Vivante on the Coast

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by staff and explained the purpose of the visit. On February 9, 2026, the Orange County Regional Office received an incident report regarding an unwitnessed fall of Resident 1 (R1). The investigation determined the following: R1 was admitted to the facility on November 1, 2025. Per incident report, R1 had an unwitnessed fall on February 3, 2026. Staff was present when R1 fell, but they did not witness the fall itself. R1 was transported to the hospital on February 3, 2026, where an X-ray of the right shoulder revealed an acute neck fracture. R1 was treated and returned to the facility the same day. Interviews with six out of six staff stated R1 was able to ambulate with a walker or cane prior to the fall. Three out of those six staff added fall mitigation measures were implemented including lowering R1’s bed to the lowest position; placing a mat next to the bed; having R1 participate in physical therapy; and enrolling R1 in a toileting program that takes R1 to the bathroom every two to three hours. R1’s physician report dated October 28, 2025, did not indicate any motor impairment and noted R1 was able to transfer independently to and from bed. The physician’s report indicated R1 was ambulatory. Per R1’s Resident Assessment dated November 1, 2025, R1 ambulates without assistive devices and was independent in mobility but used a cane. Although R1 sustained a fall, it remains unclear if the fall occurred as a result of neglect. Based on the investigation, the Department has concluded there is insufficient evidence to support the allegation staff neglected or failed to provide a sufficient level of care in R1 having an unwitnessed fall leading to a fractured right shoulder. Therefore, the allegation is deemed unsubstantiated. A copy of this report was provided to Administrator Bob Fiorentinothe state’s words, verbatim · CDSS document, Jun 26, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Robert Fiorentino and discussed the purpose of the visit. LPA arrived at the facility to collect documents for Resident #1 (R1) and was informed by AD that the facility does not have access to nurses notes, etc. for R1 at the time of request due to the facility changing systems and not being able to gain access to the old system. Based on interviews conducted a citation is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report, LIC9099D and appeal rights were provided to the facility at the time of the visit.the state’s words, verbatim · CDSS document, Mar 18, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Apr 8, 2026

Resident Records 87506(e ) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by: AD informed LPA that they do not have access to documents from their previous system to see documents pertaining to R1s file. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Licensee stated they will request access to the system to provide documents to LPA and send a statement of understanding by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Bob Fiorentino and discussed the purpose of the visit. LPA gathered documentation for Resident #1 (R1) that was requested by the Department on January 15, 2026. AD informed LPA that they sent the requested documents and provided LPA with email proof that they were sent on March 6, 2026, and provided copies to LPA. LPA discussed with AD that documents are to be given upon request. An exit interview was conducted and a copy of this report along with a technical violation were given at the time of the visit.the state’s words, verbatim · CDSS document, Mar 10, 2026

