Westmont of Brentwood

Allegation investigated: Licensee did not ensure staff provided adequate meals to residents

On 02/25/2026 at 09:48AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to investigate and deliver complaint findings for the allegations above in regard to the allegation above. LPA met with Executive Director, Scott Shahade, and explained the purpose of visit. During the course of the investigation, LPA interviewed witness, staff and residents. LPA reviewed and obtain the following documents,: Resident roster, resident’s dining comment cards and facility’s breakfast, lunch and dinner menus for the month of December 2025. Continue on LIC9099C.... Unsubstantiated Continued from LIC9099 Allegation: Licensee did not ensure staff provided adequate meals to residents Based on interviews with S2, R1, R3, R4, it was revealed food is not served cold. Interviews also revealed, food has not been served undercooked. Record review revealed residents were given comment cards for a month of December 2025 for the chef regarding food and food services. The comment cards received back from residents have more positive than negative comments. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 15-AS-20251216091603

Type of visit: Required - 1 Year

On 01/15/2026 at 09:36AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to continue the 1-Year Annual Required inspection visit. LPA met with Executive Director (ED), Scott Shahade, and explained the purpose of the visit. The facility’s fire clearance was approved for 190 non-ambulatory and 10 bedridden residents. Facility has hospice waiver for 20 residents. LPA toured the facility with Administrator including but not limited to apartments, bathrooms, kitchen, common area and outside. LPA toured apartments #2, #9, #24, #137, #238, and #241. All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the resident’s shared bathroom was measured at 119.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Facility has food deliveries weekly on Tuesdays and Fridays. Continue on LIC809C….. Continued from LIC809 Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/13/2025. Emergency disaster plan last updated 01/06/2026. First aid kit was observed to be complete. Fire drill was last conducted on 12/31/2025. LPA reviewed ten (10) staff records, ten (10) resident’s record and they were complete. LPA requested the following documents to be submitted to CCLD by 01/22/2026. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance No deficiencies cited during visit. Exit interview conducted. A copy of the appeal rights and the report provided.the state’s words, verbatim · CDSS document, Jan 15, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, (LPA) T. Syess-Gibson, arrived on October 23, 2025, for an unannounced case management visit to follow up on a substantiated allegation complaint investigation. LPA met with Executive Director, Scott Shahade, and explained the purpose of the visit. On February 19, 2025, the Department concluded a complaint investigation regarding the following allegation “staff pushed resident resulting to resident sustaining injuries.” The Licensee was cited for California Code of Regulations (CCR), Title 22 § 87468.1(a)(3) Personal Rights of Residents in All Facilities. At the time of the complaint visit on February 19, 2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by facility staff (S1) pushing a resident (R1) and causing R1 to fall. R1 suffered a closed compression fracture of the L-4 vertebrae and forehead contusion. Continue on LIC809C Continued from LIC809 Today, October 23, 2025, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on February 19, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal Rights provided to Scott Shahade and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Oct 23, 2025

Type of visit: Case Management - Other

On 10/21/2025, Licensing Program Analysts (LPAs), T. Syess-Gibson and L. Hall arrived unannounced to conduct a case management visit. LPAs met with Scott Shahade, Executive Director and advised of purpose visit. LPAs visit was regarding a previous visit dated February 19, 2025. During visit LPAs were informed CCLD have to correct documents before delivery. LPAs will return at a later date. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 21, 2025

Allegation investigated: Staff hit resident

On 09/18/2025 at 9:50AM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegation above. LPA met with Scott Shahade, Executive Director, and explained the reason for the visit. During the course of the investigation, LPA interviewed five (5) staff members and attempted to interview residents (R1). LPA obtained and reviewed the following documents: Resident’s (R1’s) admission agreement, physician’s report, service plan, emergency information and incident reports from July 2025- September 10, 2025. Continued on LIC9099C Substantiated Continued from LIC9099 Staff roster with contact information, staff schedule, staff S2, S3 and S4’s written statements of incident that occurred on 09/05/2025. S1’s resignation letter and training records. Allegation: Staff hit resident documentation and Interviews with staff members revealed that S2, S3 and S4 witnessed S1 slapping resident. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. Exit interview conducted. A copy of this report and appeal rights provided. Continued from LIC9099 Allegation: Staff did not provide resident's authorized representative with an explanation of incidents Interviews with ED, and RP, revealed facility did call RP on 09/08/2025 to explain the incident of staff slapping resident. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 15-AS-20250909163308

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 19, 2025

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by staff(S1) slapping resident which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: Executive Director has agreed to retrain all staff on personal rights and submit staff sign-in sheet and training materials to CCLD by POC date. *statf(S1) resigned on 09/08/2025*

Allegation investigated: Staff did not provide adequate supervision resulting in resident wandering away from facility.

