Westmont of Escondido

Allegation investigated: Staff verbally abused a client

Licensing Program Analyst (LPA), Robert Campbell, conducted an unannounced visit to deliver findings for complaint investigation regarding the above allegation. LPA met with Executive Director, Austin Irwin, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews and documentation review. On July 7, 2026, Community Care Licensing Division (CCLD) received a complaint alleging staff verbally abused a client. It was reported that Staff Member called Resident #1 inappropriate names and indicated that “nobody likes her.” Information obtained from an interview with Executive Director stated that the “Staff Member” mentioned in the allegation has never worked or has been associated to the facility. Additional interviews corroborated the information listed above. LPA reviewed pertinent documentation such as LIC500, staff schedules, and Guardian Roster confirming the reported staff member was not listed on any roster. (Continued on LIC9099C...) Unfounded Continued.... Based on the documentation obtained and from interview the allegation that staff verbally abused a client is unfounded. A finding of UNFOUNDED means the allegation could not have happened, is false, and/or is without reasonable basis. An exit interview was conducted. A copy of the report was discussed and provided to Executive Director Austin Irwin.the state’s words, verbatim · CDSS document, Aug 14, 2026 · control 18-AS-20260702153208

Allegation investigated: Staff are not administering resident's medication. Staff are not following resident's doctors order.

This report supersedes the previous reports LIC9099 and LIC9099C, created on May 5, 2026. The findings regarding the complaints remain unchanged. On July 3, 2026, the department conducted a follow-up visit, met with the Resident Services Director (RSD) Socorro Garcia, and explained the purpose of the visit. On May 5, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced follow-up complaint visit. On April 28, 2026, the department obtained several documents, including the Personnel Report (LIC 500) and the Resident Roster, both dated that day. The department reviewed and collected documents for Resident R1, including the face sheet, admission agreement, physician's report dated 07/11/2024, medical assessment dated 09/09/2024, pre-placement appraisal, and the Medication Administration Record (MAR). The department also obtained documentation for 7 hours of staff training. The department interviewed the Administrator (A1), two Med Techs (MT1 and MT2), the Resident Services Director (RSD), the Memory Care Director (MCD), a maintenance staff member, five additional staff members (S1-S5), and seven residents (R1-R7). On May 5, 2026, the department interviewed R1’s Physician. Unsubstantiated Allegation: #1 Staff are not administering resident’s medication. The complaint alleged that staff sometimes bring R1's medication in the morning, while at other times R1 has to seek out staff to receive their medication. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegation, stating that the Medication Technicians (Med Tech) follow the doctor's orders and ensure that all medications are given to R1 on time. On the same date, the department also interviewed two Medical Technicians (MT1 and MT2), who denied the allegation and explained that while they follow doctor’s orders, they do not assist R1 with medications, as R1 has been managing their own medications. They also mentioned that if the facility receives medications without a doctor’s order, they contact the doctor’s office to request that the orders be faxed. They emphasized that medication must be administered 1 hour before or after the scheduled time. Additionally, they stated that they use the Electronic Medication Administration Record (E-MAR) system to assist with residents' medications and to prevent errors. Moreover, the department interviewed five staff members (S1-S5), all of whom denied the allegations and confirmed that only Med Tech assist with administering medications. The department also spoke with seven residents (R1-R7); six of them denied the allegations and reported that staff helps them with their medications without any issues. Resident R1 stated that they do not require assistance with their medications and can manage them independently. On April 28, 2026, the department reviewed R1's records, including the Medication Administration Record from July 8, 2024, to August 19, 2024, and found no discrepancies 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. Allegation #2: Staff is not following resident's doctors order. The complaint alleged that staff were not allowing Resident #1 (R1) to manage their own medications, despite the doctor’s approval. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegation. A1 stated that the medication technicians follow the doctor's orders and ensure that all resident medications are delivered on time. A1 also explained that when a resident is admitted to the facility, a medication self-management assessment is conducted to determine whether the resident is capable of self-medicating. When R1 was admitted to the facility on July 19, 2024, R1 expressed a desire to self manage their medications; however, R1's physician report dated 07/11/2024 indicated that R1 needs assistance with medications. After a month of admission, the facility performed a medication self-management assessment on September 9, 2024, which indicated that R1 was capable of storing and managing their medications. Since that assessment, the facility has not been involved in storing or managing R1's medications. Also, R1 refused to provide the facility with the doctor's notes or after a visit to a physician. On April 28, 2026, the department also interviewed two Medical Technicians (MT1 and MT2), who denied the allegation. They stated that they follow the doctor's orders and that the facility does not charge a fee for managing residents' medications under the Assisted Living Waiver (ALW), since R1 is in the ALW program. They further explained that the facility requires a pharmacy profile for residents and, if everything is in order, approves the self-management of medications. Report continued on LIC9099C The department conducted interviews with five staff members (S1-S5), all of whom denied the allegations and confirmed that only Med Tech assist with medication related tasks. On the same day, the department interviewed seven residents (R1-R7). Six of these residents denied the allegations and reported that staff assisted them with their medications without any issues. One of these seven residents indicated that they now manage their own medications. On July 3, 2026, the department interviewed the Resident Services Director (RSD). The RSD stated that after admission, the facility needed to ensure that resident R1 was capable of managing their own medications. To evaluate R1's ability to administer their own medications, the facility conducted an Assessment for Medication Self-Management on September 9, 2024. Since R1's self-management was approved, the facility stopped providing assistance with or managing R1’s medications. Additionally, the department interviewed R1's doctor, who confirmed during R1's final visit on August 19, 2024, that R1 was indeed capable of managing their own medication regimen. However, on April 28, 2026, the facility indicated that they had not received any physician reports regarding R1. The department later reviewed a physician report dated July 11, 2024, which stated that R1 needed assistance with medications. 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. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Lifestyle Director Kelli Grissom.the state’s words, verbatim · CDSS document, Jul 3, 2026 · control 18-AS-20240905080940

Allegation investigated: Staff did not provide a refund

Licensing Program Analyst (LPA), Robert Campbell, conducted and unannounced visit to deliver findings for complaint investigation regarding the above allegation. LPA met with Executive Director Austin Irwin, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of an interview with Administrator and documentation review. On June 8, 2026, Community Care Licensing Division (CCLD) received a complaint alleging "Staff did not provide a refund". Regarding the allegation that "Staff did not provide a refund", information obtained from an interview with Administrator stated that they refunded the amount of $3700.00 on May 7, 2026 check#5718 to the RP and showed documented proof of refund. The Administrator also reported in the interview that the facility refunded the amount of $500.00 dollars with documents on June 11, 2026 check#5791 for a total of $4200.00 refunded to the RP. Continued on LIC9099C Unfounded Continued.... Based on the documentation obtained and from interview the allegation that "Staff did not provide a refund". is unfounded. A finding of UNFOUNDED means the allegation could not have happened, is false, and/or is without reasonable basis. An exit interview was conducted. A copy of the report was discussed and provided to Executive Director Austin Irwin.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 18-AS-20260608143558

