Westmont of La Mesa

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Eryn Kane, Amy Rodgers, and Leticia Arroyo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Director of Memory Care River Pagala and Executive Director Matthew Ryan. According to the facility’s license, the facility has a maximum capacity of one hundred sixty four (164) clients, non ambulatory, of which 12 may be bedridden. Approved for delayed egress in the memory care portion of the facility and a hospice waiver for eighteen (18). LPAs Kane and Arroyo, accompanied by staff, toured the interior and exterior of the facility and inspected multiple rooms. The facility was clean, sanitary, and in good repair, with unobstructed pathways free of slip hazards. Resident bedrooms contained the required furnishings, and doors, windows, screens, toilets, and showers were all observed to be in working order. The facility had sufficient space and equipment to support dining, laundry, visitation, meetings, and resident activities. The ambient indoor temperature was comfortable, and hot water temperatures at taps accessible to residents were compliant. Food supply met regulatory requirements, with at least two days of perishable items and seven days of non-perishable food, all properly stored. Cooking and dining equipment and utensils were present. No sharp objects, toxic chemicals, fireplaces, or open-faced heaters were accessible to residents. Medications were properly labeled and stored in locked areas, as required. Overall, the facility environment was pleasant, and residents appeared content and engaged in a variety of activities during the visit. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] LPAs noted a pool on the property. The pool area was appropriately secured and not accessible to residents without staff assistance. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility. LPAs interviewed multiple staff and residents. The interviews did not raise any significant licensing concerns. Interviews indicated that staff have an appropriate understanding of their responsibilities and the facility’s operational practices. Interviewed residents conveyed a positive overall impression of the facility’s living conditions. LPAs reviewed multiple staff and client records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Executive Director Ryan, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 14, 2026

Allegation investigated: Staff are not addressing resident's fall risk Resident sustained injuries due to staff neglect

Licensing Program Analyst (LPA) Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themself and disclosed the purpose of the visit to Executive Director Wes Hebner. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside source, review of records, and LPA observations. On January 29, 2026, the Community Care Licensing Division (CCLD) received a complaint alleging that staff are not addressing the resident’s fall risk, and the resident sustained injuries due to staff neglect. The Reporting Party submitted an SOC 341 stating Resident #1 (R1) experienced multiple unwitnessed falls over a period of months, resulting in injuries including a skin tear, bruising, eyebrow laceration, and pain. Unsubstantiated (Continued from LIC9099) Department staff interviews revealed R1 frequently refused to sleep in the bed and instead slept in a recliner, which contributed to repeated falls or near falls. Staff stated that R1 did not consistently use ambulatory devices. Staff confirmed multiple unwitnessed falls and stated they responded promptly, contacted 911 when needed, notified the POA, and assisted R1 back to bed or chair as appropriate. Staff stated R1 was monitored with regular rounds. Department was unable to interview R1 due to discharge from the facility and subsequent placement. Department outside source interview revealed (OS1) they observed R1 attempting to stand from the recliner in an unsafe manner. OS1 reported never witnessing a fall during visits but observed balance issues, weakness, and progressive decline. OS1 also reported that staff appeared attentive and caring and observed multiple staff on duty and throughout the building during their visits. Department records review revealed that facility care notes documented repeated unwitnessed falls dating back to September 2025. Records repeatedly documented that R1 refused to sleep in the bed and preferred to sleep in a recliner, which may have contributed to falls when attempting to get up without lowering the footrest. Records also documented refusal or inconsistent use of the cane and shoes, intermittent confusion, and several instances of R1 sliding, kneeling, or being found on the floor. Department observations revealed on multiple occasions over the months that staff were present and attentive. Staff demonstrated knowledge of resident care needs and fall-risk protocols. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 08-AS-20260129154601

Allegation investigated: Staff are mistreating a resident Staff yell at a resident Staff inappropriately grabbed a resident Staff are not properly feeding a resident Staff leave a resident unattended Resident sustained unexplained injuries while in care

