Walnut Creek Willows

Type of visit: Case Management - Other

On 08/17/26, Licensing Program Analyst (LPA) conducted a subsequent unannounced case management visit and met with staff (Licensee (LC) and Administrator (ADM)). LPA explained the purpose of the visit with staff. At 12PM, LPA obtained the original case management reports dated 08/13/26 from Licensee/Administrator and gave them the amended case management reports dated 08/17/26. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 17, 2026

Type of visit: Case Management - Other

This is an AMENDMENT to the case management report dated 08/13/26. On 08/17/26 at 11:30AM, Licensing Program Analyst (LPA) conducted a subsequent unannounced case management visit and met with staff (Licensee (LC) and Administrator (ADM)). LPA explained the purpose of the visit with staff. On 08/13/26 at 1PM ,LPA advised staff that a facility staff member shared private information regarding a resident residing at the facility to another resident's family member. Staff (LC, ADM) stated that they will conduct an in-service retraining on all staff on residents' personal rights. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Sep 11, 2026

To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by a staff member sharing personal information on a resident which poses a potential healt and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: By POC due date, ADM agrees to complete and submit in-service staff retraining on residents' personal rights in compliance with Section 87468.2 regulations.

Type of visit: Case Management - Deficiencies

On 07/02/2026 at 3:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit. LPA met with Assistant Administrator, Lynette Sandoval, and explained the purpose of the visit. While LPA was at the facility for another visit, LPA observed the following deficiencies were not cleared from previous visits on 02/03/26 and 06/02/26 with Plan of Correction (POC) due dates 02/04/26, and 06/09/26 : Deficiencies not cleared: 87309(a) Type A $1000.00 87463(a) Type B $250.00 Civil Penalties assessed today at $1250.00. These deficiencies are being re-cited with repeat violation civil penalties for failure to correct by POC due date. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 20, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions...and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having Clorox Bleach and Shurgard HP disinfectant chemicals inaccessible to residents in unlocked laundry room and Clorox Bleach under cabinet in memory care unit which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Administrator will conduct In-Service training with all staff and submit sign-in sheet to CCLD by POC due date. Repeat Civil Penalty $1000.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jul 9, 2026

87463(a) Reappraisals (a) ...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... This requirement is not met as evidenced by: Based on observation, file review, interview, the licensee did not comply with the section cited above by not updating the Appraisal Needs and Services Plan (ANS) for R1 annually or significant changes in condition which poses a potential safety, personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Administrator agreed to submit an updated signed by administrator and resident/resident's responsible party, ANS for R1 to CCLD by POC due date. Repeat Civil Penalty $250.00

Type of visit: POC

On 07/02/2026 at 1:00 p.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Proof of Correction (POC) visit. LPA met with Medication Technician Michelle and explained the purpose of the visit. Assistant Administrator Lynette Sandoval arrived approximately one hour later. On 06/02/2026, LPA conducted the facility's required one-year annual inspection, during which deficiencies were cited. The Proof of Correction (POC) due date for those deficiencies was 06/23/2026. Additionally, on 06/17/2026, LPA conducted a subsequent visit to deliver the findings for Complaint #15-AS-20260129093204. During that visit, a deficiency was cited under California Code of Regulations, Title 22, Section 87468.1(a)(8)(9). The POC due date for that deficiency was 07/01/2026. Deficiencies cleared: CCR Section 87463(h), cited on 06/02/2026, with a POC due date of 06/09/2026. CCR Section 87405(d)(2), re-cited on 02/03/2026, with a POC due date of 02/10/2026. LIC809-C (Page 2) Deficiencies not cleared: CCR Section 87470(a)(2)(B): $100.00 per day × 9 days = $900.00 CCR Section 87303(a): $100.00 per day × 9 days = $900.00 CCR Section 87303(i)(1)(A): $100.00 per day × 9 days = $900.00 HSC Section 1569.695(a)(1): $100.00 per day × 9 days = $900.00 HSC Section 1569.695(c): $100.00 per day × 9 days = $900.00 CCR Section 87468.1(a)(8) and (9): $100.00 per day × 1 day = $100.00 The total civil penalties assessed during this visit are $4,600.00 The facility is subject to ongoing civil penalties until all cited deficiencies have been corrected and verified by the Department. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 2, 2026

Type of visit: Case Management - Deficiencies

On 06/17/2026 at 3:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Administrator Assistant, Lynette Sandoval, and explained the purpose of the visit. While conducting complaint investigations #15-AS-20260129093204 and #15-AS-20260531173932 on 06/17/2026, LPA Alexander made the following observations during a facility walk-through: The following deficiencies were observed during the visit: 9:20 AM – Kitchen floors were dirty and contained spill stains. 9:21 AM – The countertop containing KitchenAid mixers, blenders, and other kitchen equipment was dirty, and equipment was not properly stored. 9:33 AM – Ten cases containing approximately 15 dozen fresh eggs were observed unrefrigerated and stored on the pantry floor. 9:36 AM – The laundry room door was unlocked and standing open with no staff attendant present. LIC809-C (Page 2) 9:39 AM – A spray bottle containing cleaning solution was observed under a kitchen cabinet in the Memory Care Unit. 9:43 AM – Resident 1's (R1's) bed linens were stained and soiled with blood. 10:02 AM – An unattended cleaning cart containing a dustpan and bucket filled with cleaning solution was observed in the hallway. 10:03 AM – Two cans of Lysol disinfectant spray and body cleanser products were observed under the sink cabinet in an unlocked restroom. 10:04 AM – Multiple bottles and tubes of cleaning products were observed in an unlocked cabinet located behind the nursing station. 10:04 AM – The medication room door was unlocked with no staff attendant present. 10:45 AM – Residents were not offered snacks unless they were participating in scheduled activities. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Jun 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(b) · Plan of correction due date: Jul 15, 2026

87309(a) Storage Space and Access (a) Except...(b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, ...and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in by not having spray bottle with toxic cleaning solution disinfectant, located in memory care unit, toxic cleaning solutions in bucket located on cleaning cart in hallways, inaccessible to residents and unattended by staff which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Administrator will conduct In-Service training with Staff/Housekeeping Staff on keeping disinfectants, cleaning solutions, poisonous substances inaccessible to residents and left unattended by staff. Submit participant sign-in sheet with topic summary to CCLD by POC due date. Immediate Civl Penalty Assessed $500.00

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Jul 15, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. Based on observation, the licensee did not comply with the section cited above in by not having the medication room door locked, unopened and left unattended by staff which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Administrator will conduct In-Service training with Med Techs/Staff on keeping medications safe/locked and inaccessible to residents. Submit participant sign-in sheet with topic summary to CCLD by POC due date. Immediate Civl Penalty Assessed $500.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(3) · Plan of correction due date: Jul 15, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (3) Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. Based on observation, and interviews the licensee did not comply with the section cited above in by not ensuring that all residents receive snacks between their 3 daily meals which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Administrator agreed to conduct In-Service training with all staff on providing between-meal nourishment or snacks to all residents and send to CCLD by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(23) · Plan of correction due date: Jul 15, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. Based on observation, and interviews the licensee did not comply with the section cited above in by not ensuring that all readily perishable foods, i.e., fresh eggs are properly refrigerated which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Administrator agreed to conduct In-Service training with all kichen staff on storing perishable foods with a dietician consultant and send particiapnat sign in sheet to CCLD by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jul 15, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. Based on observation the licensee did not comply with the section cited above in by not ensuring all kitchen areas shall be kept clean which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Administrator agreed to conduct In-Service training with all kitchen staff on ensuring kitchen areas shall be kept clean and send to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(29) · Plan of correction due date: Jul 15, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. Based on observation the licensee did not comply with the section cited above in by not ensuring all kitchen areas shall be kept clean, including kitchen counter, appliances including but not limited to food mixers, blenders, food processors and stored away when not in use which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Administrator agreed to conduct In-Service training with all kitchen staff on ensuring kitchen areas shall be kept clean, including kitchen counters and all food appliances when not in use stored properly and send sign in sheet to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Jul 15, 2026

87307 Personal Accommodations and Services (a) Living accommodation.. The following provisions shall apply: (3) Equipment and supplies necessary for personal care...the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases...shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. Based on observation the licensee did not comply with the section cited above in by not ensuring that R1's bed linens were changed and clean which had blood stains on pillow case and sheets which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Administrator agreed to conduct In-Service training with all staff on ensuring that clean linen is in use by residents at all times and send sign in sheet to CCLD by POC due date.

Type of visit: Case Management - Other

On 06/02/2026 at 4:30 p.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Administrator, Elizabeth Cortes, and advised her of the purpose of the visit. While conducting complaint investigation #15-AS-20260129093204 on 06/02/2026, during record review and observation, LPA observed that Resident 1’s (R1) Appraisal Needs and Services Plan had not been updated since 12/26/2024. In addition, LPA observed that R1 is currently bedridden and receiving hospice services in a shared bedroom. The bedroom in which R1 currently resides is not an approved bedridden room. Furthermore, the facility did not have a signed written agreement between roommates acknowledging that one resident is receiving hospice services. Deficiencies were observed and cited from the California Code of Regulations, Title 22 (see LIC809D). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Jun 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Jun 3, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved...(2) Bedridden persons This requirement is not met as evidenced by: Based on observation, file review and interview the licensee did not comply with the section cited above by not having R1 in a bedridden room with approved fire clearance which is a immediate health, safety, persoanl rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2026

Plan of correction: Administrator to move resident to a room with an approved bedridden fire clearance and send a photo showing the move to CCLD by POC due date. Immediate Civil Penalty Assesed $500.00 today.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Jun 9, 2026

87463(a) Reappraisals (a) ...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... This requirement is not met as evidenced by: Based on observation, file review, interview, the licensee did not comply with the section cited above by not updating the Appraisal Needs and Services Plan (ANS) for R1 annually or significant changes in condition which poses a potential safety, personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 2, 2026

Plan of correction: Administrator agreed to submit an updated ANS for R1 to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(h)(5) · Plan of correction due date: Jun 9, 2026

87633 Hospice Care of Terminally Ill Residents (h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident’s record: (5) A statement signed by the resident's roommate...who will share a room with a person who is terminally ill... acknowledgment that the resident intends to receive hospice care in the facility for the remainder of the resident's life, and the roommate's voluntary agreement to grant access to the shared living space to hospice caregiver.... This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Jun 2, 2026

Plan of correction: Administrator agreed to send acknowledgemt from R2 or R2's authorized representative to CCLD by POC due date.

Type of visit: Required - 1 Year

On 06/02/2026 at 1:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Med Tech, Vanessa, and explained the purpose of the visit. The facility’s fire clearance was approved for capacity 72 residents all may be non-ambulatory, 15 of which may be bedridden and hospice waiver for fifteen (15) residents. LPA toured the facility including but not limited to five (5) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 108, 103.8, 104 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LIC809-C Continued... LPA reviewed six (6) residents records. LPA reviewed staff records. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: 2:35pm boxes of Castille materials, flooring debris, mud bed mix, 2:36pm ladder located side yard, shovel, siding, wood, Custom Blend, brooms, buckets, Amazon boxes, plastic dish pans 2:37pm broken yard figures, tree limbs/shrubs 2:40pm more shovels, cleaner, boxes, tables Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/09/2026: LIC 308 Designation of Administrative Responsibility- Reviewed LIC 309 Administrative Organization - Reviewed LIC 500 Personnel Report - Reviewed LIC 610E Emergency Disaster Plan - (Page 9) Copy Liability Insurance Exit interview conducted and a copy of this report provided along with Appeal rights.the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: POC

On 02/05/2026 at 4:30 p.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Proof of Correction (POC) visit. LPA met with Administrative Assistant Lynette Sandoval and explained the purpose of the visit. LPA also spoke with the Licensee/Administrator, Elizabeth Cortes, regarding the reason for the visit. Ms. Cortes subsequently departed the facility and authorized Ms. Sandoval to sign the report on her behalf. On 02/03/2026, LPA L. Alexander conducted a Case Management visit during which deficiencies were cited. The POC due date was 02/04/2026. Ms. Sandoval stated that Suncrest Hospice had been scheduled to provide in-service training to caregiver staff. Ms. Sandoval further stated that a contractor was scheduled to inspect and verify the facility’s water temperature on 02/07/2026 at 2:00 p.m. The following deficiencies were verified as cleared during this visit: CCR 87412(f) CCR 87506(d) CCR 87632(d) The following deficiencies were not cleared at the time of this visit: CCR 87303(e)(2) CCR 87309(a) No additional deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to the facility representative.the state’s words, verbatim · CDSS document, Feb 5, 2026

Type of visit: Case Management - Deficiencies

On 02/03/2026 at 6:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. Upon arrival, LPA met with Medication Technician, Vanessa Ladaban, and explained the purpose of the visit. Licensee/Administrator, Elizabeth Cortes, was not available at the time of the visit. On 12/19/2025 LPA received an email with subject taining certificates. After review of documents received the training certificates does not show the requirement per POC which was RCFE laws, regulations and staff requirements. The deficiency will be re-cited again and civil penalties will be assessed for repeat. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Feb 10, 2026

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)...(2) Knowledge...ability...the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on record reviews, the licensee did not comply with the section cited above in by completing the required 2hrs minumum courses with a approved CCLD vendor to cover policy procedures, laws and staff requirements in regards to staff trainings. The training certificates were for other topics and previous dates other than the proposed 12/10/25 class date. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Licensee will send training certificates that cover the topics on policies/regulations with staff, including but not limited to staff RCFE 20hrs trainings on how to train new staff and current staff. Civil Penalty $250.00 for repeat violation.

