Vista Terrace of Belmont

Type of visit: Case Management - Other

On May 18, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. The purpose of this visit is to follow up on a "Decision and Order" for the exclusion of Staff 1 (S1). During the visit, Administrator confirmed that S1 no longer are employed with the facility. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, May 18, 2026

Type of visit: Case Management - Incident

On May 5, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 4/20/26. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. The Licensee reported on 4/20/26, Resident 1 (R1) reported Staff 1 (S1) was sending "disturbing communications" via Facebook to R1. R1 emailed administrator screen shots of the messages between him/her and S1. On 4/22/26, S1 was put on administrative leave. Belmont Police and all other required parties were notified. During the visit, LPA interviewed administrator, collected documents, and interviewed R1. According to the administrator, when he interviewed S1, he/she denied allegations of disturbing communications with R1, however administrator stated and showed LPA screen shots and there was proof of S1 asking R1 for money, S1 sending R1 a photo of what looks like a S1 with a deceased person, and many more concerning messages. Administrator stated S1 resigned when he was interviewing him/her. According to R1, he/she did not report this matter sooner because he/she thought S1 needed a friend and S1 just needed someone to talk to as R1 believed S1 had mental health issues. R1 indicated that he/she feels safer and comfortable now that S1 is no longer working at the facility. No citations are issued during this visit. Report is reviewed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, May 5, 2026

Allegation investigated: Staff do not allow residents to visit at facility

On April 23, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. Regarding the allegation, staff do not allow residents to visit at facility, according to the reporting party, he/she wants to visit residents at the facility, however staff are not allowing him/her to do so. According to the reporting party, staff are telling the reporting party that he/she needs an invitation to visit residents at the facility and needs to give prior notification. During the investigation, LPA reviewed the facility's visitation policy and conducted interviews. The facility's visitation policy on the residency agreement indicates, "All visitors must register at the front desk when entering Cogir of Belmont. We reserve the right to remove or deny entry to Cogir of Belmont to any visitor whom we determine is disruptive or dangerous." According to the interviews conducted, it does not seem like facility has a fixed policy in place for visitation as interviews conducted indicates that the policy is determined by individual receptionists. (Continue to 9099C). Substantiated Furthermore, according to Staff 1 (S1), he/she had an interaction with the reporting party when the reporting party came to the facility to visit to current residents. S1 indicated he/she notified Staff 2 (S2) to let the residents know that the reporting party was at the facility to visit them, however according to S2, he/she indicated that he/she was never told to go check on the residents to see if they wanted the reporting party to visit. Nevertheless, the facility denied resident rights to visitors. Based on interviews conducted and information collected during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 14-AS-20260311101613

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Apr 30, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (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: (11) To have their visitors...permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by: According to the interviews conducted, it does not seem like facility has a fixed policy in place for visitation as interviews conducted indicates that the policy is determined by individual receptionists. In addition, based on staff interviews, when R1 came to visit two residents at the facility, S1 indicated he/she notified S2 to let the residents know that the reporting party was at the facility to visit them, however according to S2, he/she indicated that he/she was never told to go check on the residents to see if they wanted the reporting party to visit.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Licensee/administrator shall create a new visitation policy and provide a copy to CCLD and post a copy of the visitation policy at every facility entrance. Licensee/administrator to conduct an in-service training with staff regarding visitation policy and submit a copy of sign-in sheet to LPA by 4/30/26

Type of visit: Required - 1 Year

On April 23, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual inspection. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. LPA toured the facility inside and outside including but not limited to; a random sample of resident rooms, communal bathrooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a three story facility. LPA toured main dining room and kitchen on the first floor. LPA observed 2 days perishables and 7 days non-perishables. LPA observed medication room on the first floor to be locked and inaccessible to residents. Communal bathrooms on the first floor were clean and in good repair. Communal areas and were observed clean and free from tripping hazards. All resident rooms have a full bathroom. There is a laundry room on each floor, no chemicals were observed. Medication and sharps are locked and inaccessible to residents in care. LPA observed unlocked housekeeping carts with chemicals on the second and third floor. Hot water temperature fluctuated throughout the facility. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of November 2025. Emergency drills are logged and done every 3 months. LPA reviewed 5 resident records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Apr 23, 2026

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 - Incident

On January 28, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 1/19/26. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. The Licensee reported on 1/19/26, the concierge reported an alleged theft of $40.00 cash from Resident 1's (R1's) purse located in R1's room. R1 stated that he/she saw the housekeeper (S1) take the money out of his/her purse. R1 confirmed it was $40. Police department, ombudsman, and R1's responsible party was notified. During the visit, LPA discussed the incident with the administrator and business office manager and obtained S1's personnel records. According to Administrator, S1 is an agency staff who has only worked at the facility once. Administrator indicated when he was on his way to the facility to have a conversation with S1 regarding the incident, S1 clocked out and left. The agency was notified about the incident. Records reviewed showed that S1 is fingerprint cleared. LPA was unable to interview R1 during the visit as R1 was out of the community. No citations are being issued during the visit today. Further investigation is required. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jan 28, 2026

Allegation investigated: Facility did not safeguard Resident's Personal Belongings Illegal Rate Increase