Type of visit: Case Management - Health Checks

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Fred Arias for the purpose of a health and safety check. LPA met with Assistant Executive Director (AED) Maggie Pantaleon, Senior Executive Director (SED) Bob Fiorentino, and Shores Program Director Danica Coronel and explained the purpose of the inspection. During the inspection, LPA and AED toured the facility. LPA conducted health and safety checks on residents and confirmed they were doing well and observed no health and safety issues. LPA observed the facility clean and organized. LPA observed utility services operational. LPA requested and reviewed copies of resident roster, staff roster, and resident files. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by staff and explained the purpose of the visit. On July 17, 2025, the Orange County Regional Office received an incident report regarding an unwitnessed fall of Resident 1 (R1). The investigation determined the following: R1 had been admitted to the facility on December 31, 2021, and was a documented fall risk per facility fall risk assessment conducted on December 15, 2021. R1 sustained unwitnessed falls on April 14, 2023; January 4, 2025; January 5, 2025; March 11, 2025; June 19, 2025; July 5, 2025; and July 11, 2025. Physician communications between the facility and R1’s physician and facility progress notes for R1 confirmed R1 sustained a total of seven falls. Although R1’s assessment appraisals was updated at least six times during the falls and identified them as a fall risk, the facility did not document or implement specific fall-prevention interventions or mitigation measures. On July 11, 2025, at approximately 4:30am, R1 was found on the floor of their apartment following an unwitnessed fall as indicated on the progress note and physician communication for R1 dated the same day. Interviews with two out of three facility staff confirmed that R1 did not activate their pendant to request assistance. All three staff interviewed reported that no routine safety checks were conducted during the night shift for R1 despite R1’s history of falls. Facility records documented that R1 had signed a Night Shift Resident Check Waiver during the admission process on December 15,2021 indicating they did not want to be checked on during the night, despite R1 being identified as a fall risk. R1 was transported to Hoag Memorial Hospital for evaluation on July 11,2025, where diagnostic imaging revealed multiple compression fractures, including acute fractures of S1, L4, and T12, as well as chronic compression fractures of L1 and T13. R1 passed away on July 14, 2025, while hospitalized. Based on the totality of evidence obtained, the Department has concluded that the facility failed to provide adequate care and supervision to a known fall-risk resident by not implementing reasonable safety measures or monitoring practices resulting in R1 sustaining an unwitnessed fall and injury. The following is being cited per California Code of Regulations, Title 22. A Civil Penalty is pending determination by Community Care Licensing Division as per H&S Code 1569.49(f). An exit interview was conducted with Senior Executive Director Bob Fiorentino and Assistant Executive Director Maggie Pantaleon and a copy of this report, the LIC 809-D, the LIC 421IM and Appeal Rights were provided to the facility. A copy of this report will be mailed to the licensee to the address on file.the state’s words, verbatim · CDSS document, Jan 23, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 24, 2026

Basic Services 87464(f)(1) Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: The Licensee failed to identify fall preventative measures needed to meet R1’s needs resulting in R1 sustaining multiple falls and obtaining a fracture diagnosis on the last fall. This poses an immediate risk to resident’s health and safety.the state’s words, verbatim · CDSS document, Jan 23, 2026

Plan of correction: SED stated interventions are put in place based on the fall risk assessment conducted by the Director Health Services. An in-service training will be conducted to ensure intervention measures are implemented for those residents identified as a fall risk. SED to provided proof of training to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(c)(3) · Plan of correction due date: Jan 30, 2026

Reappraisals 87463(c)(3) … the licensee shall document all of the following in the resident’s reappraisal: Interventions to be implemented to minimize the risks to the health and safety of the resident... This requirement is not met as evidenced by: The Licensee failed to document interventions to be implemented to minimize falls after identifying R1 as a fall risk. This poses a potential risk to resident’s health and safety.the state’s words, verbatim · CDSS document, Jan 23, 2026

Plan of correction: SED stated in-service training will be conducted to ensure intervention measures are documented in the resident's file.

Type of visit: Case Management - Health Checks

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Fred Arias for the purpose of a health and safety check. LPA met with Assistant Executive Director (AED) Maggie Pantaleon and Senior Executive Director (SED) Bob Fiorentino and explained the purpose of the inspection. During the inspection, LPA and AED toured the facility. LPA conducted health and safety checks on residents and confirmed they were doing well and observed no health and safety issues. LPA observed the facility clean and organized. LPA observed utility services operational. LPA requested and reviewed copies of resident roster, staff roster, and resident files. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Case Management - Health Checks