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive DIrector Wes Hebner. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On 7/2/24, it was alleged Staff are mistreating a resident Staff denied mistreatment and described professional and respectful interactions with residents. No concerns were reported by staff regarding the treatment of Resident 1 (R1). R1 and other interviewed residents denied experiencing or witnessing mistreatment. Residents reported feeling safe and well cared for. Outside sources (OS1) familiar with Unsubstantiated R1’s care reported no concerns and confirmed that R1 appeared well cared for and content. Records Review: No documentation indicated any incidents of mistreatment. R1’s LIC 602 showed no cognitive impairments and confirmed R1’s ability to make decisions. LPA Observations: R1 was observed to be well-groomed, alert, and oriented. The living environment was clean and organized, with no signs of neglect or mistreatment. On 7/2/24, it was alleged staff yell at a resident. Staff denied yelling at residents and described using calm, respectful communication. Residents, including R1, denied being yelled at or witnessing staff yelling at others. Outside Source Interviews, no reports or concerns were raised regarding staff yelling at residents. A review revealed no incident reports or documentation supported this allegation. LPA Observed observed staff interacting with residents in a calm and professional manner during the visit. On 7/2/24, it was alleged that staff inappropriately grabbed a resident. Staff denied any physical misconduct and described appropriate handling techniques. R1 and other residents denied being grabbed or witnessing inappropriate physical contact. Outside Source Interviews revealed no concerns regarding physical handling of residents. Records Review revealed no documentation or incident reports supported the allegation. LPA Observations: No signs of injury or distress were observed. R1 had no visible bruising or open areas. On 7/2/24, it was alleged staff are not properly feeding a resident staff Interviews reported that meals are served regularly and residents are offered adequate food and hydration. R1 and other residents confirmed that meals are satisfactory and food is available throughout the day. Outside sources confirmed that R1 has not expressed concerns about meals and appears well nourished. Records Review revealed no documentation indicated issues with nutrition or feeding. LPA Observations revealed R1 appeared well nourished and reported satisfaction with meals and food availability. On 7/2/24, it was alleged staff left a resident unattended. Staff reported regular monitoring of residents and confirmed that R1 is non ambulatory and in the memory unit but still checked on routinely. R1 stated that staff are consistently present and responsive. Other residents confirmed staff availability. Outside Source Interviews revealed no concerns were raised regarding residents being left unattended. Records Review revealed R1’s LIC 602 indicates independence in daily living activities and no need for constant supervision. LPA Observations revealed staff were present and engaged with residents during the visit. R1 was not observed to be unattended. On 7/2/24, it was alleged that a resident sustained unexplained injuries while in care. Staff denied any incidents involving unexplained injuries to R1 and reported that they bump into things while using the wheelchair and the staff attend to their bumps on their hands. Resident Interviews: R1 denied sustaining any injuries and reported no issues with care. Outside Source Interviews revealed no reports or concerns were raised regarding injuries. Records Review revealed bumps to R1's hands that needed bandages but no broken skin. LPA Observations revealed bandaged on R1 hands that were from bumping into the walls and the bumps were being monitored as needed. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, all allegations are UNSUBSTANTIATED. An exit interview was conducted with WesHebner, Executive Director], to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 25, 2026 · control 08-AS-20240702142950

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management visit. The LPA introduced herself and disclosed the purpose of the visit to Executive Director Wes Hebner, later Memory Care Director River Jon Pagala joined the visit. Today's visit was in response to an Incident Report (Dated 3/19/2026) submitted to the Department for Resident 1 (R1). Per facility reporting, R1 sustained a fall on 3/13/2026, which resulted in a clavicle fracture. Reports indicate R1 was taken to the hospital and returned to the facility the same day. LPA conducted a review of R1's pertinent records and interviewed staff. LPA conducted a health and safety check for R1. No health and safety concerns were identified and no deficiencies were cited during today's visit. An exit interview was conducted with Memory Care Director Pagala, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Allegation investigated: Lack of supervision resulting in resident sustaining severe bruising Staff did not notify responsible party of change in resident's condition Staff did not observe resident following change in condition Staff did not meet resident's needs Licensee did not provide resident a safe environment Licensee did not provide required resident activities