On 12/11/2025, Licensing Program Analyst (LPA) Murial Han and Licensing Program Analyst (LPA) John Calandra conducted an unannounced visit to deliver the complaint investigation findings. LPA met with administrator and explained the purpose of today's visit. Regarding the allegation of- facility did not safeguard Resident's Personal Belongings, the reporting party stated that resident-in- question (R1) and all the residents were evacuated to another facility due to an electrical emergency. When R1 returned, R1's personal items were missing from R1's room. As part of the investigation, LPA interviewed the Regional Vice President of Operations, R1, R1's family member, and reviewed documents. Substantiated The Regional Vice President of Operations stated she has seen photos of the missing furniture in R1's room before and after the relocation but she stated that she did not have any specific details because it was handled by the previous management company, Integral Senior Living (ISL) and they did a major clean up before the residents returned. According to R1, many furniture and other personal belongings were missing from the apartment after returning to the facility. R1 also stated that a laptop was missing, many garbage bags that were packed with personal items were thrown away without his/her permission. According to R1's family member, they made a police report after discovering the furniture and other items were missing from R1's apartment and they have photos to proof. R1's family member stated that they have shared these photos with Cogir management, and they were told that they would be reimbursed when the police report was finalized. Based on the before and after photos of R1's apartment, it revealed that many furniture was missing such as a bookshelf, table, chairs, entry furniture, etc. Based on the written communication dated February 4, 2025, the Regional Vice President of Operations stated that the facility will reimburse R1's family member for the missing items when the police report was finalized. However, a copy of the police report dated 2/18/2025 was provided but the reimbursement was not issued. After the investigation, this allegation is deemed to be substantiated because there was photos to proof that furniture and other items were missing from R1's apartment after R1's returned to the facility, and there was a written communication in February 2025 from the Regional Vice President stating that R1 will be reimbursed but as of today, R1 and R1's family member has yet been reimbursed. Regarding the allegation of - illegal rate increase, the reporting party stated that the facility increased R1's rent and charged for the administrative work. As part of the investigation, LPA interviewed R1, R1's family member, the State Official, the Director Of Health Services, the Administrator, the Business Office Director, and the Regional Vice President Of Operations. According to R1, the facility increased the rate for level of care and it was based on an assessment but R1 did not remember having any type of assessments. In addition, R1 stated that R1's family member was forced to pay for the increase as R1's family member did not want the facility to evict R1 due to non-payment. According to R1's family member, initially the facility stated that the level of care increased was a mistake as the billing was done by an outside company and it would be corrected. However, in February 2025, the facility informed them that there would be a level of care increase starting March 2025 due to extra care. R1's family member stated that R1 did not require any extra care, and they have never gotten a written notice of the level of care increase and an explanation of the increase. LPA interviewed the Administrator and the Director Of Health Services, and neither could provide any details as they were both new to the facility. LPA interviewed the Business Office Director who did not have any details pertaining to the level of care increase but stated that R1's family member has been paying the additional level of care increase since April 2025. LPA interviewed the Regional Vice President of Operations who stated that the monthly rent was increase due to R1's behaviors. LPA interviewed the State Official who stated that he/she was invited to a meeting in February 2025 with the Regional Vice President of Operations and R1's family member to discuss the level of care increase but during the meeting, there was no conversation about the care, it was about R1's behaviors that triggered the level of care. Based on R1's care plan detail dated 12/30/2024, R1 was independent and did not require care. In addition, the care plan detail was not signed by the resident, the party responsible and facility representative to proof that it was reviewed and discussed accordingly. After the investigation, this allegation is deemed to be substantiated as the facility increased R1's level of care but based on R1's care plan detail dated 12/30/2024, R1 did not have any care needs. In addition, R1 and R1's family member did not receive a written notice with details explaining the level of care increase. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided. Regarding the phone services, the Administrator and the Business Office Manager stated that the phone on the 3rd floor is always available for residents to use. They also stated that R1 utilized that phone as well as the phone in S3's office to make confidential calls. According to R1, there is a phone of the 3rd floor, and he/she has been using that phone, but it is not always available. R1 also stated that he/she has been using the phone in S3's office to make confidential calls and R1 stated that he/she has a cell phone. According to S3, R1 has been going to S3's office very often to use the phone and S3 would leave the office to private privacy. S3 reported that there were times when R1 spent a long time on the phone where S3 needed to tell R1 that she needed to do something in the office. According to the State Official, the facility has been accommodating R1 with providing a phone services. Regarding S1 staying in the lobby and talking to the receptionist and/or other staff after S1 clocked out for work, LPA interviewed S1, the Administrator, S2, and other residents. According to S1, he/she stayed after work to decompress after a long day of work by talking to different people. S1 stated that he/she did not bother anyone by doing that. According to the Administrator, the lobby area is not a private space to have any private conversation. The administrator stated lobby is a common space for everyone to use including S1, other staff members, visitors, residents, etc. The Administrator stated that when a resident wants to have a private conversation with a staff, it will be conducted at a private space. LPA interviewed other residents and all of them reported that their privacy was honored by the facility. Regarding hiring professional movers to assist with moving residents back to the facility due to the emergency evacuation except for R1, R1 stated that the other residents were provided with a company credit card to pay for the movers except for R1. According to the State Official, R1 was very particular of the transportation arrangement and R1 arranged for a friend who has a van to drive R1 back to the facility. The State Official stated that some other residents moved their furniture to their temporary location but R1 did not, so the van was big enough to fit all of R1's belongings. According to the Regional Vice President of Operations, the relocation arrangements were made by the previous management, ISL and she did not have the details. After the investigation, this allegation is deemed to be unsubstantial. Regarding the allegation of - facility provided false assessment to CCL to support the eviction, the reporting party stated that the facility provided false unusual incident reports concerning to R1 to CCL of the events that never happened. As part of the investigation, LPA interviewed R1, the Administrator, and reviewed unusual incident reports. According to R1, the facility reported false incidents to CCL, for example, he/ she was yelling and screaming, wearing inappropriate attire in the public area, and the facility provided accurate information to the mobile crisis team that resulted in R1 being hospitalized. According to the Administrator, the facility was following the reporting requirement by reporting the incidents that were observed. The Administrator stated that there were a couple of events that triggered a call to a local community outreach support agency and R1 was taken to the hospital for further evaluation based on their assessment of the situation. Based on the incident reports submitted by the facility, each of them indicated an unusual incident that happened at the facility which triggered the facility to report it to the Department as part of the Reporting Requirement under Title 22. After the investigation, this allegation is deemed to be unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Based on the eviction letter, it indicated the reasons supporting the eviction, and other required resources. In addition, a copy of the letter was provided to CCL. After the investigation, this allegation is deemed to be unfounded as the facility provided proper notification to R1 and to the Department according to Title 22 Regulation- Eviction Procedures. Based on interviews, record review, and observations, the department has determined that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegation is UNFOUNDED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 14-AS-20251013105535

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Dec 18, 2025

87217 Safeguards for Resident Cash, Personal Property, and Valuables(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met as evidenced by based on interview, records review and observation, R1 was evacuated to another facility due to an electrical issue at the facility and upon returned, R1 and R1's responsible party discovered many items were missing that were there before which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: The administrator will discuss with the Regional VP on an action to address this finding and the administrator will provide a plan of correction to prevent this from happening again. The administrator will provide a copy of the plan of correction to CCL by 12/18/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.657(a) · Plan of correction due date: Dec 18, 2025

§1569.657Rate increase due to change in level of resident care; notice(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative,.. written notice of the rate increase.. The notice shall include a detailed explanation.. This requirement is not met as evidenced by based on record review, and interview R1 and R1's responsible party was not provided a written notice of the level of care increase which poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: The administrator will discuss with the Regional VP on an action to address this finding and the administrator will provide a plan of correction to prevent this from happening again. The administrator will provide a copy of the plan of correction to by 12/18/2025.