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Fred Arias for the purpose of a health and safety check. LPA met with Executive Director (ED) Selene Lopez and Senior Executive Director (SED) Bob Fiorentino and explained the purpose of the inspection. During the inspection, LPA and ED toured the facility. LPA conducted health and safety checks on residents and confirmed they were doing well and observed no health and safety issues. LPA observed the facility clean and organized and found no health and safety issues. LPA observed utility services operational. LPA requested and reviewed copies of resident roster and resident files. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Fred Arias and Kimberly Lyman arrived unannounced for the purpose of conducting the Required 1 Year Annual Evaluation. LPAs were greeted and granted entry by staff and explained the reason for the visit. LPAs met with Senior Executive Director (SED) Bob Fiorentino, Executive Director Selene Lopez and Assistant Executive Director Maggie Pantaleon. There are two buildings, north and south, with separate entries. The South Building, 1640, is comprised of an Assisted Living (AL) and Memory Care (MC). The North Building, 1650, is comprised of an AL. All common areas in both buildings were inspected which includes but is not limited to: Fitness Centers, pool/jacuzzi, dinning area, emergency food and water storage, rec room, and activity rooms. LPAs inspected ten resident apartments which had all required elements. The residents' personal bathrooms were checked. Toilets, water faucets, and grab bars were secure. Showers were free of mold/mildew. The hot water temperature for the ten bathrooms measured within range as per regulation between 108.3 and 116.2 degrees Fahrenheit. LPAs inspected the kitchens. Facility maintains ample supply of perishables and non-perishable food. At 11:05am, LPA observed a gallon of bleach stored under the sink unlocked in the prep kitchen in the memory care area. The fire extinguishers were mounted and fully charged. The smoke detector testing passed on September 8, 2025 and September 10, 2025 per the fire alarm system inspection report conducted by VFS Fire & Security Services. LPAs toured the outside grounds. LPAs observed the courtyards which had sufficient shading and seating. The walkways were clear of hazards. The swimming pool gates were secure. LPAs observed sufficient emergency food and water in both buildings. LPAs observed residents participating in activities such as exercising, swimming, and story time. Continued on LIC809-C dated 10/15/2025 Emergency evacuation drills are conducted quarterly with the last drill conducted on September 18, 2025. LPAs observed the 'See Something, Say Something' (PUB475) poster in the correct size. Facility maintains a current liability insurance. LPAs conducted an audit of ten residents' files and ten personnel files. No discrepancies noted. Medications were audited. No discrepancies noted. Based on the observations made during today's visit, a deficiency is being cited. An exit interview was conducted and a copy of this report was provided along with appeal rights.the state’s words, verbatim · CDSS document, Oct 15, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility did not follow safe food handling practices.

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. It was alleged facility did not follow safe food handling practices. During the investigation, LPA conducted interviews with staff, reviewed records obtained and made observations. The investigation determined as follows: regarding the allegation facility did not follow safe food handling practices, it was reported resident 1 (R1) ate contaminated food. LPA record review revealed R1’s son reported R1 had vomited during on outing on April 7, 2021. Upon his return the same day to the facility, R1 reported they were fine and no longer nauseous. On April 8, 2021, R1 had diarrhea and the facility sent R1 to the hospital for evaluation. Continued on LIC9099-C dated 08/22/2025 Unsubstantiated R1 returned to the facility on April 10, 2021 from the hospital with a diagnosis of C-diff. Resident was prescribed antibiotics and was placed on isolation precautions. LPA interviews with three out of three staff stated the kitchens in both the north and south buildings have never been closed due to contamination. One out of three staff stated they recall an instance from April 11, 2021 to April 13, 2021 when in-person dining services were suspended due to an outbreak of Rotavirus. The facility followed isolation and sanitation protocols and offered meals delivered to residents in their rooms prepared in the facility kitchens. On a previous visit on July 29, 2025 regarding this complaint, LPA reviewed valid food handler certificates for 104 current kitchen staff. LPA toured the facility and observed kitchen staff following sanitation protocols including wearing gloves while prepping food, using separate types of cutting boards for meats and produce, and washing of kitchen utensils and tools in both the north building kitchen and south building kitchen. A third party Dietician report for the facility dated June 17, 2021 did not indicate any major concerns for the facility kitchens. A third party Dietician report for the facility dated July 17, 2025 did not indicate any major concerns for the facility kitchens and stated "Overall, the kitchen was in compliance with temperature requirements, safe, and organized." for each kitchen observed. Therefore based on staff interviews, records observed, and LPA observations, the allegation facility did not follow safe food handling practices is therefore deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 22-AS-20210409100807

