Walnut House

Type of visit: Case Management - Other

On 9/1/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Administrator . On 8/25/26, Admin notified this LPA of an alleged incident between R1 and S1. R1 was reported to have disclosed to a friend that R1 and S1 had a consensual adult contact event. This report was investigated by several agencies. R1 has stated it is over. R1's accounting to various people have not been consistent. S1 denies that anything of the sort occurred. LPA and Administrator discussed possible further communication with R1's healthcare providers. LPA interviewed R1 who stated they feel safe and they do not wish to have further discussions about it. This incident has been investigated by local law enforcement, the Ombudsman's office and CCLD. The allegation does not appear credible based on current evidence. LPA also discussed a medication error that occurred on 8/27/26 involving R2 and S2. S2 administered a PRN medication to R2. The medication provided to R2 was not intended for the condition that R2 was experiencing. R2 suffered not ill effects of the medication given. The incident was reported as required. S2 has received retraining and there is currently additional oversight of S2 to ensure medication procedures are followed. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report was providedthe state’s words, verbatim · CDSS document, Sep 1, 2026

Allegation investigated: Staff are not allowing resident to return to the facility

On 8/11/26 , Licensing Program Analyst (LPA) Kevin Mknelly arrived and met with Administrator to deliver investigation findings. The department conducted record review and interviewed staff regarding complaint allegations. Staff interviewed stated that resident, R1 were living at the facility from April 2026 . R1 sent to hospital on 8/3/26 due to change in health conditions and having suicidal ideations. Facility was working with hospital staff for R1’s return to the facility and requesting all required paperwork including clearance for psychiatric evaluation to ensure the safety of R1. Record review indicated that facility received all required documents which included recent medical assessment (LIC602) , clearance for psychiatric evaluation from hospital around 8/6/26 and R1 returned to the facility on 8/6/26. LPA interviewed R1. Based on the information gathered, this allegation was UNFOUNDED. A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.Exit interview conducted. A copy of this report has been provided to Administrator. Unfoundedthe state’s words, verbatim · CDSS document, Aug 11, 2026 · control 59-AS-20260805085612

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/11/26 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with Administrator who assisted with the inspection. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator discussed some minor facility maintenance issues that are in process of being addressed LPA reviewed 6 resident and 6 staff files. Files were complete. LPA advised regarding some records to update. Resident med review conducted with RCC found med error issues for R1, R2, R3, R5 and R6. Issues were meds not refilled, meds not given due to med not found, documentation errors of med given or not. LPA requested the following documents to update the facility file: Copy of the most recent version of Admission Agreement, Liability Ins. certificate, LIC 500 and LIC 9020 (or equivalent). LPA notified Admin that annual fees are due this month. Deficiency is being cited as a result of todays inspection. Exit interview conducted with Administrator and copy of report and appeal rights left at the facility.the state’s words, verbatim · CDSS document, Aug 11, 2026

Allegation investigated: Staff did not treat resident in care with dignity and respect

On 6/19/26, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Administrator. LPA conducted records review, room inspections and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. The allegations involved R1 alleging a hostile interaction with staff. Interviews with staff, other residents and R1 were unable to determine what exactly was said by whom during the interaction in question. As a result of this investigation, LPA finds allegation to be (US)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 with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 19, 2026 · control 59-AS-20260424130202

Allegation investigated: Staff do not ensure that resident is provided comfortable accommodations. Staff do not safeguard resident's personal belongings.

On 6/19/26, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Administrator. LPA conducted records review, room inspections and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. The allegations involved R1 alleging care staff were tampering with R1 personal belongingings and health. LPA was inable to identify physical evidence of wrongdoing by caregivers toward R1. As a result of this investigation, LPA finds allegation to be (US)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 with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 19, 2026 · control 59-AS-20260511082055

Type of visit: Case Management - Other

On 6/19/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with the Administrator . The licensee informed LPA Mknelly and submitted a SOC 341 regarding R1 alleging physical abuse by a caregiver (S1). The report was also submitted to Ombudsman and local law enforcement. Police and Ombudsman did not find evidence to support the allegation. In today's visit, LPA interviewed R1. R1 they recalled the event and a description of S1. LPA interviewed Admin, S2 and S3. S1 was known to management and coworkers to be courteous and respectful in care of residents. Discussions of R1's condition found them to have occasional confusion and regular movement in bed where R1 has their face against their bed rails. LPA was unable to find evidence that R1 was assaulted by S1. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Jun 19, 2026

Type of visit: Case Management - Other

On 3/11/26, Licensing Program Analyst (LPA) Kevin Mknelly met with Administrator, Diana Paz. The purpose of the visit was to meet for the first time with the new Administrator. Several issues were discussed and contact information was exchanged. LPA will update the program's profile. No deficiencies were noted during this visit. This report ti be emailed to the Administrator for signature.the state’s words, verbatim · CDSS document, Mar 11, 2026

Allegation investigated: Licensee does not ensure residents are provided food of good quality.

On 2/2/26, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Administrator. LPA conducted records review, kitchen inspection and interviews. LPA is unable to find and or meet the preponderance, per policy. LPA found the kitchen to have sufficent supplies, food is stored safely and prep areas are clean. LPA's interviews with residents found disagreements regarding preparations of various meals but it spoke to their personal prefernces vs. food safety and nutrition. LPA discussed the issues with resident food satisfaction and the Administrator stated there is continued efforts to adapt to resifdent tastes and preferences. As a result of this investigation, LPA finds allegation to be (US)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 with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 2, 2026 · control 59-AS-20251212111805

Type of visit: Case Management - Other

On 2/2/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with The Director. On 1/28/26, Administrator phoned LPA regarding a resident accusation, and submitted a report on 1/29/26. The report was that R1 accused a caregiver, S1, of yelling at and intimidating them. At today's visit, LPA interviewed R1 for an extensive period. R1 told LPA that they have come to the realization that her perception and interpretation of an interaction with S1 was incorrect and was influenced by their health and cognitive status at the time. R1 was emphatic that S1 did not do what she had previously stated while hospitalized. R1 trusts and feels comfortable with having S1 as a care provider. During the interview with R1, they stated that they have other issues regarding other caregiver conduct that they plan to discuss with the director. R1 agreed that that other issue does not rise to a complaint level at this time. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 2, 2026

Type of visit: Case Management - Incident

On 11/13/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator. The department received a death report for R1's unexpected passing in 10/18/25. LPA reviewed records and interviewed staff. R1 was observed by staff on 10/17/25 to not have any notable change of condition. R1 records showed R1 to have several co-morbidities. The department will seek a death certificate and most recent medical assessment from R1's primary care physician. As a result of today’s inspection, no deficiencies were noted at this time. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Nov 13, 2025

Allegation investigated: Facility staff failed to respond to residents need for assistance in a timely manner. Facility staff mismanage resident medication Facility staff did not dispense resident medications as prescribed

On 10/15/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Administrator. LPA conducted records review, physical inspection and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. Document, records, observations and interviews did not find sufficent evidence to prove or disprove this allegation. Call response time documents review found no correlating incidents where call response delays caused a safety risk. Call response records reviewed did not show excessive response times. What was found were timesr eported where a first staff responded timely and calls for a second staff assist may have had delays. However, resident recived initial response timely. Medication management and dispensing of medication had some verbal reports of incidents yet there was not supporting docuements to substantiate. This complaint was also reporting events over several months without clear dates for which supporting evidence was unavailable. Unsubstantiated As a result of this investigation, LPA finds allegation to be (US)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 with administrator and report copy provided. R1 is blind and was unaware that their blinds were open or that they were being observed. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 59-AS-20250827143242

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(1)(1) · Plan of correction due date: Oct 16, 2025

Additional Personal Rights of Residents in Privately Operated Facilities - (a) (1) To have a reasonable level of personal privacy in accommodations,...This requirement was not met based on interviews that found R1 was photographed without knowledge or consent and the inforation was shared with others. This posed an immediate risk to resident rights.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Administrator agrees to provide a plan, by the POC date, for staff retraining regarding resident rights, facility photo policy and mandated reporting. The plan for training will include training be completed by 10/22/25. Administrator also agrees to inform LPA of supervisory action to be taken with S1 pending an internal investigation

Allegation investigated: Staff do not ensure serve residents food of good quality

On 10/15/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Administrator. LPA conducted records review, menues, physical inspection and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. Document, records, observations and interviews did not find sufficent evidence to prove or disprove this allegation. In several inteviews residents at times voiced food prefences that are not routinely served, however, food served appears to meet nutritional guidelines and special diet needs of residents. As a result of this investigation, LPA finds allegation to be (US)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 with administrator and report copy provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 15, 2025 · control 59-AS-20250804092049

Allegation investigated: Staff does not ensure facility's plumbing is in good repair.

On 8/7/25, Licensing Program Analyst (LPA) Kevin Mknelly LPA Mknelly arrived and met with Administrator to deliver investigation findings. LPA reviewed staff records, facility records, and attempted interview with R1. LPA finds that facility met Tittle 22 requirements. LPA found that R1 resides in the independent living portion of the property that is not a part of the community's license. As such R1 is a renter, not receiving assisted living and not subject to Title 22 regluations. This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and report provided. Unfoundedthe state’s words, verbatim · CDSS document, Aug 7, 2025 · control 59-AS-20250731153830

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/7/25 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents stated they are happy with care. LPA reviewed 5 resident files. Files are complete and well organized. LPA reviewed 5 staff files. Files are complete. No deficiencies are being cited as a result of todays inspection. Exit interview conducted with licensee and copy of report left at the facility.the state’s words, verbatim · CDSS document, Aug 7, 2025