Type of visit: Case Management - Incident

On December 4, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 11/26/25. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. The Licensee reported on 11/26/25, Resident 1 (R1) and R1's responsible party reported to the administrator that there were items missing from R1's room. Belmont Police Department and LTCO was notified. During the visit today, LPA reviewed R1's file and interviewed R1. According to R1, he/she wanted to wear his/her earrings for Thanksgiving, however when R1's responsible party went to get them, R1's responsible party observed all of R1's jewelry missing. R1 remembers talking to a staff member and showing a staff member the jewelry, however does not remember when and who it was. R1 indicated he/she did not notify staff about bringing his/her jewelry into the facility. Based on R1's personal property and valuables log signed by R1's daughter, R1 declined to record any items on the log. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Dec 4, 2025

Allegation investigated: Staff financially abused resident

On November 20, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. Regarding the allegation, staff financially abused resident, according to the reporting party, about 2-3 years ago, Resident 1’s (R1’s) wallet was stolen and unauthorized charges were made by Staff 1 (S1). During the investigation, the Department reviewed documents. Although S1 did take R1’s wallet and financially abused R1, S1 was not employed with the facility. S1 was employed through an outside third-party agency. After the investigation, this allegation is deemed to be unfounded. Report is reviewed with Administrator and a copy is provided. Unfoundedthe state’s words, verbatim · CDSS document, Nov 20, 2025 · control 14-AS-20251013174433

Type of visit: Case Management - Incident

On November 13, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 11/4/25. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. The Licensee reported on, 11/4/25 at 7:45pm, Resident 1 (R1) eloped from the facility. According to the Licensee, prior to the elopement, R1 became verbally and physically aggressive towards his/her one-on-one caregiver, instructing the caregiver not to enter his/her room. The one-on-one caregiver left R1's room, leaving R1 alone. R1 then exited the facility without authorization. Police department was immediately notified. R1 was located on the street in front of the community and was escorted back to the facility. During the visit, LPA interviewed the administrator, staff and reviewed R1's file. According to staff interviewed, R1 left through the third floor exit doors and was found outside around the bushes by the first floor entrance. According to staff interviewed, at around 8:15pm, the one-on-one caregiver noticed R1 was not in his/her room and notified the med-tech on shift. Based on file reviewed, R1 has a Parkinson's Disease, is unable to leave the facility unsupervised, has unsafe wandering behaviors, and is at risk for elopement, therefore, the facility worked with the family and the family decided to hire a private caregiver through a third party agency. According to Health and Wellness Director, when a private caregiver starts working with residents at the facility, the Health and Wellness provide orientation and let the private caregivers know that if there is an incident that occurs while assisting a resident, to notify the med-tech on shift. According to the staff interviewed, the one-on-one caregiver did not endorse or notify the facility med-tech that R1 and the caregiver got into an argument and was not with R1 until the one-on-one caregiver noticed R1 was missing. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Case Management - Other

On November 13, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case-management visit. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude a Staff 1 (S1) from the facility. The letter was given to the Administrator. This report is reviewed and discussed with the Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Case Management - Other

On November 4, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case-management visit. LPA met withMaintenance Director, Alan Harris and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude a Staff 1 (S1) from the facility. The letter was given to the Maintenance Director. This report is reviewed and discussed with the Maintenance Director and a copy is provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Case Management - Incident

On September 16, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to follow up on two incidents that occurred on 8/28/25 and 9/3/25. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. On 8/28/25, the Licensee reported that the agency nurse failed to provide Resident 1 (R1) his/her PM medications. During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. Based on R1's medication list, R1 is required to receive his/her one 15mg tablet of Mirtazapine daily at 8:00pm, however the facility did not provide R1 his/her medication. The facility failed to provide R1's medication as prescribed by the physician. On 9/3/25, the Licensee reported that an agency CNA (S1) was attempting to assist Resident 2 (R2) with changing his/her brief and started rummaging through R2's nighstand drawer. R2 refused assistance and S1 threw R2's pajamas at R2 and told R2 to not call for assistance again. All required parties were notified, including the Belmont Police Department. Regional Sales Specialist, Jessica Wiggins ended S1's shift and immediately walked the S1 out. S1 is no longer allowed in the community. During the visit, LPA reviewed the facility's internal investigation, attempted to interview R2, discussed the incident with the administrator, and reviewed R2's file. Based on R2's file reviewed, R2 has a diagnosis of Parkinson's Disease. Based on R2's service plan, R1 is independent and does not require assistance with toileting and dressing. According to staff interviewed, although R2 is independent, due to his/her Parkinson's disease, facility staff check in on R2 and offer assistance. Based on the facility's internal investigation, R2 was not missing any personal belongings and R2 was not injured. LPA was unable to interview R2 during the visit. A statement was provided to facility by S1 indicating, he/she was only trying to assist R2 with changing R2's pants and diaper. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. A civil penalty of $1,000.00 is issued today for a repeat violation within the last 12 months for CCR 87465(a)(4). Report is reviewed with the administrator and a copy is provided with appeal rights. A copy of civil penalty is provided.the state’s words, verbatim · CDSS document, Sep 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 17, 2025

87465 Incidental Medical and Dental Care: (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. This requirement is not met as evidenced by: Based on R1's medication list, R1 is required to receive his/her one 15mg tablet of Mirtazapine daily at 8:00pm, however the facility did not provide R1 his/her medication as prescribed by the physician which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee/Administrator shall submit a plan in writing on how to ensure agency med-techs are trained prior to administering medication to avoid med-errors. A civil penalty of $1,000 is assessed today for a repeat violation. Facility was cited for the same deficiency on 2/27/25, 4/29/25, 5/6/25, 7/1/25 and 8/26/25

Allegation investigated: Staff are not administering residents' medications as prescribed Facility failed to report incident to CCLD Facility failed to ensure resident's beds were in good repair

On August 26, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Regional Sales Specialist, Jessica Wiggins and explained the purpose of the visit. Regarding the allegation, staff are not administering residents' medications as prescribed, according to the reporting party, Resident 1 (R1) is not being administered the correct dosage of his/her Gabapentin medication as prescribed by the physician. During the investigation, LPA interviewed R1, reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. According to R1, on 8/8/25 and 8/10/25, he/she was supposed to receive 3 tablets of Gabapentin at 8pm, however on both days, only 1 tablet was provided. Resident 2 (R2) noticed and reported to the med-tech that R1 is supposed to receive three tablets of Gabapentin instead. The med-tech fixed the error immediately. Although this incident was caught by R2 and fixed by the med-tech, the med-tech would have administered one tablet of Gabapentin to R1 at 8pm on both days if R2 did not catch this error. (continue to 9099C). Substantiated During the visit, LPA reviewed R6’s call button response log and interviewed R6. According to R6, staff are responding to his/her call button on time. In addition, R6 indicating that he/she understands and is not complaining when staff take longer to respond at times as staff are assisting other residents. Based on R6’s call button response log, staff do respond timely to R6’s calls. Based on interviews conducted and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Regional Sales Specialist, Jessica Wiggins and a copy is provided. A civil penalty of $250 is issued today for a repeat violation within the last 12 months. The facility has received a deficiency for California Code of Regulations, 87465 Incidental Medical and Dental Care in relation to the med-errors on 2/27/25, 4/29/25, 5/6/25, and 7/1/25. Regarding the allegation, facility failed to report incident to CCLD, according to the reporting party, the facility is not reporting R1’s med errors to CCLD. During the visit, LPA reviewed records and interviewed staff. Based on records, it was observed that the facility has not submitted any incident reports to CCLD regarding R1’s med-errors that occurred on 8/8/25 and 8/10/25. According to staff interviewed, they believed that an incident report did not have to be submitted because although the med-errors occurred, it was caught by R2 and fixed by the med-tech. Regarding the allegation, facility failed to ensure resident's beds were in good repair, according to the reporting party, Resident 3’s (R3’s) and Resident 4's (R4’s) bed collapsed because the maintenance director did not assemble the beds correctly. During the visit, LPA interviewed staff, R3 and R4. According to R3, he/she was sitting on the side of the bed that was provided by the facility, when the bed's slate underneath the mattress slipped, causing the mattress to collapse on the floor. LPA was unable to interview R4, however according to staff interviewed, they indicated that R4's bed did not collapse, R4 just rolled out of it. In addition, according to staff interviewed, R3's bed was not able to hold his/her weight causing the slate to shift and the mattress to collapse. Although LPA was unable to interview R4, R3's bed was not in good repair, causing R3's bed mattress to collapse. Based on the interviews conducted, records reviewed and information collected, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Regional Sales Specialist, Jessica Wiggins and a copy is provided with appeal rights. A copy of the civil penalty is provided.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 14-AS-20250813150601