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Case Management visit. LPA was greeted and granted entry by North Executive Director Selene Lopez and explained the reason for the visit. During today's visit, LPA interviewed three staff and obtained the following documentation for review: resident/ personnel rosters (for north/south buildings), memory care staff assignment, fingerprint clearance for Individual #1 (I1), face sheet, physician's report, appraisal, needs and services plan, and admission agreement. PD stated that the home care agency documentation for Resident #1 (R1) will be submitted to LPA by end of today's business day. No deficiencies are being cited. An exit interview was conducted with North Executive Director Selene Lopez and Shores Program Director Danica Coronel, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Aug 13, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to follow up on the deficiencies issued during the Case-Management- Deficiencies and Complaint visits on July 29, 2025 from 10am to 3:40pm. Based on the review of the two type A deficiencies, 87464(f)(1) and 87465(g), cited during the complaint investigation visit for complaint control no. 22-AS-20250130140500, facility has complied with the terms of the Plan of Corrections (POCs). Based on the review of the three type A deficiencies, 87412(e)&(h), 87463(a), 87211(a)(1), cited during the case-management visit, facility has complied with the terms of the POCs. An exit interview was conducted with Shores Program Director Danica Coronel, and a copy of this report including the five Letter of Deficiency Citations Cleared were provided at the end of this visit.the state’s words, verbatim · CDSS document, Aug 13, 2025