On 09/10/2025 at 2:55PM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegation above. LPA met with Scott Shahade, Executive Director, and explained the reason for the visit. During visit, LPA interviewed five (5) staff members, and witness. LPA obtained and reviewed documents including Staff roster with contact information, staff schedule (memory care) for the month of May 2025, elopement policy & procedure, elopement protocol, resident (R1) admission agreement, physician's report, needs & service plan, emergency information, care notes, and incident reports. Continue on LIC9099C .... Substantiated Continued from LIC9099 Interviews with staff revealed that R1 was last seen by staff at approximately 8:20PM, minutes later, the facility realized R1 AWOL, and was found hours later around the corner of the facility at John Muir Center. Facility's alarm system did not sound throughout memory care building. Based on LPA’s information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 15-AS-20250530085756

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

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs...by staff that are sufficient in numbers... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by having resident leave the facility unassisted which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2025

Plan of correction: Facility has agreed to create a written plan to address future wandering behaviors and submit the written plan to CCLD by POC date.

Type of visit: Case Management - Incident

On 09/10/2025 at 9:30AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a case management visit in regard to an incident report received. LPA met with Jennifer Lawson, Business Office Director, and explained the purpose of the visit. Based on the incident report dated 09/08/2025, staff were assisting resident (R1) for bed, R1 started to get combative with staff members, staff member slapped R1. During case management visit, LPA received a complaint 15-AS-20250909163308 with same allegation. No deficiencies are being cited on this date during today’s visit. Exit interview conducted with Scott Shahade. A copy of this report providedthe state’s words, verbatim · CDSS document, Sep 10, 2025

Allegation investigated: Facility staff do not ensure that resident's room is clean and sanitized. Facility staff did not ensure that resident had clean linens.

On 06/16/2025 at 2:30PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to deliver findings for the above allegations. LPA met with Scott Shahade, Executive Director and explained the purpose of the visit. During the course of the investigation, LPA T. Syess-Gibson and L. Hall interviewed staff, LPAs were unable to interview resident (R1) due to diagnosis. Admission agreement, housekeeping cleaning checklist, august health report (care report) for R1, R2, and R3 and staff scheduled (memory care)for the month of March 2025 were reviewed and obtained. Continue on LIC9099C Unsubstantiated Continued from LIC9099 Facility staff do not ensure that resident's room is clean and sanitized. During the investigation LPAs interviewed staff and reviewed cleaning logs. During interviews with S1, S2 and S3 it was revealed that all residents’ rooms are scheduled to be cleaned weekly, if a resident needs cleaning in between their scheduled cleaning day, staff or memory care director will clean the residents’ room. During recorded review it was revealed which parts of the room was attended to during scheduled cleaning day. Facility staff did not ensure that resident had clean linens. During the investigation LPAs interviewed staff, and it was revealed that all residents have a schedule laundry day, if a resident has an accident in their bed and needs new linen it is changed immediately and washed. LPAs reviewed cleaning checklist with date and description of what was cleaned in residents’ rooms. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 15-AS-20250307133031

Allegation investigated: Illegal eviction Facility staff did not ensure resident took medications as prescribed Facility staff did not ensure resident's call pendant was working Facility staff did not ensure resident's bedroom light was working Facility staff did not ensure resident's bathroom had toilet paper Facility staff did not safeguard resident's belongings Facility staff did not prevent residents from engaging in inappropriate behaviors towards each other