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 27, 2025

87465 Incidental Medical and Dental Care: (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. This requirement is not met as evidenced by: Based on interviews and records reviewed, on 8/8/25 and 8/10/25 at 8pm on both days, R1 was administered only one tablet of Gabapentin instead of three tablets by the med-tech. R2 caught the error and notified the med-tech who fixed the error. Although this incident was caught by R2 and fixed by the med-tech, the med-tech would have administered one tablet of Gabapentin to R1 at 8pm on both days if R2 did not catch this error which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: Licensee/administrator will submit a plan in writing on how to ensure med-errors will not keep continuing in the future. Plan shall include, training, audits and the frequency of audits, hiring med-techs. A civil penalty of $250 is assessed today for a repeat violation within the last 12 months. Facility was cited for the same deficiency on 2/27/25, 4/29/25, 5/6/25 and 7/1/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 2, 2025

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: Based on records, it was observed that the facility has not submitted any incident reports to CCLD regarding R1’s med-errors that occurred on 8/8/25 and 8/10/25. According to staff interviewed, they believed that an incident report did not have to be submitted because although the med-errors occurred, it was caught by R2 and fixed by the med-tech. This poses a potentional health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: Licensee/administrator shall review CCR 87211 Reporting Requirements and submit acknowledgement that regulation has been reviewed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 2, 2025

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on interviews conducted, R3 indicated he/she was sitting on the side of the bed that was provided by the facility, when the bed's slate underneath the mattress slipped, causing the mattress to collapse on the floor. ccording to staff interviewed, R3's bed was not able to hold his/her weight causing the slate to shift and the mattress to collapse which poses a potentional health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: Licensee/administrator shall ensure that a proper pre-appraisal is done to ensure that resident's furnishings are equipped and appropriate for them. Licensee/administrator shall submit a plan in writing on how to ensure residents furnishings are in good repair and alternatives options are provided if needed.

Type of visit: Case Management - Incident

On July 1, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to an incident that occurred on 6/22/25. LPA met with Health and Wellness Director, Carmen Bodnar and explained the purpose of the visit. On 6/22/25, the Licensee reported that registry LVN/Med-tech administered an incorrect dose of Lacosamide medication to Resident 1 (R1) during the AM shift. R1 was supposed to receive 100mg of Lacosamide, however 150mg of Lacosamide was given. During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. Based on R1's medication list, R1 is required to take 1 tablet of Lacosomide (100mg) medication daily at 8am, however the med-tech administered 150mg. The facility failed to provide R1's medication as prescribed by the physician. According to the Health and Wellness Director, registry med-techs are always trained prior to administering medications for residents. In addition, it was reported that during each shift, med-techs are required to count all residents' medications. On 6/26/25, the Licensee reported that registry med-tech, provided R1 one tablet (100mg) of Gabapentin at night at 8pm, however Resident 2 (R2) noticed and reported that R1 is supposed to receive three tablets of Gabapentin instead. The med-tech then provided R1 with two more tablets. (Continue to 809C) During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. Based on R1's medication list, R1 is required to take 1 tablet of Gabapentin (100mg) at 9am, two tablets of Gabapentin at 1pm and three tablets of Gabapentin at 8pm. Although this incident was caught by R2 and fixed by the med-tech, the med-tech would have administered one tablet of Gabapentin to R1 at 8pm if R2 did not catch this. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. A civil penalty of $250.00 is issued today for a repeat violation within the last 12 months. Report is reviewed with the Health and Wellness Director and administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 2, 2025

87465 Incidental Medical and Dental Care: (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. This requirement is not met as evidenced by: Based on R1's medication list, R1 is required to take 1 tablet of Lacosomide (100mg) medication daily at 8am, however on 6/22/25, the med-tech administered 150mg. The facility failed to provide R1's medication as prescribed by the physician. In addition, Based on R1's medication list, R1 is required to take 1 tablet of Gabapentin (100mg) at 9am, two tablets of Gabapentin at 1pm and three tablets of Gabapentin at 8pm. Although this incident was caught by R2 and fixed by the med-tech, the med-tech would have administered one tablet of Gabapentin to R1 at 8pm on 6/26/25 if R2 did not catch this.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: Licensee/Administrator shall submit a plan in writing on how to ensure agency med-techs are trained prior to administering medication to avoid med-errors. A civil penalty of $250 is assessed today for a repeat violation. Facility was cited for the same deficiency on 2/27/25, 4/29/25, and 5/6/25.

Allegation investigated: Licensee does not ensure safe pathways are provided for residents use Staff does not ensure elevators are made accessible for residents at all times.

On May 15, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Jose Acumabig and explained the purpose of the visit. Regarding the allegation, Licensee does not ensure safe pathways are provided for residents use, according to the reporting party, the facility is currently undergoing construction and the walk path that is available for use has uneven pavement and bricks on the ground making it difficult for residents who are disabled and require wheelchair access. During the investigation, LPA toured the outdoor passageway at the facility that residents use to come into the facility and leave the facility. LPA observed uneven pavement, uneven bricks, and overgrown greenery on the side of the walk way. Regarding the allegation, staff does not ensure elevators are made accessible to residents at all times, according to the reporting party, the staff are not tending to the service elevator for residents in wheelchairs and walkers in a timely manner to help them get to the areas of the facility. (continue to 9099C). Substantiated During the investigation, LPA interviewed staff and residents. According to the administrator, the elevator service being used currently during construction requires a key to get inside and/or outside the facility. According to staff interviewed, depending on the day and time, it may take staff longer to get to the elevator to assist residents, however all residents have access to the elevators. Based on the residents interviewed, there have been several times where it's taken staff more than 10 minutes to open the elevators to go inside and/or outside the facility causing residents to miss their appointments and/or sit in their cars. Based on the interviews conducted and information collected, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator, Jose Acumabig and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, May 15, 2025 · control 14-AS-20250428155423

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: May 16, 2025

87307 Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This regulation is not met as evidenced by: Based on observations, LPA observed uneven pavement, uneven bricks, and overgrown greenery on the side of the walk way which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2025

Plan of correction: Licensee/administrator to submit a plan in writing giving CCLD a timeline in which the passageways will be fixed. Plan shall include; company being hired to fix the passageway and timeframe.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 22, 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 regulation is not met as evidenced by: Based on staff interviews, it was acknowledged that depending on the day and time, it may take staff longer to get to the elevator to assist residents. Based on the residents interviews, there have been several times where it's taken staff more than 10 minutes for staff to open the elevators to go inside and/or outside the facility causing residents to miss their appointments and/or sit in their cars.the state’s words, verbatim · CDSS document, May 15, 2025

Plan of correction: Licensee/administrator shall conduct an in-service training with staff to ensure response times are reduced. Additionally, Administrator purchased 5 more elevator keys for residents to use when leaving the facility.