Type of visit: Case Management - Other

On 02/03/2026 at 5:00 p.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Medication Technician (Med Tech) Vanessa Ladaban and advised her of the purpose of the visit. Ms. Ladaban notified Administrator Elisabeth Cortes by telephone. While conducting complaint investigations #15-AS-20260202152031 and #15-AS-20260129093204 on 02/03/2026, LPA conducted a review of facility records. LPA requested the following documents for review: resident admission agreements, Physician’s Reports (LIC 602), Appraisal Needs and Services plans (LIC 625), hospice care plans, home health care service plans, resident care notes, staff schedules, staff roster (LIC 500), staff contact information (telephone numbers), and incident reports for Residents R1 through R8. Facility staff were unable to produce the requested documents at the time of the visit. Failure to maintain and provide required resident and facility records constitutes a violation of the California Code of Regulations, Title 22. The deficiencies were documented on LIC 809D. Failure to correct the cited deficiencies may result in civil penalties. An exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(f) · Plan of correction due date: Feb 4, 2026

87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Based on file review and interview, the licensee did not comply with the section cited above by not having staff records available including but not limited to staff schedules for Nov '25 thru Feb '26, LIC 500 (staff roster) and staff contact information which poses an health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Administrator will submit copies of requested staff rosters, LIC 500 with staff contact information to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(d) · Plan of correction due date: Feb 4, 2026

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement is not met as evidenced by: Based on file review and interview, the licensee did not comply with the section cited above by not having resident records for R1-R8 available for Licensing review including but not limited to admission agreements, emergency contact info., physician's reports, appraisals/Appraisal Needs and Services, hospice care plans, home health care plans, care notes, MARS, doctor's orders which poses an health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Administrator will submit copies for requested records for R1-R8 to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(d)(2) · Plan of correction due date: Feb 4, 2026

87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver..to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. Based on file review and interview, the licensee did not comply with the section cited above by not notifying Licensing of residents (R2-R10) with a notice of hospice services initiated within 5 working days which poses an health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Administrator will read the regulation and self-certify understanding and send self-certification to CCLD by POC due date. In addition, send notices of all residents currently on hospice to CCLD by POC due date.

Type of visit: Case Management - Health Checks

On 02/03/2026 at 11:00 am., Licensing Program Analyst (LPA) Lori Alexander conducted a Health and Safety inspection in response to a Priority 1 complaint. LPA met with Medication Technician (Med Tech) Vanessa Ladaban and explained the purpose of the visit. Ms. Ladaban notified Administrator Elisabeth Cortes by telephone. Upon entry into the Assisted Living and Memory Care units, LPA observed eleven (11) residents participating in a Bingo activity and nine (9) residents watching television. Other residents were observed resting in their rooms. LPA conducted a tour of the facility, including but not limited to residents' bedrooms, bathrooms, common areas, kitchen, and outdoor areas. Hot water temperature measured 97.5 and 94.3 degrees Fahrenheit in two residents' shared bathroom. The facility maintained a seven (7) day supply of non-perishable food and a two (2) day supply of perishable food. Facility staff reported food supplies are ordered on a weekly basis. Refrigerator temperature was observed at 26 degrees Fahrenheit. Resident medications were observed secured and locked in the medication room. The first aid kit was complete. The fire extinguisher was fully charged and last serviced on 04/14/2025. LIC809-C Continued... LIC809-C (Page 2) During the inspection, LPA observed the following deficiencies: At 11:20 a.m., LPA observed cardboard boxes and bags on the hallway floor. At 11:27 a.m., LPA observed the laundry room door open with toxic chemicals, including Shurgard HP and Clorox Bleach, unsecured. At 11:32 a.m., LPA observed shower room floors were not clean. At 11:33 a.m., LPA observed tile flooring in assisted living resident rooms was cracked and buckled. At 12:48 p.m., LPA observed tile flooring in the Memory Care unit was cracked, buckling, and lifting. At 12:49 p.m., LPA observed Clorox Bleach unsecured under a cabinet in the Memory Care unit. At 12:50 p.m., LPA observed food items in the top freezer were uncovered and not stored in proper food containers. At 12:52 p.m., LPA observed oxygen tanks were not stored properly. LIC809-C Continued... At 2:17 pm., 6+ wheelchairs, walkers, commodes, Hoyer lifts outside behind shed in parking lot At 2:19pm BEHR full paint bucket, dried up paint bucket, ladders, 8 large tubs of MGDemaGel 62 sitting outside on side of building At 2:21 broken debris, 2-3 garbage cans, oxygen tank, two folding tables, stacks of Castille/La Rocca materials At 2:20pm washing machine, tables, brooms, plastics dish pans located outside on side yard At 2:25 PM cooking oil in a steel contaciner located outside near back door entrance The above deficiencies were documented on LIC 809D and cited pursuant to the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Feb 4, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions...and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having Clorox Bleach and Shurgard HP disinfectant chemicals inaccessible to residents in unlocked laundry room and Clorox Bleach under cabinet in memory care unit which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Administrator will conduct In-Service training with all staff and submit sign-in sheet to CCLD by POC due date. Immediate Civil Penalty assessed for $500.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a)(1) · Plan of correction due date: Feb 10, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having shower floors clean, resident bedroom floors repaired with cracks, tile bulkling in assisted living and memory care units which poses an health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Administrator will clean flooring and repair flooring in residents rooms and facility and send contractor receipts of repairs and photos to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(E)(I) · Plan of correction due date: Feb 10, 2026

87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. (I) Equipment shall be removed from the facility when no longer in use by the resident. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having oxygen tanks secured in a stand/wall and removed when resident was discharged or passed away which poses an health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Administrator will read regulation, self-certify understanding by submitting self-certification and photos of oxygen tanks secured and/or removed if no longer in use by resident to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(e)(2) · Plan of correction due date: Feb 4, 2026

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having water temperatures maintained at 105-120 degrees F. in residents' shared bathrooms. Water temps measured at 94.3 and 97.5 degrees F. in assisted living memory care units which poses an health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Administrator will set water temperatures for residents' bathrooms according to regulation and send photos of water temperatures in assisted living and memory care units bathrooms to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a) · Plan of correction due date: Feb 11, 2026

(a) The facility shall be...in good repair at all times... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having disrepair flooring in residents rooms with tiles cracked, buckling and lifting which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Licensee agreed to submit a detail plan of when they will have the flooring repaired in all residents rooms including but not limited to assised living and memory care units and submit photos of repaired floors to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(23) · Plan of correction due date: Feb 11, 2026

87555 General Food Service Requirements (23) All readily perishable foods... shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having food in the freezer uncovered and not in a food container in memory care unit which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Administrator will remove food a conduct In-Service training with all staff on food storage including but not limited to all perishable foods and send sign in sheet to CCLD by POC due date.

Allegation investigated: Staff do not treat resident with dignity and respect Staff are not serving food of quality to residents Staff retaliated against resident complaining

On 10/07/2025 at 9:30 AM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Medication Technician, Daffodale Fernandez, to deliver the findings of above allegations. LPA explained the purpose of the visit with Daffodale Fernandez. Licensee/Administrator, Elizabeth Cortes wasn't available. Daffodale called Elizabeth Cortes to inform and received approval from Ms. Cortes to sign report. During investigation, LPA obtained the following documents: Resident Registry, Staff Roster, Shower Schedules for North and South Wing Residents. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Allegation: Staff do not treat resident with dignity and respect Finding: Unsubstantiated LPA interviewed Staff 2 (S2), who denied speaking rudely to Resident 1 (R1). S2 stated they always served R1’s food tray in the dining area and collected trays along with those of the other residents. LPA also interviewed Staff 1 (S1), who stated the facility does not use bleach in the laundry. S1 explained that a commercial laundry system is used to address stains. It was noted that the concern regarding staff treating residents without dignity and respect was substantiated in a prior complaint involving the subject resident and staff, and has already been addressed with the facility. Allegation: Staff are not serving food of quality to residents Finding: Unsubstantiated LPA interviewed R1, R2, R3, R4, and R5. All residents reported that the food served was acceptable. On 03/13/25 and 04/09/25, LPA observed lunch and dinner meals, which included a sandwich on wheat bread, lasagna, mixed vegetables, and wheat bread. The concern regarding food quality was substantiated in a prior complaint and has been addressed with the facility. Allegation: Staff retaliated against resident complaining Finding: Unsubstantiated On 03/13/25, LPA interviewed R1, who stated they did not want S2 to clean their room or provide care. R1 alleged that video footage showed S2 entering their room with Staff 3 (S3) while R1 was absent from the facility. LPA interviewed Staff 4 (S4), who currently works in the kitchen. LIC9099-C (Page 3) S4 denied retaliating against R1 and explained that, due to prior conflicts, they avoid interaction with R1. S4 reported that R1 verbally harassed them, including cursing, making derogatory comments, and threatening to call their family. S4 further stated that R1 has a special diet but sometimes eats their own food. Staff 1 confirmed that R1 maintains frozen meals for personal use. Regarding laundry, S1 reported the facility uses the “Omni” laundry system with detergent and sanitizer only, and bleach is not used. LPA toured the laundry room and observed no bleach present. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 15-AS-20250306135204

Allegation investigated: Lack of care being provided

On 10/07/2025 at 8:45 AM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Medication Technician, Daffodale Fernandez, to deliver the findings of above allegation. LPA explained the purpose of the visit with Daffodale Fernandez. Licensee/Administrator, Elizabeth Cortes wasn't available. Daffodale called Elizabeth Cortes to inform and received approval from Ms. Cortes to sign report. The Administrator arrived approximately 10:16AM. During investigation, LPA L. Hall obtained the following documents: Resident Roster, Staff Roster. LPA L. Alexander obtained the following documents: R1’s admission agreement, Appraisal, Needs and Services plans (dated 07/25/24, 08/16/24, and 09/30/24), physician’s reports (dated 07/09/24 and 08/15/24), hospice care plan (dated 08/16/24). LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Allegation: Lack of care being provided Finding: Unsubstantiated On 10/28/24, Licensing Program Analyst (LPA) L. Hall interviewed Witness (W1). W1 stated that Resident 1 (R1) is receiving hospice services and had recently participated in a care conference with Staff 1 (S1). During the conference, S1 explained that the facility is working to establish a baseline for R1. W1 reported there has been no communication between the hospice agency and the facility. W1 stated that R1 told them he often waits 45–90 minutes for staff to respond to his call light. W1 was informed that the call system had been malfunctioning, which caused delays in staff response. R1 also reported that one weekend he was cleared to shower, and his wound dressing became wet. R1 was unsure who authorized the shower and who was responsible for changing the dressing. The following day, the wound area appeared red. W1 expressed uncertainty regarding what type of care the facility staff should be providing to R1. On 12/16/24, LPA Alexander interviewed W2, who stated that Suncrest Hospice provides services three times a week for wound care, bathing, and dressing R1. However, hospice staff also reported that they visit R1 daily to provide bed baths, and on days hospice does not come, facility caregivers provide R1 with a bed bath. W2 further confirmed that R1 cannot take showers due to wounds on his body. LPA interviewed S1 that stated that R1 was on hospice and that hospice staff provided R1 with a bed bath Monday through Friday, while facility caregivers provided bed baths on weekends. LPA interviewed Residents 2–6 (R2, R3, R4, R5, and R6), who stated that caregivers respond to their rooms and turn off the call lights. The issue regarding wait times for call light response had been substantiated in a prior complaint and was already addressed with the facility. LIC9099-C (Page 3) LPA L. Alexander reviewed R1’s physician’s reports, hospice care plan, and appraisal/needs and services plans. Based on record review and interviews, the evidence demonstrates that facility staff were aware of and providing the services required to meet R1’s care needs. Although concerns were reported regarding communication between the hospice agency and facility staff, response times to call lights, and wound care, there is insufficient evidence to prove or disprove that a lack of care occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 15-AS-20241021152551

Type of visit: Case Management - Deficiencies

On 10/07/2025 at 10:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. Upon arrival, LPA met with Medication Technician, Daffodale Fernandez, and explained the purpose of the visit. Licensee/Administrator, Elizabeth Cortes, was not available at the time of the visit. Daffodale contacted Ms. Cortes via phone, informed her of LPA’s presence, and received authorization to sign the report on her behalf. Ms. Cortes arrived at approximately 10:16 AM. On 08/20/2025, LPA Alexander conducted a Case Management visit during which a deficiency was cited with a Plan of Correction (POC) due date of 09/03/2025. LPA was unable to conduct a follow-up POC visit within the 10-day period. The Administrator was required, per the POC, to complete a course through a Community Care Licensing Division (CCLD)-approved vendor but reported being unable to locate a vendor that covered the required topic. As a result, the deficiency will be re-cited with a new due date. Additionally, during the 08/20/2025 visit, a POC review was conducted for the previously cited deficiency under HSC §1569.625 – Staff Training. The deficiency was not cleared, and civil penalties were assessed. As of today’s visit, the deficiency is cleared. LIC809-C (Page 2) The following deficiencies cleared as of this visit: HSC §1569.625(b)(2) – Staff Training The following deficiencies remain uncleared as of this visit: CCR §87405(d)(2) – Administrator Qualifications and Duties The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Nov 22, 2025

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)...(2) Knowledge...ability...the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on record reviews, interviews and observations, the licensee did not comply with the section cited above in by not having RCFE specific 20 hours staff annual trainings completed since annual inspection on 06/03/25. Which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Administrator will complete minimum 2hrs of Administrator Policies and Procedures including but not limited to RCFE laws, regulations and staff requirements with an approved CCLD vendor and submit to CCLD by POC due date.

