Wellquest of Menifee Lakes

Type of visit: Required - 1 Year

On 06/16/2026, Licensing Program Analyst (LPA) Imaculada Vasquez made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Executive Director, Eva Tawfik who was informed of the purpose of the visit. LPA conducted a tour the facility The facility consists of 3-story building designated for both assisted living and memory care. There is an approved fire clearance for a 140 non-ambulatory residents of which 25 may be bedridden, with there currently being zero (0) bedridden residents. In addition the facility has an approved hospice waiver for 25, with nine (9) residents currently receiving hospice services. LPA observed the following during today's inspection , LPA observed the facility to have several amenities to promote and encourage socialization such as a movie theater, beauty salon, fitness center, library and computer area, sports bar/game room, (2) wellness centers/medication rooms, wine bar and activity room, as well as dog park. The facility has a built in pool that is surrounded by a locked fence. The medications are locked in medication carts in the wellness centers. The facility is also utilizing an electronic Medication Authorization Record (MAR). The facility food supply was observed to meet the requirements of a 2-day perishables and 7-day supply of non-perishable food items. The facility has several fire extinguishers throughout the community that fully charged with the tags in tact and were last serviced on 11/13/2025. The hot water tested at 110 degrees Fahrenheit. A signal system, pull cords and wrist tempo alert were observed to be operable. The facility has a fire alarm system consisting of smoke and carbon monoxide detectors. Emergency disaster drills are being conducted on a monthly basis, the last drill was conducted on 05/28/2026 . LPA conducted a random review of resident and staff files. The staff were observed to have obtained criminal record clearance and to be associated to the facility. The staff files were observed to have the required training. Med techs are the only position required to have CPR certification. The Executive Director Eva Tawfik was observed to possess a valid administrator certificate that expires on 07/18/2028. LPA reviewed five (5) resident files and five (5) staff files which were all complete and signed. The facility was observed to have valid liability insurance that expires on 05/01/27. The governing body was observed to be active and in good standing. Based on today's inspection there were no deficiencies observed. An exit interview was conducted and a copy of this report, 809C,and glossary was reviewed and provided to Executive Director, Eva Tawfik.the state’s words, verbatim · CDSS document, Jun 16, 2026

Allegation investigated: Resident in care sustained unexplained injury due to staff neglect/lack of supervision

On 1/6/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of launching the complaint into the allegations listed above. LPA met with Executive Director Eva Tawfik and explained to Eva the purpose of the visit. The investigation consisted of records review, interviews, and observations. Information received alleged that due to lack of supervision/staff neglect, Resident #1 (R1) sustained an unexplained injury to their right arm. Interviews with Staff #1 (S1) reported that during a brief change, S1 positioned R1 to R1’s left side in attempts to remove the brief from under R1. R1 reportedly became physically aggressive and threw their right arm back multiple times, attempting to strike S1. S1 reportedly stepped back to de-escalate the situation when S1 observed R1’s skin to be raised. S1 described the skin tear to be minor with very little to no blood protruding from the skin tear. (Continue to LIC9099 Unsubstantiated (Continuation of LIC9099) Interviews with staff reported that S1 contacted Staff #2 (S2) via walkie talkie requesting a medium size bandage. Interviews with S2 and Staff #3 (S3) reported that S2 was unable to assist S1 and S3 was redirected to deliver the bandage to S1. Interview with S2 reported asking S1 of the severity of the injury and was advised by S1 that the injury was minor. Interview with S3 reported that when they delivered the bandage to S1, S3 did not assess the skin tear but noted that they did not observe R1 arm filled with blood like it was reported when Staff #4 (S4) discovered the injury. Interview with S1 reported that after they placed the bandage on R1, S1 continued changing R1’s brief, position R1 into R1’s preferred position in bed, covered R1 with a blanket, and exited the room. Interview with Staff #4 (S4) reported that during their rounds, S4 went into R1’s room to ask R1 if they were ready to go to dinner. S4 went to R1 to uncover the blanket off of R1 and observed R1 to have blood on R1’s right arm, briefs, and blanket. S4 went to Staff #5 (S5) to advise S5 of what they observed and S5 reportedly went to R1’s room to assess R1 then contacted emergency personnel. LPA attempted to interview R1 but interview was unsuccessful as R1 reports that they do not recall how they sustained the injury and suggested that they possibly hit their arm on the bedrail. A records review conducted of R1’s physician report details that R1 is combative at times, requires assistance with repositioning, incontinence care. A review of the residents care plan and assessment details that during brief changes/toileting tasks, R1 requires a two person assist. The assessment and care plan further detail that R1 has complex skin which increases the fragility of the skin. Through observations, LPA observed R1’s bedrails to be equipped with fabric covering and was advised by Staff #6 that the covers were implemented due to R1’s combative behavior as R1 sustained bruising in the past from the bedrail when exhibiting a behavioral episode. LPA further observed R1 to have gauze wrapped around their right forearm region but was unable to view the injury. Due to insufficient evidence, the allegation of resident in care sustained unexplained injury due to staff neglect/lack of supervision is deemed unsubstantiated. A finding that the complaint is deemed unsubstantiated means that although the allegations may have occurred and/or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Through interviews and records review, LPA discovered a health and safety concern. A deficiency will be issued in accordance with Title 22 regulations. A exit interview was conducted and a copy of this report was provided to Executive Director Eva Tawfik.the state’s words, verbatim · CDSS document, Jan 6, 2026 · control 18-AS-20260105145548