Type of visit: Case Management - Incident

On May 6, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 4/26/25. LPA met with Administrator, Jose Acumabig and explained the purpose of the visit. The Licensee reported on 4/26/25, the PM shift med-tech administered an incorrect dose of Lacosamide to Resident 1 (R1). R1 is required to take 150mg of Lacosamide, however only 100mg was provided. During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, centrally stored medication record, medication administration record (MAR). Based on R1's physician's order, R1 is required to take 1 tablet of Lacosomide (150mg) medication daily at 8pm, however based on the MAR, the med-tech administered 100mg of Lacosamide instead of 150mg of Lacosamide. The facility failed to provide R1's medication as prescribed by the physician. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. A civil penalty of $250.00 is issued today for a repeat violation within the last 12 months. Report is reviewed with the Administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, May 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 7, 2025

87465 Incidental Medical and Dental Care: (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. This requirement is not met as evidenced by: Based on file reviewed, R1 is required to take 1 tablet of Lacosamide (150mg) medication once every evening at 8pm, however based on the MAR, the med-tech administered the wrong doasge and administered 100mg of Lacosamide to R1 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Licensee/administrator and/or Director of Health and Wellness will conduct an intensive training with med-techs. Director of Health and Wellness will shadow med-techs and train on how to ensure medication is provided on time and according to physician's order. Training log shall be submitted to CCLD by 5/7/25 A civil penalty of $250 is assessed today for a repeat violation. Facility was cited for the same deficiency on 2/27/25 and 4/29/25.

Type of visit: Required - 1 Year

On May 6, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Jose Acumabig and explained the purpose of the visit. LPA toured the facility inside and outside including but not limited to; a random sample of resident rooms, communal bathrooms, activity room, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a three story facility. LPA toured main dining room and kitchen on the first floor. LPA observed 2 days perishables and 7 days non-perishables. LPA observed medication room on the first floor to be locked and inaccessible to residents. Communal bathrooms on the first floor were clean and in good repair. Communal areas and activity rooms were observed clean and free from tripping hazards. All resident rooms have a full bathroom. According to the administrator, residents bring their own furniture and linens. There is a laundry room on each floor, no chemicals were observed. Chemicals, medications, and sharps were locked and inaccessible to residents. Hot water temperature throughout the facility was within regulatory requirements. Carbon monoxide detectors are working properly. All fire extinguishers were observed to be charged. Emergency drills are logged and done quarterly. Temperature throughout the facility is comfortable and lighting is sufficient for comfort. LPA reviewed 5 resident records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are issued during this visit. Report is reviewed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, May 6, 2025

Type of visit: Case Management - Incident

On April 29, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on April 20, 2025. LPA met with Administrator, Jose Acumabig and explained the purpose of the visit. On April 23, 2025, the Licensee reported on April 20, 2025, the AM shift Med-Tech did not administer Resident 1's (R1's) Lacosomide (100mg) medication at 8am. During the visit, LPA interviewed staff, reviewed R1's file and medication administration records (MAR). According to staff interviewed, it was acknowledged that the AM shift med-tech did not administer R1's medication on 4/20/25 at 8am. Based on R1's physician's order, R1 is required to take 1 tablet of Lacosomide (100mg) medication daily at 8am, however based on the MAR, the med-tech did not administer the medication to R1. The facility failed to provide R1's medication as prescribed by the physician. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. A civil penalty of $250.00 is issued today for a repeat violation within the last 12 months. Report is reviewed with the Administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Apr 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 30, 2025

87465 Incidental Medical and Dental Care: (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. This requirement is not met as evidenced by: Based on staff interviews, R1's physician's orders and MAR, R1 is required to take 1 tablet of Lacosomide (100mg) medication daily at 8am, however based on the MAR, the med-tech did not administer the medication to R1 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2025

Plan of correction: Licensee/Administrator shall re-train all med-techs and submit training log to LPA by 4/30/25. A civil penalty of $250 is assessed today for a repeat violation. Facility was cited for the same deficiency on 2/27/25.

Allegation investigated: Facility staff did not intervene in verbal altercation between residents.

On March 18, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Administrator, Kaitlyn Clarey and explained the purpose of the visit. Regarding the allegation, facility staff did not intervene in verbal altercation between residents, according to the reporting party, on March 6, 2025, it was observed Resident 1 (R1) and Resident 2 (R2) had a verbal altercation outside the dining room after a town hall meeting. Reporting party indicated, there were about 8-10 staff members present but they did not take action or step in. During the investigation, LPA interviewed administrator, reviewed staff schedule and interviewed staff. According to the administrator, there were 9 staff members on the schedule the day of the town hall meeting but none of them witnessed the altercation. The administrator indicated, she was also at the building during the town hall meeting but did not observe the altercation. LPA reviewed the staff schedule and observed 9 staff members on schedule on 3/6/25 during the town hall meeting. LPA interviewed 9/9 of the staff members present on shift during the residents' town hall meeting and they indicated that they did not observe the altercation between R1 and R2. Based on interviews conducted, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with Administrator and a copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 18, 2025 · control 14-AS-20250307083648

Allegation investigated: Facility staff did not dispense medications as prescribed

On February 27, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Culinary Service Director, Justin Kang and explained the purpose of the visit. Regarding the allegation, facility staff did not dispense medications as prescribed, according to the reporting party, Resident 1 (R1) supposed to receive his/her Carbidopa Parkinson’s medication between 6am-6:30am every morning before breakfast, however on 2/25/25, R1 did not receive his/her medication as prescribed because there was med-tech working to dispense his/her medication. R1 did not receive his/her Carbidopa medication until 8:45am. During the investigation, LPA interviewed the nurse that was on shift in the morning of 2/25/25, reviewed R1’s medications and reviewed R1’s medication administration record (MAR). According to the nurse, the AM med-tech did not show up for work and he/she had to go to the facility to give residents their medications. In addition, the nurse indicated that she did not get to the facility till about 8:15am-8:30am and immediately provided R1 his/her medication. (continue to 9099C) Substantiated Based on R1's medications reviewed and the MAR, R1 is prescribed to take two tabs of Carbidopa-Levodopa by mouth four times daily at 6am, 10am, 2pm, and 6pm. Based on the MAR, on 2/25/25, R1 was not given his/her Carbidopa medications on time in the morning, as R1 received his/her Carbidopa medication at 8:24am and the second round at 11:15am. Based on the information collected, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Culinary Service Director, Justin Kang and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 14-AS-20250225152851

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

87465 Incidental Medical and Dental Care: (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. This requirement is not met as evidenced by: Based on R1's medication reviewed and the MAR reviewed, R1 was supposed to be given Carbidopa at 6am and 10am, however was not given the medications until 8:24am and 11:15am which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: Licensee/Administrator shall submit a plan in writing on how to ensure residents receive their medication based on their doctor's orders. Plan shall include training staff and hiring more staff if necessary.