Type of visit: Case Management - Other

This is an amended report to correct LIC809-D page. Licensee/Administrator, Elizabeth Cortes, was present to sign amended report. On 08/20/2025 at 4:15 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Case Management. LPA met with Administrator Assistant, Lynette Sandoval, and informed the reason for visit. Lynette phoned the Licensee/Administrator, Elizabeth Cortes to inform. LPA spoke with Administrator on the phone. LPA spoke with S1 whom stated that they have been working on the staff trainings via in-service training with an outside trainer. LPA advised S1 that the trainings are specific which includes 8 hours dementia, 4 hours postural support, 4 hours restricted health and 4 hours hospice. The received copies of in-service training did not cover these specific areas and hours. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Aug 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 27, 2025

87405 Administrator - Qualifications and Duties a) All facilities shall have a qualified and currently certified administrator. ...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Based on LPA's visits 08/15/25, 7/29/25, 6/10/25, 6/3/25, 4/10/25, 3/13/25 and 1/15/25 the Administrator was not available. There has been multiple deficencies citations and the designated substitute does not meet the qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Administrator will submit a schedule (LIC 500) showing their work hours Monday-Friday at a minimum of 20 hours to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(2) · Plan of correction due date: Sep 3, 2025

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)...(2) Knowledge...ability...the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on record reviews, interviews and observations, the licensee did not comply with the section cited above in by not having RCFE specific 20 hours staff annual trainings completed since annual inspection on 06/03/25. Which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Administrator will complete 2hrs of Administrator Policies and Procedures including but not limited to RCFE staff trainings with an approved CCLD vendor and submit to CCLD by POC due date.

Type of visit: POC

On 08/20/2025 at 3:35 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Administrative Assistant, Lynette Sandoval, and informed the reason for visit. Lynette phoned the Licensee/Administrator, Elizabeth Cortes to inform. On 06/03/2025 LPA L. Alexander conducted an annual inspection visit in which the following deficiency were not cleared by POC original due date of 07/01/2025. LPA returned to re-cite and issued new POC due date of 08/14/2025. The following deficiency were not cleared by visit: HSC 1569.625(b)(2) $100 x 6 days = $600.00 Civil penalty of $600.00 is assessed for the period of 08/15/2025 to 08/20/2025 for failure to correct deficiency. Facility is subject to ongoing daily civil penalties until deficiencies are corrected. Exit interview conducted. A copy of this report, LIC 421FC and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 20, 2025

Allegation investigated: Wrongful Eviction.

*LPA amended document same visit day to add citation on LIC809* On 8/15/2025 at 10:30am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver a complaint finding for the allegation above. LPA met with Lynette Sandoval, Assistant Administrator, and explained the reason for the visit. During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and reviewed records. Allegation: Wrongful Eviction. Based on interview with W1, the facility conducted a wrongful eviction. S1 Continued on LIC9099C. Substantiated Continued from LIC9099. stated during interview that R1 issued a 30-day eviction notice on January 15, 2025, however, the reason for the eviction notice was for a camera and not payment. S1 stated R1 was evicted due to the Assisted Living Waiver (ALW) being revoked by the agency and the facility could not take R1 back. LPA reviewed an email between S1 and Morga Post Acute staff dated May 30, 2025, which indicated S1 stated R1 would not be able to return to the facility. S1 also stated the facility was supposed to perform an assessment on R1 to return, but when the information regarding the ALW was received S1 contacted the Skilled nursing facility (SKNF) and advised the staff that R1 will not be accepted back to the facility. Review of Moraga Post Acute notes indicated post acute staff called S1 and was informed the ALW agency stated disenrollment for R1 was effective 4/19/2025. Lastly, S1 stated there wasn’t any contact with R1 to advise R1 will not return. R1 was told by a SKNF staff member. Based on interviews and record review the facility did not follow the eviction process; therefore, the allegation is Substantiated. Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of the appeal rights and this report provided. Continued from LIC9099. complaints. The LPA spoke with eleven (11) staff. Five (5) of the eleven (11) stated that they had little or no contact with R1 and weren’t aware that any of the staff wanted R1 out of the facility. The other six (6) staff stated that they were not aware that the staff was retaliating or wanted R1 out of the facility. W2 stated during interview that they did not want to be involved. Based upon the information obtained during investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is no preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 15-AS-20250605102328

Type of visit: Case Management - Other

On 8/15/2025, at 11:30am, Licensing Program Analyst (LPA) L. Hall conducted an announced Case Management visit regarding an error that was made on a complaint visit on 8/15/2025. LPA met with Lynette Sandoval, Assistant Administrator, and explained the purpose of the visit. LPA conducted a complaint visit on 8/15/2025, for complaint #15-AS-20250605102328. LPA had to amended the original LIC9099 to state that the LIC9099D was not added. LPA created this LIC809 to add the citation for the complaint on an LIC809D only. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Aug 16, 2025

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days’ written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidence by: Based on interviews and record review the Licensee did not comply with the section cited above in giving proper notification for eviction, which poses a potential personal risk for persons in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: Assistant Administrator agreed to Review regulation 87224 and submit a self-certification that the facility will abide by the regulation going forward to CCLD by POC date.

Type of visit: Case Management - Deficiencies

On 08/07/2025 at 4:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Licensee/Administrator, Elizabeth "Beth" Cortes and explained the purpose of the visit. Beth stated that she was getting ready to leave and gave authorization for Medication Tech, Liza Sembrano to sign report. On 06/03/2025 during annual inspection the facility was cited for not completing annual staff training. The due date for Plan of Correction was 07/01/2025. LPA is re-citing the deficiency. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report, LIC421FC and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Aug 14, 2025

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not having staff annual trianings for staff (S) S1-S10 including but not limited to direct care staff which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Administrator will submit a detailed plan to how and when the annual trainings will be completed by direct care staff. Submit training certiifcates to CCLD by POC due date. Trainings include: 8hrs Dementia, 4hrs postural support, 4hrs restricted health conditions and 4hrs hospice care. Civil Penalty $250.00 assessed for repeat violation.

Type of visit: Case Management - Other

On 7/29/2025 at 12:30 PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Lynette Sandoval, Administrator Assistant, and explained the purpose of the visit. While LPA was conducting a complaint investigation 15-AS-20250605102328 on 7/29/2025, during staff interviews LPA observed during record review that S11 was not associated to the facility. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Jul 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jul 30, 2025

(e) All individuals subject to a criminal record review... shall prior to working.. in a licensed facility: (3) Request a transfer of a criminal record clearance... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having S11 associated to the facility, which poses an immediate health and safety risk to person in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator agreed to send completed copy of fingerprints to CCLD to be associated by POC date.

Type of visit: Case Management - Deficiencies

On 6/10/2025 at 11:30 AM, Licensing Program Analysts (LPAs) Y. Brown and L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Lynette Sandoval, Administrator Assistant . While LPAs were conducting a complaint investigation 15-AS-20250605102328 on 6/10/2025, upon arrival LPAs met with S2. During record review, LPAs observed that S2 was not associated to the facility. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Jun 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jun 11, 2025

(e) All individuals subject to a criminal record review... shall prior to working.. in a licensed facility: (3) Request a transfer of a criminal record clearance... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having S2 associated to the facility, which poses an immediate health and safety risk to person in care.the state’s words, verbatim · CDSS document, Jun 10, 2025

Plan of correction: Administrator agreed to send LIC9182 and S2 identification to CCLD to be associated by POC date.

Allegation investigated: Staff took residents camera without consent Staff go through resident's personal belongings

On 06/6/2025 at 10:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the above allegations. LPA met with Administrator, Beth Cortes, and explained the reason for the visit. During the investigation LPA conducted interviews and reviewed records. LPA found that on an unrelated inspection the facility was instructed by CCLD to remove the camera in R1's room due to privacy concern and personal rights violation to R1's roommate. LPA confirmed with LPA that issued the initial deficiency that the camera needed to be removed. R1 was out of the facility for medical reasons and staff removed the camera and stored it for R1's return. Therefore the allegations are UNSUBSTANTIATED. 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. Nothe state’s words, verbatim · CDSS document, Jun 6, 2025 · control 15-AS-20250421091514

Allegation investigated: Resident’s personal belongings were stolen at the facility.

On this day at 01:00 pm, LPAs David Doidge and Andrew Christy arrived unannounced to conduct 10-day investigation on the above allegation and deliver findings. LPAs met with Administrator Assistant, Lynette Sandoval and explained the purpose of the visit. During the investigation, LPAs interviewed one (1) staff (S1). LPAs obtained a copy of R1's Admission Agreement, Client/Resident Personal Property and Valuables (LIC621), and Physician’s Report (602). Allegation: Resident’s personal belongings were stolen at the facility. Investigation Finding: LPAs review resident’s LIC621 and spoke with S1 regarding the missing items. LIC621 does not list the items that went missing. S1 informed LPAs when missing item are reported an investigation with staff and other residents is conducted. If the items are not found, the facility will reimburse the resident for the missing items within a time span of two weeks or less. S1 was made aware of missing items on the 29th of May and S1 was working towards finding the missing items by the time of this report. The items were not found and S1 is in the process of reimbursing R1 for those items. Based on interview and record review conducted, the above allegation is unsubstantiated. Continued on LOC9099-C Unsubstantiated Continued from LIC9099 Although the allegation 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. No deficiencies cited during visit. Exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 15-AS-20250530104523

Type of visit: Required - 1 Year

On 06/03/2025 at 1:30 PM, Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator Assistant, Lynette Sandoval and explained the purpose of the visit. The facility’s fire clearance was approved for capacity seventy-two (72) residents. Administrator Certificate #6017472740 expires 06/04/2024. LPAs toured the facility with Lynette including but not limited to ten (10) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 degrees F. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 105, 107, 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA reviewed five (5) residents records. LPA reviewed ten (10) staff records and 10 of 10 have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/10/2025: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 3, 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.

Type of visit: Case Management - Deficiencies

On 04/10/2025 at 11:40 AM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management. LPA met with Lynette Sandoval, Administrative Assistant, and explained the purpose of the visit. LPA L. Alexander conducted Complaint visits on 03/05/2025, 11/26/2024, and cited for deficiencies. The Plan of Correction (POC) original due dates were 03/21/2025, 12/30/2024 and 12/20/2024. LPA conducted a Case Management visits on 03/06/2025, and 03/05/2025, in which there were deficiencies cited. The POC due dates were 03/31/2025 and 03/13/2025. LPA was unable conduct a POC visits for deficiencies cited during the 10 day time frame. Deficiencies not cleared will be re-cited with a new POC due date. Repeat Violations will be assessed civil penalties of $250.00 each x 6 = $1,500.00 today. Deficiencies not cleared CCR 87555(b)(25) CCR 87468.2(a) CCR 87468.2(a)(1) CCR 87307(c) CCR 87468.1(a)(1)(b)(5) CCR 87224(a) The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in continued civil penalties. Exit interview conducted. A copy of this report, LIC421FC and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(25) · Plan of correction due date: Apr 17, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in by not storing cases of Clorox Bleach and bottles of Fabuloso Multi-Purpose Cleaner in a area separate from food supplies which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Administrator agreed to remove the cleaning disinfectant products and send a photo. In addition, read the regulation and self-certify understanding the regulation moving forward. POC documents will be sent to CCLD by POC due date. Repeat Violation Immediate Civil Penalty $250.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.2(a) · Plan of correction due date: Apr 17, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: Based on observation and interview the licensee did not comply with the section cited above in by ensuring that camera with audio does not violate a residents' right to privacy and dignity as required by existing regulations. Including but not limited to all clients and residents maintain privacy and dignity rights that could be violated by negligent and/or abusive surveillance practices which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Administrator will read regulation and self-certify understanding this regulation moving forward. In addition, Administrator will have to ensure and attest that the camera does not obtain audio by sending a detailed letter to CCLD by POC due date. Repeat Violation Immediate Civil Penalty $250.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Apr 17, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights...87468.1, Personal Rights of Residents in All Facilities,...residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations... This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above in by violating R1's personal rights to privacy including but not limited to picking up R1's phone and looking at messages when they are not present which poses a potential safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Administrator agrees to conduct In-service training with all staff on personal rights including but not limited to phones devices. Training-sign in sheet and synopsis of the training topic will be submitted to CCLD by POC due date. Repeat Violation Immediate Civil Penalty $250.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(c) · Plan of correction due date: Apr 17, 2025

87307 Personal Accommodations and Services (c) Individual privacy shall be provided in all toilet, bath and shower areas. This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the section cited above in by not ensuring R1’s privacy while showering which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Administrator agreed to conduct In-Service Training with staff/caregivers and send copy of sign-in sheet to CCLD by POC due date. Repeat Violation Immediate Civil Penalty $250.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1)(b)(5) · Plan of correction due date: Apr 17, 2025