Licensing Program Analyst (LPA) Rodgers conducted an unannounced complaint visit and met with the Executive Director Wes Hebner. On July 20, 2021, Community Care Licensing Division (CCLD) received a complaint alleging lack of supervision resulting in a resident sustaining severe bruising, staff did not notify the responsible party of a change in the resident’s condition, staff did not observe the resident following a change in condition, staff did not meet the resident’s needs (ADLs, grooming, diet), licensee did not provide the resident a safe environment, and licensee did not provide required resident activities. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. (continued on LIC9099-C) Unsubstantiated (Continued from LIC 9099) page 2 of 3 The Department interviews revealed multiple caregivers, LVNs, Med-Techs, and the Resident Services Director described monitoring practices, ADL assistance, and activity offerings for Resident #1 (R1) Executive Director David Armour explained caregivers do not chart each ADL task; refusals are documented by exception in digitized Progress Notes provided to the Department. The Department records review revealed service plans included ADL assistance, safety supervision, and activity programming; care notes documented monitoring and diet changes after physician orders; the posted monthly activity calendar was observed by LPA on multiple dates. The Department observations revealed R1 was groomed, room was clean, window intact, and activities were occurring per schedule during visits on 07/21/2021 and 10/27/2021. Regarding the allegation, lack of supervision resulting in resident sustaining severe bruising. The Department interviews and records review revealed staff followed the facility’s fall response procedures when a large bruise was discovered on 07/06/2021: notifying clinical staff (Med-Tech/Resident Services Director), flagging the chart for increased monitoring, and conducting assessments. R1 denied an unwitnessed fall and exhibited full range of motion with no head trauma signs at the time of assessment. Staff increased observation after discovery. Based on evidence, staff acted according to policy. Regarding the allegation, staff did not notify responsible party of change in condition. The Department records review revealed the responsible party became aware of the bruise during their 07/10/2021 visit and was informed in person at the facility. Pursuant to Title 22, Section 87211(a)(1)(B), a written report to the licensing agency and the responsible person is required within seven (7) days for serious injuries as determined by the attending physician. The bruise did not meet the definition of “serious bodily injury” under Title 22, and there is no regulatory requirement for immediate notification in this case. (Continued on LIC9099-C) (Continued from LIC9099-C) pages 3 of 3 Regarding the allegation, staff did not meet resident’s needs. The Department interviews revealed staff provided ADL assistance, with occasional refusals due to dementia-related behaviors (e.g., layering clothing, shaving refusals). ED reported the electric razor charger was replaced and shaving resumed consistently after care conferences. The Department records review revealed diet changes were implemented following physician orders post-hospitalization for Bell’s Palsy; Progress Notes reflected monitoring and adjustments. The Department observations on 10/27/2021 documented R1 cleanly shaven, well dressed, and room/restroom in good order. Regarding the allegation, licensee did not provide resident a safe environment. The Department interviews and records review acknowledged historic concerns (e.g., cracked window and a picture frame with broken glass) that were reported and corrected. The Department observations on 07/21/2021 and 10/27/2021 revealed windows intact, no broken glass, clean non-sticky floors, and no observed hazards. Facility maintenance records and staff interviews confirmed responsive repairs.\ Regarding the allegation, licensee did not provide required resident activities. The Department interviews revealed scheduled activities in Compass Rose (memory care) including group walks, music, tactile stimulation (“busy boards”), games (e.g., dice activity), and pet therapy. The Department observations confirmed activities occurring per the posted calendar and availability of supplies (bingo, coloring, puzzles). While resident preference (walking) and engagement varied, evidence supports ongoing activity provision. Based on interviews, observations, and records review, a preponderance of evidence does not exist to prove any of the six alleged violations occurred. Therefore, these allegations are UNSUBSTANTIATED. An exit Interview was conducted with Executive Director Wes Hebner. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. The Department interviews revealed that on 07/06/2021, staff observed a large bruise on Resident #1(R1) involving the right thigh, lower leg, buttock, and hip area. Staff assessments documented full range of motion and no head trauma signs; however, staff did not notify the physician upon discovery and did not send the resident for evaluation. Staff #1 stated she was aware of the bruise but “got busy and forgot.” Staff #2 confirmed she did not notify the physician or family. The Department records review revealed the facility incident report was completed on 07/13/2021, seven days after the bruise was first observed.The responsible party transported R1 to a hospital on 07/10/2021 due to concern about possible fracture. Hospital documentation revealed diagnostic testing included an X-ray of the right hip and pelvis, which showed no acute fracture or dislocation, and a CT scan of the head, which showed no acute traumatic brain injury or subdural hematoma. Hospital staff noted the bruise appeared two to three days old and expressed concern that the facility had not notified family or reported any incident. Based on interviews, records review, and hospital documentation, the preponderance of evidence supports that staff failed to seek timely medical care for R1 after a significant change in condition was observed. Therefore, this allegation is SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with ED Hebner, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 08-AS-20210715123940

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a) · Plan of correction due date: Feb 20, 2026

87465(a) – Incidental Medical and Dental Care(a) The licensee shall ensure that residents receive assistance in meeting their medical and dental needs… promptly notifying the physician of any significant change in a resident’s condition. Based on interviews and record review, the licensee did not seek timely medical care for a resident after staff observed a significant change in condition, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: The licensee is conduct in-service training to care staff to ensure prompt physician notification and assistance seeking medical care after significant change in condition is observed. LIcensee staff will submit proof of training by POC

Allegation investigated: Unlawful eviction Licensee did not follow resident’s admissions agreement

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Wes Hebner. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On October 21,2021 , the Community Care Licensing Division (CCLD) received a complaint regarding the above allegations. Regarding the allegation, Licensee did not follow the resident’s admissions agreement. More specifically, the facility hired a one-on-one caregiver for a resident #1(R1) without consent and/or without notifying the family verbally or in writing. The department interview with Executive Director David Armour revealed the resident was determined to be at risk due to multiple falls, increased confusion, and refusal of care. Substantiated Continued form LIC9099) The facility initiated 24/7 one-on-one care using a third-party agency without prior family consent. ED Armour revealed that during the care conference, the family was not clearly informed that one-on-one care would be implemented. ED Armour also revealed a written notice was sent later via email after the service began. The department interviews with R1's Family members confirmed they were not informed prior to the initiation of one-on-one care and did not consent to its start. They later continued the service and paid for it but stated they never agreed to the initial implementation. The department's records review revealed the admission agreement authorizes the facility to require one-on-one care if the resident is a danger to self or others. However, the agreement and Health & Safety Code 1569.657 require written notice within two business days of initiating services at a new level of care, including a detailed explanation of additional services and charges. No documentation was provided showing timely written notice or a reassessment prior to initiating one-on-one care. LPA observations on October 27,2021 revealed R1 was receiving one-on-one care from a third-party agency during the visit. The facility failed to provide timely written notice within two business days of initiating one-on-one care and did not involve the R1's responsible person in care planning as required by the admission agreement and Health & Safety Code §1569.657. Regarding the allegation of an unlawful eviction, more specifically, the Reporting Party (RP) alleged that Resident #1(R1) eviction notice was invalid and retaliatory. The department interviewed staff revealed that Executive Director David Armour confirmed R1's eviction notice was sent via email body only on 10/15/21, without attachments, and admitted it did not include Ombudsman contact or appeal rights. The department records review revealed that R1's eviction notice lacked multiple required elements under HSC §§1569.682 and 1569.683, including specific facts supporting the eviction (dates, witnesses, circumstances): Relocation evaluation and resources for alternative housing; Ombudsman and CCL contact information; Complaint rights information; Mandatory unlawful detainer statement explaining court process; Formal written format (notice was sent via email body only). Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Wes Hebner to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 08-AS-20211021113053