Allegation investigated: Facility staff mismanaged residents medication

On May 13, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to investigate and deliver the finding of the allegation cited above. LPA met with Administrator and explained the purpose of the visit. During the course of this investigation, LPA conducted extensive interviews, file review and observations. The result of the investigation is as follow, please continue on LIC 9099-C. Unsubstantiated LIC 9099-C (1) Allegation: Facility staff are not providing residents with assistance in cleaning their rooms. File review of housekeeping schedule for June 2024 revealed facility has two housekeepers who work at the facility five (5) days a week. Based on interview conducted with Administrator, it revealed that R1 is an artist and likes to have art supplies in R1’s room. R1 likes to “hoard” and creates mini clutter, such as keeping scraps of paper around the room. R1 has been upset on multiple occasions when staff are cleaning R1’s room when R1 is out of the community. Interview further revealed that R1 is willing to have housekeepers vacuum the floor and clean the bathroom, but does not like staff removing papers. R1 has had external assistance for hoarding anxiety. Based on LPA’s observation of R1’s room, it revealed there is a clear pathway from the door to the bed to the bathroom. LPA did not observe any obstructions in the pathway. Interview conducted with R1 revealed that R1 likes the room the way it is. R1 does not mind staff coming in for housekeeping days to vacuum and clean, but does not like her art supplies and/or papers to be missing. R1 likes to throw crumbled papers on the floor but may “need it later” and prefers the papers not to be discarded. Therefore, the allegation is unfounded. Allegation: Facility staff do not respond to residents call buttons in timely manner. The Department conducted file reviews and interviews regarding the allegation cited above. Based on file review of six residents’ call log for June 14-20, 2024, it revealed the average response time for R2 was five (5) minutes and 23 seconds, R3 was three (3) minutes and 42 seconds, R4 was 3 minutes and 50 seconds, R5 was nine (9) minutes and 13 seconds, R6 was 12 minutes and 3 seconds, R7 was 10 minutes and 24 seconds, and R8 was 5 minutes and 19 seconds. Interview conducted with Administrator revealed that there were no unusual incident reports filed; therefore, the call button may have been pressed for minor assistance. File review of incident reports and/or charting notes revealed that there were no medical emergencies for R2, R3, R4, R5, R6, R7, and R8 during this duration. The allegation is unfounded. Please continue on LIC 9099-C (2). LIC 9099-C (2) Allegation: Facility staff are not properly assisting residents with showering. Interview conducted with Administrator revealed that residents are showered twice a week, with approximately 80% of residents needing assistance with showering. Interview further revealed that if residents in care refuse showers, caregivers are to be notifying supervisors immediately so supervisors can intervene and negotiate with the resident on showering. Interview conducted with R10, R11, R12, R13, R14 and R15 revealed that there are no concerns and/or issues regarding showering at the facility. Interview further revealed they do not have issues with receiving shower services. Interview conducted with S3 revealed S3 is a caregiver at the facility. S3 stated that if a resident declines a shower on their shower day, then it is to be documented and will attempt to rescheduled for the following day if working. Interview conducted with S4 and S5 revealed that they provide approximately three (3) to five (5) showers per shift depending on the hall and if the residents are frequent refusers. Interview further revealed that if residents refuse showers, caregivers are to "change face" and have another caregiver offer the showering, if declined, then supervisor will intervene. If unsuccessful then the shower refusal form will get signed by supervisor on the floor. The allegation is unfounded. Allegation: Facility staff are not providing adequate laundry services for resident. The Department conducted extensive interviews regarding laundry services. Interview conducted with Administrator revealed facility provides residents in care with washing and drying. There is a full-time laundry staff at the facility from Sunday to Thursday, with an assigned hall per day. Laundry is to be washed and returned to residents within the same day. Interviews conducted with R9, R10, R11, and R12 revealed that they do not have any concerns regarding basic laundry services at the facility. Interview conducted with R13 revealed R13 has been a resident at the facility for over two (2) years. R13 indicated that laundry services have gotten better. During the day of the interview, it was R13’s laundry day, which was gathered for washing at approximately 7:00 a.m. and returned to room at approximately 1:30 p.m. The following allegation is unfounded. Based on information obtained through file review, interviews, and observations, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was provided. LIC 9099-C Allegation: Facility staff mismanaged residents medication. The Department conducted several interviews regarding staff mishandling medications. Interview conducted with R12 revealed that R12 does not have any issues regarding medications not being passed. Interview revealed R12 does not have dementia and is able to identify their own medication. There have been a few occasions when R12 had to remind the medication technician (med tech) on the floor that a medication was missing from administration. Interview conducted with R15 revealed R15 did not receive their medication for the day. Additionally, R15 was unable to identify the day’s date. File review of R15’s LIC 602 Physician’s Report revealed R15 has dementia. Interviews conducted with S1 and S2 revealed they both ensure it is the right medication, right time, right dose to the right person. Interview revealed that with the new electronic medication administration records system, medication administration has been easier, where S1 does not confirm medication has been taken in the system until confirmed passing. Interview further revealed that in the past, it was not clear if it was mandatory to visually confirm medications have been passed, but with the implementation of Administrator’s policy and procedures, all med techs are now required to stand and confirm medication has been taken before moving to the next resident in care. Information provided by Reporting Party included a photo of a napkin with pills on top of a dresser and a pill on the floor; however, LPA was unable to confirm the time, date and place of photo taken. On date of deliver finding, LPA observed med techs conduction medication pass and observed med techs to be watching residents to confirm medications has been taken. The following allegation is unsubstantiated. A finding that the complaint allegation of: Facility staff mismanaged residents medication is unsubstantiated meaning that 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 was conducted and a copy of this was report was provided.the state’s words, verbatim · CDSS document, May 13, 2025 · control 59-AS-20240621115513

Allegation investigated: Due to neglect, resident sustained fractures.

On April 16, 2025, Licenisng Program Analyst (LPA) Cassie Yang arrived at the facility to deliver the findings of the allegation cited above. LPA met with Administrator and explained the purpose of the viist. During the course of this investigation, LPA has conducted extensive file reviews to conclude the finding of the allegation. Please continue on LIC 9099-C. Unfounded LIC 9099-C Allegation: Due to neglect, resident sustained fractures. Based on file review of LIC 624 UNUSUAL INCIDENT/INJURY REPORT, it revealed on April 8, 2024 at approximately 7:20 pm R1 was observed on the floor during rounds, appeared to have a fall. Staff contacted paramedics immediately, along with family and primary care physician. R1 was transported to the emergency room for evaluation. Based on file review of Sutter Roseville Medical records, it reveal primary impression was traumatic injury. R1 disclosed to paramedics that R1 was "getting out of bed to go smoke and I rolled off my bed onto the floor." Records revealed that Public Safety Answering Point (PSAP) was notified of fall on April 8, 2024 at 19:25:26 (7:25:26pm) where emergency medical services was notified for dispatch at 19:25:34 (7:25:34pm) which emergency medical services was en route at 19:28:37 (7:28:37pm) and arrived to the facility at 19:44:37 (7:44:37pm) assisting R1 at 19:47:00 (7:47pm). File review of staff schedule revealed during time of fall, there was two shift managers on the floor, along with four care staff. Review of R1's Alarms By Apartment By Location from April 1, 2024 to April 30, 2024 revealed there was no call for assistance. File review of R1's incident reports did not reveal any history of falls. File review of R1's LIC 602A PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE) revealed R1 has primary diagnosis of Severe protein calorie malnutrition with secondary diagnosis of "COPD". File review of Sutter Health Medical records further revealed R1 is "on Eliquis for history DVT and rheumatoid aortitis with additional pertinent history of dementia and osteoporosis". Medical records further revealed R1 sustained bilateral femur fracture who then found to be tachycardic with elevated troponin which resulted to R1 being placed on comfort care measures until R1 passed away. Based on the information obtained through file reviews, it revealed R1 did sustained fracture due to an unwitnessed fall, but facility did seek medical attention immediately. Facility did not indicate any neglect as staff completed post-dinner routine checks on residents in care which led to finding R1 on the floor. Please continue on LIC 9099-C(2). LIC 9099-C (2) Based on information obtained, the allegation Due to neglect, resident sustained fractures, is determined UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was provided to Administrator.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 59-AS-20240429170257

Allegation investigated: Staff do not speak to residents in an appropriate manner.

On April 8, 2025, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Administrator, Allison Lopez. LPA conducted records review and interviews. LPA is unable to find and or meet the preponderance, per policy. The information provided by the complainant regarding the alleged incident lacked specific time or alleged staff involved. LPA was unable to interview R1 as R1 no longer residend at the facility and R1 lacked the capacity to report historical events. Administrator reported that this alleged incident was discussed some time ago and there was not enough information to investigate further. There were no known witnesses to such an incident. As a result of this investigation, LPA finds allegation to be (US)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 with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 8, 2025 · control 59-AS-20250225135032

Type of visit: Case Management - Incident

On April 8, 2025 (4/8/25) , Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Administrator (Admin) Allison Lopez. On 3/22/25, the department received an incident report regarding a medication error for R1. The incident report stated that on 3/15/25, at approximately 6 AM, R1 was given and ingested a medication that was prescribed for R2. LPA interviewed Admin. Admin stated that the internal inquiry found that medication technician (Med tech) S1 did not follow medication administration procedures. Med techs are instructed to do a "live pour "for each resident and to verify the right resident,medication, time, dose, and route before dispensing medications. It was reported to LPA that S1 apparently pre-poured medications and gave R1 medications intended for R2. When S1 realized they had made the error, appropriate notification were made and R1 was monitored for possible side effects. S1 was removed from medication administration and R1 suffered no adverse effects. All medication procedures have been reviewed with all current med techs. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Apr 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 15, 2025

Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met based on records and statements with found the facility's plan was not followed for correct medication administration. This posed a potential risk.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Following the incident, S1 was removed from med passing and all med techs received retraining. Licensee will submit proof of training to CCLD by the POC date of 4/15/25.

Type of visit: Case Management - Incident

On April 8, 2025 (4/8/25) , Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Administrator (Admin) Allison Lopez. On 3/16/25, the department received a death report regarding R1. The report stated that on 3/8/25, R1 was found unresponsive on the floor, at the side of their bed, by caregiver, S1, at approximately 10:20 AM. LPA requested and received, on 3/25/25, the physician's report, services plan and medication administration records (MAR) for R1. At today's visit, LPA interviewed Administrator and med tech, S2, regarding the events of 3/8/24. Administrator stated that procedures for confirmation of residents location and well-being are being updated and staff training is pending. LPA received additional documents. LPA will conduct additional interviews and collect additional records to continue this incident review. As a result of this inspection, no deficiencies are cited at this time. Report reviewed. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 8, 2025

Allegation investigated: Staff are not ensuring that resident’s hygiene needs are being met.

On February 27, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegation above. LPA met with Administrator and explained the purpose of the visit. During the course of the investigation, LPA conducted extensive interviews, file review, and observations. Please continue on LIC 9099-C. Unsubstantiated LIC 9099-C(1) Allegation: Staff are not properly trained. The Department conducted extensive interviews regarding staff training on bed bugs. Based on interview conducted for S1 revealed S1 was informed to observe residents skin for redness and/or rash. Additionally S1 was informed to inspect the bottom of the beddings for bugs as bed bugs are nocturnal and likes to be hidden in darkness. S1 stated if confirmed bed bugs are observed in the room, S1 is gather clothing for the resident for a hot wash, then shower the resident and relocate the resident to a new room. S1 stated bed bugs reporting are to be reported to Administrator for pest control services. Interview conducted with S2 revealed S2 has been working as maintenance for a long time at multiple facilities. S2 stated S2 is aware how bed bugs looks like and if it was observed in residents room, S2 will assist with contacting pest control services and block off the room while caregivers are to assist with washing residents clothing with hot water, and providing residents with a shower before relocating the resident to a vacant pest free room. Interview conducted with S3 revealed that S3 often assist with housekeeping. S3 stated if there is suspicions of bed bugs, staff are to contact maintenance for inspection, once confirmed, resident will need to be showered while their clothing are being washed then resident and clean clothing are relocated to a new room until their original room is serviced. Interview conducted with S4 revealed that S4 is a caregiver and assist with bed making in the morning. S4 stated that when making the bed, they are to look under the bed mattress to ensure no bugs are detected. S4 stated if S4 observes bedbugs, S4 is to notify front desk or manager on the floor. S4 stated S4 will then assist with the resident relocation by making sure residents and their clothes are cleaned then will relocate to the new room. Interview conducted with S5 revealed S5 is aware of the facility bed bugs issue. S5 stated if staff complains of itchiness or rashes, then skin check will be conducted along with room inspection. S5 stated if confirmed bed bugs are present, the room will need to be closed off. Resident will need to be showered. Caregviers will bag residents clothing for a hot wash in laundry room then deliver cleaned clothes to the new room. Based on the information provided, LPA found the allegation to be unfounded. Please continue on LIC 9099-C(2) LIC 9099-C(2) Allegation: Staff are not providing comfortable accommodations for resident. Based on information provided by the reporting party, R1 was relocated to a new room due to bed bugs. R1's temporary room was observed to have no television, no phone and no other source of entertainment. Interview conducted with Administrator on April 24, 2024, it revealed Administrator was informed of the concerns from R1's family members. Administrator stated based on Title 22, facility is not required to provide televisions in resident's room. Administrator stated R1's television was unable to be moved to the new room at the time to prevent cross contamination, if it was to be moved to the new room there would be a possibility of transferring bed bugs to the new temporary room. Administrator stated based on information provided by pest control company, bed bugs can be hidden between beds, outlets, lamps, television. Based on Title 22, it is required for bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. Based on the room inspection conducted for R1's temporary room and four additional other rooms, it was observed facility was compliance to 87307 Personal Accommodations and Services. Based on information obtained, the allegations of Staff are not properly trained and Staff are not providing comfortable accommodations for resident are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was provided to Administrator. LIC9099-C. Allegation: Staff are not ensuring that resident’s hygiene needs are being met. The Department conducted interviews regarding the allegation of this complaint. Based on interview conducted with R1 revealed R1 is not sure if staff are changing R1 regularly. R1 stated R1 is not sure who is R1's caregiver for the day. File review revealed R1 has vascular dementia with mental condition of confused and disoriented. Interview conducted with S1 revealed S1 is R1's caregiver of the day of interview. S1 stated R1 has been changed in the morning. S1 stated R1 has been changed by S1. Based on LPA's observation during day of visit, R1 was observed to be clean. Based on interview conducted with Administrator, it revealed the incident regarding R1's hygiene needs are not met was due to staff showering R1 in the communal shower. Administrator stated staff had forgotten R1's clean clothing after the shower and could not leave R1 unattended in the shower room therefore, R1 was transferred back to R1's room in R1's same clothing. Administrator stated that was when R1's family member came to the facility and became upset that R1 was in the same clothing, denying R1 was showered. A finding that the complaint allegation of: Staff are not ensuring that resident’s hygiene needs are being met is unsubstantiated meaning that 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 was conducted and a copy of this was report was provided to Administrator.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 59-AS-20240415090932

Allegation investigated: Staff did not prevent a resident from developing pressure injuries while in care. Staff left a resident on a toilet for a long period of time.