Type of visit: Case Management - Deficiencies

On 1/6/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of following up on complaint control number 18-AS-20260105145548. LPA met with Executive Director Eva Tawfik and explained the purpose of LPA’s visit. During the complaint visit, LPA learned through interviews and records review that Resident #1 (R1) requires a two person assist with all toileting task and transfers. Through interviews, it was reported that R1 did not receive a two person assist when receiving a brief change on 12/31/2025. It was further reported that staff have assisted R1 with transferring without additional assistance as required by the care plan and assessment. Due to facility staff not following R1’s care plan, a deficiency will be issued in accordance with Title 22 Division 6 regulations as it placed R1 at a health and safety risk. A exit interview was conducted, and a copy of this report was provided to Executive Director.the state’s words, verbatim · CDSS document, Jan 6, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87606(f)(1)(B) · Plan of correction due date: Jan 20, 2026

(f) To accept or retain a person who is bedridden, a licensee shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the licensee intends to meet the overall health, safety and care needs of residents who are bedridden. (B) The needs of residents who are terminally ill and who are bedridden shall be met. This requirement was not met with evidence by: (2) two out of (2) staff did not follow Resident #1's care plan by not performing a two persons assist with transferring and/or assisting with toileting tasks which poses a health and safety risk to R1.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: Per Executive Director, facility staff in the memory care unit will receive an in-service training on two-person assist and staff will also be reminded on which residents require the two-person assist. Proof of in-service training will be submitted to LPA by Close of Business on 1/20/26 which includes a brief explanation of was covered in the training along with the names of all caregiving staff name in attendance and their signatures.

Allegation investigated: Staff did not dispense medication as prescribed

On 10/7/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering investigative findings into the allegation listed above. LPA Flores met with Administrator, Jonetta Eads, and explain to Jonetta the purpose of the visit. The investigation consisted of interviews and records review. Information received alleged Staff #1 (S1) did not dispense Resident #1’s (R1) medication as prescribed. Interviews conducted with R1 and staff corroborated that at approximately 8AM on 08/04/2025, S1 arrived to R1’s room to assist with administering R1’s prescribed medication. Staff and R1 reported that all medications are dispensed into a small clear cup with the residents room number on the lid. Interview with S1 reported that all residents medications are dispensed in a clear cup prior to being passed out to all residents. S1 further reported that this tasks takes approximately 1 hour to complete and does not include the time the it takes when staff are conducting their medication rounds throughout the facility. (Continue to LIC9099C...) Substantiated (Continuation from LIC9099) S1 reported that S1 did not confirm if the clear cup matched R1’s room number and proceeded to give R1 the medication. S1 watched R1 swallowed the medication and walked out the residents room. According to S1, S1 did not notice the error until arriving to Resident #2’s (R2) unit and could not find R2’s medication. S1 called Staff #2 (S2) and informed S2 of the error. S1 was instructed to wait for S2’s guidance. Interview conducted with staff and R1 confirmed R1 was informed approximately 2 hours after the medication error. R1’s primary physician and responsible party were notified of the error. Interview with staff reported that R1’s Primary Care Physician instructed staff to monitor R1 for any side-effects. Interviews with staff and R1 confirmed R1 did not receive R1’s normal AM dosage of medication after the medication error as instructed by the Primary Care Physician. Interviews conducted with R1 and staff detailed that R1 was placed on alert charting where R1’s vitals were taken every hour. Records review conducted of the facility’s incident report confirmed the details of the incident. A records review conducted for R1’s physician report confirmed R1 requires assistance with medication management (i.e. assistance with administering medication, PRN medication, and storing medication). A records review conducted of R1’s Electronic Medication Administration Record (EMAR) confirmed that R1 did not receive their morning dosage of medication as instructed by the Primary Care Physician. Based on interviews and records review, this allegation is deemed Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Pursuant to the California Code of Regulations, Title 22, Division 6, Health and Safety Code, a deficiency is cited on the attached LIC 9099-D. An exit interview was conducted where a copy of this report was provided and discussed, along with a copy of LIC9099-D, and Appeal Rights were provided to Administrator, Jonetta Eads.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 18-AS-20250813103203