Allegation investigated: Staff did not ensure the facility was free of bedbugs

Licensing Program Analyst (LPA), Robert Campbell, conducted and unannounced visit to deliver findings for complaint investigation regarding the above allegation. LPA met with Executive Director Austin Irwin, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and residents, file reviews, and observations. On April 07, 2026, Community Care Licensing Division (CCLD) received a complaint alleging "Staff did not ensure the facility was free of bedbugs". Regarding the allegation that staff did not ensure the facility was free from bedbugs, information obtained from an interview with Administrator stated that they were advised of bed bugs on August 10, 2025, September 01, 2025, January 18, 2026. It was advised that Orkin Pest Control was contacted on August 11, 2025, September 03, 2025, and January 20, 2026. Continued on LIC9099C Unfounded Continued.... Further information advised stated that on January 21, 2026: Units 222A*/B, 224, and 220 were treated with both chemical and heat applications. 2/06/2026 ORKIN report states cleared from Bed Bugs. Further information advised stated that on September 4, 2025: Units 221, 223*, and 225 were treated with both chemical and heat applications. 9/18/2025 ORKIN report states cleared from Bed Bugs. Further information advised stated that on August 13, 2025: Units 340, 342*, and 344 were treated with both chemical and heat applications. 8/12/2025 ORKIN first report states cleared from Bed Bugs. Unit 342 was reheated on 8/18. 8/25/2025 ORKIN second report states cleared from Bed Bugs. Information obtained from four (4) residents interviewed, seven (7) staff, and two (2) residents representatives reported that the facility handled the incidents of bed bugs very promptly after being reported, and all stated there are no more bed bugs. Based on the information obtained from interviews and record reviews the allegation that staff did not ensure the facility was free from bedbugs is unfounded. A finding of UNFOUNDED means the allegation could not have happened, is false, and/or is without reasonable basis. An exit interview was conducted. A copy of the report was discussed and provided to Executive Director Austin Irwin.the state’s words, verbatim · CDSS document, May 20, 2026 · control 18-AS-20260403102601

Allegation investigated: Staff are not administering resident's medication. Staff are not following resident's doctors order.

On May 5, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced follow-up complaint visit. The LPA met with the Administrator (A1), Austin Irwin, and explained the purpose of the visit. The investigation included collecting records and touring the facility. On April 28, 2026, the department obtained several documents, including the Personnel Report (LIC 500) and the Resident Roster, both dated that day. The department reviewed and collected documents for Resident R1, including the face sheet, admission agreement, physician's report dated 07/11/2024, medical assessment dated 09/09/2024, pre-placement appraisal, and the Medication Administration Record (MAR). The department also obtained documentation for 7 staff training hours. The department interviewed the Administrator (A1), two Med Techs (MT1 and MT2), the Resident Services Director (RSD), the Memory Care Director (MCD), a maintenance staff member, five additional staff members (S1-S5), and six residents (R1-R6). On May 5, 2026, the Department interviewed the R1 Doctor. The department also visited 11 rooms during the investigation. Unsubstantiated Allegation: #1 Staff are not administering resident’s medication. The complaint alleged that staff sometimes bring R1's medication in the morning, and at other times R1 has to find it. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that the med techs follow the doctor's orders and ensure that all resident medications are delivered on time. On the same date, the department also interviewed two Medical Technicians (MT1 and MT2), who denied the allegation and stated that they follow the doctor's orders. If the facility receives medications without a doctor's order, they call the doctor's office to request that the orders be faxed. They also stated that the medication must be administered 1 hour before and 1 hour after. They also stated that they used the E-MAR to assist with residents' medications. Additionally, the department interviewed five staff members (S1-S5), all of whom denied the allegation and stated that only Med Tech assist with medications. On the same day, the department interviewed six residents (R1-R6), all of whom denied the allegations and reported that staff help them with their medications without any issues. The department reviewed the R1 MAR record dated 07/8/2024 and found no discrepancy. 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. Report Continued on LIC9099C Allegation #2: Staff are not following the resident’s doctors order. The complaint alleged that staff were not allowing Resident #1 (R1) to manage their own medications, despite the doctor’s approval. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegation. A1 stated that the medication technicians follow the doctor's orders and ensure that all resident medications are delivered on time. A1 also explained that when a resident is admitted to the facility, a medication self-management assessment is conducted to determine if the resident is capable of self-medicating. When R1 was admitted to the facility on July 19, 2024, R1 expressed a desire to self-manage their medications on September 5, 2024. The facility performed a medication self-management assessment on September 9, 2024, which indicated that R1 was capable of storing and managing their medications. Since that assessment, the facility has not been involved in storing or managing R1's medications. On April 28, 2026, the department also interviewed two Medical Technicians (MT1 and MT2), who denied the allegation. They stated that they follow the doctor's orders and that the facility does not charge a fee for managing residents' medications under the Assisted Living Waiver (ALW). They further explained that the facility requires a pharmacy profile for residents and, if everything is in order, approves the self-management of medications. Report Continued on LIC9099C Additionally, the department interviewed five staff members (S1-S5), all of whom denied the allegation and stated that only Med Tech assist with medications. On the same day, the department interviewed six residents (R1-R6), all of whom denied the allegations and reported that staff help them with their medications without any problems. One of six residents stated that they now manage their own medications. The department reviewed the R1 MAR record dated 07/8/2024 and found no discrepancy. The department interviewed the R1 doctor, who confirmed that R1 could manage R1's medications during R1's last visit. 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. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator, Austin Irwin.the state’s words, verbatim · CDSS document, May 5, 2026 · control 18-AS-20240905080940

Allegation investigated: Staff are not properly trained. Facility do not have adequate supplies to care for residents. Staff does not ensure facility is free of pests.