On February 25, 2025 at approximately 12:30 PM, Licensing Program Analyst (LPA), Kevin Mknelly, arrived unannounced at Walnut House for the purpose of delivering complaint findings. LPA met with Director, Allison Lopez to deliver an amendment to the report delivered February 11, 2025. During the course of the investigation, LPA Sarangi interviewed staff members and conducted a Collateral Interview with Resident #1. In addition, LPA reviewed the facility files, resident file and medical records. The evidence gathered was reviewed by the department. Complaint alleges that Staff did not prevent a resident from developing pressure injuries while in care. Based on interviews that were conducted, resident files reviewed, and medical records reviewed, records review and interviews found that prior to the events of December 14, 2024, R1 was known to get up in the morning, dress, turn on lights, open blinds and turn on the tv, use their wheelchair to have coffee and smoke independently. On December 14, 2025, the AM med tech observed R1 to be sitting on their bed when medications were dispensed. No additional ...Report continued Substantiated observation was provided when R1 did not come out of their room for coffee or smoking. When R1 did not come to lunch, caregiver (S1) observed R1 to be using the toilet. S1 asked if R1 wanted lunch. R1 declined with head and hand gestures. R1’s family member arrived to visit R1 at approximately 2 PM. The family reported R1 was still in pajamas, blinds were closed, lights and TV were off. R1 was seated on a toilet and could not get up. Family called for assistance, 9-1-1 was called and R1 was transported to an area hospital. Medical records showed that R1 had pressure injuries to left and right buttocks as well as redness and bruising in the shape of the toilet seat. Additionally, medical records from the emergency department noted: Rhabdomyolysis, Patient confused, a&o x1. Patient has a purplish red ring around the outside of the buttocks area from being left on toilet for hours at assisted living. Also found a fluid filled blister on the R buttocks/posterior thigh. Initially, presented from assisted living facility after being found on the toilet for hours due to weakness. Mild nontraumatic and nonexertional rhabdomyolysis and AKI with CK 3469 in the absence of any trauma or exertional causes. Per collateral information obtained from (R1’s family), patient has had progressive decline in function over the last few months on top of already limited baseline mobility due to prior MCA stroke. Etiology of rhabdomyolysis is suspected due to atorvastatin medication. The Mayo clinic describes the most common signs and symptoms of rhabdomyolysis include: · Severe muscle aching throughout the entire body · Muscle weakness Report continued Complaint also alleges that Staff left a resident on a toilet for a long period of time. Based on interviews that were conducted, resident files reviewed, and medical records reviewed, the preponderance of evidence standard has been met. During a review of the Medical Records on January 22, 2025, LPA learned that the resident was on the toilet for hours. Staff records and interviews found that R1’s baseline is to have minimal verbal interaction, independently wake, dress toilet and transfer. On December 14, 2024, R1 had a change in their baseline patterns and activities. Facility staff did not recognize the change in behavior of R1 until alerted to R1’s change in condition by visiting family at 2:00 PM on December 14, 2024. No evidence was found that staff initiated increased communication efforts to determine if R1 needed assistance to get up from the toilet. R1 is known to have aphasia, English as a second language and to not readily request nor accept assistance. The caregiver assigned to R1 on December 14, 2024 has been employed for approximately 3 months. Caregiver failed to recognize R1’s change of condition. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Licensee along with Appeal Rights.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 59-AS-20241227120434

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 26, 2025

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes ...and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as …, deterioration of mental ability or a physical health condition are observed, the licensee shall ensure... changes are... brought to the attention of the resident's physician and... This requirement was not met based on records and statements which found R1’s changes to physical and social function were not responded to. This posed an immediate risk to R1. Civil Penalty Applied.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: Administraor agreed to provide training to all staff regarding observation and communication of resident status. The POC is to provide a date that training will be completed by. Training to be comleted by 3/12/25. Proof of training completed will include procedures for observation and communication throughout all employees for obsrving residents and alerting to changing in condition or activity. Proof of training to be submitted when completed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 26, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a)Residents shall .. rights: (4) To care, supervision, and services …by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met based on records and statements that found staff did not recognize and respond to R1’s change of condition and increased need for assistance. This posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: Administraor agreed to provide training to all staff regarding awareness of changes and communication skills for communicating with residents with communication disabilities. The POC is to provide a date that training will be completed by. Training to be comleted by 3/12/25. Proof of training completed will include General observations of residents for what would possible indicate a change for that resident as well as types of communication strategies for non-verbal residents. Proof of training to be submitted when completed.

Type of visit: Case Management - Other

On February 25, 2025 Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Allison Lopez . LPA and Administrator discussed to following incident reports submitted to the department: On 1/27/25, R1 exhibited a change of condition and was provided the necessary medical care. LPA and Administrator discussed when non-emergency medical transport may be used and when 9-1-1 is appropriate for residents in Hospice Care; On 2/1/25, R2 died unexpectedly while returning to the facility from a medical appointment. LPA received more details of the event. LPA will continue to seek records for R2 from outside providers the day of their passing; On 2/8/24, R3 died unexpectedly. LPA requested physician's report, appraisals and services plan for R3. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 25, 2025

Allegation investigated: Facility is not kept clean and sanitary

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Allison Lopez, to deliver findings regarding complaint allegation listed above. During the investigation, the Department conducted a tour of the facility, conducted interviews, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility is not kept clean and sanitary ** Report continued on 9099-C ** Substantiated Multiple relevant parties reported facility to be not clean and sanitary. One (1) relevant party reported communal shower to be unclean. Another relevant party reported resident's apartment to be filthy, specifically the shower and bathroom floors. During visit conducted on February 21st, 2025, LPA Michael Hood conducted a tour of the care home, including communal shower, dining room, kitchen, common areas, and multiple resident apartments. LPA observed communal shower to be clean. LPA observed Shower Room Cleaning Schedule posted at the facility and observed communal shower to be cleaned for the months of September 2024, October 2024, and ongoing. LPA observed dining room and kitchen to be clean. LPA observed linoleum in resident (R5's) apartment to be in disrepair and coming apart in their apartment bathroom. LPA observed feces on the toilet of residents (R6 and R7's) apartment bathroom. Based on LPA's observations, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $250 is assessed for today's date for a repeat violation. Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. Multiple relevant parties reported that facility has a bed bug infestation. Interviews with staff members S1, S2, and Administrator indicated that the facility has been receiving regular treatment for bed bugs and is still contracted with services to prevent further infestation of bed bugs on the premises. Interviews with S1 and S2 indicated that it has been three (3) months since any bed bugs have been observed on the premises. LPA observed multiple invoices for pest control targeting bed bugs from July 2024 to December 2024. Treatment conducted on December 30th, 2024 indicated no activity found or reported regarding bed bugs. Interview with resident R1 indicated that they feel the facility is doing a good job addressing pests at the facility. Interviews with residents R2, R3, and R4 indicated that they have not observed pests at the facility. During multiple visits conducted at the facility, LPA Michael Hood did not observe any pests on the premises. Based on interviews conducted, observations, and records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 59-AS-20241007123509

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 7, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA's observations, the facility did not ensure that the premises was clean and in good repair when R5's apartment had linoleum coming apart and R6 and R7's apartment had feces on the toilet, which poses a potential health, safety, and personal rights violation to the residents in care.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: Facility will conduct an in-service training for staff regarding observation of the premises and reporting if housekeeping or repairs are needed. Facility will submit proof of training to LPA by POC due date on 3/07/2025. A civil penalty for $250 was assessed for a repeat violation.

Allegation investigated: **report ammended** Staff did not ensure that a resident was provided meals and water. Staff did not ensure that resident's clothing was changed.

*** Report amended Additional report for amended findings*** .On February 11, 2025 at approximately 08:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Walnut House for the purpose of delivering complaint findings. LPA was greeted at the door by Med Tech, Kim Taylor, and was granted access into the facility. During the course of the investigation, LPA Sarangi interviewed staff members and conducted a Collateral Interview with Resident #1. In addition, LPA reviewed the facility files, resident file and medical records. Complaint alleges that Staff did not prevent a resident from developing pressure injuries while in care and Staff left a resident on a toilet for a long period of time. Based on interviews that were conducted, resident files reviewed, and medical records reviewed, LPA could not prove or disprove the allegations occurred.***This finding is amended. *** (Report continued on LIC 9099C) Unsubstantiated LPA reviewed the Service Plan and observed that the resident was on Level II care that required no assistance as it relates to transfers and mobility. In addition, the Service Plan was signed and dated on December 10, 2024, by the Responsible Party. LPA reviewed the call bell log for the date in question and observed that the resident did not press the call pendent or alert staff. During a review of the Medical Records on January 22, 2025, LPA learned that the resident was on the commode for 7 hours. However, the hospital could not determine what caused the resident to be on the commode for that long. On January 21, 2025, LPA conducted a collateral interview with Resident #1 but could not obtain additional information as to what occurred. During interviews, LPA received inconsistent statements as it relates to the allegations. LPA could not corroborate the allegations. Complaint alleges Staff did not ensure that a resident was provided meals and water. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. Furthermore, during interviewing, LPA learned of no concerns as it relates to the food service at the facility. LPA could not corroborate the allegation. Complaint alleges Staff did not ensure that resident's clothing was changed. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. Furthermore, during interviewing, LPA learned of no concerns as it relates to the changing of resident’s clothing. LPA could not corroborate the allegation. A finding that the complaint allegations of: Staff did not prevent a resident from developing pressure injuries while in care, Staff left a resident on a toilet for a long period of time, Staff did not ensure that a resident was provided meals and water, Staff did not ensure that resident's clothing was changed are unsubstantiated meaning that 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 was conducted and a copy of this was report was signed and given to the Med Tech.the state’s words, verbatim · CDSS document, Feb 11, 2025 · control 59-AS-20241227120434

Allegation investigated: Facility staff are not dispensing medications as prescribed Facility staff yell at residents

On January 21, 2025 at approximately 11:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Walnut House for the purpose of conducting an investigation. LPA was greeted at the door by Administrator, Allison Lopez, and was granted access into the home. During the course of the investigation, LPA interviewed staff, and a random sample of residents in care. In addition, LPA reviewed resident files. Complaint alleges that Facility staff are not dispensing medications as prescribed. Based on interviews that were conducted, LPA received inconsistent statements. LPA could not prove or disprove the allegation occurred. During a tour of the facility on January 21, 2025, LPA observed no medications being left on dining tables and accessible to residents in care. Furthermore, during interviews, LPA learned of no concerns as it relates to medications being left on dining room tables. (Report continued on LIC 9099C) Unsubstantiated Complaint alleges that Facility staff yell at residents. Based on interviews that were conducted, LPA received inconsistent statements. LPA could not prove or disprove the allegation occurred. Furthermore, during interviews with a sample of residents in care, LPA learned of no concerns as it relates to staff and resident interactions. A finding that the complaint allegations of: Facility staff are not dispensing medications as prescribed and Facility staff yell at residents are unsubstantiated meaning that 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 was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Jan 21, 2025 · control 59-AS-20241125141614

Allegation investigated: Facility staff did not provide adequate food service to resident in care. Facility staff did not address residents being left in soiled clothing in a timely manner.