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (b) All residents in all residential care facilities for the elderly shall be protected from all of the actions specified in this subsection. (5) Willfully and repeatedly fail to use a resident’s preferred name or pronouns after being informed of the resident’s preferred name or pronouns in a clear manner. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in by not according dignity and respect with bathing, showering, toileting, and addressing residents by their preferred names and pronouns which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Administrator agreed to conduct In-Service Training with staff/caregivers and send copy of sign-in sheet to CCLD by POC due date. Repeat Violation Immediate Civil Penalty $250.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(a) · Plan of correction due date: Apr 17, 2025

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above in by serving R1 with an appropriate eviction notice after deciding not to accept R1 back to the facility once R1 was discharged from the hospital ER which posed a potential health and safety risk and personal rights to persons in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: The licensee will read regulation 87224 and submit self-certification that it has been read, understood and they will abide going forward to CCLD by POC due date. Repeat Violation Immediate Civil Penalty $250.00

Type of visit: POC

On 04/10/2025 at 9:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Administrative Assistant, Lynette Sandoval, and informed the reason for visit. Lynette phoned the Licensee/Administrator, Elizabeth Cortes to inform. On 03/06/2025 LPA L. Alexander conducted a Complaint (#15-AS-20250303150627) visit in which the following deficiency were not cleared by POC due date of 04/03/2025. The following deficiency were not cleared by visit: CCR 87555(b)(9)(15) $100.00 x 7 days = $700.00 Civil penalty of $700.00 is assessed for the period of 04/04/2025 to 04/10/2025 for failure to correct deficiency. Facility is subject to ongoing daily civil penalties until deficiencies are corrected. Exit interview conducted. A copy of this report, LIC 421FC and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 10, 2025

Allegation investigated: Staff served poor quality food to residents Staff was unable to communicate due to language barrier Staff did not respond to resident's requests for assistance in a timely manner

On 04/09/2025 at 3:00 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrative Assistant, Lynette Sandoval, to deliver the findings of above allegations. LPA explained the purpose of the visit with Administrator. During investigation, LPA obtained the following documents: Resident Registry, admission's agreement, Appraisal Needs and Services, hospice care plan, Physician's Report and Pre-Placement Appraisal LIC9099-C Substantiated Allegation: Staff served poor quality food to residents Finding: Substantiated LPA interviewed W1 that stated the food at the facility is not nutritious. W1 stated that lunch, dinner is cold food. On 03/13/2025, LPA interviewed R1, R2, R3, R4, R5, R6, R7, R8 and R9. R1-R9 all stated that the food served is ok, sometimes it's cold. R1-R9 stated that they have not seen a menu and that they don't have choices. LPA observed the meals for lunch/dinner on 03/13/2025 and 04/09/2025. Meals observed was a sandwich on wheat bread, lasagna, mixed veggies with a slice of wheat bread. Allegation: Staff was unable to communicate due to language barrier Finding: Substantiated LPA interviewed W1 that stated one of the caregivers, S2, does not speak English and when R1 needed a bed bath, S1 used his phone to translate through Google. On 03/13/2025, LPA interviewed S1 that stated S2 does not know English and is currently taking classes to learn English. LPA interviewed R1 that stated it is frustrating sometimes to keep asking or telling a caregiver something with your care need and they don’t understand. R1 stated that it would be good if the caregivers utilized a translator app to communicate. LIC9099-C Continued... LIC9099-C Continued... Allegation: Staff did not provide resident’s records to resident’s authorized representative Finding: Unsubstantiated On 12/16/2024, LPA interviewed witness (W). W1 stated that they requested some information regarding Suncrest Hospice and was denied the file by one of the Med Techs Staff (S). W1 stated that they are the responsible party of resident (R) R1. On 03/13/2025, LPA interviewed staff (S). S1 stated that W1 asked for the shower schedule which included other resident’s names and that is why S2 denied the file to W1. S1 further stated that W1 always had R1’s hospice file. On 04/09/2025, LPA interviewed S2 that stated the particular file requested was a file that consisted of other residents' care notes and shower schedules written by caregiver staff. S2 stated that they told R1's authorized rep that they couldn't give them the file because the file had other resident's information which is confidential. Allegation: Staff did not ensure resident's room was cleaned and sanitized Finding: Unsubstantiated LPA interviewed W1 that stated they were told by the hospice aide that the bathroom was filthy and smelled of urine. W1 stated that there are four (4) residents that share bathroom and W1 has observed urine and poop on the floor. LIC9099-C Continued... On 03/13/2025, LPA observed the shared bathroom. The bathroom toilet and floor appeared clean. On 04/09/2025, LPA interviewed R2 that stated housekeeping cleans the shared bath room 2 times a week. LPA interviewed S1 that stated housekeeping cleans the bathroom 4-5 times a week. If there is an accident and housekeeping isn’t available, the caregivers will clean the bathrooms. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of report was given. LIC9099-C Continued... Allegation: Staff did not respond to resident's requests for assistance in a timely manner Finding: Substantiated On 03/05/2025, LPA interviewed fifteen (15) residents (R). R2, R3, R4, R6, R7, R8, R9, R13, R14 all stated that when they use their call button for assistance with care, it will take from 20 to 30 mins before someone comes to their room to respond. R2, R3, R4, R6, R7, R8, R9, R13, R14 stated that the caregiver comes to the room, turns the light off and then never returns. R7 most of the time it is during the night shift that doesn’t show up to work and weekends. R5 stated that once they had to wait for the following day before someone would come help them. R5, R10, R12 and R15 stated that they have no use for the call button. R5 stated that they heard their neighbor yelling out to the staff for help and said, “I pressed my call button but how come no one here to help me”. R5 further stated that the staff came to their neighbor’s room and just said I will come back but never did. On 03/05/2025, LPA tested the call button while waiting for a response in a resident’s room. The time of the test was around 1:00 pm and it took approximately 16mins before a caregiver responded. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Apr 9, 2025 · control 15-AS-20241212150702

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(5) · Plan of correction due date: Apr 30, 2025

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: (5) To be served food of quality and quantity necessary to meet their nutritional needs. This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by not serving hot food that should be hot, nutritious and of quality and quantity which poses an health, safety and personal rights risk for persons in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: Administrator agreed to have ALL staff cooks to take a food course on food, sanitation and preparation of meals and will submit certificates to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: May 8, 2025

87411 Personnel Requirements – General (d) All personnel shall be given on the job training...This training...shall provide knowledge of and skill in the following, as appropriate for the job assigned... (3) Skill and knowledge required...including the ability to communicate with residents. This requirement is not met as evidence by: Based on interview, the licensee did not comply with the section cited above by ensuring staff has the ability to communicate with residents when providing care which poses an health, safety and personal rights risk for persons in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: Administrator agreed to create a plan on how to address this issue with communications with language barriers with staff providing care to residents and submit to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 30, 2025

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: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on observation, interview and record review, the licensee did not comply with the section cited above by not, including but not limited to, responding to residents' call buttons in a timely manner and addressing the residents' care needs after turing off the call light which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: Administrator agreed to create a chart for each caregiver and their rounds. Rounds will have 2hr checks for incontinence and everything else by signing off. Administrator will submit the chart to CCLD by POC due date. Repeat Violation Civil Penalty Assessed $250.00

Allegation investigated: Staff do not accord dignity to resident(s) in care. Staff do not ensure that resident's diapering needs are met while in care. Staff do not ensure that resident's hygiene needs are met while in care.

On 03/13/2025 at 10:30 AM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator Assistant, Lynette Sandoval, to deliver the findings of above allegations. LPA explained the purpose of the visit with Administrator. During investigation, LPA obtained the following documents: Resident Roster, Staff Roster. LIC9099-C Continued... Substantiated LIC9099-C (Page 2) Allegation: Staff do not accord dignity to resident(s) in care. Finding: Substantiated LPA interviewed W1 that stated lack of respect when requesting the caregiver to change their diaper and that it makes them feel uncomfortable. LPA interviewed R1, R2 and R3 and all stated that they don't feel comfortable with some of the caregivers that don't cover them when showering or getting their diapers changed. Allegation: Staff do not ensure that resident's diapering needs are met while in care. Finding: Substantiated LPA interviewed W1 that stated that they were left in a wet diaper until the next shift started. LPA interviewed R1, R2, R3 that all stated that they have been left in wet diapers. R1, R2 and R3 all stated that during the NOC shift that they have to wait till the next shift starts before getting their diapers changed. Allegation: Staff do not ensure that resident's hygiene needs are met while in care. Finding: Substantiated LPA interviewed W1 that stated that the caregivers do not answer their call buttons and that caregiver comes in the room, turn the light off, goes out and doesn't return back. LPA interviewed R1, R2, R3 and all stated that they have experienced when they use the call buttons specifically during the NOC shift, it takes approximately 30 mins before a caregiver responds. R3 stated that when the caregiver cleans them they are not completely clean and still have "poop" on them. LIC9099-C Continued... LIC9099-C (Page 5) LPA interviewed S1, S2, S3 and all stated that they have not heard or seen any caregivers yell at any of the residents. The subject staff caregiver no longer works at the facility to interview. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 13, 2025 · control 15-AS-20240618130238

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.261(b) · Plan of correction due date: Apr 24, 2025

§1569.261 Legislative intent; fundamental rights for residents of residential care facilities (b) In establishing this bill of rights, the Legislature intends that persons residing in residential care facilities for the elderly be treated with dignity, kindness, and respect, and that their civil liberties be fully honored. Based on interviews the licensee did not comply with the section cited above in by treating residents with dignity, kindness and respect including but not limited to how staff communicates while giving care to residents in care which poses a potential health and safety risk and personal rights to persons in care.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Administrator agreed to read the regulation and self-certify. In addition, will conduct a In-Service training with all staff on all shifts with treating residents with dignity, kindness and respect in communication and giving care. Submit self-certification and in-service training sign-in sheet and a copy of what was covered during training to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 10, 2025

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: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on interviews the licensee did not comply with the section cited above in by responding to call light buttons timely, changing diapers including but not limited to making sure residents' are completely cleaned after soiled diaper changes during NOC shift and between shift changes which poses a potential health, safety risk and personal rights to persons in care.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Administrator agreed to submit a detailed plan on how they will ensure that diaper changes and hygiene care needs are completed with staff during all shifts and submit to CCLD for review by POC due date.

Allegation investigated: Staff do not respond timely to the residents alerts

On 03/13/2025 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrative Assistant, Lynette Sandoval, to deliver the findings of above allegation. LPA explained the purpose of the visit with Lynette and they called the Administrator/Licensee, Elizabeth Cortes, to inform. During investigation, LPA obtained the following documents: Resident Roster and Staff Roster. LIC9099-C Continued... Substantiated LIC9099-C (Page 2) Allegation: Staff do not respond timely to the residents alert. Finding: Substantiated On 03/05/2025, LPAs L. Alexander and K. Nguyen interviewed fifteen (15) residents (R). R2, R3, R4, R6, R7, R8, R9, R13, R14 all stated that when they use their call button for assistance with care, it will take from 20 to 30 mins before someone comes to their room to respond. R2, R3, R4, R6, R7, R8, R9, R13, R14 stated that the caregiver comes to the room, turns the light off and then never returns. R7 most of the time it is during the night shift that doesn’t show up to work and weekends. R5 stated that once they had to wait for the following day before someone would come help them. R5, R10, R12 and R15 stated that they have no use for the call button. R5 stated that they heard their neighbor yelling out to the staff for help and said, “I pressed my call button but how come no one here to help me”. R5 further stated that the staff came to their neighbor’s room and just said I will come back but never did. On 03/05/2025, LPAs tested the call button while waiting for a response in a resident’s room. The time of the test was around 1:00 pm and it took approximately 16mins before a caregiver responded. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. LIC9099-C Allegation: Staff do not meet the residents hygiene needs. Finding: Unsubstantiated On 03/13/2025, LPA interviewed witness (W). W1 stated that there were a number of residents at the facility who require and have requested nail care, but are not getting them regularly. W1 stated they are also told they cannot have more than one shower. , the nail care is still not being done regularly, and neither is the showers, due to there not being enough staff to provide the services. LPA interviewed residents (R). R1, R2, R3, R4 and R5 all stated that they get their showers which is scheduled. R1 stated that they get one (1) shower a week but they don't want more than one and it is there choice. LPA interviewed staff (S). S1 stated that they implemented a nail care schedule and that one of the Med Techs is following up with all the residents that need nail care. LPA reviewed Walnut Creek Willows Wellness Log dated 02/07/2025 that included all residents in both North and South wings with a schedule to have nail care scheduled and completed. Allegation: Staff do not properly safeguard a resident's personal belonging Finding: Unsubstantiated LPA did not receive any details to which resident was missing items delivered on one day and then missing the next day. LPA interviewed S1 about missing delivered items and S1 stated when packages are delivered the facility gives the items to the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 13, 2025 · control 15-AS-20250304113010

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a) · Plan of correction due date: Apr 24, 2025

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: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on observation, interview and record review, the licensee did not comply with the section cited above by not, including but not limited to, responding to residents' call buttons in a timely manner and addressing the residents' care needs after turing off the call light which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Administrator agreed to provide a written plan to address the long response time for call button. Administrator will submit the written plan to CCLD for review by POC date.

Allegation investigated: Staff did not use food service sanitation practices to protect the resident's food from contamination.