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.683 · Plan of correction due date: Feb 20, 2026

Eviction notices; Reasons for Eviction Contents; Service: In addition to complying with other applicable regulations, the notice to quit shall include all required information listed on H&S 1569.683. This requirement was not met as evidenced by: Based on record review licensee did not issue a lawful 30 day notice for (R1) which posed a potential personal rights violation.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: Licensee executive staff agreed to attend/review training on Evictions and provide proof of training by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Feb 20, 2026

1569.657(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident's representative, if any, written notice of the rate increase within two business days after initially providing services... This requirement has not been met as evidenced by: Based on interviews and record review, the Licensee did not provide the resident’s responsible party with a notice of services at a new level of care . This posed a potential personal rights risk to R1.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: Licensee executive staff agrees to review the facility’s admission policy as it pertains to Health & Safety Code §1569.657(a) regarding providing services and notifying residents and their representatives of any change in level of care and associated charges by POC

Allegation investigated: Staff did not met resident's hygiene needs

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Wes Hebner. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review. On 10/27/2025, Community Care Licensing Division (CCLD) received a complaint alleging staff did not meet resident’s hygiene needs. More spefically, the reporting Party alleged that Resident #1 (R1) was often dirty and in clothing soiled with feces upon arrival. The department observations revealed that common areas and bathrooms were clean and sanitary; a random sample of resident rooms inspected were clean, odor-free, and stocked with hygiene supplies. Substantiated (Continued from LIC9099) The department interviews with staff as well as records review reveal staff reported that EMS(Emergency Medical Services) was called for serious falls, and the resident was transported to the hospital on multiple occasions between late January and mid-February 2025. Facility documentation reflects several falls during this period, with medical transports occurring for the most significant incidents. There is no documentation indicating that the staff or the POA refused medical care. The department Interviews with outside sources indicated differing perspectives: While some confirmed that facility staff responded appropriately and did not refuse medical care, others provided accounts suggesting concerns about the timeliness or adequacy of the response. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Wes Hebner to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from lic9099) The department staff interviews revealed that staff reported hygiene care was provided daily and that supplies were available. Department records review revealed that facility documentation, including service plans, indicated regular care for R1. However, outside source interviews (OS1 and OS2) revealed frequent observations of R1, a resident of Compass Rose, in soiled briefs, sometimes saturated through clothing, upon their arrival. They stated they assisted R1 with incontinence care and showers during their visits. One source also described an incident involving another resident who remained soiled for approximately two hours before staff responded. Based on interviews, records review, and outside source statements, the Department determined that a preponderance of evidence exists to support that staff did not consistently meet R1’s hygiene needs as alleged. Therefore, the allegation is SUBSTANTIATED. An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 08-AS-20251027152209

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Feb 6, 2026

Section 87625(b)(2) – Managed Incontinence…the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidenced by: Based on records review, interviews with staff, and outside sources, the licensee did not provide incontinent care to meet R1’s needs. This posed a potential health, safety and personal risk to 1 of 122 residents in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: The licensee will provide in-service training on proper incontinence care protocols and submit documentation of staff training by the POC.

Allegation investigated: Staff do not accord privacy to resident(s) in care.

Licensing Program Analyst (LPA) Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Myra The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On 4/15/25, it was alleged that Staff do not accord privacy to resident(s) in care. Staff interviews revealed residents are provided privacy during personal care routines, including bathing, dressing, and toileting. Staff demonstrated knowledge of residents’ personal rights and facility policies regarding privacy and dignity. Staff denied sharing confidential resident information with unauthorized individuals. Staff demonstrated awareness of confidentiality policies and HIPAA requirements. Unsubstantiated Resident interview revealed that staff knock before entering rooms and provide privacy during care. No residents reported concerns or incidents of privacy violations. No additional witnesses were identified to corroborate the RP’s claim. No residents or family members reported concerns regarding unauthorized disclosure of medical information. Records review confirmed that employees received training on confidentiality and HIPAA compliance. Training logs confirm annual refreshers and orientation materials that emphasize safeguarding resident information and respectful communication. During the visit, LPA observed staff maintaining resident confidentiality during interactions and care. No breaches of privacy were observed. This agency has investigated the complaint alleging the above allegations. The Department has found that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Myra to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 08-AS-20250415101814