On 06/16/2025 at 12:30PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to deliver findings for the above allegations. LPA met with Scott Shahade, Executive Director and explained the purpose of the visit. During the course of the investigation, LPA T. Syess-Gibson interviewed staff, LPA was unable to interview resident (R1) due to diagnosis on physician report (LIC602). LPA attempted to interview complainant but was unsuccessful. R1’s admission agreement, physician’s report, and incident reports dated November 11, 2024, and January 19, 2025 were reviewed and obtained. Continue on LIC9099C Unsubstantiated Continued from LIC9099 staff roster with contact telephone numbers, resident’s roster with apartment numbers, device activity report (call button), maintenance log (work orders), housekeeping cleaning checklist were obtained and reviewed. Illegal eviction During the investigation, LPA reviewed an eviction notice issued by the licensee on 03/18/2025. After reviewing eviction notice, the 30-day notice does meet requirements in regulation 87224. Facility staff did not ensure resident took medications as prescribed During investigation, LPA reviewed Medication Administration Record (MAR) and observed R1’s medication was administered as prescribed. Facility staff did not ensure resident's call pendant was working During investigation, LPA reviewed work orders and toured R1 room and observed call button on the wall near bed and in the restroom was in operating condition. LPA also reviewed the work order report and did not see any reported issues with the call button for room #2. Facility staff did not ensure resident's bedroom light was working During interviews, it was revealed the facility changed the light bulb at the entrance of residents’ room the same day the light bulb went out. Continue on LIC9099C Continued from LIC9099C Facility staff did not ensure resident's bathroom had toilet paper During interviews and document review, it was revealed that housekeeping clean residents’ room weekly, replaces toilet tissue during the time of cleaning, if a resident needs toilet tissue in between the cleaning schedule it is replaced or if housekeeping sees toilet tissue running it will be replaced with a new roll. Facility staff did not safeguard resident's belongings During interviews, it was stated that R1 walks around with his box and leaves the box in random places such as dining room, activity room and television room in memory care. It was also stated that staff has found the box many times and returned it to the resident. Facility staff did not prevent residents from engaging in inappropriate behaviors towards each other During the investigation and review of documents, staff did take the proper steps in separating both residents during the time of the altercation and monitoring both residents after inappropriate behavior acts. The facility notified CCL , resident’s responsible person and has reached out to R1’s physician for a possible medication adjustment for new aggressive behaviors. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 15-AS-20250219100005

Allegation investigated: Staff did not obtain doctor's order for medication. Staff is not administering medication to a resident. Resident lost weight.

On 06/16/2025 at 1:30PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to deliver findings for the above allegations. LPA met with Scott Shahade, Executive Director and explained the purpose of the visit. During the course of the investigation, LPAs T. Syess-Gibson and L. Hall interviewed staff, LPAs was unable to interview resident (R1) due to diagnosis on physician report (LIC602). Admission agreement, physician's report, medication list, service plan, staff schedule, staff roster with contact numbers, weight log for R1, R2 and R3, R1’s Electronic Medication Administration Record (E-MAR) and august health report were reviewed and obtained. Continue on LIC9099C Unsubstantiated Continued from LIC9099 Staff did not obtain doctor's order for medication. During investigation LPAs interviews with staff, and reviewed records, during interviews it was revealed that there was a period of time when the facility waiting for the resident’s doctor to authorize the medication. During record review it was revealed one of R1’s medication wasn’t listed on LIC602 (physician report) dated in December 2024, however, was listed on the new LIC602. LPAs also reviewed documentation of communication between the facility and R1’s physician regarding orders of medication. Staff is not administering medication to a resident. During investigation LPAs interviews with staff and it was revealed R1 missed some days of taking the medication because the facility was waiting for authorization from R1’s physician to administer the medication. The facility had two physician’s report, one with the medication listed and the other without medication listed. Resident lost weight. During investigation LPAs reviewed R1’s Physicians Report (LIC602) and it was revealed during record review the medication R1 was prescribed causes weight loss and R1 was on a restricted diet per doctor orders. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 15-AS-20250307165508

Type of visit: Case Management - Incident

On 06/16/2025 at 10:07AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a case management visit in regard to an incident report received. LPA met with Executive Director (ED), Scott Shahade and explained the purpose of the visit. Based on the incident report dated 06/03/2025, resident (R1) informed staff (S1) of accidentally ingesting liquid laundry soap. R1 reported that R1 mistakenly ingested liquid laundry soap that was transferred to a plastic water bottle to make it easier to use when doing R1's laundry. S2 called R1's responsible person and 911 so R1 could be evaluated by medical professionals. During visit, LPA interviewed staff and reviewed R1's file including physician's report, and incident report. R1's physician's report stated that R1 isn’t confused or disoriented. No deficiencies are being cited on this date. LPA may return on a later date. Exit interview conducted with Scott Shahade. A copy of this report providedthe state’s words, verbatim · CDSS document, Jun 16, 2025

Allegation investigated: Staff did not provide assistance to a resident in a timely manner. Insufficient staffing