Allegation investigated: Staff did not prevent resident from being assaulted at the facility resulting in multiple injuries. Facility did not seek medical attention in a timely manner.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of delivering the investigation findings into the above allegations. LPA met with Assistant Executive Director Maggie Pantaleon, Shores Program Director Danica Coronel, and North Executive Director Selene Lopez after explaining the reason for the visit. On January 30, 2025, the Department received a complaint alleging neglect/lack of care and supervision of Resident #1 (R1) and Resident #2 (R2), and the investigation was initiated on January 31, 2025. During the course of the investigation, the Department interviewed thirteen staff and two witnesses and obtained the following documentation: Resident Rosters South building (November 7, 2024 and current), Personnel Report Summary, Personnel Contacts, November 2024 Caregiver Schedule for Memory Care (MC), November 2024 Licensed Vocational Nurse/Medication Technician Schedule, November 2024 Concierge Schedule MC, Face Sheets, Physician's Reports, Memory Care Appraisals, Service Agreements, Progress Notes, Hoag Hospital Medical Records, and Police Records involving Resident #1 (R1) and Resident #2 (R2). Substantiated Regarding the allegation, Staff did not prevent resident from being assaulted at the facility resulting in multiple injuries, the investigation is as follows: On November 19, 2024, at or approximately 3:30pm, Staff #1 (S1) and Staff #4 (S4) was called for assistance concerning a scream coming from R1’s room in the memory care unit. A witness, who had heard the scream through the shared wall, observed R2 exiting R1’s room at the time the screaming occurred. R1 was observed on the floor alone with discoloration to the face and reported being punched by a male resident. The medical report dated January 2, 2025 of page 156 diagnosed R1’s injury as a closed traumatic nondisplaced fracture of neck of the left femur as a result of the fall caused by the punch. Based on the review of R2’s records, R2 was admitted to the facility on August 12, 2024. R2 resides in the memory care unit and has a diagnosis of Dementia, confusion/disorientation with sundowning behavior, and was noted not to display any inappropriate or aggressive behaviors per the Physician’s Report dated August 7, 2024. However, there were twelve instances where R2 displayed behaviors prior to the incident occurring on November 19, 2024, all of which were documented on the progress notes with the first incident starting the next day R2 moved in. Examples of incidents include R2 continuously wandering into residents’ rooms, physically assaulting residents and staff (by hitting, grabbing, pushing, and throwing objects) between the period of August 13, 2024 to October 31, 2024. The September 13, 2024 memory care appraisal also documented R2 not exhibiting behaviors and requiring status checks at regular intervals even though there were six documented instances prior to September 13th. Conversely, the service agreement dated September 13, 2024, documented R2 requiring “staff intervention and/or redirection” due to exit seeking and wandering behaviors which contradicts the appraisal. Per the November 2024 caregiver schedule, seven staff were scheduled during the 2pm-10pm shift which was verified per the time cards for November 19, 2024. There were 52 memory care residents registered on November 19, 2024 also confirmed by staff. Based on the interviews, thirteen out of the thirteen staff did not recall the care staff assigned to monitor R1 and R2 on November 19th. Two direct care staff, Staff #2 (S2) and Staff #3 (S3) confirmed conducting checks on R1 at approximately 2pm. The Department requested copy of the care staff assignment for November 19, 2024, to demonstrate adequate staff coverage, however the facility failed to provide requested documents stating that care staff assignments were archived and kept only for 90 days. Out of the thirteen staff, four reported insufficient staffing and indicated that many other staff expressing the need for an additional staff for R2 multiple times prior to the incident. It was reported that facility accepted the wishes of R2’s family not to implement any changes of care, therefore additional staff was not provided. Two staff reported having 5-6 staff on duty during the PM shift on November 19th, however staff expressed challenges caring for R2 with six staff as R2 required constant monitoring. Regarding the allegation, facility did not seek medical attention in a timely manner, the physical assault occurred at or approximately 3:30pm on November 19, 2024. R1 sustained a closed traumatic non-displaced fracture of neck of the left femur as a result of the punch thrown by R2, exacerbated their chronic back pain, developed a new left hip pain, and was hypoxic per page 156 of the hospital medical report. S1 and S4 reported to R1’s room after being informed by a witness who heard the scream coming from R1’s room. S1 and S4 found R1 on the floor visibly upset with discoloration to the face and complained of generalized pain. S1, S4, and Staff #5 (S5) performed a physical assessment on R1 including the upper and lower extremities and observed no visible injuries per staff interviews. The facility record “Outside Agency Documentation” dated November 19, 2024, documented R1 meeting with their social worker for their weekly therapy appointment following the incident from 3:40pm-4:55pm. Prior to the visit, R1 was asked by S3 and the social worker if R1 wanted to reschedule the visit. R1 expressed wanting to proceed with the visit but continued to complain feeling sore from the fall during the meeting. Staff assumed that R1 is “doing okay” at approximately 5:18pm as R1 was eating their dinner and conversing with other residents at their table. However, facility progress notes document that R1 continued to complain of pain, so 911 was called at 6:03pm. It was reported that R1’s representative who had arrived at the facility between 6-7pm had prompted the staff to call 911 because the call had not been made which was aligned with the documentation on the Physician Communication for R1 dated November 20, 2024. The investigation revealed substantial evidence corroborating the need for additional staff for R2 based on the information obtained during the interviews and the increase in behaviors that were documented on the progress notes between August 13th to November 20, 2024. There were twelve documented incidents that occurred prior to November 19th. The need for increased staffing for R2 was critical to ensure the safety and well-being of R2 and other residents and staff. Regarding seeking medical attention in a timely manner, although there were no visible injuries as per interviewed staff, R1 had complained of pain at the time of the physical assessment after the fall. R1 continued to express pain at their weekly therapy appointment and dinner. The physician’s report dated February 21, 2024, documents R1 being able to communicate their needs. Even though R1 had no visible injuries as per interviewed staff and had allegedly refused medical treatment initially, it was imperative that facility sought medical attention considering the nature of the fall and R1’s Dementia diagnosis. R1 did not receive medical attention until 3 hours later after the fall and not before family member prompted the staff to call 911 even though R1 continued to express pain. Therefore, based on the Department’s interviews and the review of records, the preponderance of evidence standard has been met, therefore the following allegations: Staff did not prevent resident from being assaulted at the facility resulting in multiple injuries and Facility did not seek medical attention in a timely manner are deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of California Code of Regulations. Deficiencies are being cited on the attached LIC9099D, and an immediate Civil Penalty (CP) is being assessed. See the attached LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) as per Health & Safety Code 1569.49(f). An exit interview was conducted with Assistant Executive Director Maggie Pantaleon, Shores Program Director Danica Coronel, and North Executive Director Selene Lopez in person and Executive Director Bob Fiorentino by telephone, and a copy of this report including the LIC9099Cs, LIC9099D, LIC421IM, LIC811s, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 22-AS-20250130140500