Allegation investigated: Staff yelled at resident in care Staff did not safeguard resident's personal property

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Mayra Rodriguez Business Office Manager The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On 10/21/24, it was alleged that Facility staff yelled at a resident in care. Staff members were interviewed, and the staff denied yelling at any resident. The staff described using calm, respectful communication and demonstrated knowledge of residents’ rights and facility policies regarding appropriate conduct. Resident 1 (R1) and other residents interviewed denied being yelled at or witnessing staff yelling at residents. R1 stated that staff are respectful and responsive to resident needs. Outside sources familiar with R1’s care reported no concerns regarding staff behavior and confirmed that R1 had not disclosed any incidents of verbal abuse. Unsubstantiated Records reviewed revealed no incident reports or documentation indicated any occurrences of staff yelling at residents. R1's care notes and logs reflect routine care and monitoring of R1. There were no entries indicating behavioral incidents other than R1's forgetfulness, complaints, or concerns related to staff yelling at R1. R1’s records show consistent engagement in daily activities, episodes of confusion which is R1's baseline condition related to dementia. During the facility visit, LPA Domingo observed staff interacting with residents respectfully and professionally. Staff were attentive to residents’ needs, communicated clearly and calmly, and demonstrated patience and compassion in their approach. Residents appeared comfortable and engaged, and no instances of inappropriate behavior, yelling, or mistreatment were observed. On 10/21/24, it was alleged that Facility staff did not safeguard a resident’s personal property. Staff Interviews revealed that residents’ personal belongings are stored securely and that procedures are in place to safeguard property. Staff were aware of the facility’s policies regarding resident property and described steps taken to prevent loss or damage. Resident Interviews revealed that R1 and other residents did not report any missing or damaged personal items. R1 stated that their belongings were intact and that staff respected their property. Outside Source 1 (OS1) confirmed that R1 does not have any property missing. OS1 stated that R1 has memory deficits and has a history of claiming they have missing items. Records reviewed revealed documentation in R1's records regarding R1's report of missing money, there was an investigation, and there was no record of R1 having money in their wallet or in their room. OS1 verified that R1 did not have any money in their room or wallet. The facility theft and loss policy was reviewed, and the facility followed its policy and began an investigation. R1 had a personal property inventory that did not reflect any money. During the facility visit, LPA Domingo observed R1's room and personal belongings. The room was clean, well-organized, and clutter-free. R1’s personal items—including clothing, hygiene products, and mobility equipment—were present, properly stored, and appeared to be in good condition. There were no signs of missing, damaged, or mishandled property observed. LPA did not observe any unsecured valuables or items that would indicate a lack of safeguarding. This agency has investigated the complaint alleging the above allegations. The Department has found that 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 with Mayra Rodriguez Business Office Manager, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 08-AS-20241021105536

Allegation investigated: Staff are mismanaging residents' medication

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Wes Hebner. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On July 10, 2025 it was alleged that staff are mismanaging residents’ medication. More specifically, It was alleged that staff provided medication intended for one resident to another. Staff interviews with Staff #1 and Staff #2 revealed that prescribed medication (fiber powder) intended for Resident #2 (R2) was mistakenly administered to resident #1(R1). The incident occurred in the medication room while staff were preparing medications for the resident’s temporary off-site stay, following notification from Outside Source 1 (OS1) and the RP would be leaving the facility for several days. Staff reported that the short notice contributed to the medication error and immediately conducted a in-service training with all med-techs. (continued on LIC9099) Substantiated (Continued from LIC9099) The Reporting Party revealed concerns about receiving another resident’s medication and expressed frustration with the facility’s handling of the medication release process. The Department records review revealed that an annual visit was conducted on July 15, 2025, and the October 9, 2025, audit confirmed current compliance with medication management practices, except for this singular incident. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with executive Director Wes Hebner, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. .the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 08-AS-20250710080946

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

87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement has not been met as evidenced by: Based on interviews, the Licensee did not ensure that staff correctly assisted residents with medication administration, which poses a potential health risk for 1 of 123 residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: Resident Service Director stated that an in-service medication training was conducted on 8/28/2025 after the incident. RSD submitted proof of training to the department on 10/15/2025 while at the facility.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA's) Amy Rodgers and Angelica Boyles conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA's Rodgers and Boyles was welcomed by, identified themselves to, and discussed the purpose of the visit with Operations Specialist Benjie Doctolero. According to the facility’s license, the facility has a maximum capacity of one hundred sixty four (164) clients, non ambulatory, of which 12 may be bedridden. Approved for delayed egress and a hospice waiver for 12. This facility does not feature a secured perimeter and does feature delayed egress in the memory care community LPA Boyles, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was complaint Hot water temperature at taps accessible to residents were all compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Operations Specialist Benjie Doctolero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 20, 2025