On 3/18/2025 at 10:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Executive Director (ED), Scott Shahade and informed him reason for the visit. ED was unable to sign the report and authorized Resident Service Director, Mercedes Villarreal to sign the reports. During the course of investigation, LPA interviewed 6 residents, 7 staff, witness, and complainant. LPA reviewed and obtained documents (staff roster with contact information, staff schedule, call button records, physician's report, emergency information, care notes, and care plan). Staff did not provide assistance to a resident in a timely manner. After reviewing R1's call button records, it was identified there were multiple incidents where R1 waited over 30 minutes for staff to respond to the call in March of 2024. Interview with witness revealed that R1 waited over 30 minutes for assistance. Interview with R2 indicated that night shift response time can take 30-60 minutes. (Continue on LIC9099C...) Substantiated Insufficient staffing Interview with staff indicated that R1 needed 2-person assist and R1 would need to wait a long time for the second staff during showers, transfers, toileting, and other ADL (Activities of Daily Living) needs. Staff stated there was an incident where R1 and S8 waited over 40 minutes for the second staff to respond to call button for assisting R1's ADL care. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. Exit interview conducted with Mercedes Villarreal. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 18, 2025 · control 15-AS-20240326163152

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 7, 2025

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not responding to call button in a timely manner which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: Facility has agreed to create a plan to address staffing needs/call button response and will provide a copy of the plan to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 7, 2025

Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers...to meet resident needs... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not having sufficient staffing which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: Facility has agreed to create a plan to address staffing needs/call button response and will provide a copy of the plan to CCLD by POC date.

Allegation investigated: Staff do not ensure reporting requirements are followed.

On this day, 2/27/25, at 11:45 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an investigation of the above allegation. LPA met with Business Office Director Jennifer Lawson, and informed the purpose of visit. Executive Director (ED) Scott Shahade arrived at around 12:00 noon. Allegation: Staff do not ensure reporting requirements are followed. Reporting party (RP) stated that the facility failed to report elder abuse timely to various agencies. Ombudsman was not given SOC341 elder abuse reports within the last several months relating to resident, R1. RP also stated that the facility did not report the other abuse to local law enforcement relating to another resident (R2). ....continued on 9099C (page 2) Substantiated Page 2 During the course of investigation, LPA obtained copy of resident roster and conducted interviews. LPA also reviewed the Unusual Incident Report (UIRs) and SOC341s submitted by the facility to Community Care Licensing (CCL) for R1 and R2 which showed the abuse were reported to CCL past the required timeline of 48 hours and not reported to the Ombudsman and local law enforcement. These were discussed with the ED. ED stated the other alleged abuse incident relating to resident (R3) was reported to CCL on which a copy of SOC341 was provided by ED on this same day, 2/27/25. LPA and ED spoke to staff (S1) who stated she did not submit the LIC624 for R3 to CCL. LPA interviewed the Ombudsman (OMD) on 2/21/25. OMD stated not receiving copies of SOC341s for R1 and R2. Based on interviews and review of documents, the preponderance of evidence has been met, therefore, the allegation of staff do not ensure reporting requirements are followed is substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 15-AS-20250221145851

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Mar 13, 2025

87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24)hours as required by Welfare and Institutions Code Section 15630(b)(1)....a written report shall be sent...within two working days. -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above in not submitting the written report to the agencies within the time frame.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: Executive Director agreed to do the following and submit proof by 3/13/25: 1. Complete the LIC624. 2. Submit the SOC341s to the local law enforcement and ombudsman. 3. In-service the staff and ensure reporting requirements are followed.

Allegation investigated: Staff pushed resident resulting to resident sustaining injuries

On 02/19/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with Executive Director/administrator (ED/ADM) to deliver the finding of above allegation. LPA explained the purpose of the visit with ED. During investigation, the department obtained the following documents from administrator – Personnel record, Residents roster, R1’s admission agreement, physician's report, Needs/Services plan, Hospice care plan, incident report, hospital discharge report. Health & safety check conducted see LIC 809 dated 02/22/24. Continued on next page, LIC 9099-C Substantiated Allegation: Staff pushed resident resulting in resident sustaining injuries. Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff (ED, S1, S2, S3, S4), residents (R1, R2, R3, R4), R1’s responsible party (POA), third party witnesses (W1, W2) and reviewed resident (R1) documents. Review of R1’s records showed she was first admitted at the facility on 03/03/22 and resided in the memory care unit due to dementia. On 02/16/24 around 0600 hours, R1 exhibited exit-seeking behaviors by attempting to leave the facility through one of the back doors of the memory care unit. S1 attempted to stop R1 from leaving which started an argument. R1 acted aggressively against S1 by yelling racial slurs and by pushing/shoving her walker into S1. S1 reacted by pushing R1’s walker back into the resident causing her to fall resulting in R1 sustaining a close compression fracture of the L-4 vertebra and forehead contusion. Another staff (S2) stated she witnessed the entire incident. S2 stated that S1 pushed R1 in an aggressive manner, that it was not an accident. Other staff (S3, S4) stated that when they arrived at the incident, S1 told them that R1 pushed her walker at her so she pushed R1’s walker back at her. S1 admitted she pushed R1 but did not intend for her to fall. In addition, S2 stated S1 used both hands aimed at R1’s collar bone to aggressively push R1 down. Afterwards, S1 gathered her belongings and left the building without helping R1. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff pushed resident resulting in resident sustaining injuries was found to be substantiated. Immediate civil penalty of $500 assessed during visit for staff physical abuse of resident while in care. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 15-AS-20240216154646