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 22, 2025

87465 Incidental Medical and Dental Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility…(4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interview and record review, medication was not administered as prescribed by physician for (1) one out of (1) one as Resident 1 receive the wrong medication which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Administrator Jonetta Eads agreed to conduct an in-service training with all med-tech staff. The facility has now updated the labels on the medication dispensing cup to reflect name and room number of the receiving resident.

Allegation investigated: Staff did not re-order resident's medication timely

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegations. LPA met with Janice Dayag and explained the reason for the visit. The investigation consisted of the following: On 5/3/22 LPA Delgado conducted an initial complaint investigation visit and requested pertaining documents. On 9/17/25 LPA Flores contacted administrator via email and requested a copy of staff/resident roster. On 9/18/25 LPA interviewed 6 staff over the phone. On 9/22/25 LPA conducted a subsequent visit and interviewed 6 residents, and reviewed medication for 10 residents. On 9/23/25 LPA conducted a subsequent complaint investigation visit interviewed 4 residents and delivered findings for the complaint. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Staff did not re-order resident’s medication timely. It is alleged Resident #1(R1) was not provided with medication when needed because it was not available at the facility. Interviews conducted revealed 4 out of 10 residents stated medication is provided as prescribed and as needed medication when needed. 2 out of 10 residents are not assisted with medication, however facility staff have assisted with obtaining their medication. 2 out of 10 residents stated that medication was not provided when needed as it was not available at the facility on one occasion. 2 out of 10 residents were unable to be interviewed due to cognitive skills. Interview with staff revealed facility ensures to have a 30 supply of medication for residents in care for all routine and as needed medications. Administrator stated that R1’s lorazepam was not available on the morning of 4/24/22 and the resident was sent to the hospital to obtain the medication as a refill had not come in. Per documents reviewed R1 had a prescription order for Lorazepam. Per pharmacy’s email dated: 4/26/22, an initial request from the facility for the medication was submitted on 4/15/22 to refill the lorazepam. The pharmacy followed up on the request with the facility and physician and the medication was refilled on 4/25/22. LPA was unable to review medication sheets for April 2022 as the facility uses QuickMar system, which did not allow them to go that far to obtain the records. On 9/22/25 LPA Flores conducted a medication review and observed R1 has an order for lorazepam .5mg as needed and observed the medication available. LPA observed resident #2(R2) did not have routine Aspirin 81mg available, resident #3(R3) did not have as needed medication Clonidine HCL .1mg, and resident #4(R4) did not have hyoscyamine .125mg and senna 8.6 mg. LPA contacted hospice agency who stated facility is to contact hospice to reorder medication for R4. Although, facility attempted to obtain the lorazepam days before it run out and there is not enough evidence to say that the facility is at fault for the medication not being available when R1 needed. During the visit of 9/22/25 LPA observed routine and as needed medication was not available for R2,R3, and R4. Therefore the allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Insufficient staffing. It is alleged emergency responding agency was not able to enter the facility at night as there was no staff in the front desk. Interviews with residents revealed 8 out of 10 residents stated there is night staff available. 2 out of 10 residents were not able to answer due to cognitive skills. Interviews with staff revealed there is 2 caregivers and 2 medication technicians during the night shift. Documents reviewed revealed Staff Calendar for April 2022 notes there was a floor manager and 2 caregivers on the night of 4/23/25 scheduled to work from 10:00pm to 6:00am. Staff roster reviewed on 9/22/25 notes there are a total of 4 staff scheduled to work the night shift from 10:00pm to 6:00am. Per administrator, the Executive Director, Health and Wellness Director, Journey Director, and Maintenance Director Sales Director, and Business Office Director area available over the phone during the night. Based on documents reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 18-AS-20220425110805