On May 5, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted a follow-up unannounced complaint visit. The LPA met with the Administrator (A1), Austin Irwin, and explained the purpose of the visit. The investigation included collecting records and touring the facility. On April 28, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 04/28/26) and the Resident Roster (dated 04/28/26). The Department reviewed facility documents for six residents, including the Face sheet, Admission Agreement, physician's Report, Medical Assessment, and Preplacement Appraisal. The Department also obtained seven staff training hours and the ORKIN records services. The Department interviewed the Administrator (A1), two Med Techs (MT1-MT2), the Resident Services Director (RSD), the Memory care Director (MCD), five staff members (S1-S5), and six Residents (R1-R6). Unsubstantiated Allegation #1: Staff are not properly trained. The complaint alleged that the staff was not properly trained. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegations and stated that all staff were properly trained. The department interviewed two Med Techs (MT1-MT2), who denied the allegation and stated that MT1-MT2, the caregiver, and the Housekeepers had all completed 12 hours of training from Relias and ongoing training. The department interviewed the RSD, who denied the allegation and stated that all staff were well-trained. The department interviewed the MCD, who also denied the allegation. The department interviewed five staff members (S1-S5), who all denied the allegation and stated that they were well-trained and had completed multiple Relias subjects. On the same day, the department interviewed six residents (R1-R6), all of whom denied the allegations and stated that the staff helps them when needed. On April 28, 2026, the department reviewed Relias staff training records dated 2024 and 2025. indicate that the staff was properly trained to assist residents. 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. Report Continued On LIC9099C Allegation #2: The facility do not have adequate supplies to care for residents. The complaint alleged that the facility lacks necessary supplies to care for residents and that staff are not properly trained. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegations and stated that all staff are properly trained. The department interviewed two Med Techs (MT1-MT2), who denied the allegations and stated that the facility has sufficient supplies to address residents' scratches; however, the facility does not treat wounds or apply antibiotic ointment. Residents need a doctor's order to apply antibiotic ointment. The department interviewed the RSD, who denied the allegations and stated that all staff are well-trained. The department interviewed the MCD, who also denied the allegations. The department interviewed five staff members (S1-S5), who all denied the allegations and stated that the facility has several first-aid kits with fully stocked supplies. On the same day, the department interviewed six residents (R1-R6), all of whom denied the allegations and stated that the staff helps them when needed. On April 28, 2026, the department observed that the facility had first-aid supplies for residents in case of emergencies. 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. Report Continued on LIC9099C Allegation #3: Staff does not ensure facility is free of pets. The complaint alleged a major ant infestation at the facility. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegations and stated that the facility has ORKIN, which visits the facility monthly to service the inside and outside. The department also interviewed two Med Techs (MT1 and MT2), who denied the allegations and stated that the facility doesn’t have any ant infestation.. The department interviewed the RSD, who denied the allegations and stated that all resident rooms are pets-free. The department also interviewed the MCD, who denied the allegations. The department interviewed five staff members (S1-S5), all of whom denied the allegations and reported not observing any ants, pets, or bed bugs in residents' rooms. On the same day, the department interviewed six residents (R1-R6), all of whom denied the allegations and stated that staff help them when needed. They also reported not noticing any pets or bed bugs in their rooms. On April 28, 2026, the department toured the first, second, third, and fourth floors and visited rooms 107, 218, 224, 301, 308, 322, 327, 338, 405, 429, and 442; no ants, pets, or bed bugs were detected. The department reviewed records of ORKIN pest control services at the facility on 9/4/25, 9/13/25, 10/9/25, 10/13/25, 12/8/25, 1/6/26, 2/5/26, 2/16/26, 3/5/26, and 3/20/26. Report Continued on LIC9099C 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. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator, Austin Irwin.the state’s words, verbatim · CDSS document, May 5, 2026 · control 18-AS-20240903133752

Allegation investigated: Staff do not ensure the facility is kept free from mal odors for residents in care. Staff do not ensure residents rooms are kept in clean, sanitary conditions.

On May 1, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced follow-up complaint visit. The LPA met with the Administrator (A1), Austin Irwin, and explained the purpose of the visit. The investigation included collecting records and touring the facility. On April 28, 2026, the Department obtained several documents, including the Personnel Report (LIC 500) and the Resident Roster, both dated that day. The Department reviewed and collected documents for Resident R1, including the face sheet, admission agreement, physician's report, medical assessment, and pre-placement appraisal. The Department also obtained documentation for 7 staff training hours. The Department interviewed the Administrator (A1), two Med Techs (MT1 and MT2), the Resident Services Director (RSD), the Memory Care Director (MCD), a maintenance staff member, five additional staff members (S1-S5), and six residents (R1-R6). The Department also visited 11 rooms during the investigation. Unsubstantiated Allegation: #1 Staff do not ensure the facility is kept free from mal odors for residents in care. The complaint alleged that the 3rd and 4th floors of the facility have a bad odor; the housekeeping staff does not clean the rooms on those floors. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that the housekeepers clean the rooms once a week and as needed. On the same date, the department also interviewed two Medical Technicians (MT1 and MT2), who denied the allegation and also stated that the rooms do not smell. Additionally, the department interviewed five staff members (S1-S5), all of whom denied the claim and stated that the rooms are cleaned once a week. If a resident has an accident or spills something, the housekeeper will clean it right away. The staff members also stated that the facility has a hallway air freshener dispenser on the 2nd, 3rd, and 4th floors. The department interviewed the Maintenance staff member (M), who denied that the hallway had a bad odor. M also stated that M is on call 24/7 and will be called if anything needs to be done, and will take care of it. The department interviewed six residents (R1-R6), all of whom reported that their rooms are cleaned once a week. Reports continued on LIC9099C R6 also stated that when something was spilled, the housekeeper cleaned it right away. On April 28, 2026, the department visited rooms 107, 218, 224, 301, 308, 322, 327, 338, 405, 429, and 442; no odor was detected. During the facility tour, there were no odors on the first, second, third, or fourth floors. 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. Allegation: #2: Staff do not ensure residents rooms are kept in clean, sanitary conditions. The complaint alleged that the “housekeeper refused to clean the rooms in memory care, when residents have accidents and spills get on the floor from urine and feces.” On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that the housekeepers clean the rooms once a week and as needed. When a resident spills something on the floor, the housekeepers clean it right away. On the same date, the department also interviewed two Medical Technicians (MT1 and MT2), who denied the allegation and stated that the rooms are cleaned regularly and that, if any residents or staff members noticed anything, they would report it. Reports Continued on LIC9099C Additionally, the department interviewed five staff members (S1-S5), all of whom denied the claim and stated that the rooms are cleaned once a week. If a resident has an accident or spills something, the housekeeper will clean it right away. The department interviewed the Maintenance staff member (M), who denied that the hallway had a bad odor. M also stated that M is on call 24/7 and will be called if anything needs to be done, and will take care of it. The department interviewed six residents (R1-R6), all of whom reported that their rooms are cleaned once a week. R6 also stated that when something was spilled, the housekeeper cleaned it right away. On April 28, 2026, the department visited rooms 107, 218, 224, 301, 308, 322, 327, 338, 405, 429, and 442; no odor was detected. During the facility tour, there were no odors on the first, second, third, or fourth floors outside the hallway. 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. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator, Austin Irwin.the state’s words, verbatim · CDSS document, May 1, 2026 · control 18-AS-20240814161934

Allegation investigated: Staff are not permitting residents to have privacy during visits.