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 30, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews and record review, licensee did not find a solution necessary to prevent and address R2’s behavior needs (i.e. aggressive behaviors) resulting in R1 sustaining injuries from the assault due to lack of care and supervision.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Assistant Executive Director, Shores Program Director, North Executive Director, and Executive Director stated that R2 was reassessed, sent to pscyh eval, and a private caregiver was retained by R2's family. The above individuals indicated that a psych eval will be conducted upon admission if needed as well as ensure sufficient coverage of staffing to meet the residents needs and an Acknowledgement of Understanding of the said deficiency and the above statement will be submitted to LPA by POC due date.

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

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: Based on interviews and record review, R1 complained of pain at the time of the physical assessment after the fall and continued to express pain resulting in a 3-hour delay to seek medical attention.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Assistant Executive Director, Shores Program Director, North Executive Director, and Executive Director stated that proof of an in-service training covering 911 calls in the event of an incident/emergency and an Acknowledgement of Understanding of the said deficiency will be submitted to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced Case-Management-Deficiencies visit and met with Executive Director Bob Fiorentino by telephone and in person with North Executive Director Selene Lopez, Assistant Executive Director Maggie Pantaleon, and Shores Program Director Danica Coronel and explained the reason for the visit. During the investigation of Complaint Control #: 22-AS-20250130140500, the following deficiencies were discovered: The investigation revealed that when facility care staff assignments from November 19, 2024, were requested, Staff #1 (S1) indicated that caregiver assignments have been archived while Staff #2 (S2) indicated that caregiver assignments are only kept for 90 days which is in violation of the Title 22 regulation requiring records to demonstrate adequate staff coverage necessary for facility operations be retained. Based on the review of records, the facility was not updating documented behaviors of Resident #1 (R1) from September 2024 to October 2024 on the service plan dated/effective on December 15, 2024. The service plan documented the incidents occurring in November 2024. The incidents never addressed the increase and frequency of R1’s aggressive behaviors and if additional staff was needed to meet the behavioral needs of R1. Additionally, the facility did not self-report any incidents involving R1 documented in the facility’s Progress Notes dating back from August 13, 2024 which is in violation of the Reporting Requirements which also includes any incidents which threatens the welfare, safety, or health of any resident. Therefore, deficiencies are being cited as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809Ds. An exit interview was conducted with Executive Director Bob Fiorentino by telephone and in person with North Executive Director Selene Lopez, Assistant Executive Director Maggie Pantaleon, and Shores Program Director Danica Coronel, and a copy of this report wiht the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(e)&(h) · Plan of correction due date: Jul 30, 2025

87412 Personnel Records (e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. (h) All personnel records shall be retained for at least three (3) years following termination of employment. This requirement was not met as evidenced by: Based on interviews and record review, staff assignments for 11/19/24 were not provided during the investigation as they were archived and only kept for 90 days.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Assistant Executive Director, Shores Program Director, North Executive Director, and Executive Director stated that an Acknowledgement of Understanding of the said deficiency will be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(a) · Plan of correction due date: Jul 30, 2025

Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. This requirement was not met as evidenced by: Based on interviews and record review, the service plan for R1 was incomplete as it did not document behaviors from September 2024 to October 2024 and include how the facility will address the increase or frequency of R1’s aggressive behaviorsthe state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Assistant Executive Director, Shores Program Director, North Executive Director, and Executive Director agreed to submit proof of R1's appraisal, conduct an inservice with staff, and submit an Acknowledgment of Understanding of the said deficiency by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 30, 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 and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below… This requirement was not met as evidenced by: Based on record review, facility did not furnish written incident reports to the Department involving R1 since 8/13/24 with the exception of the incident on 11/19/24.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Assistant Executive Director, Shores Program Director, North Executive Director, and Executive Director stated that proof of in-service training covering reporting requirements will be submitted to LPA by POC due date.