On 03/06/2025 at 12:10 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator, Elizabeth Cortes to deliver the findings of above allegation. LPA explained the purpose of the visit with Administrator/Licensee. During investigation, LPA obtained the following documents: Resident Roster, Staff Roster, Menus for February and March 2025, care plans for residents on modified diets. LIC9099-C Continued... Substantiated LIC9099-C (Page 2) Allegation: Staff did not use food service sanitation practices to protect the resident's food from contamination. Finding: Substantiated On 03/03/2025, LPA L. Alexander interviewed witnesses (W) W1 and W2. W1 stated that on 02/01/2025 the facility served fish and that the fish was undercooked. W1 stated that the fish was baked, and it was cooked on the outside but when they used their knife to cut into the fish it was uncooked. W1 stated that they returned the meal back to the caregiver. W2 stated that on 02/06/2025, Resident (R), R1, told them that the chicken was raw and that they didn’t eat it. W2 stated that they observed that protective gloves are not worn when preparing meals. W2 stated the meals are not nutritious nor well prepared. Both W1 and W2 stated that lunch and dinner are served at around 11:30am and 4:30pm. On 03/05/2025, LPAs L. Alexander and K. Nguyen interviewed fifteen (15) residents (R). R6, R9, R13 stated that they have been served raw food before, the food is not good and most times food is served cold. R2, R3, R4, R5, R6, R7, R8, R12, R14 and R15 all stated that the food is not good and is served cold. R9 stated that the food is okay. R11 stated that they’re on a modified diet. Therefore, they haven’t experienced the quality of food temperature and taste of the food served. On 03/05/2025, LPAs L. Alexander and K. Nguyen toured the kitchen around 11:50 am and observed four (4) staff (S) members in the kitchen preparing food and prepping food on trays to serve the residents. LPAs observed S1 stirring food in a pot with just one (1) glove on and the three (3) other staff were not wearing gloves or protective hair nets while handling food and food trays. LIC9099-C (Page 3) At around 12pm three (3) out of the four (4) staff that were in the kitchen started to place protective gloves on their hands. LPAs observed S2 handling food, then handling paper menus with the same gloves on. At around 4:39 pm LPAs observed three (3) staff members in the kitchen prepping food to serve residents for dinner who were not wearing protective gloves nor hair nets on their heads. LPAs observed two (2) other staff serving dinner plates to the residents in the dining area who were not wearing protective gloves. LIC9099-C (Page 5) Allegation: Staff retaliated against resident for complaining Finding: Unsubstantiated On 03/03/2025, LPA L. Alexander interviewed witness (W) W1. W1 stated that on 02/08/2025 they went to the kitchen and knocked on the door three times and on the third knock S2 opened the door with an attitude. W1 further stated that S5 was told by S4 that R1 was not served their lunch tray and that S5 said “I don’t care.” W1 stated that it feels like retaliation from some of the staff caregivers. W2 stated that they felt retaliation if they complain about something. On 03/05/2025, LPAs interviewed R2. R2 stated that they have heard S4 being rude to R1. R2 stated that R1 yells at staff. R3 thru R15 all stated that they do not have any trouble with the caregiver staff. R3 thru R15 all stated that they get good care from the caregivers and that they have not felt any type of retaliation. R3 thru R15 all stated that they have not heard any of the staff caregivers speak of any residents in a negative way that would suspect retaliation. On 03/06/2025, LPA interviewed S2. S2 stated that they do not talk to R1 due to previous issues. S2 stated that R1 chooses not talk to with them. S2 stated that S3, S4, S5 and S6 all have expressed frustration because R1 is always complaining to or about them. S2 stated denial of retaliation towards R1 but they just won't be talking to them anymore. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 6, 2025 · control 15-AS-20250303150627

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9)(15) · Plan of correction due date: Apr 3, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food... (15) All persons engaged in food preparation and service...food services sanitation practices which protect the food from contamination. This requirement is not met as evidence by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not including but not limited to having staff practicing safe food sanitation when preparing and serving food. In addition, serving food that is of good quality, taste and is not cold to residents which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 6, 2025

Plan of correction: Administrator agreed to conduct an In-Service Training with staff on personal hygiene and food services sanitation practices which protect the food from contamination. All kitchen staff/cooks shall submit food handler certifications to CCLD by POC due date. Also Administrator agreed to schedule an appointment for a nutritionist, a dietitian, or a home economist to do consultations during meal time at the facility and will send the consultant's report to CCLD through March 2026.

Type of visit: Case Management - Other

On 03/06/2025 at 2:30 pm Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Administrator/Licensee, Elizabeth Cortes and explained the purpose of the visit. While LPA was at the facility for a complaint investigation (15-AS-20250303150627) and taking a self guided tour of the kitchen deficiencies were observed. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 1:53pm, LPA observed three (3) cases of Clorox Bleach and one (1) 210 oz bottle of Fabuloso Multi-Purpose Cleaner, Lavender sitting on the floor in the food pantry/storage area which was unlocked At 1:54pm, LPA observed one (1) case of Clorox Bleach and two (2) 210 oz bottles of Fabuloso Multi-Purpose Cleaner, Lavender sitting on the floor in the food pantry/storage area between freezer and refrigerator. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(25) · Plan of correction due date: Mar 13, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in by not storing cases of Clorox Bleach and bottles of Fabuloso Multi-Purpose Cleaner in a area separate from food supplies which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 6, 2025

Plan of correction: Administrator agreed to remove the cleaning disinfectant products and send a photo. In addition, read the regulation and self-certify understanding the regulation moving forward. POC documents will be sent to CCLD by POC due date.

Allegation investigated: Staff did not provide a resident with privacy while in care.

On 03/05/2025, at 10:30 am, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct initial 10-day complaint visit and deliver for the above allegation. LPAs met with Administrative Assistant, Lynette Sandoval, and explained the reason for the visit. Lynette phoned Administrator, Elizabeth Cortes, to inform. LPAs obtained: Resident Registry. LIC9099-C Continued... Substantiated LIC9099-C (Page 2) Allegation: Staff did not provide a resident with privacy while in care. Finding: Substantiated On 3/03/2025, LPA interviewed Witness (W). W1 stated that on 02/17/2025 while Resident (R), R1, was taking a shower and asked Staff (S), S1, to go to their room and get their "grabbers." W1 stated that R1 has a camera in their room and later observed that S1 picked up R1's phone and was looking at their phone. On 03/05/2025, LPAs interviewed R1. R1 stated that on 02/17/2025 they asked S1 to go get their "grabbers" from their room while they were taking a shower. R1 stated that they viewed video footage from an App on their phone of S1 picking up their phone and looking at their phone while they were in the shower. On 03/05/2025, LPAs interviewed S2. S2 stated that R1, sent them a video showing S1 picking up R1's phone and confirmed that the person in the video was S1 in R1's bedroom. S2 stated that they observed S1 picking up R1's phone and scrolling through the phone while R1 was not present in the room. LPAs also viewed and observed S1 in the video picking up a phone, looking at the phone, grabbed the grabbers and walked out the room. On 03/05/2025, LPAs interviewed S1 via phone call. S1 stated that they do not have any knowledge of picking up R1's phone and looking at the phone. S1 stated that they have no knowledge of anyone else picking up R1's phone and looking at it while they were not present. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 15-AS-20250224153947

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Mar 21, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights...87468.1, Personal Rights of Residents in All Facilities,...residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations... This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above in by violating R1's personal rights to privacy including but not limited to picking up R1's phone and looking at messages when they are not present which poses a potential safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: Administrator agrees to conduct In-service training with all staff on personal rights including but not limited to phones devices. Training-sign in sheet and synopsis of the training topic will be submitted to CCLD by POC due date.

Type of visit: Case Management - Deficiencies

On 03/05/2025 at 5:00 pm Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a Case Management - Deficiency. LPAs met with Administrative Assistant, Lynette Sandoval, and explained the purpose of the visit. Lynette phone, Administrator, Elizabeth Cortes to inform. On a previous visit, LPA cited a deficiency, General Food Service Requirements, CCR 87555(b)(17) which had a Plan of Correction (POC) due date of 12/30/2024. The deficiency was not cleared. LPA was not able to return before the POC time frame visit. LPAs interviewed Staff (S1) that stated that they are still trying to hire a cook for the kitchen. LPAs will re-cite the deficiency today. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(17) · Plan of correction due date: Mar 12, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in by not having a full-time qualified employee by formal training responsible for food services which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: Administrator agreed to hire an full-time employee with formal training and send copy of certifications to CCLD by POC due date.

Type of visit: Case Management - Other

On 03/05/2025 at 4:30 pm Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a Case Management visit. LPA met with Administrative Assistant, Lynette Sandoval. Lynette phoned Administrator, Elizabeth Cortes to inform. While LPAs L. Alexander and K. Nguyen was at the facility for a complaint investigation (#15-AS-20250224153947), the following deficiency was observed. LPAs observed that resident, R1, has a “Personally Operated Video Surveillance with Audio Recording” in a shared bedroom with R2. LPAs reviewed R2’s records that showed that the camera with audio is being used without the written and documented consent of the resident or the resident’s responsible party. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a) · Plan of correction due date: Mar 31, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: Based on observation and interview the licensee did not comply with the section cited above in by ensuring that camera with audio does not violate a residents' right to privacy and dignity as required by existing regulations. Including but not limited to all clients and residents maintain privacy and dignity rights that could be violated by negligent and/or abusive surveillance practices which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: Administrator will read regulation and self-certify understanding this regulation moving forward. In addition, Administrator will have to ensure and attest that the camera does not obtain audio by sending a detailed letter to CCLD by POC due date.

Allegation investigated: Wrongful Eviction

On 1/15/2025 at 10:30 AM, Licensing Program Analyst (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct a complaint investigation and deliver findings in regard to the allegations above. LPAs met with Administrator assistant, Lynette Sandoval, and explained the purpose of the visit. During the course of the investigation LPAs interviewed W1 and S1 and reviewed R1s eviction notice. LPAs determined that the eviction issued to R1 did not meet regulation. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Jan 15, 2025 · control 15-AS-20241202123509

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(2)(f) · Plan of correction due date: Jan 15, 2025

87224(a)(2)(f) Eviction Procedures: A licensee of a licensed residential care facility for the elderly shall...(2) Provide each resident...with a written notice.... The notice shall include all of the following: (F) The contact information for the local long-term care ombudsman, including address and telephone number. Based on record review the licensee did not comply with the section cited above. The eviction notice did not include contact information which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2025

Plan of correction: Licensee shall provide an eviction notice that meets regulation to CCL by 1/15/2025.

Type of visit: Collateral

Licensing Program Analyst (LPA) Vincent Moleski and Auditor Preston Saitta arrived unannounced to conduct a collateral visit. LPA Moleski and Auditor Saitta met with facility administrator Elizabeth Cortes and explained the purpose of the visit. Auditor Saitta and LPA Moleski interviewed a staff member (S1) during this visit. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Cortes.the state’s words, verbatim · CDSS document, Dec 4, 2024

Allegation investigated: illegal eviction

On 11/26/2024 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator, Elizabeth Cortes to deliver findings of above allegation. LPA explained the purpose of the visit with Administrator. During the course of investigation, LPA interviewed two (2) witnesses (W) W1, W2, two (2) staff (S) S1, S2 and resident (R) R1. LPA obtained and reviewed R1’s documents including Resident Appraisal, Physician’s Report, Admission Agreement, Advanced Health Care Directive, Letter of Agreement, Assisted Living Waiver Program document, Unusual Incident Report, Medication Technician Notes and Resident Registry. LIC9099-C Substantiated LIC9099-C (Page 2) Allegation: illegal eviction Finding: Substantiated On 07/16/2024, the LPA interviewed S1 that stated R1 called 911 themselves and was transported to emergency room. S1 stated that R1 said that they were not coming back and that their ex-wife came to the facility to pick up all their personal belongings and confirmed that R1 was not coming back because they were going to another facility located in Antioch. On 09/30/2024, the LPA interviewed W1 that stated R1 was transported to Kaiser Walnut Creek Emergency Room (ER) from Walnut Creek Willows (facility) on 07/01/2024. W1 stated that after R1 was treated in the ER, R1 was ready to be discharged and return to facility. W1 stated that they called Walnut Creek Willows several times but there was no answer. W1 stated that on 07/042024 they called the facility, and spoke to one of the Med Techs, (S2), that told them that R1 was discharged and that they were not taking him back. W1 stated that S2 told them that they could not make the decision. W1 further stated that when they did hear back from S3, they told them that they were not going to accept R1 back because they were notified that R1 was not going to return to the facility. W1 stated that S3 acknowledged that they did not give R1 a 30-day notice. W1 concluded statement that there were no bedside evaluations, no exploring alternative placement options, and no confirmation if facility had an opened bed available. On 09/30/2024, the LPA interviewed W2 that stated R1 called 911 and was transported to Kaiser Walnut Creek Emergency on 07/01/2024. W2 stated that R1 was ready to be discharged on 07/03/2024 and that the facility refused to accept R1 back at the facility. W2 stated that they spoke with S1 that told them that R1 was the one that called 911 and that they were told that R1 was not coming back to the facility. W2 stated that at the time R1 was ready to be discharged from Kaiser Walnut Creek ER, that R1 did not have another confirmed placement at another facility. W2 stated that Kaiser team had to find another placement for R1. LIC9099-C (Page 2) LIC9099-C (Page 2) On 11/13/2024, the LPA interviewed R1 that stated they feared for their life because how they were being treated at the facility and that is why they called 911. R1 stated that they wanted to be checked out at the hospital and get some tests done. R1 stated that Kaiser was calling trying to get in touch with the administrator at Walnut Creek Willows but there was no response. R1 stated that they never told anyone at the facility that they were not coming back. R1 stated that they always paid their rent by the 5th of each month and paid by money order. Based on LPA’s observations and interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 15-AS-20240708161505

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Dec 20, 2024

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above in by serving R1 with an appropriate eviction notice after deciding not to accept R1 back to the facility once R1 was discharged from the hospital ER which posed a potential health and safety risk and personal rights to persons in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: The licensee will read regulation 87224 and submit self-certification that it has been read, understood and they will abide going forward to CCLD by POC due date.