On May 1, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted a follow-up unannounced complaint visit. The LPA met with the Administrator (A1), Austin Irwin, and explained the purpose of the visit. The investigation included collecting records and touring the facility. On April 28, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 04/28/26) and the Resident Roster (dated 04/28/26). The Department reviewed and collected documents for residents R1, including the Face sheet, Admission Agreement, physician's Report, Medical Assessment, and Preplacement Appraisal. The Department also obtained seven staff training hours. The Department interviewed the Administrator (A1), two Med Techs (MT1-MT2), the Resident Services Director (RSD), the Memory care Director (MCD), five staff members (S1-S5), and six Residents (R1-R6). On April 30, 2026, the department interviewed the Power of Attorney (POA). Unsubstantiated Allegation #1: Staff are not permitting residents to have privacy during visits. The complaint alleged that during a visit, the Executive Director stayed in the room and didn’t allow them any privacy. On April 28, 2026, the department interviewed the Administrator (A1), denied the allegations, and stated that ED asked if R1 wanted ED to stay in the room with R1. R1 stated yes. That’s the only reason ED stays inside the room. Also stated that the facility respects each resident's privacy with their family, unless the resident and the Power of Attorney limit the resident's visitors. The department interviewed two Med Tech (MT1-MT2), who denied the allegation and stated that when a resident had a visitor, staff provided privacy unless the resident requested a staff member to be present. The department interviewed the RSD, who denied the allegation and stated that this is all the residents' right to have privacy when they have a visitor. The department interviewed the MCD, who also denied the allegation. The department interviewed five staff members (S1-S5), who all denied ever being in any resident's room when a resident had visitors. On the same day, the department interviewed six residents (R1-R6), all of whom denied the allegations and stated that they always have privacy when family members visit. Report Continued on LIC9099C On April 30, 2026, the department interviewed the Power of Attorney (POA), who denied the allegation and stated that R1 maintains privacy regarding visitors. The POA also stated that there are some visitors that the POA and R1 want staff to be aware of when visiting R1 and to be present in the room. Otherwise, R1 has plenty of privacy. 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. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator, Austin Irwin.the state’s words, verbatim · CDSS document, May 1, 2026 · control 18-AS-20241001144629

Allegation investigated: Facility staff did not dispense medications as prescribed.

On April 8, 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegation and to deliver findings. The Department was met by Austin Irwin Executive Director Investigation consisted of the following: On December 26, 2023, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegation mentioned above. During the visit, it was determined that the complaint required further investigation. On April 8, 2026 The department obtained a copy of resident roster, interviewed Administrator (A1) and 1 staff (S1) Page 1 of 2 Unsubstantiated The investigation revealed the following: Allegation: Facility staff did not dispense medications as prescribed. The detail of the complaint alleges R1’s medication was not dispensed as prescribed. Discontinued medication was allegedly given to R1. On April 8, 2026 at 12:30pm, the Department interviewed Executive Director (A1), who denied the allegation on the basis that R1 does not live at the facility, nor has R1 ever lived at the facility. It should be noted that the complaint did not provide a date of birth for R1. The department reviewed the current roster and could confirmed that R1 doesn't appear on the roster. Through the interview process, with A1, the department found that there was a resident with a similar name [one letter off]--who resided in the facility during time of the complaint, however that resident did not match the detail of the complaint. On April 8, 2026 the Department interviewed the Resident Services Director (S1), who also stated that there was no resident by R1's name who resided in the facility. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today's visit. Exit interview conducted and copy of report provided. Page 2 of 2the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 18-AS-20231222112819

Type of visit: Case Management - Incident

On 12/11/2025, Licensing Program Analyst (LPA) Valerie Flores made an unannounced visit to the facility for the purpose of conducting a case management - incident visit. LPA met with Executive Director, Austin Irwin, whom was informed the purpose of the visit. During the visit, LPA collected pertinent documentation and conducted interviews with relevant parties. On 12/11/2025 at approximately 10:30AM, LPA received a call from Executive Director Austin Irwin informing LPA of a possible suicide. Upon arrival, information received reported that Home Health nurse was conducting a routine visit with Resident #1 (R1). Home Health nurse entered into R1's bedroom and did not observe R1 to be present inside the bedroom. Home Health nurse further observed R1's oxygen cord lying on the floor. Home Health nurse followed the cord which lead out to R1's second floor balcony and observed R1, who was lying on the flowerbed at ground level. Home Health nurse immediately called emergency services and notified Executive Director. It was reported that Home Health Nurse, Executive Director, and Resident Service Director ran out to assess R1. R1 was observed to be unresponsive and without a pulse. R1 resided in a shared unit but had their own bedroom. R1 was residing at the facility for approximately two months. During the time of stay, staff did not observe any changes of behaviors. R1's physician report conducted on 10/3/2025 divulged that R1 did not have suicidal ideations and did not require constant supervision. Resident #2 (R2), who shares a common wall with R1, reports that R1 and R2 went down to eat breakfast together that morning. Upon returning to their shared unit, R2 reports that they did not hear nor observe anything out of the ordinary. At this time, the death determination is still pending autopsy. LPA requested a copy of the death certificate once it has been available to the facility. During today's visit, LPA did not observe any health and safety concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator, Austin Irwin.the state’s words, verbatim · CDSS document, Dec 11, 2025

