Visionary Carmel-By-The-Sea Assisted Living

Type of visit: Required - 1 Year

On 06/27/2026, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct Required Annual Inspection. LPA met with staff/ care giver Selena Hernandez. Administrator (AD) Julie Conners was notified, certification number 6074739740 and expiration date 01/16/2027. LPA conducted facility tour inside and out of facility with staff. Residents observed at the facility in common area, and others in rooms during quite time. The facility was observed to be at a comfortable temperature of 75 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 09/30/2025 Last fire drill recorded in May 2026 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered once a week. The facility is comprised of three level sections; five residents’ rooms on the upper level, five residents’ rooms on main level with dining and kitchen, and lower level is a laundry room and large storage area. The census during the visit is 9 assisted living residents, three out them are under hospice care. LPA toured resident bedrooms. Residents' rooms were toured and observed adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 115 degrees F. LPA observed securely fastened grab bar and non-skid mat in shower area. Medications were stored in a locked medication cart in the hallway. Medications records were reviewed. The first Aid Kit was observed with all required items. LPA toured the laundry room and observed chemicals were stored and locked in for staff use only. The facility courtyard was toured and observed to be free from debris. LPA requested facility files for review. Exit interview conducted, report signed and copy of this report provided for facility recordsthe state’s words, verbatim · CDSS document, Jun 27, 2026

Type of visit: Case Management - Incident

On 12/30/25, Licensing Program Analyst (LPA) V Gorban conducted an unannounced case management visit. LPA met with house manager, administrator designee Shawniee Jackson was notified of licensing visit. This case management visit is being conducted based on incident report dated 10/28/25 where R1 have not received medication as prescribed. Resident R1 Deficiency has being cited on the attached 809-D in accordance to California Code of Regulations, Title 22, Division 6. An exit interview was conducted. A copy of this report and appeal rights was provided to house manager, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Dec 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jan 2, 2026

87465 Incidental Medical and Dental Care. (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not observed as evidenced by: The facility staff failed to ensure R1 receives medication prescribed as ordered by medical professionals. This is poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: The facility administrator designee will provide a written statement ensuring regulation been followed regarding medication administration according to the physician directions by POC due date.

Allegation investigated: Staff did not properly transfer a resident in care. Staff did not ensure that resident had supplies for medical device.

On 12/02/2025, Licensing Program Analyst (LPA) V. Gorban arrived unannounced to deliver findings on a complaint investigation. LPA explained the purpose of the visit to house manager Veronica Magana and was allowed entry, administrator was notified of licensing visit. During the course of the investigation, LPA conducted a facility tour, conducted interviews, and reviewed records. The Department has investigated the allegations: Staff did not properly transfer a resident in care and Staff did not ensure that resident had supplies for medical device. Based on interviews staff are sufficient in numbers and trained/educated to provide services to residents in care. Based on interviews and observation, facility store sufficient amount of care supplies to provide services to all residents in care. Although the allegations may have happened or valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, report signed and copy of this report provided to facility staff. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 2, 2025 · control 24-AS-20251125171355

Allegation investigated: Staff not present during night shift.

On 11/06/2025, Licensing Program Analyst (LPA) V. Gorban conducted an unannounced initial complaint investigation. LPA explained the purpose of visit to staff Tiera Maxwell and was allowed entry. During the course of the investigation, LPA conducted a facility tour, interviewed administrator and client, and reviewed records. The Department has investigated the allegation: Staff not present during night shift. Based on interviews staff confirmed that earlier this year in January no staff member was present in the facility grounds from 7AM to 8AM, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited of attached LIC9099-D Exit interview conducted, repot signed and copy of this report with appeal rights provided to staff for facility records. Substantiatedthe state’s words, verbatim · CDSS document, Nov 6, 2025 · control 24-AS-20251031162259

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 10, 2025

87411 Personnel Requirements - General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not observed as evidenced by: The facility failed to ensure staff is sufficient in numbers to provide care to all residents at all times. This is poses potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: The facility will provide a plan on make sure wstaff is on duty at all times, skywell to monitor staff presence and attendece. POC to be provide to LPA byemail by POC due date.

