegation investigated: Resident was attacked by another resident

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver findings for the above allegations. LPA was greeted by buniess office manager and explained the reason for the visit. Allegation 1 Resident was attacked by another resident is UNSUBSTANTIATED. Based on information gathered both residents are not able to clearly state what might have happened based on there dignosies and R2 has passed way. LPA was not able to find the allegation did or did not occur. Due to the information gathered LPA finds allegations to be UNSUBSTANTIATED. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. An exit interview was held and a copy of this report was given. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 12, 2024 · control 27-AS-20231009145007

Allegation investigated: Staff are not ensuring that residents' hygiene needs are being met while in care. Staff do not ensure that residents are provided with adequate bedding while in care. Staff do not prevent resident(s) from abusing other resident(s) in care. Staff are not ensuring that residents' diapering needs are being met while in care. Staff are not ensuring that residents take their medication(s) as prescribed while in care.

This document has been amended to change the wording on the LIC 9099D page. On 12/01/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation regarding the above allegations. LPA introduced herself, the purpose of the visit, and asked to speak with the Designated Facility Administrator (DFA). LPA met with Prithika SIngh and a brief interview followed. Regarding: Staff are not ensuring that residents' hygiene needs are being met while in care. During an unannounced visit on 10/12/23 to investigate this complaint, this LPA observed a resident in care with unwashed greasy hair. LPA took a photo for reference and spoke to staff about this resident. This LPA learned from staff that this resident (R5) did not like taking showers and would decline. When LPA returned a week later, R5’s hair was unwashed and R5 was wearing the same outfit. This LPA also learned during the course of this investigation that other residents have remained in the same clothes for consecutive days. On 10/12/23LPAs heard S4 mention to R5 that S4 thought R5 was wearing the same shirt they were wearing when they last saw R5. R5 confirmed that they had been wearing that shirt since their last Substantiated shower 2 days ago. During this LPA’s visit on 10/12/23, LPA observed R6 barefoot and confused wandering the lobby, speaking softly stating that they were cold. LPA brought the Administrator out to assist R5. LPA observed long uncut toenail that were curling under. LPA took a photo for reference and brought the resident’s hygiene needs to the attention of the Administrator. The Administrator replied, “That resident has dementia and is on hospice.” This LPA reminded the Administrator that they should then call hospice and make arrangements for this resident’s care. On 10/19/23, LPAs Viarella and Valerio observed another resident with long uncut toenails that had begun to curl downward. LPA Viarella took a photo for reference. Based on observation and interviews, the preponderance of the evidence standard has been met and the department found the allegation, “Staff are not ensuring that residents' hygiene needs are being met while in care,” to be SUBSTANTIATED. Regarding: Staff do not ensure that residents are provided with adequate bedding while in care. On 11/15/23 Licensing Program Analyst (LPA) Kimberly Viarella and Licensing Program Manager (LPM) Stephen Richardson made an unannounced visit to this facility to continue this complaint investigation. This LPA interviewed 7 staff members and 6 residents. All stated that there was enough bedding, and if a resident requested additional linens or blankets, the facility had an adequate house supply on hand to meet any requests. LPA/LPM inspected the House supply and found that the facility only had 5 blankets in reserve. If anything were to happen to the heating system, or if there were a particular cold front or emergency situation, there would not be enough bedding for the residents in care. The preponderance of evidence standard has been met and the department found this allegation to be SUBSTANTIATED. Regarding: Staff do not prevent resident(s) from abusing other resident(s) in care. During this LPA’s 3 separate visits on 08/09/23, 10/12/23, and 10/19/23, this LPA did not observe any resident conflicts or aggression. However, during the course of this investigation, this LPA learned that on 10/04/23 the Modesto Police responded to an incident of battery involving 2 residents. The police report also stated that “this is an ongoing issue with the same suspect at Vintage Faire.” The preponderance of evidence standard has been met and the department found this allegation to be SUBSTANTIATED. Regarding: Staff are not ensuring that residents' diapering needs are being met while in care. LPA found this facility to be malodorous on 08/09/223, 10/12/23, and 10/19/23. LPAs learned that at the present time, NOC shift were responsible for the incontinent care of 19 residents. During a tour of the facility on 10/19/23, LPAs observed the carestaff assisting a minimum of 5 residents in their rooms with their incontinent care. LPAs observed a sign in the employee breakroom which stated, “Get 4-6 residents up by 6:45 AM fully dressed and ready for breakfast.” LPAs heard 2 residents complain with raised voices that they wanted to be left alone. Of the two, LPA Valerio observed that carestaff were able to achieve compliance with one, who cooperated with carestaff upon their second visit to their room. LPAs were unable to confirm if the remainder of the 19 residents with an incontinence care plan were assisted prior to their arrival. By 7:00 AM, NOC staff moved on to distributing medication and preparing residents for breakfast at 8:00 AM. 4 out of 5 staff interviewed confirmed that residents’ incontinent care needs were not being met as evidenced by saturated briefs, clothing, and beds. On 10/19/23, LPAs observed 3 residents that required a 2 person assist to reposition and be changed. During the course of this investigation, this LPA reviewed punch logs for NOC employees from 10/25/23 to 11/25/23. This LPA learned that on 22 separate occasions, only 1 staff member was in the building to care for the 35+ residents in care from 11:00 PM - 6:00 AM. This presented a health and safety risk to residents in care who could have possibly been injured since assistance with transferring, repositioning, and changing, was not available. Their care plan could not be followed at that time as it wasn’t possible to adequately attend to the needs of those who required a 2-person assist. If a resident fell and there was only one carestaff present, they have been instructed to call 911 to request a lift assist from non-emergency personnel. On 10/12/23 the Designated Facility Administrator informed this LPA that they have been experiencing a large number of callouts. On 12/01/23, the Designated Facility Administrator informed this LPA that 2 new employees have been hired specifically for the NOC shift and that a third would be scheduled to be on call in order to prevent any staff member from working alone going forward. The preponderance of evidence standard has been met and the department found this allegation to be SUBSTANTIATED. Regarding: Staff are not ensuring that residents take their medication(s) as prescribed while in care. LPAs reviewed the Medication Administration Record (MAR) for 3 residents in care. LPA took photos for reference. Of the 3 records: the first was missing 28 entries, the second, 33 entries, and the last, 20 entries, with the latest being reviewed entered on 10/16/23. Total missing entries for three resident medication records for the month of October in 2023 was 81. There was also a post-it note dated 10/14/23 attached to R4’s record that stated: “Resident came back from the hospital with the doctor’s order to stop taking XXXXXX and XXXXXX, but there not on the MAR - faxed Dr.,” with the staff members initials. LPAs also heard R4 tell one also heard R4 tell one of the NOC shift staff that they missed administering an earlier medication. Staff confirmed that they had, and immediately provided the medication. Based on observation, interview, and a review of records, the preponderance of the evidence standard has been met and the department found the allegation, “Staff are not ensuring that residents take their medication(s) as prescribed while in care,” to be SUBSTANTIATED. According to the California Code of Regulations Title 22, deficiencies were observed and cited and may be found on the LIC 9099D pages. A copy of this report was provided along with Appeal Rights. Exit interview.the state’s words, verbatim · CDSS document, Dec 1, 2023 · control 27-AS-20230807114928