On January 21, 2025 at approximately 11:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Walnut House for the purpose of conducting an investigation. LPA was greeted at the door by Administrator, Allison Lopez, and was granted access into the home. During the course of the investigation, LPA interviewed staff, and the former resident. In addition, LPA reviewed resident files and facility file. LPA made attempts to interview Witness #1 but was unsuccessful. Complaint alleges that Facility staff did not provide adequate food service to resident in care. Based on interviews that were conducted, LPA could not prove or disprove that the allegation occurred. LPA received inconsistent statements. Furthermore, during an interview with Resident #1, LPA learned of no concerns as it relates to the food service at the facility. LPA could not corroborate the allegation. (Report continued on LIC 9099C) Unsubstantiated Complaint alleges Facility staff did not address residents being left in soiled clothing in a timely manner. Based on interviews that were conducted, LPA could not prove or disprove that the allegation occurred. LPA received inconsistent statements. During the incident in question, LPA learned that Resident #1 was preoccupied with retrieving the cell phone, and did not summon for help as the resident did not want help changing out of clothes as the resident can perform that function. LPA reviewed the Service Plan which indicated that the resident needed minimal assistance with toileting and dressing. LPA could not corroborate the allegation. A finding that the complaint allegations of: Facility staff did not provide adequate food service to resident in care and Facility staff did not address residents being left in soiled clothing in a timely manner are unsubstantiated meaning that 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 was conducted and a copy of this was report was signed and given to the Administrator. Administrator acknowledged of being aware of this because of a bad Yelp review. Administrator retrieved the medication from the former residents room (See LIC 9099D). LPA educated the Administrator on the importance of ensuring that all residents medications are kept locked and secured. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.the state’s words, verbatim · CDSS document, Jan 21, 2025 · control 59-AS-20241226151401

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 28, 2025

87465(h)(2) 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. This requirement was not met as evidenced by: Based on an interview with the Administrator, Administrator acknowledged that after seeing a bad Yelp review, medications were found in the former residents room which presents a potential health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2025

Plan of correction: Licensee/Administrator shall fill out an LIC 9098-Self Certification understanding of the regualtion. Licensee/Administrator shall conduct staff training and provide proof of staff training. Licensee/Administrator shall provide a statement on how future compliance will be met. POC Due date: January 28, 2025.

Type of visit: Office

An office meeting was held via Microsoft Teams on December 5, 2024 at 1:00 PM, to discuss Long Term Care Ombudsman's current concerns at the facility. Present in the meeting are: Licensing Program Manager, Anthony Perez, Licensing Program Analyst, Cassie Yang, Long Term Care Ombudsman, Randy Dinning, Facility Administrator, Allison Lopez, and CiminoCare Regional Director Robert Godfrey. Topics discussed: Medication Procedure Resident and Family Council Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Staff do not assist residents with dental hygiene Staff do not safeguard residents personal belongings

On 10/29/2024, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to investigate and deliver the findings of the allegations cited above. LPA met with Administrator and explained the purpose of the visit. During the course of the investigation, the Department conducted intensive file reviews, interviews and observations. The result of the allegations are as follow, please continue on LIC 9099-C. Unsubstantiated LIC 9099-C Allegation: Staff do not assist residents with dental hygiene Interviews and file review was conducted for the following allegation. File review of R1’s service plan and R8’s service plan revealed R1 and R8 has maximum assist for dental care. Interview conducted with Administrator on 11/21/2023 revealed R1’s responsible party has not visit R1 often due to responsible parties living out of town and/or state. Administrator stated R1’s care requires dental assistance which facility complies. Interview conducted with R1 on 11/21/2023 revealed “care is really good”. R1 stated there is no issues with staff as all caregivers are nice and helps R1 as needed. Interview conducted with R8 revealed that R8 is not sure who their caregiver is. R8 indicated they are unsure if staff assist with dental care. Interview conducted with S1, it revealed that S1 is R8’s caretaker for the shift. S1 stated S1 assisted R8 with bowel incontinence care and additionally with morning dental care. File review of R1’s physician report revealed R1 has mild cognitive impairment but is disoriented to time. File review of R8’s physician report revealed R8 has vascular dementia and is often confused. The allegation is unsubstantiated. Allegation: Staff do not safeguard resident’s personal belongings. The Department conducted interviews and inspection of the following allegation. Interview conducted with Administrator on 11/21/2023 revealed facility does not handle residents' cash resources. Based on observation of Room 14, Room 23, Room 41, Room 44, Room 47, Room 52, Room 60, and Room 64, it revealed all rooms have a lock on the doorknob to ensure safeguarding. Based on observation, it revealed resident locks are to be “dummy locks” which can be unlocked with a coin. Interview conducted with R1 revealed R1 is not sure if any clothing is missing as R1 has not checked. Interview conducted with current Administrator revealed there has been some complaints of missing clothings but when investigated, clothings are still folded in the laundry room. Observation revealed laundry room has a code lock and only accessible to staff. At this time, allegation is unsubstantiated. With the information obtained, LPA found the allegations to be 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 the report was provided. LIC 9099-C (1) Allegation: Staff do not ensure residents room is kept in safe clean, sanitary condition and in good repair at all times. The Department conducted file review and interviews. File review revealed that there is housekeeping once a week, and additional at an extra charge. Interview conducted with R1 revealed R1’s room does get clean weekly, but caregiver assist with daily trash and bed making in the morning. R1 stated staff is very nice and helpful. Interview conducted with R3 revealed that staff are good with assisting as needed. R3 stated there are times R3 informed staff to help clean the trash. Interview conducted with R6 revealed R6 is very particular with housekeeping. R6 stated there is no concerns regarding getting bedroom clean in a timely manner however, R6 would like caregiver to check in periodically for garbage check. Interview conducted with R7 revealed R7 does not have concerns regarding housekeeping since R7 can be minimal and clean. Interview conducted with Administrator on 11/21/2023 revealed that caregivers are to assist with day-to-day cleaning such as emptying the trash and making the bed whereas housekeeping assist with the deep cleaning such as vacuuming and bathroom cleaning. Therefore, allegation is unfounded. Allegation: Staff do not ensure residents have access to clean linens. Based on observation conducted for Room 14, Room 23, Room 41, Room 44, Room 47, Room 52, Room 60, and Room 64, it revealed facility has clean linen present. Observation conducted of facility spare linens, it revealed facility has ample supply of clean linen, including blankets, bed sheets, pillowcases, and bath towels. The linen observed to be in good repair. Based on interview conducted with current Administrator on 10/29/2024, it revealed during resident’s housekeeping day, linens are to be removed and transported to the laundry room for washing. Based on interview conducted with S1 revealed if residents had an incontinence accident on the linen, caregivers would replace the linen with a clean set. Based on interview conducted with R1 on 11/21/2023, it revealed that R1 is often in bed but if needed staff will change the linens for R1. Therefore, the allegation is unfounded. Please continue to LIC 9099-C(2) LIC 9099-C(2) Allegation: Staff do not ensure residents has sufficient storage space The Department conducted an inspection of the following allegation. Based on observation of Room 14, Room 23, Room 41, Room 44, Room 47, Room 52, Room 60, and Room 64, it revealed facility has met the required resident personal accommodation of portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided. Therefore, allegation is unfounded. Allegation: Staff do not ensure residents wheelchair is in good repair. The Department conducted extensive interviews. Based on interview conducted with R1 revealed R1’s wheelchair has been fine and no concerns. Based on interview conducted with Administrator on 11/21/2023 revealed facility does not provide residents in care with wheelchairs but if there is a surplus at the facility, facility will lend a spare to residents in care. Interview conducted on 10/29/2024 with current Administrator revealed that it is not often for work orders to be placed for wheelchairs. If needed and brought to attention by staff and/or residents in care, facility will contact wheelchair company for repairs. Administrator stated she assisted R9 with physician order and insurance order for a new wheelchair as R9’s wheelchair was having complications. Interview conducted with R9 revealed facility assisted R9 with new wheelchair order. Allegation is unfounded. Allegation: Staff do not ensure residents room is free of malodors The Department conducted an inspection of the following allegation. Based on observation of Room 14, Room 23, Room 41, Room 44, Room 47, Room 52, Room 60, and Room 64, it revealed the rooms observed did not have a malodor and/or remains free of odors from incontinence. Based on observation of the facility conducted on 11/21/2023 and 10/29/2024, it revealed no concerns of malodor. Therefore, allegation is unfounded. Based on information obtained, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left with Administrator.the state’s words, verbatim · CDSS document, Oct 29, 2024 · control 59-AS-20231113145847

Allegation investigated: Facility staff do not store cleaning chemicals locked and inaccessible to residents in care

Licensing Program Analsyt (LPA) Cassie Yang arrived unannounced at the facility to investigate the allgation above. LPA met with Administrator and explained the purpose of the visit. Based on observation during a tour, LPA found two Shout chemicals left in resident's room with door left opened. LPA took two photos of the following and stopped a caregiver on the floor to retrieve the chemicals. During the time of observation, there was two other residents walking with LPA. Interview conducted with Administrator revealed it may have been from resident's family member as facility does not use the following. The allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview and a copy of the report and appeal rights was provided. Substantiatedthe state’s words, verbatim · CDSS document, Oct 17, 2024 · control 59-AS-20240621115513

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Oct 25, 2024

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the section above as LPA observed two cleaning supplies in R1's vacant room. LPA was informed family members may have dropped it off to resident as facility does not use the folowing cleaning supply, which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: -Cleaning supply was confiscated immediately by staff on the floor. -Licensee will provide a newletter to residents and their responsible party a reminder that no chemicals are to be purchased and dropped off to resident's room. POC is due by next Friday October 25.

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

Allegation investigated: Staff are not intervening residents from being harassed by another resident in care.

On 10/2/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to open a complaint the Department received regarding the allegation cited above. LPA met with Administrator and explained the purpose of the visit. During today's investigation, LPA conducted extensive interviews with Administrator, three residents and two facility staff. The result of the investigation is as follow. Continue on LIC 9099-C. Unfounded LIC 9099-C Allegation: Staff are not intervening residents from being harassed by another resident in care. The Department conducted interviews to investigate the following. Interviews conducted with R1 revealed that R1 has witnessed R2 and R3 yelling at each other often. R1 stated that R2 has been trying to antagonize R3 to trigger R3 to react. R1 stated staff often breaks up R2 and R3 if an altercation was to occur. Interview conducted with R2 revealed that facility had advised R2 to avoid going to a certain wing when trying to go to the lobby. R2 felt this is unfair as R2 is the only one being punished therefore, R2 does not follow the advisory. Interview conducted with S1 revealed that S1 has witnessed R2 and R3 yelling at each other. S1 intervened by separating the residents to opposite side of the common areas and de-escalating the situation. Interview conducted with Administrator revealed that Administrator had advised residents to avoid going a certain pathway to reduce chances of running into each other creating altercations. Administrator stated due to R3's current health condition, an eviction is not likely but facility will be implementing possible staggered meal times and/or additional caregiver supervision in the common area during meal times to minimize further altercations. Based on information obtained through interviews, the allegation listed above is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 59-AS-20240930120610

Allegation investigated: Facility staff did not dispense medications as prescribed Facility staff did not safeguard resident's personal items