Type of visit: Case Management - Incident

On 12/2/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of following up on a self-reported SOC341 provided to the department by the facility. LPA met with Executive Director Austin Irwin and informed him of the purpose of the visit. Information received alleged Staff #1 (S1) physically assaulted Resident #1 (R1). The visit consisted of interviews and observations. On 12/1/2025 at 9:30AM, Resident #1 (R1) who resides in Assisted Living shared unit 222B reported to Staff #2 (S2) that R1 was punch in the face by Staff #1 (S1). Interview with R1 and facility staff reported that R1 requested that S1 assist R1 with a brief change. It was reported that S1 became aggressive and struck R1 near the right jaw/chin area. Administrator contacted Escondido Police Department. A police report number was provided for the incident, but law enforcement did not detain and/or arrest S1 as they did not have sufficient basis to arrest S1. Facility staff reported that R1 did not have marking's and/or bruising from the incident but S1 was placed on leave, undergoing an internal investigation. Administrator provided LPA a termination letter for S1. The termination letter has yet to be provided to S1 by 12/3/2025. During the health and safety check, LPA did not observe any bruising and/or redness to R1’s face. Due to insufficient evidence, LPA could not corroborate that the incident took place. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. No deficiencies were observed or cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Executive Director, Austin Irwin.the state’s words, verbatim · CDSS document, Dec 2, 2025

Allegation investigated: Facility did not assist in seeking medical attention for a resident in a timely manner Resident is not being adequately fed Resident is not being assisted with showering

On 9/23/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering investigative findings into the allegations listed above. LPA Flores identified herself and discussed the purpose of the visit with Administrator, Austin Irwin. The investigation consisted of records review and interviews. Information received alleged facility staff did not assist in seeking medical attention for Resident #1 (R1) within a timely manner after R1 experienced an unwitnessed fall. A record review conducted of R1 divulge R1 is not a fall risk and does not require assistance with ambulation. An interview conducted with R1 explained R1 lost balance and fell to their knees. R1 reported they did not have complaint of pain and/or sustain injuries from the unwitnessed fall. (Continue to LIC9099C) Unfounded (Continuation LIC9099..) Interviews conducted with R1 and relevant parties corroborated R1 did not report the fall to facility staff. Interview with R1 further confirmed R1 did not require medical attention from the fall. Information received alleged R1 is not being adequately fed. Records review conducted of the facility meal check confirmed R1 is offered (3) three meals a day. A record review conducted of the End of Shift reports documented on July 11th and July 21st of 2025, reported R1 refused lunch as R1 ate a late breakfast. A record review conducted of R1’s weight chart shows R1 has maintained static weight since being admitted into the facility. An interview conducted with R1 confirms the facility staff provide R1 with (3) three meals a day with snacks in-between. Interview with R1 confirmed R1 will refuse a meal from time to time when the previous meal was filling. Interviews conducted with relevant parties indicated R1 does not refuse meals often to lead to cause of concerns. Interview conducted with Resident #2 (R2) and staff reported that R1 often attends meals with R2 which encourages R1 to attend meals. Information received alleged R1 is not being assisted with showers. A record review conducted of R1 revealed R1 is independent and does not require shower assistance. The facility does not maintain a shower log for R1 as R1 is independent. A record review conducted for R1 physician report verified R1 did not require assisting with bathing, grooming, dressing, feeding, and/or tioleting. Interviews conducted with facility staff explained staff will ask R1 if R1 has showered and facility staff will offer verbal reminders. An interview conducted with R1 and relevant parties corroborated that R1 will refuse to shower at times but there is no cause of concerns. R1 is independent and does not require reassessment. Based on interviews and records review, the allegations of facility did not assist in seeking medical attention for a resident in a timely manner, resident is not being adequately fed, and resident is not being assisted with showering are unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator, Austin Irwin.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 18-AS-20250731164102

Type of visit: Required - 1 Year

On 9/23/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced 1-year required annual visit. LPA was greeted by facility staff and was granted entry. LPA advised Administrator, Austin Irwin, of the purpose of the visit. A tour of the facility was conducted. LPA Flores observed the following during todays visit: The facility is a five story structure with a lock perimeter memory care unit on the first floor. The facility is licensed for (200) two hundred non-ambulatory residents to which (10) ten residents may be bedridden. The facility is currently approved for (15) fifteen hospice waivers. LPA observed the facility to be clean and in good repair. Lighting is sufficient for safety. Laundry is done in the designated laundry room on each floor, as well as the location located in the garage’s parking structure. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the Housekeeper’s closet. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The facility maintains a current emergency disaster plan is maintained. There are no fireplaces at this facility. There is (1) one indoor pool at the facility which has an enclosed and secured perimeter. There are gates located in the front and back of the building. Resident bedrooms had the required bedding, furniture, seating, and lighting. Bathrooms were equipped with grab bars and slip resistant mats in the shower area. Food prep areas are clean and organized. Food supply meets the requirement of (2) two-day supply of perishable and (7) seven-day supply of non-perishables foods. There are food deliveries that come three days out of the week. (Continue to LIC809C...) (Continuation from LIC809) Facility maintains a sufficient amount of emergency food and water supply. There is a secured location for knives and other sharp items located in the kitchen. LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. The facility is maintained at a comfortable temperature for the residents. Per Administrator, Austin Irwin, there are no firearms and/or ammunition on the premises. LPA conducted records review for (10) ten residents. Resident records included but not limited to identification and emergency information, preplacement appraisals, admission agreement, medical assessment, and TB test results, safeguard for personal property/valuables, and personal rights notification. LPA conducted records review for (5) five staff. Staff records included but not limited to first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Austin Irwin Administrator’s certificate expiration date is 05/08/2026. During today's visit, LPA did not observe any health and safety concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator, Austin Irwin.the state’s words, verbatim · CDSS document, Sep 23, 2025

Allegation investigated: Financial exploitation by another resident

On 7/29/2025, Licensing Program Analyst (LPA) Valerie Flores arrived at the facility for the purpose of delivering findings into the allegations listed above. LPA met with Administrator, Austin Irwin and explained to Austin the purpose of the visit. LPA conducted a tour of the facility and did not observe any health and safety concerns. Information received alleged that Resident #1 (R1) was being financially exploited by Resident #2 (R2). The allegation stemmed from a computer that R1 obtained. LPA conducted records review and discovered that R1 is in full control of their own finances. Through interviews, revealed R1 was gifted a computer from Resident #3 (R3) and monies were not exchanged for the computer. R1 was gifted the computer by R3 because R1 was experiencing computer issues. R3 refurbishes computers and gifted an spare computer to R1. (Continue to LIC9099C) Unfounded (Continuation from LIC9099) R2 was mentioned in the initial complaint as it was allegedly told to the reporting party that R2 drove R1 outside of the community to purchase the computer and R1 had past experience of being financially exploited by other persons non-related to the allegation. There are no receipts to corroborate the purchase. LPA made several unsuccessful attempts to speak with R1. An interview conducted with R1's responsible party confirmed the incident was a miscommunication and R1 being financially exploited by R2 never occurred. R1’s Responsible Party explained that the miscommunication occurred when they expressed their concerns of R1 leaving the facility unassisted. Per R1's physician report, R1 is able to leave out into the community unassisted. Based on interviews and records review the allegation of financial exploitation by another resident is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator, Austin Irwin.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 18-AS-20250708085936