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(6) · Plan of correction due date: Sep 24, 2025

87464 Basic Services: (f) Basic services shall at a minimum include:v(6) Arrangements to meet health needs, including arranging transportation... This requirement is not met as evidence by: Based on medication review the licensee did not ensure that R2, R3, and R4 had their routine or as needed medication available at the facility which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Administrator will provide in-service training to Med-techs on medication needs, availability, and audting the medicaiton timely and will providing a copy of training with topic, date, time, and signature by POC due date 9/24/25.

Type of visit: Required - 1 Year

On 05/19/2025, Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Administrator, Jonetta Eads who was informed of the purpose of the visit. LPA conducted a tour the facility The facility consists of 3-story building designated for both assisted living and memory care. There is an approved fire clearance for a 140 non-ambulatory residents of which 25 may be bedridden, with there currently being (1) bedridden resident. In addition the facility has an approved hospice waiver for 25, with (12) residents currently receiving hospice services. LPA observed the following during today's inspection , LPA observed the facility to have several amenities to promote and encourage socialization such as a movie theater, beauty salon, fitness center, library and computer area, sports bar/game room, (2) wellness centers/medication rooms, wine bar and activity room, as well as dog park. The facility has a built in pool that is surrounded by a locked fence. The medications are locked in medication carts in the wellness centers. The facility is also utilizing an electronic Medication Authorization Record (MAR). The facility food supply was observed to meet the requirements of a 2-day perishables and 7-day supply of non-perishable food items. The facility has several fire extinguishers throughout the community that fully charged with the tags in tact and were last serviced on 11/29/24. The hot water and signal system (pull cords) were tested in random resident apartments. The pull cords were observed to be operable and the water temperatures to be within regulatory limits ranging from 108.6-113.5 degrees Fahrenheit. The facility has a fire alarm system consisting of smoke and carbon monoxide detectors. Emergency disaster drills are being conducted on a monthly basis, the last drill was conducted on 04/30/25. LPA conducted a random review of resident and staff files. The staff were observed to have obtained criminal record clearance and to be associated to the facility. The staff files were observed to have the required training. Med techs are the only position required to have CPR certification. The Executive Director Jonetta Eads was observed to possess a valid administrator certificate that expires on 08/16/26. LPA observed for the resident files reviewed had updated physician's reports, with one pending as well as signed admission agreements. The facility was observed to have valid liability insurance that expires on 05/01/26, and for the annual licensing fees that were due on or before 06/30/25 to have been paid. The governing body was observed to be active and in good standing. Based on today's inspection there were no deficiencies observed. An exit interview was conducted and a copy of this report, 809C, glossary, and LIC911-Confidential names list was reviewed and provided to Administrator Jonetta Eads.the state’s words, verbatim · CDSS document, May 19, 2025