Allegation investigated: Neglect resulted in serious bodily injury. The licensee did not provide timely medical care

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Executive Director Benjamin and discussed the purpose of the visit. The Department’s investigation consisted of a review of client and outside source records, interviews with staff and residents, and interviews with outside sources. On July 11, 2023, Community Care Licensing (CCL) received a complaint alleging neglect resulted in serious bodily injury, and the licensee did not provide timely medical care. Interviews with the staff provided consistent accounts of the care and supervision provided to Resident 1 (R1). R1 was placed in hospice in March of 2023, due to declining cognitive impairment and his risk of falls. R1’s was provided with a 24 hours 7 (seven) days a week companion to assist with small tasks and ensure they did not try to get out of bed without assistance. (Continued on LIC9099C 2 0f 3) Unsubstantiated (Continued from LIC9099 2 of 3) On the 1st of July 2023, R1 companion hours were decreased from 24 hours, 7 days a week, to 8:00 AM until 8:00 PM. Facility staff checked on R1 every two hours while they were in their room at night. R1 suffered an unwitnessed fall on July 6, 2023. During a routine check on R1, they were found on the floor in their room by a caregiver between 5:00 AM to 5:30 AM. The on-duty Med-Tech was called, and R1 was assessed for injuries. The Med-Tech immediately notified hospice, and a hospice nurse arrived at 6:30 AM to reassess R1. X-rays were conducted the same day (July 6, 2023), and initially, the report indicated there were no breaks or fractures. R1 was treated at the facility by hospice for pain management. A second X-ray report was sent on July 10, 2023, which revealed R1 had a fractured hip. R1 was then sent to the hospital for further evaluation at the request of Outside Source 1 (OS1). Facility staff were proactive in trying to mitigate the risk of falling and sustaining injury. Once it was determined that R1’s risk of falling had increased, R1 was placed in hospice and provided a companion. In addition, staff were conducting regular checks on R1 while they were in their room at night. It was alleged that neglect/lack of care and supervision resulted in a resident not getting timely medical attention. R1 was found on the floor in their room on July 6, 2023, between 5:00 AM and 5:30 AM. The on-duty Med-tech was immediately called to assess R1. R1 had cuts/abrasions on both elbows, but there were no head or other visible injuries. The Med-Tech immediately notified hospice, and a hospice nurse arrived at 6:30 AM to reassess R1. X-rays were conducted the same day, July 6, 2023, and initially, the report indicated there were no breaks or fractures. R1’s care was discussed amongst the hospice nurse and OS1, and it was decided R1 would remain at the facility and be treated by hospice for pain management. A second X-ray report was sent on July 10, 2023, which revealed R1 had a fractured hip. R1 was then sent to the hospital for further evaluation at the request of OS1. Interviews were conducted with 3 (Three) residents. The residents reported that they received adequate care and supervision from the staff and have not experienced or witnessed any neglect or lack of supervision. Interviews were conducted with outside sources, and they confirmed that they have observed staff providing attentive care and supervision to their loved ones and have no concerns about a lack of supervision or neglect. (Continued from LIC9099C 3 0f 3) During the visit, the resident’s living environment and interaction with the staff were observed. Staff were seen providing attentive care and supervision, ensuring the safety and well-being of residents. The environment was found to be free from hazards. A review of the resident's care plan, medical records, and incident reports for the past quarter showed that the resident received appropriate care and supervision. The records indicated that the resident's fall and resulting hip fracture were promptly addressed, with immediate medical attention provided. The facility's policies on care and supervision were reviewed and found to be comprehensive and in compliance with Title 22 and California Health and Safety regulations. The policies outline procedures for monitoring residents and preventing falls. The Department has investigated the above-mentioned allegations and based on observations, interviews, and records review. The Department has found that although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report and licensee rights (LIC 9058 03/22) was provided. Operations Specialist, Benjjie Doctoloero signature on this form confirms receipt of these rights.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 08-AS-20230711152254

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Sabrina Priesman Today’s visit was in response to an incident which licensee self-reported via an SOC341. On 09/17/2024 The report described Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1. R1's Personal belongings were missing from R1's apartment. R1's apartment was thoroughly searched and Local Law enforcement, and the Ombudsman was notified. LPA briefly interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22) were left with the Director, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 26, 2024