Allegation investigated: Licensee does not ensure that resident's shower area is kept free from mold

On 7/29/2025, Licensing Program Analyst (LPA) Valerie Flores arrived at the facility for the purpose of delivering findings into the allegation listed above. LPA met with Administrator, Austin Irwin, and explained to Austin the purpose of the visit. LPA conducted a tour of the facility and did not observe any health and safety concerns. Information received alleged Licensee does not ensure that resident #1 (R1) shower area is kept free from mold. Photos received reveal a picture of Resident #1 (R1)’s previously white shower curtain spotted with mold spores on the bottom portion of the curtain that would have constant contact with water exposure. A second photo received shows a padded showering seat located inside of R1’s shower. Through the picture, LPA observed the seat part of the chair to have a teal color linen that was coated in black mold. (Continue to LIC9099C...) Substantiated (Continue from LIC9099...) In addition, part of the blue linen appeared to be lifted exposing additional black mold collecting under the teal-colored linen. Interviews conducted, reported that R1 spoke with Staff #1 (S1) regarding the inadequate cleaning of the shower. Additional information received corroborated S1 observed the molded shower chair and shower curtain. The shower curtain and chair were removed on 7/1/2025 per R1’s request. Based on interviews, records review, and observation, the allegation that licensee does not ensure that resident's shower area is kept free from mold was determined to be substantiated. A substantiated finding means 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 and a copy of this report, along with the Appeal Rights (LIC 9058 03/22) were provided to Administrator, Austin Irwin. (Continuation from LIC9099A) Based on the evidence pertaining to the allegations of staff did not respond to resident's requests for assistance in a timely manner, the allegation is unfounded. A finding of unfounded indicates that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted where a copy of this report was provided to Administrator, Austin Irwin.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 18-AS-20250625135111

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 8, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met based as evidence by interview and photos attained: (1) one out of (143) one hundred forty-three residents shower area was not kept free of mold which poses a potential health and safety risk for the resident in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator stated an in-service training with housekeeping will be conducted regarding what is required to be cleaned. An in-service sheet with housekeeping staff signatures will be forwarded over to LPA via email.

Type of visit: Case Management - Incident

On April 18, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Case Management Incident visit, and met Austin Irwin, Executive Director. LPA introduced herself and explained the purpose of the visit. LPA Mixson toured the facility, along with Executive Director and made observations pertaining to the incident. There were sufficient staff present and 141 residents currently. There are no imminent health and/or safety concerns observed at the time of visit. LPA requested and received pertinent documentation. LPA Mixson did not observe any health and/or safety hazards inside or outside of the facility at the time of this visit. LPA observed the facility utilities to be operating without issue. LPA Mixson assessed the available food and observed there was a variety of food types available for the residents in care. The food supply meets the requirement of a two-day supply of perishable foods and a seven-day supply of non-perishable foods. The medications were found to be in sufficient supply, locked, and inaccessible to the residents in care. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. No deficiencies were observed or cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Executive Director, Austin Irwin.the state’s words, verbatim · CDSS document, Apr 18, 2025

Allegation investigated: Facility staff failed to properly supervise residents Facility has insufficient staff

Licensing Program Analyst (LPA), Kathleen Banrasavong, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Administrator, Austin Irwin, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of observations, interviews with staff members and residents, and a review of records. On March 10, 2025, Community Care Licensing received a complaint alleging that facility staff failed to properly supervise residents and facility has insufficient staff. The LPA conducted an interview with the Reporting Party (RP) to attempt to obtain more information regarding the allegations. The RP indicted that they did not want to file a new complaint, rather this complaint was one that was previous filed with the Department. Please refer to complaint control number # 18-AS-20240602104312. Unsubstantiated The RP stated that they would not provide any more new information regarding the allegations listed above. The LPA attempted to contact the alleged victim in order to conduct an interview. The LPA made three attempts. There were three attempts to contact R1 for an interview on the following dates: 10/09/2024, 03/18/2025 (phone call), 03/28/2025 (phone call and email). The LPA was unable to obtain an interview. The LPA interviewed the Executive Director, Austin Irwin. Irwin indicted that there was sufficient amount of staffing to help with the residents at the facility. Irwin indicted that the staff have regular in-service trainings. The staff interview revealed that there was adequate staffing. The interviews with residents indicted that there was no issues or concerns with getting the assistance that they needed in regards to their Activities of Daily Living (ADLS). In regards to the allegation that facility staff failed to properly supervise residents. The LPA attempted to contact the RP and was unable to conduct an interview. The RP did not provide any additional information. The LPA was unable to interview the alleged victim. Resident 1 (R1) was contacted on three attempts. The LPA contact R1 for an interview on the following dates: 10/09/2024, 03/18/2025 (phone call), 03/28/2025 (phone call and email). The Executive Director indicted that the staff properly supervise the residents. Irwin indicted that there is enough staff to meet the needs of the residents. He indicated that the staff are trained to redirect and monitored the residents if there is an incident that occurs between residents. Due to the LPA being unable to interview all pertinent parties, the allegations that Facility staff failed to properly supervise residents and Facility has insufficient staff are unsubstantiated. Based on the information obtained during the investigation, this agency has investigated the complaint that staff engaged in inappropriate behavior toward a resident in care. Although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was discussed with and provided to the Executive Director, Austin Irwin.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 18-AS-20250310140013

Allegation investigated: Resident sustained unexplained injuries while in care Staff did not seek medical attention for resident in a timely manner Staff did not prevent an altercation between residents