Allegation investigated: Staff do not ensure that resident's toilet is in good repair Staff do not ensure that the facility temperature is comfortable

On December 11, 2024, Licensing Program Analyst (LPA) Komal Charitra conduted an unannounced 10-day complaint visit. LPA met with Administrator, Kaitlyn Clarey and explained the purpose of the visit. Regarding the allegation staff do not ensure that resident's toilet is in good repair, according to the reporting party, the toilet in Resident 1’s (R1’s) room has been broken and repaired approximately three times recently. In addition, reporting party stated the toilet lever isn't working in the R1’s room. During the investigation, LPA toured R1’s room and observed the toilet. Toilet was observed to be in good working condition and the toilet lever was observed to be in good repair. Regarding the allegation staff do not ensure that the facility temperature is comfortable, according to the reporting party, the dining room is cold and the staff don’t turn the heat on in the dining room. (Cont. to 9099C) Unsubstantiated During the investigation, LPA interviewed residents and toured the dining. The dining room temperature was observed to be at 74 degrees F. LPA interviewed 5 residents, according to 4/5 residents interviewed, all 4 residents indicated that the dining room was at a comfortable temperature and they felt warm. Based on observations and interviews conducted, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Dec 11, 2024 · control 14-AS-20241210153327

Allegation investigated: Staff did not inform residents of planned fire inspection

On November 14, 2024, Licensing Program Analyst (LPA) Komal Charitra conduted an unannounced 10-day complaint visit. LPA met with Administrator, Kaitlyn Clarey and explained the purpose of the visit. Regarding the allegation, staff did not inform residents of planned fire inspection, according to the reporting party, on 11/7/24, the facility conducted some sort of fire drill/inspection at the facility and staff failed to inform and communicate with residents about this matter, resulting in panick and stress. During the investigation, LPA interviewed administrator, staff and residents. The administrator acknowledged that no notice was provided to the residents. According to the Maintenance Director, this is a yearly fire inspection where outside vendor, Cintas comes to the facility and checks the sprinkler system and fire alarms. The Maintenance Director acknowledged that he was aware that Cintas was going to conduct their inspection for only the sprinkler system on 11/7/24 a few days prior to the scheduled date, however during the inspection, Cintas observed other overdue inspections, including fire alarm. The Maintenance Director admitted he allowed Cintas to continue with all inspections and did not notify the residents prior to allowing Cintas to continue with their inspection. In addition, based on 4 staff interviewed, they indicated they were not aware the fire inspection drill was going to be conducted on 11/7/24. (continue to 9099C). Substantiated Furthermore, according to 4/4 residents interviewed, no notification was provided to them and staff did not communicate to them regarding the fire inspection. Residents interviewed indicated that they were scared, nervous, and did not feel safe because the fire alarms were loud and went on for about 20-25 minutes. In addition, residents stated they were not sure what to do as staff did not tell them anything. Therefore, the allegation staff did not inform residents of planned fire inspection is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 14-AS-20241107125642

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 21, 2024

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: The facility failed to provide residents notification or communicate with residents regarding a fire inspection that occurred on 11/7/24, resulting in residents to feel unsafe, scared, and nervous. According to the Maintenance Director, he was aware that outside vendor, Cintas was going to come to the facility a few days prior and was aware that Cintas was going to test the fire alarms, however admitted that he allowed them to continue and test the alarms without any notification to residentsthe state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Licensee/administrator shall submit a plan in writing regarding how to ensure proper communication is provided to all residents regarding the facility.

Allegation investigated: Staff did not assist resident with toileting

On 7/12/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director Douglas Blake & Resident Care Coordinator Nelsaand explained the purpose of today's visit. Regarding the allegation of staff did not assist resident (R1) with toileting, Reporting Party (RP) stated that R1 called for staff to come help to the bathroom during the night and no one would come. Based on records review, the pendant or call buttons pressed by the R1 was all answered by staff. The log reviewed were from March 16 to June 26, 2024. It showed that all calls were answered by the staff. LPA also interviewed ED and Resident Care Coordinator and mentioned that the staff normally does 2-hour intervals for checking on residents. Response time for call buttons is between 2 to 8 minutes. Based on interviews & records review, the department has determined 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. Report is reviewed and copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 12, 2024 · control 14-AS-20240612121234

Allegation investigated: Facility staff did not dispense medications as prescribed

*** This is an amended report *** On 7/16/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director Douglas Blake and explained the purpose of today's visit. Regarding the allegation facility staff did not dispense medications as prescribed, Reporting Party (RP) stated that staff do not dispense medications as prescribed to resident (R1). Per RP, on Tuesday 5/28/24 the resident was given a yellow pill with his morning meds (6am). R1 knew he/she doesn't normally take a yellow pill so he/she told the staff who immediately told him/her not to take it because the pill was given in error. page 1 of 2 Unfounded LPA reviewed medication records and it was found out that the medication that is needed to be taken on specific time and interval were not given accordingly on both months of February and March of 2024, the medication were administered on the following times, 2 tablets every 6:30am, 12:00pm, 6:00pm. Having an interval of 4.5 hours to 6 hours. There were no doctors’ orders specific to the time that the medication needs to be given. All that was provided was that it needs to be administered 3x/day. LPA was able to obtain a copy of the order but was dated 4/10/2024. This has been followed upon receiving this order. The medication administration record since April already reflected that it is given at 6am, 11am & 5pm. LPA was also able to interview R1s physician (DR). DR confirmed that the medication should be taken every five hours and that based of the medication orders given it should be at taken at 6am,11am & 5pm. LPA also interviewed a staff (S1) and It was stated that the yellow pill mentioned is an order for daily aspirin, in the morning. That tablet is in fact small and pale yellow in color. During the interview S1 stated that there were no discrepancies, errors, refusals, or conversations about the medications as they were given as prescribed the morning of the 28th. LPA also observed one of the medications for R1 as having a pale yellow in color. Based on interviews and observations, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Jul 12, 2024 · control 14-AS-20240530100108

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 13, 2024

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance...(4) The licensee shall assist residents with self-administered medications as needed. This was not met as evidenced by, based on records review, the medication that needs to be given on a specific time was not administered on time between Ferbruary and March 2024, which poses an immediate health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 12, 2024

Plan of correction: Licensee has already corrected this and has been giving time sensitive medications on time.