On 9/23/2024, Licenisng Program Analyst (LPA) Cassie Yang arrived to the facility unannounced at the facility to deliver the findings of the complaint above. LPA met with Administrator and explained the purpose of the visit. The course of the investigation, LPA conducted interviews and file reviews. The results of the investigation is as follow, please continue to LIC 9099-C. Unfounded LIC 9099-C Allegation: Facility staff did not dispense medications as prescribed. The Department conducted a file review and interviews. Based on file review, it revealed that R1's physician has placed an order for Zyrtec 5 mg tablet daily. Interview conducted with R1 revealed that R1 has been receiving their Zyrtec medication in halves only. Interview conducted with Administrator revealed that Zyrtec comes in 10 mg tablet; therefore with the physician order of 5 mg, facility has been providing R1 with half Zyrtec tablet daily. Administrator stated that the following was addressed to R1's primary care physician which the physician order has now been changed to 10 mg which the facility is complying by providing R1 with a whole Zyrtec tablet. Allegation: Facility staff did not safeguard resident's personal items. The Department conducted interviews. Interview conducted with R1 revealed that facility safeguards R1's personal hygiene products. When R1 asked for more from facility staff, R1 was informed his personal supplies has been all used. Interview conducted with Administrator revealed that R1's personal hygiene products was not used by other residents in care. R1 receives personal hygiene shipments from R1's insurance, but the supplies has been placed on hold by a former facility staff. Administrator stated the order has since been placed for ongoing, and additionally, facility has ordered supplies for R1 until shipment arrives. Based on information obtained through file review and interviews, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left with Administrator.the state’s words, verbatim · CDSS document, Sep 23, 2024 · control 59-AS-20240910083137

Allegation investigated: Facility staff are not properly addressing pest infestation in facility

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the finding of the allegation cited above. LPA met with Administrator, Allison Lopez, and explained the purpose of the visit. During the course of this investigation, LPA conducted file review and interviews. The result of the investigation is as follow in LIC 9099-C. Unfounded LIC 9099-C Allegation: Staff are not ensuring that facility is free of pests The Department conducted interviews and file review. Based on interview with former Administrator on 10/27/2023, it revealed that facility does not have a cockroach and/or bedbug infestation but there has been a few occasion of bedbug detection in residents room. Interview revealed that it is unclear where and/or how bedbugs are entering the facility but Licensee is taking active actions wherever pest is detected by caregivers. Based on interview conducted with current Administrator conducted on 9/6/2024, it revealed facility had a recent bedbug treatment was conducted on 8/21/2024 for Room 47, Room 66 to Room 76 and no evidence of active bedbug was detected. Interview revealed that pest control treatments at the facility has been ongoing as needed. Interview further revealed that facility has been in contact with Aantex Pest Control for treatments for bedbugs the moment it is detected and additionally facility is being serviced for monthly pest control. File review revealed there are invoices from Aantex Pest Control for monthly service and/or bedbug treatments on 1/17/2024, 1/29/2024, 2/21/2024, 2/22/2024, 2/23/2024, 3/1/2024, 3/7/2024. Additionally, file review further revealed there are invoices from Clark Pest Control from 3/18/2024 and 6/19/2024 for bedbug treatments. Based on information obtained through file review and interview, the allegation listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left with Administrator.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 59-AS-20240621115513

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

Allegation investigated: Staff are not ensuring that facility is free of pests

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the finding of the allegation cited above. LPA met with Administrator, Allison Lopez, and explained the purpose of the visit. During the course of this investigation, LPA conducted file review and interviews. The result of the investigation is as follow in LIC 9099-C. Unfounded LIC 9099-C Allegation: Staff are not ensuring that facility is free of pests The Department conducted interviews and file review. Based on interview with former Administrator on 10/27/2023, it revealed that facility does not have a cockroach and/or bedbug infestation but there has been a few occasion of bedbug detection in residents room. Interview revealed that it is unclear where and/or how bedbugs are entering the facility but Licensee is taking active actions wherever pest is detected by caregivers. Based on interview conducted with current Administrator conducted on 9/6/2024, it revealed facility had a recent bedbug treatment was conducted on 8/21/2024 for Room 47, Room 66 to Room 76 and no evidence of active bedbug was detected. Interview revealed that pest control treatments at the facility has been ongoing as needed. Interview further revealed that facility has been in contact with Aantex Pest Control for treatments for bedbugs the moment it is detected and additionally facility is being serviced for monthly pest control. File review revealed there are invoices from Aantex Pest Control for monthly service and/or bedbug treatments on 1/17/2024, 1/29/2024, 2/21/2024, 2/22/2024, 2/23/2024, 3/1/2024, 3/7/2024. Additionally, file review further revealed there are invoices from Clark Pest Control from 3/18/2024 and 6/19/2024 for bedbug treatments. Based on information obtained through file review and interview, the allegation listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left with Administrator.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 59-AS-20240415090932

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

Allegation investigated: Facility is not kept free of pests

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to continue the investigation and deliver the findings. LPA met with Administrator, Allison Lopez, and explained the purpose of the visit. During the course of this investigation, LPA conducted file review and interviews. The result of the investigation is as follow in LIC 9099-C. Unsubstantiated LIC 9099-C Allegation: Facility is not kept free of pests The Department conducted interviews and file review. Based on interview with former Administrator on 10/27/2023, it revealed that facility does not have a cockroach and/or bedbug infestation but there has been a few occasion of bedbug detection in residents room. Interview revealed that it is unclear where and/or how bedbugs are entering the facility but Licensee is taking active actions wherever pest is detected by caregivers. Based on interview conducted with current Administrator conducted on 9/6/2024, it revealed facility had a recent bedbug treatment was conducted on 8/21/2024 for Room 47, Room 66 to Room 76 and no evidence of active bedbug was detected. Interview revealed that pest control treatments at the facility has been ongoing as needed. Interview further revealed that facility has been in contact with Aantex Pest Control for treatments for bedbugs the moment it is detected and additionally facility is being serviced for monthly pest control. File review revealed there are invoices from Aantex Pest Control for monthly service and/or bedbug treatments on 1/17/2024, 1/29/2024, 2/21/2024, 2/22/2024, 2/23/2024, 3/1/2024, 3/7/2024. Additionally, file review further revealed there are invoices from Clark Pest Control from 3/18/2024 and 6/19/2024 for bedbug treatments. Based on information obtained, LPA finds the allegation to be 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 the report was provided. LIC 9099-C(1) Allegation: Staff do not provide proper medication assistance to resident in care The Department conducted interviews and file reviews. Based on interview conducted with former Administrator on 10/27/2023, it revealed that there are two med techs on shift for AM and PM shift and one med tech for NOC shift. Administrator stated that when med tech calls off their shift, facility often utilize registry for staffing fill-ins. Interview further revealed that residents often complains that medications are not given in a timely manner but it is still given as prescribed such as "twice a day". Interview further revealed that medications that are prescribed "before meals" then it is prioritized to ensure facility is in compliance to medication orders. Interview conducted with current Administrator indicated that at this moment facility are staffed with two med techs and four caregivers per shift for AM and PM and then one med tech and one caregiver for NOC shift. Based on file review of staff schedule of July 2024, August 2024 and September 2024, it revealed that facility is staffed with with adequate med techs per day. Allegation: Resident's furniture is in disrepair The Department conducted interviews and observations for the following allegation. Interview conducted with former Administrator, it revealed that facility has a vacant room utilized for storage. Former Administrator stated that Licensee is often compliance with ordering extra mattress for emergency. Interview revealed that if a bed is dirty, facility will attempt on cleaning the mattress and if stain and/or the issue is not resolved then a new mattress is often replaced. Interview conducted with R1 revealed that R1 has never had an issue with getting a new mattress if needed. R1 stated that the facility is "really good" with replacing items. Interview conducted with R2 revealed that R2 does not have any furniture in disrepair but will notify Administrator if needed. Based on LPA's observation of ten residents room on 10/27/2023, 11/21/2023 and 8/14/2024, LPA observed no broken and/or disrepaired furnitures present. Allegation: Residents in care are not provided housekeeping services The Department conducted extensive interviews and file review. Interview conducted with former Administrator on 10/27/2023 revealed that there is one housekeeper at the moment but is in the process of hiring a second housekeeper. Interview revealed that all staff are taking a turn to clean residents room to fulfill the weekly housekeeping duties. Former Administrator stated that she has been assisting with cleaning rooms along with additional caregivers, the receptionist and maintenance supervisor. Interview conducted with S1 revealed that S1 has been cleaning rooms at the beginning of S1's shift although it is not S1's job duty. S1 stated that all staff are working together to keep the facility operating until vacancies are filled. File review conducted 7/12/2024 revealed that there are two housekeepers scheduled for the month of June 2024 with designed rooms to clean throughout the week. Interview conducted with Administrator on 9/6/2024, revealed there are now three housekeepers on schedule. Please continue on LIC 9099-C (2) LIC 9099-C(2) Allegation: Resident in care has not been provided with a clean mattress. The Department conducted observations and interviews. Based on LPA's observation of ten residents room on 10/27/2023, 11/21/2023 and 8/14/2024, LPA did not observed any mattress that needed to be cleaned. Interview conducted with R1 revealed that R1 does not have an issue with R1's mattress. Interview conducted with R2 revealed that R2's mattress is "fine" and does not need a replacement. Interview conducted with R3 revealed that R3 is happy with everything in R3's room and does not need anything from the facility at this time. Interview conducted with R3 revealed that R3's mattress is clean and does not need a new mattress. Interview conducted with former Administrator on 10/27/2023 revealed that caregivers are responsible for making residents bed and if observed to be dirty, caregivers are to notify management team so deep cleaning can be conducted or a new mattress if needed. Based on information obtained through interviews, file review and observations, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 59-AS-20231017104138

Allegation investigated: Medication being administered late

On 8/14/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the finding of the allegation cited above. LPA met with Administrator, Allison Lopez, and explained the purpose of the visit. During the course of this investigation, LPAs had conducted interviews and extensive file reviews. The result of the investigation is as follow, please continue to LIC 9099-C. Unfounded LIC 9099-C Allegation: Medication being administered late The Department conducted interviews and file review. Based on interview conducted with R1, it revealed that they are receiving muscle relaxers and anxiety medications late and was developing symptoms due to late administration of medications. R1 stated that based on physician orders, the anxiety medications are to be given by 9 AM for morning administration and by 6 PM for evening distribution. Interview reviewed R1 has received morning medications several times after 10 AM. Based on file review, it revealed that Lorazepam 0.5mg tablet was prescribed to R1, with physician orders, effective 5/23/2024, to be given one tablet by mouth twice a day as needed for anxiety. File review revealed that during complaint investigation, a new physician communication was faxed for all morning medications for 8:30 AM and all evening medication for 5:30 PM. File review revealed Lorazepam 0.5mg was prescribed as a PRN (pro re nata) medication not Based on information obtained through file review and interview, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left with Administrator.the state’s words, verbatim · CDSS document, Aug 14, 2024 · control 59-AS-20240529145732

Type of visit: Required - 1 Year

On 8/14/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required 1-year annual inspection utilizing the CARE tool. LPA met with Administrator, Allison Lopez, and explained the purpose of the visit. Facility's census is 63, with two (2) residents on hospice services. Facility is licensed for 110 non-ambulatory, hospice waiver of 8. LPA and Administrator conducted a tour of the interior of the facility to ensure the health and safety of residents in care. During today's tour, LPA observed eight (8) residents rooms, activity room, living room, shower room, dining room, bathrooms, beauty shop, med room and the common areas. LPA observed fire extinguisher to be serviced on 1/15/2024. LPA observed residents eating lunch in the dining room. During time of visit, LPA was unable to inspect kitchen as it was being occupied. LPA observed the shower room flooring to have pink discoloration, what observed to be possible mildew, around the floor border. Additionally, LPA observed the air vent to be dusty. LPA advised facility to clean the filter to improve ventilation in the shower room. LPA took four photos of the following observation. File review conducted of five (5) personnel records and seven (7) residents records. CARE inspection tool completed and as a result of today's inspection, deficiencies was cited. Please see LIC 809-D. Exit interview conducted, and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 14, 2024

Allegation investigated: Staff does not meet resident's dental care needs. Staff does not allow resident to select the clothes they wear. Staff does not treat resident with dignity and respect.