On 04/07/25, Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Executive Director Austin Irwin and explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff members and residents, records reviews, and a medical record review. On 06/02/2024, Community Care Licensing received a complaint alleging that Resident 1 (R1) sustained unexplained injuries while in care, staff did not seek medical attention for the resident in a timely manner, and staff did not prevent an altercation between residents. Unsubstantiated On 06/25/2023, R1 was sent out to an acute hospital by staff under the incorrect name. It was advised that R1’s family spent hours trying to locate R1 and was finally assisted by an emergency services operator. R1’s responsible party met with the Executive Director who confirmed that Staff 2 (S2) provided the paramedics with the wrong name. An interview with S2 indicated that S2 mistakenly verified another resident’s name and that the Med Tech confirmed it. S2 gathered the wrong paperwork while waiting for the ambulance. After the family contacted the facility to say they could not locate R1, the facility reviewed the records and realized the mistake. Responsible party was notified and able to locate R1. Regarding the allegation that staff did not provide records to the resident's authorized person, it was alleged that the facility did not provide Serious Incident Reports (SIRs) to R1’s responsible party. Information obtained from interview with additional witness stated on 03/18/2024 they requested copies of all SIRs, but only received a few. It was also reported that there was an incident in which R1 was choked by another resident and the responsible party was denied a copy of the report. Administrator stated that the Serious Incident Reports were provided to R1’s responsible party on the date of 03/18/2024. Regarding the allegation that staff did not provide language services for the resident as agreed, it was alleged that the facility did not provide German-speaking services to R1. It was advised that facility administration agreed to provide language cards in order to communicate with Resident, but they were never provided or used. Interviews with the Executive Director revealed that staff used language cards and an app on their phones to translate. Staff interviews indicated that the cards were rarely used. It was also reported that the app began to be used on 06/10/2024. Resident was placed at the facility on 02/28/2023. Based on interviews and records review, the allegations of staff did not provide emergency personnel with the correction information for the resident and staff did not provide language services for the resident, the preponderance of evidence standard has been met. Therefore, the above allegations are SUBSTANTIATED. This poses a health and safety risk for clients in care. The facility will be cited. An exit interview was conducted. A copy of this report was discussed and provided to Executive Director Austin Irwin, along with copies of the LIC811, LIC9099D, and appeal rights. In regards to the allegation that Resident sustained unexplained injuries while in care, it was reported that Resident 1 sustained bruising and cuts on their body. Information obtained from interview with Administrator denied that any staff harmed R1. Administrator stated that he was unsure how R1 sustained the bruising, but noted staff receive ongoing in-service training and refreshers as needed. Information obtained from interview with Staff #1, (S1) revealed that R1 has experienced multiple falls and that the responsible party would be notified before any transfer to the hospital. The falls were documented on the facility’s charting. The falls were reported to Licensing during the time period of 06/28/2023 to 04/19/2024. Interviews with staff denied that R1 was physically abused by staff. Staff stated that Resident sustained injuries due to being in altercations with other residents, as well as unwitnessed falls during the course of R1’s residency at the facility. LPA was unable to obtain any additional information from Resident #1 regarding the allegation due to not obtaining contact. Regarding the allegation that staff did not seek medical attention for the resident in a timely manner, it was alleged that the facility did not seek medical attention for R1 in a timely manner. It was reported that an incident occurred on 03/18/2024. R1 fell off the couch. Staff notified R1’s POA of R1’s incidents at the facility. The POA confirmed that they declined immediate medical care and did not approve R1’s transfer to the hospital after an unwitnessed fall. The facility’s incident report showed that the family declined R1’s transport. The POA stated that they had a nurse come out, whom they contracted independently. The POA stated that they came to assess R1 and saw a large gash on R1’s elbow and a bruise on R1's thigh. The POA asked why they didn’t send R1 out, it was stated that the POA would take R1 to the hospital themselves. Interview with the care staff indicted that they contacted the POA as requested and the POA stated that they would have a nurse come check on R1. The Administrator indicated that it is the facility’s protocol to send R1 out if any head injury is suspected and that the responsible party is always contacted. Interviews with care staff revealed that the POA would request staff to contact them before calling for a transfer to the hospital. According to the facility policy, the Med Tech assesses the resident after an incident. If the resident is able to move and communicate, they will be helped up or left on the floor, depending on the situation. The Med Tech will then call 911, and the responsible party will be notified of any incidents. Interviews were not able to be conducted with R1 regarding the incident, with four attempts to contact R1 on the same dates as above. Regarding the allegation that staff did not prevent an altercation between residents, it was reported that on December 13, 2023, there was an altercation between R1 and R2. It was reported that R2 pinned R1 under R1’s walker, causing R1 to sustain a skin tear. Information obtained from Administrator stated that R1 would get into altercations with other residents. Information obtained from interviews with staff stated that they did not observe the entire altercation, but separated, redirected, and increased supervision of the residents. Interview with R2 revealed no information due to R2’s diagnosis. Additional information was unable to be obtained from additional residents due to the residents’ diagnosis and residency in memory care. LPA was unable to interview R1 in regards to the allegation. The incident was reported to Licensing. Based on the information obtained during the investigation, the allegations that R1 sustained unexplained injuries while in care, staff did not seek medical attention for R1 in a timely manner, and staff did not prevent an altercation between residents are unsubstantiated. Although the allegations may have occurred or could be valid, there is not enough evidence to prove that the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was discussed with and provided to Executive Director Austin Irwin.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 18-AS-20240602104312

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87506(c)(1) · Plan of correction due date: Apr 16, 2025

87506 (c)(1) (c) All information and records obtained from or regarding residents shall be ... (1) ...shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not being met as evidenced by: facility staff did not provide all requested records to R1's POA. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: The Executive Director, Austin Irwin stated he will be created a log of the requested documents and when the documents were provided. Documentation will log person(s) requesting forms, and date provided to the requestor. This sign affidavit is due to the LPA by email on COB on the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87506(b)(1) · Plan of correction due date: Apr 16, 2025

87506 (b) (1) (b) Each resident’s record shall contain at least the following information: (1) Resident's legal name and preferred name, as indicated by the resident. This requirement was not being met as evidenced by: facility staff not providing correct name for R1 to be admitted in the hospital. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: The Executive Director, Austin Irwin stated he will be create a 2 factor verification by his staff, prior to any resident going to the hospital. This sign affidavit is due to the LPA by email on COB on the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468(d) · Plan of correction due date: Apr 16, 2025