Allegation investigated: Facility failed to ensure residents received hot water prior to emergency evacuation Facility failed to provide sufficient staffing to meet residents needs

On May 1, 2024, Licensing Program Analyst (LPA) John Calandra conducted a conclusionary complaint investigation at the facility and met with Michelle Baker, Business Office Director. The purpose of the visit was to deliver conclusionary findings to the initial complaint investigation on October 31, 2023. LPA gathered information relevant to the above complaint allegations and interviewed staff and residents. Regarding the allegation that residents did not have hot water prior to an emergency evacuation, based on interviews, it was determined to be true that residents had lost access to hot water after the power outage. In regards to the allegation of insufficient staffing to meet the needs of residents, it was determined to be true based on conducted interviews. During the time of the power outage, there was not enough staff to meet residents’ needs. Substantiated The Department has investigated the above complaint allegations of a possible violation of a resident’s personal rights and insufficient number of staffing to meet the resident needs. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegations are determined to be substantiated. The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 6, Chapter 8: Maintenance and Operations and Personnel Requirements-General This report is provided and reviewed with facility representative and a copy of this report must be made available for public review upon request. Appeal rights discussed and provided.the state’s words, verbatim · CDSS document, May 1, 2024 · control 14-AS-20231023131617

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 10, 2024

87411(a): Personnel Requirements-General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on interviews with residents, the Licensee did not comply with this requirement in 1 out of 1 instances, in which the facility did not have enough staff to meet residents' needs, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 1, 2024

Plan of correction: Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 2, 2024

87468.2(a)(4): Additional Personal Rights of Residents in Privately Operated Facilities 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: (4) To care, supervision, and services that meet their individual needs. The licensee did not comply with the section cited above in 1 out of 1 instances in which residents did not have access to hot water prior to an emergency evacuation, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 1, 2024

Plan of correction: Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

Allegation investigated: -Facility staff do not properly dispose of medications which were not taken with the resident(s) upon termination of services

On March 27, 2024, Licensing Program Analyst (LPA) Komal Charitra delivered an amended copy of the LIC9099. LPA met with Co-administrator, Douglas Blake and explained the purpose of the visit. During visit today, LPA changed the report from confidential to public. Report is reviewed with Co-administrator and a copy is provided. On March 19, 2024, Licensing Program Analyst (LPA) Komal Charitra delivered a copy of amended LIC9099. LPA met with Administrator, Kaitlyn Clarey and explained the purpose of the visit. On March 19, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Kaitlyn Clarey and explained the purpose of the visit. Regarding the allegation, facility staff do not properly dispose of medications which were not taken with the resident(s) upon termination of services, according to the reporting party, facility has old medication stored for clients who no longer reside at the facility and/or are expired. During the visit, LPA interviewed administrator, facility staff and observed medication room. According to administrator, she acknowledged this allegation and indicated that when the facility reopened back in January 2024, she was unable to get the third-party waste company to come to the facility to pick up the medications, however due to unpaid invoices from previous management, the waste company provider did not come to the facility. A new medical waste company was contacted and contract was signed as of March 4, 2024 to pick up the expired medication an as of March 4, 2024. Continue to 9099C. Substantiated During the visit, LPA observed medication room on the first floor to be locked and inaccessible to clients. LPA observed a locked cabinet with expired medications and medications for residents who no longer reside at the facility. Based on interviewed staff, the expired medications and medications for residents who no longer reside at the facility has been at the facility since they've reopened back in January 2024. Staff indicated they notified the Regional Health and Wellness Director, Blanca Hurtado and the administrator, however they were unsure why the medications were not disposed of immediately after notifying them. Therefore, the allegation facility staff do not properly dispose of medications which were not taken with the resident(s) upon termination of services is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 14-AS-20240315135733

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(i) · Plan of correction due date: Mar 20, 2024

87465 Incidental Medical and Dental Care: (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of… shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following... Violation of this regulation is not met as evidenced by: Based on observations, LPA observed expired medication and medications for residents who no longer reside at the facility in a locked cabinet in the medication room. In addition, based on interviews conducted, facility staff were aware of the medications that should've been disposed since the facility reopened in January 2024.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: Facility administrator and another facility staff took the medication to a drop box at CVS pharmacy and provided LPA a copy of the medication destruction log.

Type of visit: Required - 1 Year

On March 19, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Kaitlyn Clarey and explained the purpose of the visit. LPA toured the facility inside and outside including but not limited to; resident rooms, communal bathroom, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a three story facility. LPA toured main dining room and kitchen on the first floor. Residents were observed eating lunch. LPA observed 2 days perishables and 7 days non-perishables. LPA observed medication room to be locked and inaccessible to residents. Communal bathrooms on the first floor were clean and in good repair. Communal area on the third floor was observed clean and free from tripping hazards. Chemicals, medications, and sharps were locked and inaccessible to residents. Hot water temperature throughout the facility was between 113-115 degrees. Carbon monoxide detectors are working properly. All fire extinguishers have been checked and current as of October 2023. Emergency drills are logged and done monthly. Extra linen and first aid kit was observed present. Temperature throughout the facility is comfortable and lighting is sufficient for comfort. LPA reviewed 5 resident records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are issued during the visit. Report is reviewed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Mar 19, 2024

Type of visit: Case Management - Health Checks

On January 4, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced health and safety check. LPA met with Interim Administrator, Kaitlyn Clarey and explained the purpose of the visit. During the visit, LPA observed two residents in the dining room eating lunch, one resident unpacking their belongings in his/her room. LPA observed 7-day non-perishable and 2-day perishable. According to Kaitlyn, there is one resident who requires assistance with medication. Medications were observed locked and inaccessible to residents. Residents interviewed indicated they were content to be back. A total of 5 residents have returned back to the facility, a few more residents are to return this weekend, and will continue till next week. No citations are issued during the visit. Report is reviewed with Kaitlyn and a copy is provided.the state’s words, verbatim · CDSS document, Jan 4, 2024

Type of visit: Case Management - Other

On December 6, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on a visit conducted on 11/28/2023. LPA met with Maintenance Director, German Briones and explained the purpose of the visit. LPA also spoke to Administrator, Dave Peper via phone and explained the purpose of the visit. On 11/28/2023, LPA Charitra conducted a health and safety visit as a result of facility being closed since April 2023 due to electrical disrepair. During the visit, LPA toured the facility to ensure facility is ready, safe, and comfortable for residents to move back. LPA observed the facility's water temperature to be fluctuating throughout the facility; not within regulatory requirements. In addition, LPA observed the faucet in the beauty salon to be leaking and in disrepair. On 12/6/2023, LPA made a follow up visit to ensure water temperature was within regulatory requirements and to ensure the leaking faucet in the beauty salon was fixed. During the visit today, LPA checked water temperature in 9 resident apartments (3 apartments per floor), 2 communal bathrooms, and the beauty salon. Water temperature measured between 105-120 degrees F. LPA observed faucet in the beauty salon to be repaired and in good working condition. No deficiencies are cited during the visit. LPA reviewed report with Maintenance Director and a copy is provided.the state’s words, verbatim · CDSS document, Dec 6, 2023