Allegation investigated: Facility staff failed to seek medical attention in a timely manner Facility staff speak inappropriately to resident Staff do not ensure that facility carpets are kept clean

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. An initial investigation via telephone was conducted on May 17, 2021 by LPA Lydia Martinez. During the call, LPA Martinez requested pertinent facility and resident records. It was alleged facility staff failed to seek medical attention in a timely manner, facility staff speak inappropriately to resident, and staff do not ensure the facility carpets are kept clean. During the investigation, LPA Arias conducted interviews with clients in care and staff. LPA Arias reviewed records obtained. The investigation determined as follows: Regarding the allegation facility staff failed to seek medical attention in a timely manner, it was reported staff did not seek medical care for Resident 1 (R1). Continued on LIC9099-C dated 07/24/2025 Unsubstantiated LPA record review revealed R1 began receiving wound care by Home Health May 17, 2021 on their left leg due to tubi grip used to manage R1's leg swelling. Home Health nurse recommended wound care evaluation by physician in which R1 declined to do so. Wound care by Home Health continued several times per month. R1 was diagnosed with basal cell carcinoma of skin of left lower limb and was admitted for surgery June of 2022. Home Health wound care continued after and wound healed September of 2022. Based on R1's physician's report dated July 8, 2022, R1 is cognitive. Regarding the allegation, facility staff speak inappropriately to resident, it was reported staff members made fun of R1's weight. LPA interviews with three out of three staff familiar with R1 stated they have never made fun of or observed any other staff make fun of or speak inappropriately to R1. LPA interviews with three out of three residents stated staff is friendly and attentive. Three out of three residents stated they have never been spoken to inappropriately or have observed other residents being spoken to inappropriately by staff. Regarding the allegation staff do not ensure that facility carpets are kept clean, it was reported R1's carpet in their room had not been cleaned in two years. LPA interviews with 2 out of 3 staff familiar with R1 stated they do not recall seeing dirty carpets in R1's room. LPA observed R1's room who was now being occupied by another resident has wood panel flooring. The remaining 1 out of 3 staff stated the wood panel flooring was present when R1 lived at the facility. LPA interviews with 3 out of 3 residents stated staff always helps them clean their apartments. Therefore based on client interviews, staff interviews, records observed, and LPA observations, the allegations of facility staff failed to seek medical attention in a timely manner, facility staff speak inappropriately to resident, and staff do not ensure that facility carpets are kept clean are therefore deemed unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of the report was left with the facility representative. LPA record reviewed revealed R1 did not have a responsible party on file. R1 was admitted to the facility on July 16 2013. The admission agreement was signed by R1 as the resident with no responsible party listed. LPA reviewed the latest face sheet for R1 printed on July 24, 2025, there was no responsible party listed. R1's physician's report dated July 8, 2022 showed R1 is cognitive. One out of one staff interviewed stated there was no responsible person or durable power of attorney on file during R1's stay at the facility. Regarding the allegation staff do not adhere to the terms in the resident's admission agreement, it was reported R1 was being charged additional fees for medication management without informing R1. LPA record reviewed revealed R1's physician's report dated July 8, 2022 did not allow R1 to administer own medications. Assessment conducted by the facility on April 2, 2022 indicated R1 required assistance with medication administration. The assessment was signed by the facility representative and R1. The facility provided R1 with invoice including care fees due on May 1, 2022. Based on record review and staff interview, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report was left with the facility representative.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 22-AS-20210505135400