Allegation investigated: Staff does not treat resident with respect

On 11/26/2024 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Licensee/Administrator, Elizabeth Cortes to deliver findings of above allegation. LPA explained the purpose of the visit with Licensee/Administrator, Elizabeth Cortes. During the course of the investigation, LPA interviewed four (4) residents (R) R1, R2, R3, R4, two (2) staff (S)S1, S2, and complainant. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Allegation: Staff does not treat resident with respect Finding: Unsubstantiated On 09/05/2024, the LPA interviewed R1 that stated, “S2 continues to purposely sing loud passing my room.” R1 stated that S2 has antics ongoing. R1 further stated that S1 did speak to S2 and told them that “S2 was just happy because they got more hours.” On 11/08/2024, the LPA interviewed R2-R4. R2-R4 all stated that they have not had any issues with staff singing while passing their rooms. Interviews with R2-R4 stated that housekeeping cleans their rooms and that they have not had any issues with the housekeeper. On 11/08/2024, the LPA interviewed S1 and S2. S1 stated that they spoke to S2 regarding the singing when passing by R1’s room and said, that S2 was listening to a song that made them happy. S2 stated that they sing because they are happy, but they are not singing purposely to upset R1 or any of the residents. S2 stated that they currently work in laundry in the backroom and that is where they play their music. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 15-AS-20240826162149

Allegation investigated: Staff do not safeguard resident's personal possessions.

On 11/26/2024 at xx:xx AM/PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Licensee/Administrator, Elizabeth Cortes to deliver findings of above allegation. LPA explained the purpose of the visit with Administrator, Elizabeth Cortes. During the course of the investigation, LPA interviewed three (3) residents (R) R1, R2, R3, two (2) staff (S) S1, S2, and complainant. LPA obtained and reviewed documents including staff roster and staff schedule. LIC9099-C Unsubstantiated LIC9099-C (Page 2) Allegation: Staff do not safeguard resident's personal possessions. Finding: Unsubstantiated On 09/30/2024, the LPA interviewed R1 that stated they ordered three (3) banana bread muffins online on 09/03/2024. R1 stated that they left the muffins in a basket next to their bed. R1 stated that they ate one (1) of the muffins so that left them with two (2) muffins. R1 stated that the last person in the room was S2. R1 stated that S1 spoke with S2 regarding the missing banana bread muffin and that S2 denied that they took anything and that they did not touch anything in R1’s room. R1 stated that S1 replaced the muffin. R1 further stated that on 09/21/2024 they bought three (3) bottles of coconut water that they kept in the locked refrigerator in the back kitchen. R1 stated that one (1) of their bottled coconut waters were missing and one (1) of their yogurts was also missing from the refrigerator. R1 stated that they labeled their food items with their name and date and that other residents use this same refrigerator. On 10/07/2024, the LPA interviewed S1 and S2. S1 stated that they spoke with S3 and that S3 said that they did not touch nor take anything in R1’s room. S1 stated that they went to the store and bought R1 another banana bread muffin to replace the missing muffin. S2 stated that residents can place their personal food items in the locked refrigerator and that no one has access to the refrigerator. S2 stated that only kitchen staff are allowed in the kitchen and when a resident wants their food, they can ask the staff to get the item. LIC9099-C Continued... LIC9099-C (Page 3) On 11/08/2024, the LPA interviewed R2 and R3 that stated that they have not had anything missing from the facility and nothing missing from out the refrigerator if they used it. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 15-AS-20240903114802

Allegation investigated: Facility does not have sufficient wash cloths Facility does not provide a variety of food Facility staff does not treat client with dignity

On 11/26/2024 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator, Elizabeth Cortes to deliver findings of above allegations. LPA explained the purpose of the visit with Administrator. During the course of the investigation, LPA interviewed seven (7) residents (R) R1, R2, R3, R4, R5, R6, R7, four (4) staff (S) S1, S2, S3, S4, and witness (W) W1. LPA obtained and reviewed documents including September menu and resident roster. LIC9099-C Continued... Substantiated LIC9099-C (Page 2) Allegation: Facility does not have sufficient wash cloths Finding: Substantiated On 09/23/2024, the LPA interviewed W1. W1 stated that residents shared with them that there are no towels or wash cloths when residents shower. W1 stated that on 09/05/2024 they observed two (2) towels and one (1) wash cloth in the shower room. On 09/24/2024, the LPA interviewed R1, R2 and R3. R2 stated that they have their own towels that they brought from their home. R3 stated that the facility does not have towels. R4 stated that the facility has towels, but the towels are small, the washcloths are low in quantity and the towels are ripped and have stains on them. On 11/08/2024, the LPA observed approximately ten (10) towels in the shower room. The towels appeared thin, stained, and ripped. LPA brought the observation to the S1 and S2. S1 stated that they have more towels that are getting laundered, and they showed LPA new packages of towels in their office. S1 stated that a lot of towels are thrown away because the caregivers use the towels on residents and that they have to throw them away after use. Allegation: Facility does not provide a variety of food Finding: Substantiated On 09/17/2024, LPA interviewed W1. W1 stated that the facility does not follow the posted menu next to the kitchen and that residents are not given fresh fruits, fresh vegetables and constantly given canned vegetables or processed foods. W1 stated that they inquired about cream, sugar, salt, and pepper for the residents with S3 and that S3 said, “if residents want that, they can buy it.” LIC9099-C Continued... LIC9099-C (Page 3) W1 stated that S3 told them that they tried hiring a new cook, but he did not show up. W1 stated that they explained to S3 that residents have the right to have options and that some residents have dietary needs. W1 stated that S3 said, “residents do not pay her enough to request more.” On 09/24/2024, the LPA interviewed S4. S4 stated that they follow the menu that was provided from a company that they use. S4 stated that they were expecting a food delivery tomorrow with fresh veggies and watermelon. On 09/24/2024, the LPA interviewed R1-R7. R1 stated that the food is not good and taste bland; no snacks are offered and that they don’t follow the menu. R1 further stated that they are served a lot of pork, the presentation doesn’t look good and that you don’t know if it’s meat. R2 stated that the food is pretty good, they have had fresh strawberries. R3 stated that the food is ok but could be better. R3 stated that they get snacks, fresh fruits, and veggies. R4 stated that the facility does not serve fresh vegetables and not enough fresh fruits. But sometimes they have served fresh strawberries and bananas. R5 stated that they have not been served fresh fruits and everything comes from Costco. R6 stated that the breakfast is good with eggs, bacon, and sausage. R6 stated, “the food here sucks,” and that they buy their own food. R6 further stated that the fruits are all canned fruit. R7 stated the food is pretty good, yes, they get a variety of foods and that they also get fresh veggies and fruits On 09/24/2024, the LPA observed bananas, oranges and two (2) watermelons in the food pantry. The bananas were observed with brown spots. Staff stated that they were expecting a food delivery with fresh fruits and other foods. LIC9099-C Continued LIC9099-C (Page 4) Allegation: Facility staff does not treat client with dignity Finding: Substantiated On 09/17/2024, the LPA interviewed W1. W1 stated that during a visit to the facility on 08/05/2024 they observed a bathroom door wide open, north wing, while a male resident was naked with his bottom facing the door. W1 stated that they closed the door to preserve the resident’s dignity. W1 stated that on this same day they observed a staff member enter the same bathroom to sweep the floor while the caregiver was assisting the male resident to the toilet. W1 stated that they attempted to address their concerns with S3 on 08/22/2024, to which they never heard back from. W1 stated that on 09/05/2024 they observed staff referring to a resident using the incorrect pronouns. W1 stated that they spoke with subject resident and that they told them that staff “do it all the time,” and that they don’t like how it makes them feel. On 09/24/2024, the LPA interviewed R1, R3, R4. R1 stated that the caregivers will take off the gown only and you’ll have a diaper on. R1 stated, “I’m not going out there with no clothes” and then the caregiver will place a cover over them. R1 stated that the caregivers are in a rush to give a shower. R3 stated that they’re not always treated with respect and have had words with two (2) of the caregivers. R3 stated that you get little notice for showers and that showers are rushed. R3 stated that the caregivers will cover them with a towel, sometimes a sheet and then push them out to the shower room on a shower chair. R3 stated that the facility is low on staff, but they prefer a female caregiver to give them a shower. LIC9099-C Continued... LIC9099-C (Page 5) R3 stated that the caregivers don’t know no better when it comes to respecting people’s gender identity. R3 stated that their pronouns are She/Her and that they have told the caregivers, but they sometimes call them Him/He. S2 stated that staff were calling R3 "He" but they asked R3 what did she want to be called and she told them "She." R4 stated that they observed the caregivers taking their roommate (R5) out for a shower and they only had a hospital gown on. R4 stated that R5 wasn’t completely covered and that you can see parts of their thighs. R6 stated that they are covered up when the caregivers give them a shower. But sometimes they will try to shower themselves. Based on LPA’s observations and interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided to Administrator.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 15-AS-20240917103055

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Jan 10, 2025

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care...(C) Clean linen...The quantity shall be sufficient... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in by not having clean bath towels, hand towels and wash cloths with sufficient quantity for residents in care at all times which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administrator agreed to purchase towels and send copy of receipts to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(17) · Plan of correction due date: Dec 30, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in by not having a full-time qualified employee by formal training responsible for food services which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administrator agreed to hire an full-time employee with formal training and send copy of certifications to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1)(b)(5) · Plan of correction due date: Dec 30, 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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (b) All residents in all residential care facilities for the elderly shall be protected from all of the actions specified in this subsection. (5) Willfully and repeatedly fail to use a resident’s preferred name or pronouns after being informed of the resident’s preferred name or pronouns in a clear manner. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in by not according dignity and respect with bathing, showering, toileting, and addressing residents by their preferred names and pronouns which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administrator agreed to conduct In-Service Training with staff/caregivers and send copy of sign-in sheet to CCLD by POC due date.

Allegation investigated: Staff does not treat resident with dignity or respect.

On 11/26/2024 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator, Elizabeth Cortes to deliver findings of above allegations. LPA explained the purpose of the visit with Administrator. During the course of the investigation, LPA interviewed one (1) resident (R) R1, two (2) staff (S) S1, S2, and complainant. LPA obtained and reviewed documents including staff roster. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Allegation: Staff does not treat resident with dignity or respect. Finding: Unsubstantiated On 10/06/2024, the LPA interviewed R1. R1 stated that S1 continues to purposely sing loud while passing their bedroom. R1 stated that S2 was very rude to them and talked with an attitude. R1 stated that they asked S2 if the breakfast was pancakes and S2 responded, “Do you want breakfast or not?” R1 stated that S2 took their food tray to the dining room. R1 stated that S3 squeezed between them and the wall while they were walking with their walker. R1 stated that they didn’t know that S3 was there, and they said, “excuse me,” to S3. On 10/07/2024, the LPA interviewed S2. S2 stated that they didn’t say anything rudely to R1. S2 stated that R1 asked if the breakfast was pancakes and S2 responded, “Yes.” S2 stated that they took the plate to the dining room. S2 stated that they have no issues with R1 and that they both say “Hi” to each other all the time. On 11/08/2024, the LPA interviewed S1. S1 stated that they sing because they were listening to a song that made them happy. S1 stated that they play their music in the backroom where they do laundry. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 15-AS-20241003160505

Allegation investigated: Quality of Care Accomodations

On 11/26/2024 at 12:30 PM, Licensing Program Analyst (LPA), L. Alexander arrived unannounced to deliver complaint findings for the allegation above. LPA met with Administrator, Elizabeth Cortes and explained the reason for the visit. LPA interviewed witness, staff, resident, obtained resident roster, staff roster, and copy of text messages between S2 and R1. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Based on witness' interview facility did not purchase equipment to accommodate R1. Witness stated the facility had equipment, but the quality of the equipment did not meet the qualifications for R1. During interview R1 stated a request was made to R1’s doctor but it was too much to undergo, therefore R1 gave up and requested the facility to purchase equipment in June. R1 stated the acceptable chair arrived the first week of October. S2 stated there was equipment that R1 had been using located on the north wing of the facility before the request was made. S2 stated R1 requested a special type of equipment. LPA reviewed text messages between S2 and R1 regarding the equipment. S2 stated the conversation about the equipment started the beginning of September. S2 stated the facility ordered equipment on September 20, 2024, but it was too small. The facility then reordered equipment and it arrived on October 10, 2024. Based upon the information obtained and the interviews conducted during investigation the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 15-AS-20241021141250

Allegation investigated: Facility staff are not assisting resident with meeting their bathing needs Facility staff are not meeting residents dietary need Facility staff are retaliating against resident due to previous complaint