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Feb 19, 2025

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by staff physically abusing a resident which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Immediate civil penalty of $500 assessed during visit due to resident injuries sustained from abusive staff. Incident was investigated internally and S1 terminated on 02/20/24. Also, Memory Care Director was also terminated on 04/26/24. Deficiency corrected during visit. In-service staff retrainings on how to properly redirect dementia residents with behaviors completed on 02/21/24. ED gave LPA copy of completed staff re-trainings.

Type of visit: Required - 1 Year

On 02/025/2025 at 1:00PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and C. Fowler, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPAs met with Executive Director (ED), Scott Shahade, and explained the purpose of the visit. The facility’s fire clearance was approved for 190 non-ambulatory and 10 bedridden residents. Facility has hospice waiver for 20 residents. LPAs toured the facility with Administrator including but not limited to apartments, bathrooms, kitchen, common area and outside. LPAs toured apartments #002, #015, #113, #117 and #145. All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/24/2024. Emergency disaster plan last updated 02/01/2024. First aid kit was observed to be complete. Fire drill was last conducted on 01/15/2025. Continued LIC809C. Continued from LIC809. LPAs reviewed five (5) staff records, five (5) resident record and they were complete. LPA requested the following documents to be submitted to CCLD by 02/12/2025. · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan · Liability Insurance No deficiencies cited during visit. Exit interview conducted. A copy the appeal rights and the report provided.the state’s words, verbatim · CDSS document, Feb 5, 2025

Allegation investigated: Staff did not ensure facility was free from pests

On 01/07/2025 at 11:10AM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegation above. LPA met with Scott Shahade, Executive Director and explained the reason for the visit. During the course of investigation, LPA interviewed the ED, three (3) staff and toured residents’ rooms, activity room and dining room area. LPA also reviewed and obtained documents including residents’ roster with apartment numbers, staff roster with contact information and monthly Pest control invoices with summary details of treatments. Allegation: Staff did not ensure facility was free from pests Based on interviews with ED and Staff members it was revealed there has been mice droppings seen in certain areas of the facility. The facility sits on open land which causes the pest to come into the facility at times. The facility has standing contract with Orkin Pest Control Company who comes out monthly to treat the pest problem at the facility. Continue LIC9099C Unsubstantiated Continued from LIC9099 Based upon the information obtained during investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given to Jennifer Lawson, Business Office Director.the state’s words, verbatim · CDSS document, Jan 7, 2025 · control 15-AS-20241106163611

Type of visit: Case Management - Incident

On 04/03/2024 at 12;00PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 03/28/2024. LPAs met with Executive Director, Scott Shahade and informed him of the reason for the visit. Based on the incident report received on 03/28/2024, resident (R1) tested positive for MRSA. Facility obtained documents regarding (R1) test results and (R1) is no longer infectious. During visit, LPAs obtained (R1) medical documents, test results and progress notes which indicates (R1) is not infectious. Facility provided precautionary policy and procedures. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Apr 3, 2024

Type of visit: Case Management - Health Checks

On 02/22/24 at 12:55PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving a priority 1 complaint. During the health and safety check, LPA observed a total of 15 staff members and 90 residents at the facility. LPA toured facility with Business Office Director, including but not limited to activity rooms, memory care unit, bedrooms, dining areas, bathrooms, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 22, 2024