Type of visit: Case Management - Other

On 11/06/25, Licensing Program Analyst (LPA) V Gorban conducted an unannounced case management-deficiency visit. LPA met with executive director Shawniee Jackson. This case management visit is being conducted based on findings during complaint investigation that incident report on multiple occasions was not reported to Licensing office: R1 emergency visit due to fall and missed medications on tow different occasions. Another deficiency observed staff records for S1 is incomplete. Based on During interviews reported that R1 fell on February 23 and was taken to emergency department due to injury. Both deficiencies are being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.An exit interview was conducted. A copy of this report and appeal rights was provided to L1, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Nov 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Nov 11, 2025

87355 Criminal Record Clearance. (2) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not observed as evidenced by: The facility failed to ensure Staff (S1) back ground cleared and associated to the facility roster. This is poses immediate health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: The facility will provide POC written plan by POC due date to LPA by email

From the deficiency page — Deficiency type: Type B · Section cited: CCR87410 · Plan of correction due date: Nov 6, 2025

87211 Reporting Requirements. (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days. This requirement was not observed as evidenced by:the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: The facility will provide POC written plan by POC due date to LPA by email

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411 · Plan of correction due date: Nov 11, 2025

87411 Personnel Requirements - General. (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not observed as evidenced by:the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: The facility will provide POC written plan by POC due date to LPA by email

Type of visit: Required - 1 Year

On 07/23/2025, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct Required Annual Inspection. LPA met with house manager Tiera Maxwell. Administrator (AD) Angelique Robinson was notified, certification number 7022987740 and expiration date 06/24/2026. LPA conducted facility tour inside and out of facility with staff. Residents observed at the facility after breakfast time. The facility was observed to be at a comfortable temperature of 74 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 09/04/2025 Last fire drill recorded in July 2025 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered once a week. The facility is comprised of three level sections; five residents’ rooms on the upper level, five residents’ rooms on main level with dining and kitchen, and lower level is laundry and storage. The census during the visit is 8 assisted living residents. LPA toured resident bedrooms. Residents' rooms were toured and observed adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 117 degrees F. LPA observed securely fastened grab bar and non-skid mat in shower area. Medications were stored in a locked medication cart in the hallway. Medications records were reviewed. The first Aid Kit was observed with all required items. LPA toured the laundry room and observed chemicals were stored and locked in for staff use only. The facility courtyard was toured and observed to be free from debris. Exit interview conducted, report signed and copy of this report provided for facility recordsthe state’s words, verbatim · CDSS document, Jul 23, 2025

Type of visit: Required - 1 Year

On 7/11/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self, stated purpose of visit, and allowed entrance by direct care staff. Licensee, Julie Conners contacted by telephone and arrived a short time later to conduct facility tour with LPA. Facility tour conducted with Licensee. Facility observed to be a comfortable temperature, clean, and well lit. All common areas have adequate seating for residents. Facility has ten (10) private bedrooms. Currently, there are (5) residents in care. All bedrooms observed to have all required accommodations for residents. Resident bathrooms toured, all bathrooms observed to have grab bars, shower chairs and non-skid mats available. Water temperature observed to be 120 degrees. Kitchen toured, LPA observed all sharps are locked and secured. Facility observed to have a 2-day supply of perishable food and a 7-day supply of non-perishable food available. LPA observed medications to be locked and secured in cabinet near kitchen. All chemicals observed to be locked under kitchen sink and additional supplies are in a cabinet in the laundry room. Outside of facility toured. All exits open free of obstruction. Seating area available for residents. No hazards observed. Fire extinguisher present with a service date of 9/06/23. Facility is equipped with sprinkler system and pull stations. Smoke and Carbon Monoxide detectors observed operational during inspection. Last fire drill conducted in April 2024 according to facility records. LPA reviewed resident and staff files. LPA requested the following forms to be submitted to Fresno Regional Office no later than 7/19/24: Personnel Report (LIC 500), Client Roster (LIC 9020), and copy of current liability insurance. No deficiencies were cited during this inspection. Exit interview was conducted and a copy of this report will be emailed to facility.the state’s words, verbatim · CDSS document, Jul 11, 2024