On 11/26/2024 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator, Elizabeth Cortes to deliver findings of above allegations. LPA explained the purpose of the visit with Administrator. During the course of the investigation, LPA interviewed four (4) residents (R) R1, R2, R3, R4, two (2) staff (S) S1, S2, and one (1) witness (W) W1. LPA obtained and reviewed documents including physician’s report, staff schedule, shower schedules, and facility menu. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Allegation: Facility staff are not assisting resident with meeting their bathing needs. Finding: Unsubstantiated On 11/08/2024, the LPA interviewed W1. W1 stated that their shower is scheduled on Sundays. W1 stated on 11/03/2024 they were scheduled to get a shower in the evening, but they declined because they prefer a certain caregiver that was not scheduled to work. W1 stated that they spoke with S1 to reschedule their shower and was told that they will get a shower the next day. LPA reviewed R1’s physician’s report and the report indicates that R1 needs assistance with bathing. On 11/08/2024, the LPA interviewed R1, R2, R3 and R4 that stated that they get showers based on the shower schedule two (2) times a week regardless which caregiver is assigned for that scheduled day. On 11/08/2024, the LPA interviewed S1 that stated the subject resident declined the scheduled shower on 11/03/2024 because they did not want the two (2) scheduled caregivers to give them a shower. S1 stated that they told subject resident that they will try to accommodate them on the following day, but it depends if the caregivers can schedule subject resident’s shower with the residents that are already scheduled. LIC9099-C Continued... LIC9099-C (Page 3) Allegation: Facility staff are not meeting residents dietary need. Finding: Unsubstantiated On 11/08/2024, the LPA interviewed W1 that stated that they cannot eat some of the foods that is prepared at the facility kitchen. W1 stated that they have an allergy with their health condition. W1 stated that they have an upcoming appointment with a dietician and R1 mentioned that their diet restriction is vegan. LPA reviewed subject resident’s physician’s report and the report indicates no food restrictions. Allegation: Facility staff are retaliating against resident due to previous complaint Finding: Unsubstantiated On 11/08/2024, the LPA interviewed S1, S2, S3 and S4. S1, S2, S3 and S4 all stated that they do not have any issues with R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 15-AS-20241105092512

Allegation investigated: Staff do not accord resident privacy.

On 11/26/2024 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator, Elizabeth Cortes to deliver the findings of above allegation. LPA explained the purpose of the visit with Administrator. During the course of the investigation, LPA interviewed two (2) staff (S) S1, S2, and one (1) resident (R) R1. The LPA obtained the following documents from the facility: resident’s roster, staff roster, shower schedule and physician’s report. LIC9099-C Continued... Substantiated LIC9099-C (Page 2) Allegation: Staff do not accord resident privacy. Finding: Substantiated On 09/30/2024, the LPA interviewed R1. R1 stated that on 09/22/2024 they were in the shower room taking a shower when S1, a male caregiver, “barged” in the shower room just to get a cup of water. R1 stated that S1 said, “Hi,” got a cup of water and then left out the shower room. R1 stated that they were naked and had to cover up their chest. R1 stated that they felt very uncomfortable. R1 stated that there was another male staff sitting on the chair outside the shower room looking down at their phone. R1 stated that they were only in a hospital gown and that they asked the male staff if they could move. The male staff got up and stood at the counter across from the shower room but was still looking at their phone. On 10/07/2024, the LPA interviewed S1 and S4. S1 stated that they are a caregiver in the South Wing, and their duties are to change diapers, grooming (trimming resident’s facial hair, giving haircuts), feeding residents and giving residents showers. S1 stated that they couldn’t find a towel and that towels are only located in the shower room. S1 stated that they came to the shower room to grab a towel and thought that the shower room was empty. S4 stated that S3 was on their phone because they were clocking in to start their shift. Based on LPA’s observations and interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 15-AS-20240923114538

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(c) · Plan of correction due date: Dec 30, 2024

87307 Personal Accommodations and Services (c) Individual privacy shall be provided in all toilet, bath and shower areas. This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the section cited above in by not ensuring R1’s privacy while showering which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administrator agreed to conduct In-Service Training with staff/caregivers and send copy of sign-in sheet to CCLD by POC due date.

Allegation investigated: Licensee does not ensure that resident's room is adequately cleaned.

This is an amendment to an original 9099 report issued on 11/26/2024. On 11/26/2024 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator, Elizabeth Cortes to deliver findings of above allegation. LPA explained the purpose of the visit with Administrator. During investigation, LPA interviewed three (3) residents (R) R1, R2, R3, one (1) staff (S) S1, and complainant. LPA obtained and reviewed documents including….. LIC9099-C Continued... Unsubstantiated This is an amendment to an original LIC9099-C report issued on 11/26/2024. LIC9099-C (Page 2) Allegation: Licensee does not ensure that resident's room is adequately cleaned. Finding: Unsubstantiated Based on interviews with R2, R3, and R4 residents' rooms are cleaned daily. R2, R3 and R4 stated that the housekeeping staff thoroughly sweeps, mops and cleans their rooms daily. R2 stated that the housekeeper thoroughly sweeps, mops and cleans their bathroom two (2) times a week. R1's bedroom and bathroom is scheduled to be cleaned two (2) times a week. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 15-AS-20241104122537

Allegation investigated: Staff are retaliating against a resident

This is an amendment to an original LIC9099 report issued on 11/26/2024. On 11/26/2024 at 12:30 pm, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator, Elizabeth Cortes to deliver findings of above allegation. LPA explained the purpose of the visit with Administrator. During the course of the investigation, LPA interviewed three (3) residents (R) R1, R2, R3, four (4) staff (S) S1, S2, S3, S4, and complainant. LPA obtained and reviewed documents including staff roster and resident registry. Allegation: Staff are retaliating against a resident Finding: Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No This is an amendment to an original LIC9099-C report issued on 11/26/2024. LIC9099-C (Page 2) Allegation: Staff are retaliating against a resident Finding: Unsubstantiated Based on interviews with R1, R2, R3 and R4 they stated that they have not had any issues with staff/caregivers nor felt that staff was treating them in any kind of retaliated way. R1, R2, R3 and R4 stated that they have not heard of any staff or residents speaking or saying anything of retaliation towards subject resident. S1, S2, S3 and S4 all stated that they are at the facility to do their job, take care of the residents and that they are not doing anything personal against any residents. S1, S2, S3 and S4 all stated that they have not heard any other staff speaking about the subject resident in any negative way. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 15-AS-20241031132116

Allegation investigated: Resident was not accorded safe, healthful comfortable accommodations

On 10/29/2024 at 3:00pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct an initial 10-day visit and deliver complaint findings for the allegation above. Lynette Sandobal, Admissions and Marketing Director, and explained the reason for the visit. Administrator, Ellizabeth Cortes, came in at 3:25pm. LPA interviewed staff, resident, obtained resident roster, staff roster, a list of R1's medications, emergency contact and identification, and a copy of motorized wheelchair demo visit. Based on witness' interview R1 is uncomfortable and in pain sitting in the wheelchair. S2 stated that R1 is on the fourth loaner wheelchair and facility has been trying to assist R1. S2 also stated R1 is waiting on insurance approval for a motorized chair. and if the facility orders a customized chair the motorized chair will be canceled. Continued on LIC9099C. Unsubstantiated Continued from LIC9099. During interview R1 stated the chair is uncomfortable but wants to wait for the motorized chair. During visit caregiver placed towel between R1 and arm rest of wheelchair to relieve some pressure. S1 stated power of attorney is coordinating with doctors for motorized chair and it has been approximately four (4) months. Based upon the information obtained and the interviews conducted during investigation the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Oct 29, 2024 · control 15-AS-20241021143448

Type of visit: POC

On 09/24/2024 at 12:55 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Admissions Director, Lynette Sandoval, and informed the reason for visit. Lynette phoned the Licensee/Administrator, Elizabeth Cortes to inform. On 09/06/2024 LPA L. Alexander conducted a Case Management visit in which the following deficiency were not cleared by POC due date of 09/20/2024. The following deficiency were not cleared by visit: HSC 1569.686(a)(3) $100.00 x 4 days = $400.00 Civil penalty of $400.00 is assessed for the period of 09/21/2024 to 09/24/2024 for failure to correct deficiency. Facility is subject to ongoing daily civil penalties until deficiencies are corrected. Exit interview conducted. A copy of this report, LIC 421FC and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 24, 2024

Type of visit: Case Management - Deficiencies

On 09/06/2024, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management, meeting with Admissions Director, Lynette Sandoval. LPA explained the purpose of the visit, and the Licensee/Administrator, Elizabeth Cortes, was informed by phone of the visit. On 09/05/2024, The Department learned that the Licensee had filed bankruptcy on 07/09/2024 and had not been notified. LPA interviewed Licensee by phone. Licensee confirmed with LPA that bankruptcy was filed and that the Department, the Ombudsman, and the Residents (or Responsible Parties) had not been notified. Per Statute, notices must be sent within 2 business days of bankruptcy filing. A Civil Penalty of $2,000.00 has been assessed (calculated at $100.00 per day, up to $2,000.00) Exit Interview conducted. A copy of this report and Appeal Rights provided.the state’s words, verbatim · CDSS document, Sep 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.686(a)(3) · Plan of correction due date: Sep 20, 2024

§1569.686 Licensee notificacified events..(a) A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their legal representatives, in writing, within two business days, and shall notify all applicants for potential residence, and, if applicable, their legal representatives, prior to admission, of any of the following events, or knowledge of the event: (3) The licensee files for bankruptcy. This requirement is not met as evidenced by: Based on interview with the licensee did not comply with the section cited above in by not notifying the Department, Ombudsman and Residents of filed bankruptcy which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Licensee will submit copies of letters sent to Residents, Ombudsman, and a copy of the bankruptcy filing, LIC 500 to CCLD by POC date. Civil Penalty of $2,000 is being assessed.

Type of visit: POC

On 09/06/2024 at 3:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Admissions Director, Lynette Sandoval, and informed the reason for visit. Lynette phoned the Licensee/Administrator, Elizabeth Cortes to inform. On 04/10/2024 LPA L. Alexander conducted an Annual Inspection in which the following deficiencies were not cleared by POC due dates of 04/26/2024 and 07/03/2024. Deficiencies cleared: CCR 80087(a) CCR 87411(f) No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 6, 2024

Type of visit: Case Management - Health Checks

On 09/06/2024 at 11:55 AM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management Health and Safety check as a result of the Department learning that the Licensee filed bankruptcy. LPA met with Admissions Director, Lynette Sandoval and explained the purpose of the visit. Lynette phoned Licensee/Administrator, Elizabeth Cortes to inform. During the health and safety check, LPA observed a total of one (1) Staff in the front common areas preparing for resident social activity with Bingo. LPA observed residents sitting in their wheelchairs or laying in their beds in their apartment bedrooms. LPA observed the residents in the Memory Care area sitting in the common area watching television and some residents were in their bedrooms watching television or laying in their beds. LPA observed that the kitchen was clean and the food supply was sufficient. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 6, 2024

Type of visit: Case Management - Deficiencies

On 08/09/2024 at 3:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Admissions, Lynette Sandoval and explained the purpose for the visit. Licensee/Administrator, Elizabeth Cortes, was not available. On 06/05/2024 LPA L. Alexander conducted an Annual Inspection in which deficiencies were cited; CCR 87411(f). The Plan of Correction (POC) due date was 07/03/2024. The deficiency CCR 87411(f) was not cleared. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Sep 6, 2024

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not having health screening and negative TB results which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: Administrator will submit health screening for S3, S5, S7-S12 and a Negative TB for S2, S4, S5, S7-S12.

Type of visit: POC

On 08/09/2024 at 9:30 AM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Plan of Correction (POC) visit. LPA met with, Manager, Marilou Ladaban. Licensee/Administrator, Elizabeth Cortes, was available for a brief moment but had to leave. The facility submitted an appeal that was received by Regional Office on 05/03/2024. The appeal was in response to citation deficiencies 80087(a), 87608(a)(3) and 87211(b) that in which 80087(a) and 87211(b) were assessed civil penalties on 04/11/2024 and 05/01/2024. On 07/31/2024 the appeal was denied by Regional Office. Facility has the following deficiencies cleared: Deficiency CCR 87608(a)(3) cleared on 05/01/2024. Deficiency CCR 87211(b) cleared on 04/19/2024. Facility has the following deficiencies that was not cleared: Deficiency CCR 80087(a) not cleared. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report, appeal rights and LIC421FC provided.the state’s words, verbatim · CDSS document, Aug 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a) · Plan of correction due date: Sep 6, 2024

80087 Buildings and Grounds (a) The facility shall be...in good repair at all times... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having disrepair flooring in residents rooms and hallways which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: Licensee agreed to submit a detail plan of when they will have the flooring completely repaired and submit photos of repaired floors to CCLD by POC date.