Allegation investigated: Staff pushed resident causing a bruise.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced complaint investigation visit to conduct follow-up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Sabrina Priesman Executive Director. The Department’s investigation consisted of interviews with staff, residents, and outside sources, records review, and a tour of the facility. It was alleged that a staff grabbed resident’s shoulder causing a bruise. Review of resident 1 (R1) (Please refer to LIC811 with confidential names), medical records revealed that R1 has a memory impairment and a diagnosis of dementia, R1 was not able to recall the events that occurred. Continued on LIC9099C Substantiated Continued from LIC9099 Review of R1’s facility records revealed that R1 had a history of agitation and did not like staff to redirect her by getting close to her. Interviews revealed that on June 6, 2023 during activities Staff 1 (S1) observed Staff 2 (S2) walking R1 backwards and sat R1 down on a chair roughly. Staff 3 (S3) also observed S2 treating R1 roughly because R1 was not listening to redirection from S2. Staff 4 (S4) also observed S2 walking R1 backwards aggressively. S1, S3 and S4 reported the incident to S5. On June 8, 2023 S5 requested Staff 6 (S6) to complete a body check on R1 and S6 discovered a quarter size bruise on R1's upper right arm. S5 concluded that S2 did not apply any of the elder abuse training that was received during S2's hiring period and monthly training. S5 discovered two previous counseling within S2's four months of working at the facility. S5 was terminated on June 8, 2023. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, the allegation is deemed substantiated. The following deficiencies are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Executive Director XX, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 08-AS-20230609102359

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jun 28, 2024

87468.1 Personal Rights of Residents in All Facilities (a) residents... shall have all of the following personal rights (3) to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement has not been met as evidenced by: Based on interviews and records review, the Licensee did not ensure R1 was free from abuse resulting in bruising. This poses an immediate personal rights risk to 1 of 126 residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: Immediate risk has been removed, LPA verified with the Licensee that S2 is no longer working at the facility as of 06/08/2023. Licensee will conduct an in-service training on reporting requirements, personal rights, and abuse training for staff and provide sign in sheet.

Allegation investigated: Neglect that contributed to resident death

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Administrator. The Department’s investigation consisted of facility and outside records review, interviews with staff, residents and outside sources. On March 2, 2023, Community Care Licensing (CCL) received a complaint of alleging neglect that contributed to resident death. (Continued on LIC9099C) Unsubstantiated [Continued from LIC9099] On January 11, 2023 hospice medical records indicated Resident 1's (R1’s), (See LIC811 Confidential Names list) health was declining citing a significant weight loss of 13 pounds from R1's admission weight. R1 was refusing to take medications and food. R1 was also experiencing auditory and visual hallucinations. Despite antibiotic treatment, R1 had not improved. R1 was a documented fall risk due to being non ambulatory and requiring a wheelchair (Geri Chair). R1 had an order for a half rail, a fall matt next to the bed and R1 was provided with a pendant to call for assistance. R1's care records documented that R1 was checked every two hours in the room and brought out to the dining or activity room during the day to be better supervised by staff. Records revealed that R1 had no documented falls requiring medical treatment prior to January 18, 2023. There is no documentation in R1’s Physician Report or Service plan that indicated R1 was a two person assist. On January 18, 2023 according to staff interview, Staff 1 (S1) had changed R1 and was preparing to transfer R1 from the bed to the Geri Chair. S1 turned away from R1 momentarily to move R1’s Geri Chair closer to the bed. When S1 turned, R1 rolled out of bed to the floor. S1 immediately called for assistance and R1 was assessed by Staff 2 (S2) for injuries. Outside Source (OS1) was called to inform OS1 about the fall and OS1 instructed S2 to assist R1 from the floor and place R1 back in bed since there were no visible injuries or complaints of pain. Once R1 was back in bed, R1 exhibited signs of pain on the hip. S2 called back OS1 and S2 was instructed to give R1 pain medication. On January 19, 2023 OS1 visited R1 and observed R1 in pain and discussed care options with Outside Source 2 (OS2). The options were to send R1 to the hospital to be evaluated or to remain at the facility and provide pain medication to R1. Outside Source 2 (OS2) elected to have R1 remain at the facility and continue to provide pain medication. On January 23, 2023 OS2 decided to send R1 to the hospital due to pain that was not subsiding with pain medication. [Continued on LIC9099C] [Continued from LIC9099C] On January 23, 2023, the hospital diagnosed R1 with a pelvic fracture. Due to R1's age, respect for R1's Code status and declining health, R1 did not undergo surgery. OS1 stated that R1's dementia was worsening and R1's health was declining prior to R1's fall. R1’s Physician Orders of Life Sustaining Treatment ( POLST) indicated Do Not Resuscitate (DNR) with Comfort Measure Treatment. OS1 stated falls causing injury are common with dementia patients and it is difficult for them to recover. Hospice was immediately notified, and care options were discussed. R1 was eventually sent to the hospital on January 23, 2023 when the pain medication was not working. Based on the Department interviews, observations and records reviewed there is not a preponderance of evidence to support that neglect contributed to the death of R1, therefore the allegation is unsubstantiated. An exit interview was conducted with Sabrina Priesman Executive Director to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. The Licensee was provided a copy of their Appeal Rights (LIC 9058 03/22), and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided to Sabrina Priesman Executive Director . [Continued from LIC9099] On January 18, 2023 Resident 1 (R1), (Please refer to LIC811 for a list of confidential names list), had a witnessed fall. Interviews with facility staff revealed that the Unusual Incident/Injury report was not completed because R1 initially did not have any visible injuries or any complains of pain. Records reviewed and staff interviews revealed that when R1 was transferred from the floor to the bed, R1 expressed pain. The facility staff confirmed that the Unusual Incident/Injury report was not completed for the incident. On January 23, 2023 R1 was sent to the hospital via 911 and was diagnosed at the hospital with a fractured pelvis. The facility staff was asked if an Unusual Incident/Injury report was completed and the staff confirmed that there was no Unusual Incident/Injury report completed for the hospital transfer of R1. On January 31, 2023 R1 passed away and the facility staff was asked if an Unusual Incident/Injury report and a Death Report was completed. The facility staff confirmed that there was not an Unusual Incident/Injury report completed for R1. Outside Source 1 (OS1) and Outside Source 2 (OS2) requested a copy of the Unusual Incident/Injury report for R1's fall, the transfer to the hospital and the Death Report and the facility staff confirmed that the reports requested were not given due to the facility staff did not complete the reports. The facility staff also confirmed that Community Care Licensing Regional Office did not receive the Unusual Incident/Injury reports because no reports were completed. Based on interviews, observations and review of documentation including medical records, the above allegation is substantiated. This finding means that the preponderance of evidence has been met and the allegation is valid. The deficiencies are cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted and a plan of correction was established with Sabrina Priesman Executive Director. A copy of this report along with licensee Appeal Rights (LIC 9098 03/22) was given to Sabrina Priesman Executive Director whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 08-AS-20230302140255