Allegation investigated: Facility staff mismanaged resident's medication

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility to deliver findings for the above allegation. LPA met with Exectuive Director, Jonetta Eads, who was informed of the purpose of the visit. The investigation consisted of LPA conducted interviews and records review. It was alleged “Facility staff mismanaged resident's medication.” Three concerns were presented regarding this allegation for Resident #1 (R1). Interview with R1 was unable to be conducted as R1 has since passed away. It was alleged Medication #1 (M1) was not discontinued in July of 2022 despite R1’s physician’s orders to discontinue M1. Substantiated LPA reviewed Medication Administration Record (MAR) from August 2022 which revealed M1 was last given and discontinued on 8/4/2022. A discontinue order for M1 was dated 8/4/2022 from R1’s physician. LPA conducted interviews with (5) staff who cared and administered medications to R1. (5) of the (5) staff interviewed revealed they could not recall if R1 was given medication past the discontinued date. Therefore, M1 was discontinued according to the physician’s orders. It was also alleged Medication #2 (M2) was not given to R1 for (4) days in August of 2022, as the medication was not refilled in time. MAR for August 2022 revealed M2 was administered and initial by staff every day. However, the Alert Charting Notes documented on 09/04/2022 revealed R1 had ran out of M2, on 09/07/2022 staff called R1’s pharmacy to order an emergency supply of M2, and on 09/08/2022 M2 was still not received by the facility. LPA reviewed the facility’s program plan on medication refills. Page 86 revealed staff would contact the dispensing pharmacy to obtain a refill at least (7) days prior to running out of a medication. LPA conducted interviews with (5) staff who cared for and administered medications to R1. (5) of the (5) staff interviewed revealed they could not recall if R1 ever ran out of medications. Staff revealed it is the facility’s procedure to contact the resident’s pharmacy ahead of time before medications run out. Therefore, the facility did not contact R1’s pharmacy in time to refill their medication. It was further alleged that R1 was being administered medications in incorrect intervals as Medication #3 (M3) was ordered to be taken 12 hours apart and was being given (8) hours apart. LPA reviewed the MAR sheet for R1 which revealed M3 was prescribed twice daily every 12 hours. MAR for August 2022 and September 2022 revealed M3 was being given (9) hours apart with initials at 8am and at 5pm. LPA conducted interviews with (5) staff who cared for and administered medication to R1. (5) of the (5) staff interviewed revealed they could not recall any medication errors for R1, or medications given at incorrect intervals. Therefore, based on LPA’s interviews and records reviewed, the allegation that staff mismanaged the resident’s medications is substantiated based on preponderance of evidence for medications being given at incorrect intervals, and medications not being given due to medication running out for R1. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. Alter Charting Notes revealed R1 was quarantined for (10) days from 07/05/2022 to 07/15/2022. Alter Charting Notes from documented R1 was checked on for vitals, was checked on at morning and evening medication passes, and their food was delivered to them in their room. LPA conducted interviews with (7) staff who care for R1. (4) of (7) staff revealed R1 was being brought their meals into their room. Therefore, the allegation that R1 was not being assisted with their meals and inadequately fed is unsubstantiated. It was alleged “Resident sustained multiple falls due to inadequate care”. It was alleged R1 sustained multiple falls occurring July of 2022 and the facility mitigated R1’s fall risk by transferring R1 to the memory care unit August of 2022. However, it was alleged R1 did not have a medical diagnosis or change in condition to warrant moving to memory care and that R1 continued to sustain falls days after this transition. Interview with R1 was unable to be conducted as R1 has since passed away. LPA conducted interviews with (7) staff who provided care for R1. (6) of (7) staff revealed R1 sustained falls while at the facility and R1 was a fall risk. (7) of (7) staff revealed the facility mitigated R1’s falls by providing R1 with a “Tempo” watch they could use as a pendant to summon staff, and to detect movement if R1 had a fall. R1 was on checks at least every (2) hours, during medication passes, and at mealtimes. R1 was also provided with escorts when ambulating. Regarding the allegation that the facility placed R1 in memory care to mitigate R1’s fall risk, (4) of (7) staff revealed R1’s confusion and decline in condition contributed to their fall risk and R1 being placed in memory care. (4) of (7) staff revealed R1 had a qualifying memory condition and denied they were solely placed due to their falls. Review of R1’s Physician’s report dated 06/09/2022 revealed R1 had a memory condition. The facility’s program plan was reviewed for fall risk mitigation which revealed on Page 111; when a resident experiences a fall staff will follow up with service plan updates. Records review of “Internal Incident Reports” for R1 revealed they sustained (3) unwitnessed falls in July of 2022 when R1 was isolating in their room due to a medical condition. The Alert Charting Notes for R1 revealed checks conducted by staff, and documented R1 experiencing increased confusion starting 7/7/2022. The Service plan for R1 was updated 7/7/2022 citing reason for assessment as “change in condition”. The admission agreement revealed R1 was admitted to the memory care unit on 08/28/2022. Alert Charting notes for R1 revealed (2) unwitnessed falls after R1 was admitted to memory care, with a fall documented on 09/06/2022. An Appraisal of Needs was conducted for R1 on 09/07/2022 which revealed R1 had decreased mobility and was frequently disoriented requiring repeated verbal prompts and directions. R1 required a (1) person escort and extensive assistance with transfers. Therefore, the interviews and records review show the facility conducted checks, and reassessed R1 after falls to meet R1’s care needs as outlined in their program plan. It was also alleged the facility gave a 24 hour ultimatum for R1 to get 24/7 care due to their falls. LPA conducted interviews with (2) administrative staff. (2) of (2) staff revealed after (3) falls, the facility suggested a 1:1 service for R1 for the first 24 hours to monitor for any subsequent falls. Staff revealed options were provided for the 1:1 for care staff, family members, or an outside agency to provide the service. Staff denied they obligated R1 to obtain any service and suggested the services due to R1’s fall risk and care needs. Therefore, the allegation that R1 sustained multiple falls due to staff neglect is unsubstantiated. It was alleged “Facility staff did not keep the facility clean and sanitary”. It was alleged that R1’s room was observed with dried feces on the floor next to R1’s bed, on R1’s bathroom wall, shower, and shower curtain. It was alleged staff had called housekeeping to clean the room but the next day R1’s room was observed in the same state. Interview with R1 was unable to be conducted as R1 has since passed away. LPA received photos of brown stains on the floor of a shower, on the base of a shower curtain and tile in the shower. The photos did not provide dates, times, and could not be matched to R1’s room. LPA conducted interviews with (7) staff who cared for R1 who revealed they could not recall a time where R1’s room was left with dried feces and not cleaned for more than (1) day. Therefore, the allegation that the staff did not keep R1’s room clean and sanitary is unsubstantiated at this time. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 28, 2025 · control 18-AS-20221101152039