Type of visit: Case Management - Annual Continuation

On 2/16/2024 at 10:20am, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPAs met with Executive Director (ED), Scott Shahade, and explained the purpose of the visit. The facility’s fire clearance was 190 non-ambulatory and 10 bedridden residents. Facility has hospice waiver for 18 residents. LPAs toured the facility with Administrator including but not limited to apartments, bathrooms, kitchen, common area, med tech room, and outside. LPAs toured apartments #210, #214, #12, and #114. All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/18/2024. Emergency disaster plan last updated 2/1/2024. First aid kit was observed to be complete. Fire drill was last conducted on 10/31/2023. Continued on LIC809C. Continued from LIC809. LPAs reviewed ten (10) staff records and ten (10) resident records. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 16, 2024

Type of visit: Case Management - Incident

On 2/16/2024 at 2:40pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived unannounced to conduct a Case Management visit for an incident that occurred on 2/16/2024. LPAs met with Scott Shahade, Executive Director (ED), and explained the purpose of the visit. While LPAs were conducting a continuation for an annual visit LPAs were informed by the ED that an incident occurred at approximately 6:00am this morning between Staff 2 (S2) and Resident 1 (R1). ED stated S2 was trying to prevent R1 from eloping, words were exchanged, and S2 pushed R1's walker causing R1 to fall. R1 was taken to the Sutter hospital. S2 was suspended pending investigation. Around 2:30pm LPAs were informed that R1 sustained a fracture and had returned to the facility. LPAs obtained a copy of the incident report, the SOC341, and discharge summary visit. For S2 LPAs obtained training records, application, and contact information. For R1 LPAs obtained admission agreement, hospice care plan, physician's report, identification and emergency contact, progress notes, and last assessment. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 16, 2024

Type of visit: Required - 1 Year

On 2/2/2024 at 3:10pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson, arrived unannounced to conduct 1-Year Annual Required inspection visit. LPAs met with Executive Director (ED), Scott Shahade, and explained the purpose of the visit. The facility’s fire clearance was 190 non-ambulatory and 10 bedridden residents. Facility has hospice waiver for 18 residents. LPAs reviewed 10 staff files. LPA requested the following documents to be submitted to CCLD by 2/9/2024. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance No deficiencies cited during today's visit. LPAs explained to ED that the inspection will have to be continued at a later date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 2, 2024

Allegation investigated: Due to staff negligence, resident is not being changed timely Due to staff negligence, staff is not assisting resident with hygiene needs

On this day at around 10:30 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct investigation on the above allegations and met with Executive Director (ED) Michael Talani and Resident Care Director (RCD) Karren Melad. LPA explained to both the purpose of the visit. During the visit, LPA interviewed 6 residents, ED, RCD and 2 caregivers on shift. Based on interviews conducted with caregivers, Staff 1 (S1) states S1 assists Resident 2 (R2) with showers and incontinence management. S1 added if R1 refuses to take shower, S1 would assist R2 in getting cleaned and changed. S1 also states that R2's diaper gets changed as often as possible. A review of R2's Health and Service Evaluation indicates standby assistance for Grooming/Personal Hygiene and Bathing. RCD states all staff are instructed to make sure incontinent residents are changed regularly. RCD added that R2 who is incontinent never had any skin breakdown because staff have been changing R2 regularly. ***continuation on Lic 9099C*** Unsubstantiated S2 states R3's shower is scheduled in the afternoon. However, if S2 observes R3 needs assistance with incontinence management that needed attention right away, S2 would assist R3 with the needed care including assisting R3 with showers. R3's Health and Service Evaluation indicates standby assistance for bathing once a week and that R3 is independent with Toileting. While conducting interview with R2, LPA observed R3 taking a shower with S2 assisting. During the visit with R2 and R3, LPA observed R2's hair and beard needed attention. RCD and ED state that R2 had an appointment with the salon a week prior. When R2 was at the salon, R2 suddenly had an accident and needed to go back to the apartment. By the time R2 was able to go back to the salon, it was closed. ED states since R2 missed the haircut appointment, the salon operator has rescheduled it for R2 in a few days. During interview with ED, he states that the facility has replaced R2 and R3's bed due to the urine smell which was caused by R2 taking off diapers and sheets. ED states the bed has been replaced twice. ED also informed LPA that R2 and R3 have a doctor's appointment on October 25 for reassessment needed due to decline in cognitive functions. ED added that R2 and R3 were scheduled for reassessment in July 2023 but the family were not able to take R2 and R3 to the appointment. Based on interviews and records reviews conducted, the above allegations are unsubstantiated. Although the allegation 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 allegation is unsubstantiated. There is no deficiency issued for today's visit.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 15-AS-20231011103912