Type of visit: Case Management - Health Checks

On November 28, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management health and safety visit at the facility as a result of facility being closed since April 2023 due to electrical disrepair. LPA met with Administrator, Joan Johnson, Regional Vice President of Operation with Integral Senior Living, Debi Witt, Vice President of Operation with Cogir Management, Dave Peper and Executive Vice President of with American Health Care, Ray Oborn. LPA toured the facility inside and outside including all three of the facility floors, resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No residents were present at the facility due to facility closure. While touring the facility it was observed that the room temperature was at 71F. Hot water throughout the facility measured between 121-125 degrees F. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current as of October 2023. Resident apartments and bathrooms were observed to be in good repair, bathrooms equipped with grab bars and non-skid mats. Due to the emergency relocation, most residents took their personal belongings to the facilities they've been relocated to. Beauty salon faucet was observed to be leaking and in disrepair. 7-day non-perishable was present, however 2-day perishables was not present as facility is still closed. Facility will purchase 2-day perishables the day before facility reopens and provide LPA a photo of receipt of perishables purchased. Medication room and medication cabinet were both observed to be locked. Required postings were observed to be present on the 1st floor. Facility is overall clean, however LPA to make a follow up visit to ensure facility water temperature is within regulatory requirements and faucet in the beauty salon has been repaired. Report is reviewed with Administrator, Joan Johnson and Regional Vice President of Operation, Debi Witt.the state’s words, verbatim · CDSS document, Nov 28, 2023

Allegation investigated: Staff are not ensuring resident has privacy Staff are discriminating against resident Staff did not ensure resident's room was free of pest

On October 24, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Joan Johnson and explained the purpose of the visit. Regarding the allegation staff are not ensuring resident has privacy, according to the reporting party, staff are entering into Resident 1's (R1's) room without permission. According to the reporting party, R1 is germaphobic and does not want anyone to enter his/her room. In addition, according to the reporting party, an agency staff member (name not identified) entered R1's room without knocking and was staring at R1's shower curtain while R1 was taking a shower. During the investigation, LPA interviewed staff and reviewed records. According to staff interviewed, staff respects R1's wishes and does not go into his/her room unless R1 allows staff to enter. In addition, interviewed staff acknowledged that the facility did use agency caregivers and they were not aware of R1's phobias, however facility administrator at the time tried to instruct all staff members to knock/ring R1's door prior to entering to respect his/her request. Based on Belmont Police Incident Report reviewed, R1 advised staff to come in and check on him/her, however the agency caregiver went into R1's room while R1 was in the shower, apologized and immediately walked outside. According to the Incident Report, R1 was concerned that the new staff was bringing germs into his/her room. (Continue to 9099C). Unsubstantiated Regarding the allegation that staff are discriminating against resident, according to the reporting party, Resident 1 (R1) is being discriminated against for standing up and eating and was told she can’t be in there if he/she is standing. During the investigation, LPA interviewed staff. Administrator denied this allegation and indicated that no staff has told R1 that he/she can't eat in the dining room if he/she is standing. Based on staff interviews, residents addressed to administrator that they were uncomfortable eating because R1 would be standing and eating in the dining room with his/her back towards residents, and would wear a garbage bag. Regarding the allegation that staff did not ensure resident's room was free of pests, according to the reporting party, the facility failed to ensure pests/flies were not in Resident 1's (R1's) room as R1 has OCD and is germaphobic. During the investigation, LPA was unable to tour and observe R1's room due to facility closure, however LPA interviewed staff. According to 3/3 staff interviewed, R1 has OCD, is germaphobic and hoards items in his/her room. Staff interviewed indicated that R1 would not allow any staff to come into his/her room, including housekeepers due to his/her phobias. In addition, according to interviewed staff, when R1 addressed the flies/pests issue to management, ECO-Lab was notified immediately and they came on a regular basis to inspect the facility. Due to R1's phobias, R1 did not let anyone in his/her apartment to inspect or treat the alleged pests. Based on the interviews conducted, record review, and information collected, the allegations above are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed with Administrator, Joan Johnson and a copy is provided.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 14-AS-20231002160539

Type of visit: Case Management - Other

On September 29, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on a letter that was received from state official. LPA met with Resident Care Director, E. Dewitt and explained the purpose of the visit. On September 24, 2023, the Department was notified by the state official of a letter that was sent to Resident 1 (R1) in regards to potential eviction due to non-compliance. R1 has been a resident at Vista Terrace of Belmont prior to the emergency evacuation. LPA requested copies of R1's signed admission agreement, physician's report, care plan, however according to interviewed staff, R1's file has been misplaced and no where to be found. In addition, it was indicated that R1 does not have a signed admission agreement. According to Resident Care Director, R1 refused to sign the admission agreement. R1's physician's report was observed to be dated 12/20/2021. According to the Resident Care Director a care conference was held on 4/19/2023, with R1, R1's family member, administrator, resident care director, and ombudsman regarding R1's care concerns and R1 was to call his/her PCP to schedule a physical on 4/21/2023 or 4/24/2023. Resident Care Director indicated R1 did not schedule the physical due to the emergency evacuation on 4/28/2023. Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Resident Care Director. A copy of this report and the Appeal Rights is provided.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Oct 6, 2023

87507 Admission Agreement: (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission... Violation of this regulation is not met as evidenced by: Based on record review, facility failed to maintain a copy of a signed and dated admission agreement for R1 prior to admission at Vista Terrace of Belmont.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator shall submit a written plan to ensure facility maintains signed and dated copies of admission agreements for each resident.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Oct 6, 2023

87506 Resident Records: 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 readily available to facility staff and to licensing agency staff. Violation of this regulation is not met as evidenced by: Based on record review and staff interviews, facility misplaced R1's file and are unable to provide R1's records (admission agreement, pre-appraisal, care plan) to licensing staff when R1 was residing at Vista Terrace of Belmont, prior to the emergency evacuationthe state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator to submit a written plan in writing describing how facility will ensure complete and current resident records are maintained as indicated on CCR 87506

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Oct 6, 2023

87458 Medical Assessment : (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. Violation of this regulation is not met as evidenced by: Based on record review, R1's physicians report is dated 12/20/2021 and R1 had a change in condition that was discussed during a care conference on 4/19/2023. Nevertheless, the facility failed to ensure R1's physician's report was current.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator to submit a plan in writing regarding how to ensure residents will follow up with their PCP is there is a change of condition or if a new physician's report is needed.