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

Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interview and record review, R1’s medication was not administered due to the facility not refilling the medication in a timely manner and being provided at the incorrect intervals. This posed a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2025

Plan of correction: The administrator agreed to conduct addtional training in medication orders and aaprobving medciation for nursing staff. Additional training about follow up on refills (7) days prior to run out of medication. The training signin sheet for staff will be due on the POC due date.

Type of visit: Required - 1 Year

On 6/10/2024, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator, Jonetta Eads who was informed of the purpose of the visit. LPA toured the facility and conducted staff and resident interviews, and reviewed records. The facility is made up of a 3-story building designated for assisted living and memory care, and has a fire clearance for a 140 non-ambulatory residents of which 25 may be bedridden. The facility has an approved hospice waiver for 25 and LPA was informed there are 12 residents currently receiving hospice services at the facility. During the tour, LPA observed the facility has large dining rooms, a large kitchen, and various activity rooms for resident leisure. There is an outdoor in-ground gated pool secured with a lock. Outside shaded seating areas are available for the residents. Indoor and outdoor passageways are free of obstruction. LPA observed fire alarm systems, carbon monoxide detectors, and charged fire extinguishers throughout the building. LPA toured the kitchen and observed food was stored in a safe and healthful manner. The facility met Departmental requirements for 2-day perishables and 7-day non-perishable food items. Resident interviews revealed kitchen staff accommodate residents’ dietary needs and the facility offers different outings each week. Medications are secured in medication carts inside medication rooms, only accessible to authorized personnel such as wellness nurses and medication technicians. LPA reviewed random resident and staff files. Resident files reviewed had updated physician's reports and signed admission agreements. Staff files reviewed had a criminal record clearance and a valid first aid/CPR certification. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Eads.the state’s words, verbatim · CDSS document, Jun 10, 2024

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Janira Arreola conducted announced visit to the facility in order to conduct a case management, due to increase in capacity. LPA met with Administrator, Jonetta Eads, who was informed of the purpose of the visit. The licensee is seeking to increase their capacity from 140 to 151 residents. The facility is a (3) story building/home with 140 bedrooms, and 124 bathroom. A Fire Clearance was approved on 08/08/2023 for 11 ambulatory, 140 non- ambulatory, 25 of which may be bedridden. LPA reviewed the updated floor plan and conducted a tour of the facility. Facility sketch shows sufficient square footage in the facility and activity rooms to accommodate the requested capacity. LPA physically rooms: 228, 237, 205, 247, 262, 236, 328, 230, 231, 325, and 181. LIC500 Staff Roster was verified for sufficient staffing coverage, and LIC610E Emergency and Disaster Plan was reviewed. No health and safety issues were observed during the time of the visit. The physical plant is ready for increase in capacity. The final approval of capacity increase is contingent upon manager's final review. Licensee will be notified by LPA once capacity increase has been approved by licensing. An exit interview was conducted where this report was reviewed and provided to, Administrator, Jonetta Eads.the state’s words, verbatim · CDSS document, Apr 5, 2024