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to continue an investigation and delivered the findings of the allegations cited above. LPA met with Interim Adminstrator, Allison Lopez, and explained the purpose of the visit. During the course of interview, LPA conducted extensive file review and interviews. The result of the allegation cited above is as follow. Please continue on LIC 9099-C(1). Unfounded LIC 9099(C)(1) Allegation: Staff does not meet resident's dental care needs. The Department conducted file review and interviews for the following allegation. Based on interview conducted with former Administrator on 9/28/2023 and Interim Administrator on 07/03/2024, majority residents in care are independent with dental care hygiene. Interview conducted with R1 indicated that R1 brushes their own teeth and does not need assistance from staff. R1 indicated that if in dental pain R1 is to notify R1's responsible party and/or notify Administrator for a dental appointment. File review for R1's service plan revealed R1 is independent/self care with dental needs. Interview conducted with R2 indicated that R2 is responsible for their own dental care and does not need staff to assist with brushing. R2 gets reminders from care staff to brush their teeth in the morning and night. File review for R2's service plan revealed R2 needs verbal cueing with dental care. Interview conducted with R3 indicated that R3 brushes their own teeth and does not need assistance from staff. File review for R1's service plan revealed R3 is independent/self care with dental needs. Interview conducted with R4 indicated that R4 brushes their own teeth and does not need assistance from staff. File review for R4's service plan revealed R4 wears dentures and is independent/self care with dental needs. Interview conducted with R5 indicated that R5 can brush own teeth without assistance. File review for R5's service plan revealed R5 is independent/self care with dental needs. Interview conducted with R6 indicated that R6 likes to be independent and can do most activities of daily living on their own, including dental care needs. File review for R6's service plan revealed R6 is independent/self care with dental needs. Based on information obtained through file review and interviews, the allegation listed above is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Allegation: Staff does not allow resident to select the clothes they wear. The Department conduct extensive interviews. Interview conducted with R1 revealed that R1 feels like they are able to select their own clothing to wear. R1 stated staff are forcing them to wear other clothing. Interview conducted with R2 revealed that R2 wears whatever they want without staff's advisory and/or enforcement. R2 stated they have never experienced an issue with selecting own clothing. Based on interview conducted with R3 revealed that R3 has never been told what to wear. Interview conducted with R4, R5 and R6 revealed they do not have an issue with selecting own clothing at the facility. Based on information obtained through interviews, the allegation listed above is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Please continue to LIC 9099-C(2) LIC 9099(C)(2) Allegation: Staff does not treat resident with dignity and respect. The Department conduct extensive interviews. Interview conducted with R1 revealed that R1 feels safe at the facility. R1 stated staff are helpful and does not have issue regarding their care and supervision. Interview conducted with R2 revealed that R2 enjoys the help of the facility staff. R2 is able to get their assistance whenever asked and staff are willingly. Interview conducted with R3 revealed that R3 does not feel disrespected by facility staff when asked for care. Interview conducted with R4 revealed that facility staff treats R4 with dignity and respect and R4 cannot recall being treated in a poor manner. Based on interview conducted with R5 revealed that R5 believes facility is trying their best to accommodate to all residents in care. R5 stated that R5 feels respected and is comfortable speaking to Administrator if there is an issue. Interview conducted with R6 revealed that R6 has been living at the facility for over three years and enjoys the facility. R6 stated that staff accommodates to their needs and has been helpful. Based on information obtained through interviews, the allegation listed above is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2024 · control 59-AS-20230927082132

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the current Administrator in place. LPA met with Facility Nurse/Interim Administrator and explained the purpose of the visit. LPA was informed current Administrator on file, Vicky Cross, is no longer working at the facility. LPA was informed Facility Nurse is currently acting as Interim Administrator until Licensee finds an Administrator that is deemed fit for the facility. LPA was informed Facility Nurse/Interim Administrator does have an active Administrator Certificate. LPA is requesting the required documents to be submitted to LPA via email to change Administrator on file until position is permanently fulfilled. Please provide the following below to LPA by Friday July 26, 2024 to remain compliance to CCR Title 22 Section 87405 Administrator - Qualifications and Duties. Active Administrator Certificate and/or Proof of Administrator Certificate renewal Document to confirm Facility Nurse has two years of college; at least three years experience providing residential care to the elderly; or equivalent education and experience as approved by the licensing agency. At this time, no deficiencies cited. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2024

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Cassie Yang unannounced at the facility to deliver the finding of the allegation cited above. LPA met with Interim Administrator and explained the purpose of the visit. During the course of the investigation, LPA conducted extensive interviews and file review. Result is as follow, please continue LIC 9099-C(1). Unfounded **LIC 9099-C (1)** Allegation: Illegal eviction The Department conducted file review and interviews. File review revealed a 30 day eviction letter dated March 1, 2024 was provided with effective date of April 2, 2024. File review revealed that R1 was evicted due to change of condition. It was determined that R1 has a need not previously identified as reappraisal was conducted on January 29, 2024 by Facility Nurse. Facility Nurse believe that the facility is not appropriate for R1 due to constant confusion of exit seeking. Care notes revealed on 3/25/2023, R1 was trying to get out of the facility to check R1's car in the parking lot, R1 was then redirected back to the room. On 7/19/2023, R1 was attempting to leave the facility through the front door at approximately 2AM. On 7/31/2023, R1 was confused and wanted to take a cart to unload things from his truck and R1 was trying to get out of the facility to look for the truck. On 8/6/2023, R1 was walking around the facility to get out. On 9/6/2023 at approximately 11PM, R1 was walking around and stated R1 had to go free the cows. On 11/4/2023, R1 was seeking exit at 2AM through the front door and then at approximately 3:30AM R1 was exit seeking through the sliding delivery door. On 12/4/2023 at approximately 1:30PM R1 gathered notebooks and informed staff R1 was looking for a bus that will take R1 home. R1 was then redirected back to the room. On 12/14/2023, R1 was very confused and was packing up personal belongings from R1's room and informed staff that someone was waiting for R1 in the car. On 12/25/2023, R1 was waiting to leave the facility and informed staff R1's family took all R1's money and that R1 wants to go get it back. On 12/26/2023, R1 was walking around all night in the living room and informed staff R1 had to leave for work. File review revealed in preplacement appraisal conducted for R1 on 12/10/2019, on page 2 under "Services Needed- Other Services Needed not identified above" it was marked no. Resident Appraisal conducted on 1/29/2024, on page 2 under "Services Needed- Other Services Needed not identified above" it was marked "yes" with the comment of "HX of exit seeking, and HX of sexually inappropriate behavior requiring frequent checks and oversight". Please continue on LIC 9099-C (2) *** LIC 9099-C(2)*** File review of R1's Service Plan conducted on 4/29/2022 revealed R1 scored zero (0) for wandering and elopement, Needs/Details: independent, no assistance R1's Service Plan conducted on 9/4/2023 revealed R1 scored four (4) for wandering and elopement, Needs/Details: Occasional, routine support with special care needs. R1's Service Plan conducted on 12/4/2023 revealed R1 scored nine (9) for wandering and elopement, Needs/Details: Occasional redirection if wandering or approaching exits. Interview conducted with S1 revealed S1 was R1's caregiver and recalled R1 being a "sweet resident" but would make comments to other residents. S1 stated R1 wandered the facility and would pack his belongings saying R1 is going to war. S1 stated in another incident, R1 started packing picture frames and informed staff R1 was going home. Interview further revealed that S1 has seen R1 exit seeking in a handful of occasions but R1 was easy to redirect back to room. R1's exit seeking was mainly at night when R1 is sundowning. Interview conducted with S2 revealed R1 was found near the front door, when asked what was R1 doing, R1 stated R1 was waiting for a ride to leave. S2 stated R1 was good with redirection. Based on information obtained through file review and interviews, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report and appeal rights was left with Interim Administrator.the state’s words, verbatim · CDSS document, Jul 3, 2024 · control 59-AS-20240329103627

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an unannounced quarterly on-site visit regarding the Stipulation and Waiver and Order, effective two years from 05/23/2022 to 05/23/2024. LPA met with Facility Nurse, Allison Lopez, and explained the purpose of the visit. During today's visit, LPA reviewed the Compliance Binder, and observed a copy of the Stipulation in the binder. LPA observed last weekly compliance calls conducted on 5/9/2024 with consultant group to discuss the medication room. LPA observed Staffing Needs Call with Human Resources to be documented on 5/7/2024 regarding continuing interviews for med techs, caregivers and housekeeping. LPA observed documentation of Licensees quarterly on-site visits ensuring quality control conducted by Licensees, Solar Senior Living and CiminoCare. LPA and Facility Nurse discussed the upcoming end of probation terms. LPA informed facility that once probation ends, a new license will be generated and mailed to the facility. At this time, LPA found facility to be in compliance with the Stipulations and Waiver; And Order. No deficiencies cited. Exit interview conducted and a copy of report will be provided.the state’s words, verbatim · CDSS document, May 22, 2024

Type of visit: Office

On 5/15/2024 at 9:45 AM, an office meeting was held with Sacramento North Regional Office via Microsoft Teams Meeting. Present in the meeting was Licensee, Mark Cimino, Administrator, Vicky Cross, Facility representatives: Allison Lopez, Robert Godfrey, Adina Nitu, Payam Saljoughian, Licensing representatives: Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Cassie Yang. The purpose of the meeting is to discuss the changes that were implemented in the facility since the office meeting last held on 1/31/2024. Topics discussed during this meeting were: Medication management Staffing Exit interview and a copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD.the state’s words, verbatim · CDSS document, May 15, 2024

Type of visit: Office

On 5/15/2024 at 9:00 AM, an office meeting was held with Sacramento North Regional Office via Microsoft Teams Meeting. Present in the meeting was Licensee, Mark Cimino, Administrator, Vicky Cross, Facility representatives: Allison Lopez, Robert Godfrey, Adina Nitu, Payam Saljoughian, and Assisted Living Waiver Program Director Senior Care Solution agent, Lauren Firenze. Licensing representatives present: Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Cassie Yang. Topics discussed during this meeting were: R1's level of care and potential new placement 30 Day Eviction Notice Facility's plan of filing Notice to Vacate, if necessary Exit interview and a copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD.the state’s words, verbatim · CDSS document, May 15, 2024

Allegation investigated: Staff does not respond to call in a timely manner. Staff are not meeting resident's showering needs. Staff did not safeguard resident's personal belongings.

On 4/24/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver findings of the allegations cited above. LPA and LPM met with Administrator, Vicky Cross, and explained the purpose of the visit. During the course of this investigation, the Department conducted extensive interviews and file reviews. The results of the investigation is as follow. Please continue on LIC 9099-C** Unsubstantiated ***LIC 9099-(C)(1)*** Allegation: Staff does not respond to call in a timely manner. The Department conducted interviews regarding the allegation cited above. Interview conducted with R1 revealed the facility does not respond to call lights in a timely manner when R1 needs assistance with rotating and/or transferring. Interview conducted with R2 revealed R2 utilizes the call light for assistance with taking the trash out. R2 revealed R2 does not mind if staff takes longer to respond as it is not an emergency. Interview conducted with R3 revealed the PM shift did not assist to call lights in a timely manner. Interview further revealed R3 usually waits approximately 20 to 30 minutes when utilizing call light. File review conducted for R1 revealed the longest response time for a call was to be 75 minutes. Interview conducted with R1 revealed R1 does not recall what assistance was needed at that time. R1 stated no fall and/or serious injury occurred during the time period of the call logs. File review conducted for R4 revealed the longest response time for a call was to be 98 minutes. Interview was unable to be conducted with R4 as R4 declined to speak to LPA. Although file review revealed there was long call response, California Code of Regulation, Title 22, does not specify a time frame of when facility is to assist to a non-emergency call. Additionally based on interview with Regional Director, it revealed that facility staff has the tendency to "forget to reset the system at the conclusion of the service they are doing". Therefore the allegation cited above is unsubstantiated. Allegation: Staff are not meeting resident's showering needs. The Department conducted interviews and file review regarding the allegation cited above. Interview conducted with R1 revealed R1 does not like certain caregivers to shower R1 as R1 feels unsafe that certain caregivers are untrained to utilize the shower transferring machine. Interview further revealed R1 will refuse showers and ask for a new caregiver. Interview conducted with R4 revealed that R4 does not like "rude" caregiver to shower R4 and would ask for a new caregiver to provide showering. Interview conducted with S1 revealed S1 has received complaints regarding R4 yelling at caregiver to "get the hell out". Interview further revealed that caregivers are to complete refusal forms for residents in care when showers are declined. Based on file review, LPA observed shower refusal forms to be completed for residents in care. File review revealed shower skin inspections for R4 which are documented when showering are completed. The allegation cited above is found to be unsubstantiated. Please continue on LIC 9099-C (2) ***LIC 9099-C (2)*** Allegation: Staff did not safeguard resident's personal belongings. The Department conducted observation and interviews regarding the allegation cited above. Based on LPA's observation, it revealed each resident room at the facility has a door lock to ensure personal safeguarding. Interview conducted with R1 revealed R1 has lost "a couple of shirts" but is unsure if it is in the closet or not. The Department conducted an interview with R2 which revealed R2 has noticed a pair of pants to be missing. Interview conducted further reviewed R2 cannot confirm if it was do to laundry error or not. Interview conducted with R3 revealed R3 does not have an issue regarding missing personal belongings. Therefore, the allegation cited above is unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted. A copy of this report was been provided. Signature on form acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Apr 24, 2024 · control 59-AS-20230505093715

Type of visit: Case Management - Other

On 4/24/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to open a complaint the department recieved. LPA met with Administrator, Vicky Cross, and explained the purpose of the visit. Case management visit was conducted as Administrator wanted to discuss the open complaints the Department has with the facility. LPA and Administrator discussed and reviewed the open complaints. LPA provided Administrator a copy of open complaints with the following open allegations. No deficiency cited. Exit interview conducted and copy of report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2024

Allegation investigated: Staff did not ensure resident's room is clean and sanitized.