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 9, 2023

Incidental Medical and Dental 87465 (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. The Licensee did not comply with the above regulation as evidenced by: By observation, interview and record review, the licensee did not ensure that the medication record was completed as evidenced by 81 missing entries. LPA also heard a resident remind staff that they were not provided with a medicated cream at the prescribes time. This posed/poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 1, 2023

Plan of correction: The Licensee shall schedule a training to review MAR protocols with all MedTech Staff to ensure their understanding. Training will include a assessment tool. Licensee will submit facilitator, date, and time, and outline of training to kimberly.viarella@dss.ca.gov by 12/02/23. Signature sheets and copies of the assessment will be submitted to the same address by 12/22/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 2, 2023

Personal Rights (a) Residents in all residential care facilities for the elderly... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The Licensee did not comply with the above regulation as evidenced by: Based on a records review of the Modesto Police Department, the Licensee did not provide a safe environment for the residents in care as demonstrated by the altercation that took place on 10/04/23.the state’s words, verbatim · CDSS document, Dec 1, 2023

Plan of correction: Licensee sent the aggressor in the altercation mentioned for a new LIC 602 and new medications were prescribed. Going forward Licensee shall train staff to de-escalate and divert agitated residents in order to avoid future conflicts. Licensee shall submit facilitator, date, and time, and outline of training to kimberly.viarella@dss.ca.gov by 12/02/23. Signature sheets and copies of the assessment will be submitted to the same address by 12/22/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Dec 6, 2023

Managed Incontinence, 87625(b)(3) (b) In addition to Section 87611... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors incontinence. The licensee did not comply with the above regulation as evidenced by: Based on observation,(facility malodorourus), a reivew of punch logs and interviews, the licensee did not keep residents dry and clean.the state’s words, verbatim · CDSS document, Dec 1, 2023

Plan of correction: Licensee has recently hired 2 new employees specifically for the NOC shift and shall schedule one person to be on call in order to ensure that there will be sufficient staffing to meet the needs of the residents in care. Licensee shall submit a schedule for the month of December to kimberly.viarella@dss.ca.gov to reflect this new practice.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Dec 22, 2023

87464 Basic Services shall at a minimum include: (4) Personal assistance and care as needed... with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... The Licensee did not comply with the above regulation as evidenced by: Based on observation, and interview Licensee did not ensure that resident's hygiene needs were being met. This LPA observed residents with long curling toenails wearing the same clothes repeatedly. LPA also learned that a resident had wore the same outfit several days in a row.the state’s words, verbatim · CDSS document, Dec 1, 2023

Plan of correction: Licensee shall review shower log protocols and strategies for gaining compliance from residents with regard to all types of hygiene. Emphasis will be placed on logging, refusals, schedule changes, and carestaff noting strategies that have worked. Licensee shall submit facilitator, date of training, and signature sheets of participants by 12/22/23 to kimberly.viarella@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Dec 22, 2023

87303 Personal Accommodations and Services (a) Living accommodations and grounds... provide comfortable living ... (3) Equipment... Licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. The Licensee did not comply with the above regulation as evidenced by: The Licensee only had blankets in their House Supply for the 38 residents in care.the state’s words, verbatim · CDSS document, Dec 1, 2023

Plan of correction: Licensee shall buy additional bedding to meet the needs of the residents in care by 12/31/23 and will submit receipt to kimberly.viarella@dss.ca.gov.