Type of visit: Required - 1 Year

On 06/05/2024 at 1:25 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Elizabeth Cortes and Marketer, Lynette Sandoval explained the purpose of the visit. The facility’s fire clearance was approved for capacity 72 in which all non-ambulatory, of which may be bedridden and a hospice waiver of fifteen (15) residents. Administrator Certificate # #6017472740 expires 06/04/2024. LPA toured the facility with Lynette including but not limited to 2 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 63 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 128.5, 120.0, 122.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA reviewed 10 residents records. LPA reviewed 10 staff records and 9 of 12 have current first aid training and associated to the facility. LIC809-Continued... LIC809-C Continued... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/12/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurancethe state’s words, verbatim · CDSS document, Jun 5, 2024

The state marks this report as 14 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

While at the facility for another reason, Licensing Program Analyst (LPA) Carol Fowler learned that a resident at the facility has a private care giver that was not finger print cleared or associated to the facility. Staff 1 (S1) has been working at the facility since 12/2023. S1 has been finger print cleared as of 5/4/2024 but is not associated to the facility. R1's personal caregiver, S1) who visits R1 and provides activities of daily living (ADL) care, five (5) days a week from 9:00am to 12:00pm and 5:00pm to 7:00pm. Administrator admitted to not having S1 finger print cleared and associated to the facility. Deficiencies are being cited in violation of California Code of Regulations (see 809D).the state’s words, verbatim · CDSS document, May 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.17 · Plan of correction due date: May 15, 2024

Fingerprints and criminal records of individuals in contact with clients...record exemption from the State Department of Social Services before his or her initial presence in a residential care facility for the elderly.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Administrator will read the Regulation and send self certification of understanding to Community Care Licensing (CCL) by POC date. In addition, licensee will not allow any individual to work, reside, or volunteer prior to being finger print cleared and associated. Administrator will also forward a copy of S1 clearance and association to CCLD by POC date.

Type of visit: Case Management - Incident

On 5/8/2024 at 2:10PM, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to conduct a case management visit regarding an incident report. LPA met with Elizabeth Cortes, Administrator and explained the reason for the visit. The Department received an incident report dated 5/2/2024. It was alleged that S1 was grabbing R1 in a rough manner while pulling and tugging aggressively, S2 was walking passed and witnessed this. S3 witnessed R1 eating R1's food when it's brought to the room. Witnesses were unavailable to interview, a written statement was provided to LPA. LPA interviewed POA via phone call. POA stated that S1 has been a caregiver with POA family for 14 years and POA wants to keep S1 on as a personal care giver, POA stated that S1 will be going through care giver training with Suncrest Hospice. POA also stated that when S1 is in need of help with R1, S1 will ask staff at the facility for help. POA also stated that S1 was interviewed by Contra Costa Police department and it was determined that there were signs of abuse on R1. Exit interview conduct and a copy of this report provided.the state’s words, verbatim · CDSS document, May 8, 2024

Allegation investigated: . Staff installed bed rails on resident's bed without proper authorization

On 05/01/2024, at 9:15 am, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct initial 10-day complaint visit for the above allegation. LPA met with Rizza Madlangbayan and explained the reason for the visit. Licensee/Administrator, Elizabeth "Beth" Cortes, was phoned. Beth arrived approximately an hour later. The following documents were obtained: 1. Resident Registry 2. Physician's Report (LIC 602A) for R1 3. Resident Appraisal (LIC603A) 4. Resident Plan of Care (Dated 04/16/24) 5. Appraisal Needs and Services Plan (LIC625 dated 04/16/24) 6. Physician's Orders 7. Appointment of Representative (MC306) 8. SNF Transition Checklist LIC9099-C Continued Substantiated Allegation: Staff installed bed rails on resident's bed without proper authorization Substantiated. On 05/01/24 LPA spoke to RP who stated that R1 stated to them that they felt like they were in "a cage." RP further explained that R1 stated that the bed rails on the bed made them feel like they were in a cage. RP stated that S1 said that R1 was a fall risk and that the bed rail was for safety. RP stated that R1 did not have a doctor's order for a bed rail, but the staff removed the bed rail while RP was at the facility on 04/22/24. LPA interviewed R1 and R1 stated that the bed rail was on the bed initially but the Staff removed the bed rail. LPA reviewed R1's Physician Report and the report did not have any information that reflected the use of a bed rail for mobility support. LPA observed that the bed rail was removed on R1's bed. LPA advised S1 that bed rail for postural and mobility support requires a doctor's order. Based on information that S1 admitted that there was a bed rail on R1's bed the allegation is substantiated.the state’s words, verbatim · CDSS document, May 1, 2024 · control 15-AS-20240429125748

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: May 2, 2024

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. Based on interview, the licensee did not comply with the section cited above in by not having a written order from a physician for a bed rail for R1 which poses 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: Administrator removed bed rail. Deficiency cleared during visit.

Allegation investigated: . Staff did not ensure a written care plan was completed for resident in care

On 05/01/2024, at 10:15 am, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct initial 10-day complaint visit for the above allegation. LPA met with Rizza Madlangbayan and explained the reason for the visit. Licensee/Administrator, Elizabeth "Beth" Cortes, was phoned. Beth arrived approximately an hour later. The following documents were obtained: 1. Resident Registry 2. Physician's Report (LIC 602A) for R1 3. Resident Appraisal (LIC603A) 4. Resident Plan of Care (Dated 04/16/24) 5. Appraisal Needs and Services Plan (LIC625) 6. Physician's Orders 7. Appointment of Representative (MC306) 8. SNF Transition Checklist LIC9099-C Continued Unsubstantiated LIC809-C Continued... Allegation: Staff did not ensure a written care plan was completed for resident in care Unsubstantiated. On 05/01/24 LPA spoke to RP who stated that R1 did not have a care plan on file. RP states that R1 was admitted on 04/16/24. LPA interviewed S1 who stated that the Walnut Creek Willows Resident Plan of Care and Resident Appraisal was completed on 04/16/24 for R1. LPA reviewed the documents for R1 which included: Physician's Report, Resident Appraisal, Walnut Creek Willows Resident Plan of Care and Appraisal Needs and Services dated 04/16/24. Based on information reviewed and interview the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, May 1, 2024 · control 15-AS-20240429125748

Type of visit: POC

On 05/01/2024, at 11:15 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Rizza Madlangbayan, Administrative Assistant, and explained the purpose of the visit. Rizza contacted the Licensee, Elizabeth "Beth" Cortes, and inform that LPA was at the facility for a POC visit. The Licensee arrived approximately an hour later. LPA toured the facility to check the flooring repairs. LPA observed cracks in the tile near the shower room in the main hallway. LPA observed silver tape on floor tiles still remained in several bedrooms (both North and South wing). LPA observed the molding was lifting in the TV common area in the North wing area. Facility has the following deficiency that was not cleared: 80087 (a) = $100.00 x 5 = $500.00 Civil Penalties in the total amount of $500.00 is assessed today for failure to meet POC date for deficiency. Facility is subject to ongoing daily civil penalties until deficiencies is corrected. Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.the state’s words, verbatim · CDSS document, May 1, 2024

Type of visit: Case Management - Other

On 04/11/2024 starting at 12:00 PM, Licensing Program Analyst (LPA) L. Alexander conducted a Case Management while at the facility for another matter. LPA met with Administrative Assistant, Rizza Madlangbayan, and explained the purpose of visit. Rizza contacted the Licensee. Elizabeth Cortes, to inform. The Licensee was not available to come to the facility. LPA was informed by letter that facility does not have an facility administrator. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Apr 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Apr 18, 2024

(a) All facilities shall have a qualified and currently certified administrator... This requirement is not met as evidence by: Based on observation and interview, the licensee did not comply with the section cited above in by not having an Administrator available which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 11, 2024

Plan of correction: Licensee to submit documents of new administrator.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87407(k)(1) · Plan of correction due date: Apr 18, 2024

(k) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office responsible for receiving information regarding personnel changes at the licensed facility with whom the certificate holder is or was associated, and Based on observation and interview, the licensee did not comply with the section cited above in by not providing written notice to CCLD the personnel changes which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 11, 2024

Plan of correction: Licensee to self-certify that they read and understand the regulation. Submit written notice of personnel changes from the last Administrator.

Type of visit: POC

On 04/11/2024, at 10:00 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Rizza Madlangbayan, Administrative Assistant, and explained the purpose of the visit. Rizza contacted the Licensee, Elizabeth Cortes, and inform that LPA was at the facility for a POC visit. The Licensee was not available to come for the visit. Facility has the following deficiencies that was not cleared: 87211(b) = $100.00 x 6 = $600.00 Civil Penalties in the total amount of $600.00 is assessed today for failure to meet POC date for deficiency. Facility is subject to ongoing daily civil penalties until deficiencies is corrected. Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.the state’s words, verbatim · CDSS document, Apr 11, 2024

Allegation investigated: . Facility staff serve a poor quality of food

On 03/29/2024, at 1:14PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct initial 10-day complaint visit for the above allegations. LPA met with Reza Madlangbayan and explained the reason for the visit. Licensee/Administrator, Elizabeth "Beth" Cortes, was phoned. Beth arrived shortly after but left at 1:56PM. The following documents were obtained: 1. Copy of menu for March 25-31, 2024 LIC9099-C Continued Unsubstantiated LIC9099-C Continued... Allegation: Facility staff serve a poor quality of food Unsubstantiated On 03/29/2024 LPA interviewed S1 which stated that there's food deliveries two times a week. S1 stated that the cooks in the kitchen do cook the meals per the menu from scratch. S1 stated that during the resident's admission they will ask on food preference. S1 stated that the facility gets fresh fruits delivered during the week. S1 stated that she is aware that some of the residents have complained about the food for dinner. S1 stated that the Administrator is trying to hiring new cooks. LPA interviewed R1 who stated that the food is not good. R1 stated that the presentation of the food isn't appealing. LPA interviewed R2 who stated that the food quality could be "upgraded". R2 stated that the food was bland and doesn't think that the cooks are following the scheduled menus LPA observed fresh fruits in the kitchen pantry: bananas, oranges, cantaloupes, watermelons and strawberries and grapes located in the refrigerator. LPA observed the cooks in the kitchen were prepping and cooking chicken jambalaya which was scheduled on the menu for dinner. Therefore, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit Interview conducted and a copy of this report provided to facility supervisor.the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 15-AS-20240327083732

Allegation investigated: . Facility floor is in disrepair 2. Facility staff did not report incident as required

On 03/29/2024, at 1:14PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct initial 10-day complaint visit for the above allegations. LPA met with Rizza Madlangbayan and explained the reason for the visit. Licensee/Administrator, Elizabeth "Beth" Cortes, was phoned. Beth arrived shortly after but left at 1:56PM. The following documents were obtained: 1. Unuusal Incident Report (LIC 624) for incident occured on 11/15/2023 2. Internal Incident Report dated 11/15/2023 3. Employee Grievance Form 11/16/2023 LIC9099-C Continued Substantiated LIC9099-C Allegation: Facility floor is in disrepair Substantiated On 03/29/2024 LPA observed cracks in the flooring, tape, nails and floor molding lifting up. LPA observed in multiple resident rooms that the tile flooring had tape attached to the floor tiles. LPA observed tape, nails and the floor molding lifting at the end of the hall towards kitchen. Allegation: Facility staff did not report incident as required Substantiated On 03/29/2024 LPA reviewed Unusual Incident that was reported to CCLD on 11/16/2023. LPA interviewed S2, who gave a copy of the facility internal report. S2 confirmed that a SOC 341 was not completed and therefore the incident was not reported to the local ombudsmen. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted with Administrator. Appeal rights and copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 15-AS-20240327083732

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a) · Plan of correction due date: Apr 26, 2024

80087 Buildings and Grounds (a) The facility shall be...in good repair at all times... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having disrepair flooring in residents rooms and hallways which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Administrator agree to repair flooring in all areas where cracks, tape, nails and molding is lifting. Send an invoice of floor repairs and photos to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(b) · Plan of correction due date: Apr 5, 2024

87211 Reporting Requirements (b) Any suspected physical abuse that results in serious bodily injury of an elder...shall be reported to the local ombudsman... This requirement is not met as evidenced by: Based on record review and interview, the Administrator did not comply with the section above for not reporting to the local ombudsman and submitting SOC341 which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Administrator will go over reporting requirements and submit a self certification of understanding of reporting requirements. Administrator shall submit self-certification to CCLD by POC due date.

Type of visit: Case Management - Other

On 03/29/2024 at 1:20pm Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Elisabeth "Beth" Cortes, License/Administrator, and explained the purpose of the visit. While LPA L. Alexander was conducting a complaint investigation 15-AS-20240327083732, on 03/29/2024. While touring facility LPA observed at 1:40 PM unlocked disinfectant cleaner (Fabuloso) in a spray bottle located in the north wing (memory care) under the cabinet. Staff stated that they just conducted in-training recently and went over that toxic cleaning solutions should be locked. LPA also observed one of the resident was laying in the bed with padding against the wall and propped underneath the resident. Staff (S1) stated that the resident has Parkinson's and can fall out of the bed. S1 stated that the R1's husband is the one that wants the padding against the walls. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Mar 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Mar 30, 2024

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having cleaning disinfecting solutions (Fabuloso) inacessible to residnts which poses a potential health and safety risk to persons in care. During visit Administrator locked the disinfective cleaning spray.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Administrator will place locks on cabinets in memory care and submit photo. Administrator will conduct an in-training with staff and submit particpant roster to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(1)(A) · Plan of correction due date: Apr 5, 2024

87608 Postural Supports (1) Postural supports shall be limited to appliances or devices...used to achieve proper body position and balance, to improve a resident's mobility...restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. (A) Physician-prescribed orthopedic devices such as braces or casts, used for support of a weakened body part or correction of body parts, are considered postural supports. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having a doctor's order for postural support fo R1 which poses a potential health and safety risk and persoanl rights to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Administrator agree to get Physician's Report updated for R1. Get a Dr's order for postural support or hospital bed for R1 and submit to CCLD by POC due date.