On 3/7/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an investigation regarding the allegation the department received. LPA met with Administrator, Vicky Cross, and explained the purpose of the visit. During the investigation, LPA conducted an inspection of R1's bedroom. Addtionally, LPA conducted a file review of R1's care plan and LIC 602. LPA obtained two photo of R1's bedroom. Result of the investigation is as follow. Please continue on LIC 9099-C... Substantiated LIC 9099-C... Allegation: Staff did not ensure resident's room is clean and sanitized. The department conducted an inspection regarding the allegation cited above. Based on observation on 3/7/2024, it revealed R1's carpet by the bed was stained. The stain is observed to be a dark brown color and approximately two feet. Based on interview with R1, it revealed R1 had spilled a drink on the carpet. It further revealed that the stain has been there for the past "several weeks". During LPA's observation, it revealed R1's bed linen and pillow case was stained with red streaks. Interview conducted revealed that the stains on the linen and pillow case has been present for "a couple of days". Additionally, based on observation, it revealed that R1's urinal bottle was stored on top of the night stand with the presence of urine inside. Observation revealed that there was opened snacks on the night stand next to the urinal bottle. Interview conducted with R1 revealed that R1 does not get assistance from staff to help clean the urinal bottle. Based on the allegation, staff did not ensure resident's room is clean and sanitized, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Civil penalty assessed as this violation was cited on 10/11/2023, within a 12 month period. Exit interview conducted, and a copy of the report and appeal rights will be provided via email to Administrator. LIC 9099-C(1)... Allegation: Staff did not properly manage incontinence care. The department conducted file review for the allegation cited above. Based on R1's care plan, it revealed R1 is independent and self-care at toileting. Based on R1's LIC 602 PHYSICIAN'S REPORT, date of exam 10/29/2021, it revealed R1 does not have bowel and bladder impairment. Interview conducted on 03/07/2024 revealed that R1 likes to use a urinal bottle since it is easier than getting up to go to the bathroom. Based on information obtained through interviews and file reviewed, the Department finds the allegation found the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of report and appeal rights will be provided via email to Administrator.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 59-AS-20240226134705

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 22, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA's observation, Licensee did not comply to the section cited above as LPA observed R1's room to have an approximate two-feet brown stain next to R1's bed, used urinal bottle on top of night stand and red stains on linens which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Mar 7, 2024

Plan of correction: R1's carpet was cleaned immediately during LPA's visit. Licensee will conduct an in-service staff training regarding facility's expectation of cleanliness and sanitary conditions of resident's room. Licensee is to notify LPA Yang of completion. $250 Repeat Violation Civil Penalty assessed

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding the incident report LPA received on 02/26/2024 regarding bedbugs at the facility. LPA met with Administrator, Vicky Cross, and explained the purpose of the visit. Based on documentation, it revealed treatments was recently conducted for the common areas and resident's bedrooms. During today's visit, it was discussed that all positive resident bedrooms has been treated on Monday. It was further discussed that there was one additional room detected for bedbugs date of visit. LPA and Administrator discussed the preventative steps facility is taking to eliminate bedbugs. LPA was informed that facility has stopped all move-in's until facility is cleared. Additionally, LPA and Administrator discussed implementing preventative treatments such as Aprehend and additionally, LPA advised facility to implement Personal Protective Equipment such as white hazmat pants and shoe booties, to prevent transfers of bedbugs from room to room.Administrator stated this matter will be discussed with Licensee. No deficiencies cited. LPA will continue monitoring this matter. Exit interview and a copy of the report will be provided via email to Administrator.the state’s words, verbatim · CDSS document, Mar 7, 2024

Type of visit: Case Management - Incident

On 2/22/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received. LPA met with Administrator, Vicky Cross, and Regional Nurse, Allison Lopez, explained the purpose of the visit. LPA discussed the incident that occurred with R1 and R2. LPA learned that on Monday February 19, 2024, R1 was upset and had pushed a chair, hitting R2's hand. Regional Nurse reported that R2 has a minor bruising but no other complaints. It was discussed that R1 was upset as he was asked to move out of another resident's seat. R2 informed LPA that since the occurrence of this incident, R1 has not sat at R2's table as R2 disagreed with R1's behavior. LPA was informed R1 apologized for the incident and has not had any reoccurrence. Administrator reported there is no concern separating R1 and R2. Administrator reported no other concerns at the facility. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Feb 22, 2024

Type of visit: Case Management - Legal/Non-compliance

On 2/22/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an unannounced quarterly on-site visit regarding the Stipulation and Waiver and Order adopted on 05/23/2022. LPA met with Vicky Cross, Administrator, and explained the purpose of the visit. During today's visit, LPA was provided the Compliance Binder, and observed a copy of the Stipulation in the binder. LPA observed weekly calls conducted with consultant group to discuss medication room operation. LPA observed in-service education of Care Plan Review conducted on 2/1/2024 with shift manager and caregivers. LPA observed documentation of monthly staff training, Dementia training conducted on 1/17/2024 and Confidentiality/HIPPA training conducted on 2/20/2024. LPA observed quarterly audit from consultant group last serviced on 11/13/2023. LPA was informed next audit is currently being conducted date of visit and the day after. LPA observed documentation of Licensees quarterly on-site visits ensuring quality control conducted on 12/5/2023 by Solar Senior Living and on 12/9/2023 by Ciminocare. At this time, LPA found facility to be in compliance with the Stipulations and Waiver; And Order. No deficiencies observed. Exit interview conducted and a copy of report will be provided to Administrator via email.the state’s words, verbatim · CDSS document, Feb 22, 2024

Type of visit: Office

On 1/31/2023 at 1:30 PM, Non-Compliance Conference meeting was held with Sacramento North Regional Office via Microsoft Teams Meeting. Present in the meeting was Licensee, Mark Cimino and Glenn Silverman, Administrator, Vicky Cross, Facility representatives: Allison Lopez, Robert Godfrey, Adina Nitu, Joel Goldman, Payam Saljoughian, Josh Allen, Maria Cash. Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Cassie Yang. Topics discussed during this meeting were: Medication management Staffing The licensees were in agreement with the drafted non-compliance plan as outlined in LIC 9111. An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD.the state’s words, verbatim · CDSS document, Jan 31, 2024

Allegation investigated: Staff mishandled resident's medication.

On 1/25/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to open and deliver the findings of the allegation cited above. LPA met with Administrator, Vicky Cross, and explained the purpose of the visit. Today's investigation, LPA obtained a copy of R1, R2, R3, R4, and R5's January 2024 medication administration records (MARs). LPA conducted a medication count for R1 and R2. Additionally, LPA took photos of R1's medication packets for reference. The result of the investigation is as follow. Please continue on LIC 9099-C... Substantiated LIC 9099-C... Allegation: Staff mishandled resident's medication. Based on the file review of R1's January 2024 MAR, it revealed R1 is to take Eliquis 5mg tablet, twice a day. January 2024 MAR revealed the prescribed medication was signed for on January 20: AM and PM, January 21: AM and PM, January 22: AM and PM, January 23: AM and PM, January 24: AM and PM and January 25: AM. R1's MAR revealed Eliquis was given six (6) times during AM shift, starting January 20. R1's MAR revealed Eliquis was given five (5) times during PM shift, starting January 20. Based on LPA and Regional Nurse medication audit, it revealed R1's AM Eliquis 5mg packet's start date was labeled as January 20, 2024. Based on the medication count, LPA and Regional Nurse observed four (4) tablets to be missing from the AM packet, instead of 6 as documented on R1's MAR. Based on LPA and Regional Nurse medication audit, it revealed R1's PM Eliquis 5mg packet's start date was labeled as January 20, 2024. Based on the medication count, LPA and Regional Nurse observed three (3) tablets to be missing from the PM packet, instead of 5 as documented on R1's MAR. Based on the file review of R2's January 2024 MAR, it revealed R2 is to take Magox 400mg tablet, once a day. January 2024 MAR revealed the prescribed medication was signed for on January 21, January 22, January 23, January 24 and January 25. R2's MAR revealed Magox was given 5 times, starting January 21. Based on LPA and Regional Nurse medication audit, it revealed R2's Magox 400 mg medication bottle's start date was labeled as January 21, 2024. Based on the medication count, LPA and Regional Nurse counted 96 pills present in the bottle out of 100 tablets, meaning 4 tablets to be missing, instead of 5 as documented on R2's MAR. Please continue the report on LIC 9099-C2... LIC 9099-C2... Based on the file review of R2's January 2024 MAR, it revealed R2 is to take Januvia 25mg tablet, once a day. January 2024 MAR revealed the prescribed medication was signed for on January 21, January 22, January 23, January 24 and January 25. R2's MAR revealed Januvia was given 5 times, starting January 21. Based on LPA and Regional Nurse medication audit, it revealed R2's Januvia 25mg medication bottle's start date was labeled as January 21, 2024. Based on the medication count, LPA and Regional Nurse counted 26 pills present in the bottle out of 30 tablets, meaning 4 tablets to be missing, instead of 5 as documented on R2's MAR. Based on the file review of R2's January 2024 MAR, it revealed R2 is to take Plavix (Clopidogrel) 75mg tablet, once a day. January 2024 MAR revealed the prescribed medication was signed for on January 12, January 13, January 14, January 15, January 16, January 17, January 18, January 19, January 20, January 21, January 22, January 23, January 24 and January 25. R2's MAR revealed Plavix (Clopidogrel) was given 14 times, starting January 12. Based on LPA and Regional Nurse medication audit, it revealed R2's Plavix (Clopidogrel) 75mg medication bottle's start date was labeled as January 12, 2024. Based on the medication count, LPA counted 91 pills whereas Regional Nurse counted 90 pills present in the bottle out of 100 tablets, meaning approximately 10 or 11 tablets to be missing, instead of 14 as documented on R2's MAR. When asked if recount is needed, Regional Nurse stated "90, 91 is close, but there is supposed to be 86 (tablets) in here". Based on the allegation, staff mishandled resident's medication, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted, and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 25, 2024 · control 59-AS-20240125123831

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 26, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on file review of R1 and R2's medication administration records and medication audit, licensee did not comply with the section cited above as LPA and Regional Nurse observed four different medication counts to be inconsistent with MAR, which poses an immediately risk to residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: This matter will be discussed during noncompliance conference on 1/31/2024. Deficiency will be cleared afterwards.

Allegation investigated: Staff are not following residents care plans.