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check of the residents at the facility. LPA was greeted and granted entry by staff. LPA met with Assistant Executive Director Maggie Pantaleon and explained the reason for the visit. LPA and staff toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured between 105.9 and 113.1 degrees Fahrenheit. LPA observed the kitchens are clean and organized. LPA observed residents participating in activities. LPA reviewed Resident 1 (R1)'s file. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 18, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Fred Arias made an unannounced case management visit to follow-up on an Unusual/ Special Incident Report (SIR) received in our Regional Office on February 20, 2025. LPA was greeted and granted entry by staff. LPA met with Health Services Director (HSD) Deisi Lujan-Ramirez, Executive Director (ED) Selene Lopez and Assistant Executive Director Maggie Pantaleon and explained the purpose of the visit. LPA obtained the following for review: Appraisal dated 2/1/2025, Service Agreement, and Needs and Services plan for Resident 1 (R1). Facility had already provided a physician's report and additional appraisals dated 1/9/2025 and 2/18/2025 prior to the visit. HSD explained the details of the incident and reviewed the facility protocols for high fall risk residents. R1 had been placed in hospice care on 1/31/2025, prior to the incident and was reported to our Regional Office by fax. LPA interviewed three staff members who were familiar with the resident. Staff members stated that resident was checked on approximately every two hours or more often in cases when R1 pressed their pendant. Pendant activation is logged into the facility's internal online systems. During the month of the incident, the resident was checked on at an average of 10-15 times per day. At the time of the incident, the resident's pendant was pressed and a staff member was at their unit in less than 3 minutes. Based on the observations, record review and interviews made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted and a copy of this report was given to the facility representative.the state’s words, verbatim · CDSS document, Mar 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Jessica Cho and Edward Kim arrived unannounced for the purpose of conducting the Required 1 Year Annual Evaluation using the Care Inspection Tool. LPAs were greeted and granted entry by Business Office Assistant (BOA) Samantha Stacey and explained the reason for the visit. LPAs met with Senior Executive Director (SED) Bob Fiorentino and Executive Director Selene Lopez. The facility is licensed to serve 430 residents of which 45 can be bedridden. Hospice waiver total care is 30. As of today, the resident census is 348 of which 19 are receiving hospice care. There are two buildings, north and south, with separate entries. The South Building, 1640, is comprised of an Assisted Living (AL) and Memory Care (MC). The North Building, 1650, is comprised of an AL. All common areas in both buildings were inspected which includes but is not limited to: Fitness Centers, pool/jacuzzi, Physical Therapy Center, Restaurant/Bar, emergency food storages, salon, library, movie theater, Rec Room, Activity Rooms, Dance Studio, Wellness Offices, dining rooms, and management offices. LPAs inspected twelve resident apartments which had all required elements. The residents' personal bathrooms were checked. Toilets, water faucets, and grab bars were secure. Showers were free of mold/mildew. The hot water temperature for the twelve bathrooms measured within range as per regulation between 107.4 and 119.6 degrees Fahrenheit. LPAs inspected the kitchens. Facility maintains ample supply of perishables and non-perishable food. The fire extinguishers were mounted, fully charged, and serviced on August 22, 2024. The smoke detector testing passed on May 6-7, 2024 per the fire alarm system inspection report conducted by VFS Fire & Security Services. LPAs toured the outside grounds. LPAs observed the courtyards which had sufficient shading and seating. The walks ways were clear of hazards. The swimming pool gates were secure. LPAs observed sufficient PPE and emergency disaster supplies including food/water in the storage rooms in both buildings. Emergency evacuation drills are conducted quarterly and facility is maintaining a log. Facility tests the generator monthly per the testing report dated August 20, 2024. LPAs observed the 'See Something, Say Something' (PUB475) poster in the correct size. Facility maintains a current liability insurance. LPAs conducted an audit of twelve residents' files and ten personnel files. No discrepancies noted. Medications were audited. No discrepancies noted. Staff and resident interviews were also conducted. Based on the observations made during today's visit, no deficiencies are being cited. An exit interview was conducted with Senior Executive Director Bob Fiorentino and Executive Director Selene Lopez, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Sep 23, 2024