87468 (d)Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language. This requirement was not being met as evidenced by: staff not using language cards for R1 whose primary langauge was not English. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: The Executive Director, Austin Irwin stated he will be conducting an in-service training with staff for any residents who speak another language. Training will be provided, regarding language cards and information provided in the resident’s native language. This sign affidavit is due to the LPA by email on COB on the POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with Executive Director, Austin Irwin. LPA was informed that one hundred and forty residents (140) reside at this facility. LPA toured the facility and observed all facility utilities to be on and operating without issue, food supply is sufficient, there is no immediate concern for residents in care. The LPA conducted a visit in regards to an incident report the Department received on 03/25/2025. The incident that occurred on 03/24/23025. It was alleged that Staff 1(S1) punched Resident 1 (R1). The LPA requested and received pertinent documents regarding (R1) and (S1). The LPA requested copies of the S1's schedule, personnel file, as well as any disciplinary action taken by the facility. The Executive Director indicted that S1 no longer works at the facility as of the date of 03/28/2025. S1 voluntarily resigned. R1 retracted R1's statement regarding S1 punching them. Based on the information obtained during today’s visit, there are no deficiencies or civil penalties being cited per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Executive Director, Austin Irwin and a copy of this report is left with the Irwin, as evidence by his signature.the state’s words, verbatim · CDSS document, Apr 9, 2025

Allegation investigated: Facility unlawfully evicted resident

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Business Office Director, Tasha Keller, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of observations, interviews with staff members and residents, and a review of records. On December 11, 2024, Community Care Licensing received a complaint alleging that Resident 1 (R1) was illegally evicted from the facility. It was alleged that the Administrator told R1 and their responsible party, that they could not return to the facility due to a change in R1’s condition. Information obtained from the interview with the Administrator indicated that the facility spoke to the Palomar Health Rehabilitation Institute, who informed the facility that R1 would need assistance with medication going forward. Unfounded Administrator spoke to R1 and their responsible party and relayed that R1 would need to be sent out each day for insulin injections or have a third-party company visit the facility to assist R1 with the insulin shots, at a cost of $150 to be paid by R1. Prior to this hospital visit, R1 managed their own medications. Administrator stated that they did not serve R1 with an eviction notice because R1 had not returned to the facility. Administrator stated that he would serve R1 with a 30-day eviction notice, as the facility is unable to meet R1’s needs. Information obtained from R1 admitted that they did use to manage their own medication and injections independently. After returning from the hospital visit, the facility conducted a reassessment, which revealed that R1 had a change in their level of care due to needing assistance with medication. R1 stated that they did not receive an official eviction notice. Information obtained from interviews with other pertinent parties corroborated that the facility did not serve R1 with a 3-day or 30-day eviction notice. During the course of the investigation, LPA verified that no eviction notices were generated for R1 or provided to R1 or their responsible party. Based on the information obtained during the investigation, the allegation that the facility unlawfully evicted the resident has been deemed unfounded, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to Business Office Director, Tasha Keller.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 18-AS-20241211131929

Allegation investigated: Staff took away resident's call button

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Executive Director, Austin Irwin, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of observations, interviews with staff members and residents, and a review of records. On November 11, 2024, Community Care Licensing received a complaint alleging that Resident 1 (R1)’s call button was taken away. It was alleged that Staff Member took R1’s call light pendant. It was also alleged that there was a video of the resident having the call light taken. During the LPA’s investigation, there was no evidence available or provided to the LPA regarding Staff Member taking R1’s pendent. Unfounded Information obtained from the interview with the Executive Director indicated that R1 has always had a call light device. Executive Director and staff members indicated that the pendant was obtained to be replaced with a handheld call light button. Interviews corroborated that R1 was provided the pendent the same day. During the initial visit, LPA verified that the call light button was operable. LPA observed and verified that the pendent was in working condition through a mock test. Information obtained from interviews with all pertinent parties corroborates the information provided to the LPA. Information obtained from interviews with additional witnesses revealed no issues or concerns regarding care or supervision. Based on the information obtained during the investigation, this agency has investigated the complaint alleging that staff took away resident’s call button. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was discussed with and provided to Executive Director, Austin Irwin.the state’s words, verbatim · CDSS document, Nov 18, 2024 · control 18-AS-20241101151835

Allegation investigated: Facility staff did not maintain kitchen dishwasher in good repair

Licensing Program Analyst, (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Executive Director, Austin Irwin, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of observations, interviews with staff members and residents, and a review of records. On October 25, 2024, Community Care Licensing received a complaint alleging that the facility did not maintain a kitchen dishwasher in good repair. It was alleged that the dishwasher was inoperable therefore, staff were delivering meals to residents in Styrofoam containers for resident’s meals. Information obtained from Administrator Irwin denied that the dishwasher was inoperable at any time. Unfounded Administrator stated residents were being brought their meals in containers due to an outbreak at the facility. Administrator stated that in an effort to mitigate the outbreak, the dining area was closed and residents were eating in their rooms. During the investigation, LPA observed and verified that the kitchen dishwasher was working and operable. Interviews indicted that there was no prior issues with the dishwasher being out of order. Interviews obtained from all pertinent parties corroborate the information provided to the LPA. Based on the information obtained this agency has investigated the complaint alleging that facility staff did not maintain kitchen dishwasher in good repair. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was discussed and provided to Executive Director, Austin Irwin. Administrator stated staff obtain the mail from the mailboxes and advise residents to obtain their mail from the front desk. Administrator indicated that the mail is pulled and residents are notified daily. Information obtained from R1 stated that mail correspondence is provided to R1 in an untimely manner. Information obtained from additional residents indicated that there are no issues with receiving their mail in a timely manner. During the inspection, LPA observed R1’s mailbox did not indicate the room subsection. LPA also observed that residents do not have direct access or keys to their mailbox. At the time of the visit, facility staff were unable to open resident’s mailboxes as keys were not available. Based on the information obtained during the investigation, this agency has investigated the complaint alleging that facility staff did not ensure resident received correspondence in a prompt manner. 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. An exit interview was conducted and a copy of this report was discussed and provided to Executive Director, Austin Irwin.the state’s words, verbatim · CDSS document, Nov 18, 2024 · control 18-AS-20241025131653

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one hundred and twenty-eight (128) residents live at this facility. The Executive Director, Austin Irwin was advised of the annual and conduct and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Austin Irwin Administrator’s certificate expiration date is 05/08/2026. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. There are food deliveries that come three days out of the week. Emergency food and water supply is present. There is a location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the designated laundry room on each floor, as well as the location located in the garage’s parking structure. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the Housekeeper’s closet. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are no fireplaces at this facility. There is one (1) indoor pool at the facility, that has an enclosed and secured perimeter. There are gates located in the front and back of the building. LPA observed emergency supplies and first aid kits. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that staff` had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed smoke detectors and carbon monoxide detectors throughout the facility. LPA observed fire extinguishers on site, date charged was 02/28/2024. The Escondido Fire Department came to inspect the facility on 07/25/2024. Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Executive Director, Austin Irwin.the state’s words, verbatim · CDSS document, Sep 9, 2024