On 01/11/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to open the complaint the Department received regarding the allegation cited above. LPAs met with Administrator, Lacy Berry, and explained the purpose of the visit. During the investigation, LPA conducted file reviews and interviews. Please continue on LIC 9099-C... Substantiated LIC 9099-C... Allegation: Staff are not following residents care plans. Based on file review of R1's care plan, it revealed R1's medication management states "Needs/Details Central storage and set up of medications Assistance with 10+ centrally stored medications" Based on LPA's inspection conducted on 10/11/2023, it revealed medications were found in R1's bedroom when it should be centrally stored responsibility of a med tech as stated in R1's care plans. LPA observed the medication found to be Ondansetron 4mg which is often used to nausea and vomiting. Interview revealed R1 wished to keep Ondansetron in the room as it is hard to get assistance for medication in a timely manner. It further revealed when call lights are pressed, R1 is unable to get assistance until an extensive period of time. Interview with R1 further revealed that R1 needs assistance with showering and incontinence care but often staff are unavailable to change diaper in a timely manner. Based on LPA's observation on 10/11/2023, it revealed LPA observed R1 pressing call light for assistance. At approximately 15 minutes afterwards, LPA checked on R1 which revealed no caregiver has entered the room for assistance yet. Interview with R2 revealed R2 needs assistance with medication as medications are centrally stored. R2 stated med techs are often late for medication administration as facility is often employed with one med tech per shift only. Interview conducted with R3 revealed R3 has occasional issues with call lights at the facility, as staff do not respond until over "10-15 minutes". Interview with R3 revealed R3 is not concern if call is not responded if it is regarding needing clean up assistance. R3 stated R3's concern is if the call light is in regards to an emergency, R3 is unsure other residents can wait that long for help. Based on the allegation, staff are not following residents care plans, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted, and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 59-AS-20230829093013

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 26, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as R1 and R2 both stated there is staff shortage at the facility resulting to delays on level of care, which poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Staffing concerns will be discussed with Licensee during in-person noncompliance conference.

Allegation investigated: Staff are not properly trained.

On 1/11/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the finding for the allegation cited above. LPA met with Administrator, Lacy Berry, and explained the purpose of the visit. During the course of investigation, LPA conducted file review of S1, S2 and S3 training. The result is as follow, please see LIC 9099-C. Unfounded LIC 9099-C... Allegation: Staff are not properly trained. Based on Relias file review, it revealed S1 completed total training hours of 17.25 from 06/26/2023 to 06/28/2023 and additionally one (1) hour of Refresher for CPR on 08/28/2023. File review on Guardian revealed S1 was added as an employee on 06/13/2023. Based on Relias file review, it revealed S2 completed total training hours of 23.75 from 06/30/2023 to 07/27/2023. File review on Guardian revealed S2 was added as an employee on 06/09/2023. Based on Relias file review, it revealed S3 completed total training hours of 20.25 from 08/18/2023 to 08/23/2023. File review on Guardian revealed S3 was added as an employee on 07/18/2023. Based on information obtained, LPA finds the allegation to be UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted, and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 59-AS-20230829093013

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the incident reports LPA received on 11/28/2023 and the SOC 341 received on 12/1/2023. LPA met with Administrator, Lacy Berry, and explained the purpose of the visit. During today's visit, LPA and Administrator discussed the incident report for R1 and R2 received on 11/28/2023 regarding bed bugs. LPA was informed exterminator arrived to the facility and conducted a "fire" treatment immediately upon discovery. When asked if Administrator is able to identify the source, Administrator stated "no it was random". Administrator reported R1 and R2 has returned to their rooms. Administrator informed LPA facility is conducting a weekly checks when residents are having lunch as a preventative. Additionally, LPA and Administrator discussed the SOC 341 received by email on 12/1/2023. LPA was informed facility was aware of this incident after Thanksgiving when R3 returned to the facility. LPA was then informed by Allison Lopez, SOC 341 was originally faxed in to CCLD on 11/28/2023. It was further discussed R3 and R4 has been separated in the dining room since acknowledgement of incident. Additionally, facility has designated a caregiver to supervise R4 with 1-on-1 care. LPA and Administrator discussed the change of condition for R4. Administrator stated R4 has been observed in the past to be packing belongings and wanting to leave the facility. LPA was informed a care conference has been attempted by the facility to discuss R4's higher level of need. Administrator informed LPA she will continue to attempt conference with R4's responsible parties and if failed, facility will discuss the next steps with LPA and Long Term Care Ombudsman. LPA attempted contact with R3 but there was no response at the door. LPA was able to contact with R4 who was having 1-on-1 care. As a result of today's visit, no deficiencies observed. Exit interview and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 6, 2023

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an unannounced quarterly on-site visit regarding the Stipulation and Waiver and Order adopted on 05/23/2022. LPA met with Lacy Berry, Administrator, and explained the purpose of the visit. During today's visit, LPA was provided the Compliance Binder, and observed a copy of the Stipulation in the binder. LPA observed Care Plan Reviews to last be conducted on 10/12/2023. LPA observed recent quarterly training to be conducted on 8/22 Fall Reduction, 9/26 Changes in Condition, 10/18 Dementia Care, along with printouts of PowerPoint presentation. LPA observed documentation of the last quarterly visit conducted by Solar Senior Living representative, Jonathan Harris, to be on August 8, 2023. LPA informed Administrator LPA will discuss with Licensing Program Managers if quarterly visits with Solar Senior Living and Ciminocare are to be conducted in tangent, as LPA observed the current quarterly visit to be offsetting. LPA obtained a copy of Solar Senior Living and Ciminocare Quarterly Visits log, and statements from 07/27/2022 to 08/08/2023. LPA observed no quarterly audit has been conducted by Allen Flores Consulting Group since LPA's last quarterly visit conducted on 8/23/2023 as the most recent audit was completed on 8/17/2023. LPA is requesting a copy of facility's LIC 309 ADMINISTRATIVE ORGANIZATION. Additionally, LPA is requesting a copy of the most recent quarterly audit conducted by Allen Flores Consulting Group on 8/17/2023. All documents are to be submitted to LPA by close of business 11/15/2023. If by 11/15/2023, no new audit has been completed by Allen Flores Consulting Group, LPA is requesting a copy of the new audit once available. Exit interview conducted. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Nov 8, 2023

Allegation investigated: Facility is in disrepair and unsanitary

On 10/11/2023, Licensing Program Analyst (LPA) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to open the complaint the Department received regarding the allegation cited above. LPAs met with Administrator, Lacy Berry, and explained the purpose of the visit. During the investigation, LPAs conducted an inspection of three bathrooms, interviewed two residents, and took 13 photos. The result of the investigation is as follow. Please continue on LIC 9099-C... Substantiated Allegation: Facility is in disrepair and unsanitary. On 10/11/2023, the Department conducted an inspection of R1's previous room and observed the bath tub faucet to be leaking while it was not in use. Interview conducted with R1 revealed that although R1 is not currently living in that room, the leaking has been ongoing prior to his temporary move to the room next door. R1 stated the reason why is was moved is not related to the leaking issue. Interview further revealed that R1 has informed Maintenance of this issue for months but it was never resolved. R1 stated the leak has caused molding in the tub when he used to reside in the room. Based on LPAs' observation, LPAs were able to see the leak has not been fixed and observed black and brown discoloration in the tub. Based on LPAs observation of R1's current room, it revealed the bed frame to be in disrepair as the headboard was not correctly mounted to the wall, causing it to be slanted approximately eight inches away from the wall. Interview with R1 revealed it is a safety hazard as the headboard is not properly secured. Additionally, based on observation of R1's current room, LPAs observed a strong odor of urine. Observation of R1's current bathroom revealed the bathroom floor to have multiple discoloration around the toilet. Interview with R1 revealed facility did not have housekeepers for months, so caregivers were in charge of the bathroom cleaning. Interview further revealed that the last housekeeping conducted, caregiver did not properly clean the bathroom floor. Based on the allegation, facility is in disrepair and unsanitary, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted, and a copy of the report and appeal rights was provided via email as LPAs experienced technical difficulties.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20231010142402

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Oct 12, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the regulation above as LPA Yang and LPA Ratajczak observed R1's room to have a strong odor of urine, unsecured headboard and multiple discoloration on bathroom floor, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2023

Plan of correction: Housekeeper was asked to clean R1's room and bathroom immediately. Licensee will notify LPA Yang when headboard and bathroom faucet is fixed. This matter will be discussed during office meeting with Licensees.

Allegation investigated: Staff did not ensure that medications are inaccessible to residents in care.

On 10/11/2023, Licensing Program Analyst (LPA) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to open the complaint the Department received regarding the allegation cited above. LPAs met with Administrator, Lacy Berry, and explained the purpose of the visit. During the investigation, LPAs conducted an inspection of R1's room and conducted file review of R1's records. The result of the investigation is as follow. Please continue on LIC 9099-C... Substantiated Allegation: Staff did not ensure that medications are inaccessible to residents in care. The Department conducted interviews regarding the allegation. Interview conducted with Administrator revealed medications are centrally stored. Based on LPAs' observation conducted on 10/11/2023, it revealed R1 has medication in her room. LPAs observed the medication was in a lockbox located in her bathroom. Interview conducted with R1 revealed R1 has frequent nausea and keeps the medication in her room because she is unable to get staff assistance in a timely manner. LPAs observed the medication found to be Ondansetron 4mg which is often used to nausea and vomiting. Based on R1's most recent LIC 602 PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY on file, date of exam 06/22/2021, LPAs observed that R1 is unable to administer own prescription medications, R1 is unable to administer own PRN medications, and additionally, LPAs observed R1 is unable to store own medications. Based on the allegation, staff did not ensure that medications are inaccessible to residents in care, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted, and a copy of the report and appeal rights was provided via email as LPAs experienced technical difficulties.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20230829093013

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 12, 2023

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. This requirement is not met as evidenced by: Based on LPAs' observation and interview with R1, Licensee did not comply with the section above as LPA Yang and LPA Ratajczak observed R1 to have Ondansetron in her room, which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2023

Plan of correction: Medication is to be removed immediately and centrally stored. This matter will be discussed in office meeting with Licensees.

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

Allegation investigated: Staff dispensed the wrong medication to a resident while in care.

Licensing Program Analaysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced to continue the investigation for the complaint the Departmenet received on 9/5/2023. LPAs met with Administrator, Lacy Berry, and explained the purpose of the visit. During the course of this investigation, the Department conducted interviews, file reviews and a medication audit of R1. The result of the investigation is as follow. Please continue on LIC 9099-C** Substantiated Allegation: Staff dispensed the wrong medication to a resident while in care. Based on LPAs' medication audit conducted on 09/28/2023, the audit included comparing R1's Medication Administration Record (MAR) with R1's medications, medication start dates and physician’s orders. During LPAs' medication count, (1) staff med tech was present at all times. Based on the medication audit conducted, file review of R1's MAR revealed on September 4th and September 5th, PM med tech did not sign that medications were administered to residents in care. LPAs conducted a medication count with S1 of R1's Glipizide. LPAs observed R1's physician order for Glipizide is to take two tablets by mouth two times a day 30 minutes before meals. LPAs observed bottle start date to be 8/31. During medication count, LPAs and S1 observed the Glipizide bottle of 120 tablets to have 11 tablets remaining, which means 109 tablets has been dispensed. Based on the signatures and/or initials on the R1's August 2023 and September 2023, total medication signed off totaled to 108 tablets, two tablets on AM shift of August 31, 2023 and 106 tablets month of September 2023. LPAs and S1 observed one tablet to be missing from R1's medication bottle and not accounted for. Based on the allegation, staff dispensed the wrong medication to a resident while in care, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted, copy of report and appeal rights was provided to Administrator.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 59-AS-20230905164434

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 29, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced: Based on observation of medication audit, Licensee comply to the section cited above as LPAs observed R1's medication to have one tablet missing from the original bottle which was also not signed off on the MAR, which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: An office meeting will be held to discuss this matter. LPA will reach out to Administrator and Licensee representatives to schedule a meeting.