From the deficiency page — Deficiency type: Type B · Section cited: CCR 872119(a)(1) · Plan of correction due date: Jul 19, 2024

Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require...A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence of..Death or any serious injury... This requirement is not met as evidenced by: Based on interview and records reviewed, the licensee did not report 1 out of 120 resident fall, hospitalization or death which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: Executive Director agreed to have all staff (Clinical team) attend a CCL approved training on Reporting Requirements. Proof of training will be provided by POC due date.

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Facility staff failed to seek timely medical attention.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA Domingo introduced herself and disclosed the purpose of the visit tSabrina Priesman Executive Director. It was alleged that Facility staff failed to seek timely medical attention for Resident 1 (R1), (Refer to LIC811 Confidential Names list). On January 18, 2023 R1 was being prepared to be transferred from the bed to the Geri Chair. Staff 1 (S1) turned away from R1 momentarily to move R1’s Geri Chair closer to the bed. When S1 turned, R1 rolled out of the bed on to the floor. S1 immediately called for assistance and R1 was assessed by Staff 2 (S2) who assessed R1 for injuries. Initially there were no visible injuries or complaints of pain. (Continued on LIC9099C) Substantiated [Continued from LIC9099] Outside Source (OS1) was called by phone to inform OS1 about the fall and OS1 instructed S2 to assist R1 from the floor and place R1 back in bed since there were no visible injuries or complaints of pain. Once R1 was back in bed, R1 exhibited signs of pain on the hip. S2 called back OS1 and S2 was instructed to give R1 pain medication. On January 19, 2023 OS1 visited R1 at the facility. OS1 assessed R1 and determined that R1 was in pain. OS1 contacted Outside Source 2 (OS2) to discuss care options. OS2 elected to have R1 remain at the facility and have OS1 provide pain medications for R1's pain. Initially the pain medication provided relief but at some point, R1 was showing signs of pain once again. From January 20, 2023 through January 23, 2023, OS2 observed R1 to be in more pain each day. Subsequently, OS2 asked for 911 to be called so R1 could be evaluated at the hospital. On January 23, 2023 Paramedics arrived and transported R1 to the hospital where R1 was diagnosed with a fractured pelvis. R1 expressed pain from the time of the fall on January 18, 2023 to the time of the transfer to the hospital on January 23, 2023. R1 was able to express pain and the pain was not relieved by medication. The facility did not seek timely medical attention to address R1's expression of pain for 5 days. The Department has investigated the above-mentioned allegation and based on interviews and records reviewed, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The deficiencies are cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted, plan of correction were reviewed and a copy of this report along with licensee Appeal Rights (LIC 9098 03/22) was given to Sabrina Priesman Executive Director whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 08-AS-20240229124243

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 27, 2024

A plan for incidental medical care shall be developed by each facility. The plan shall encourage routine medical care and provide for assistance in obtaining such care by... The licensee shall arrange or assist in arranging for medical care appropriate to the conditions and needs or residents... This requirement was not met as evidenced by: Based on interviews and records review, the licensee delayed medical attention for 1 of 126 resident that expressed pain for 5 days which posed an immediate health, safety or personal risk to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: Executive Director agreed to have all staff (Clinical team) attend a CCL approved training on timely medical attention. Proof of training will be provided by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Sabrina Priesman Executive Director. During today's visit, LPA observed residents in care, conducted a health and safety check, reviewed records, and interviewed staff and residents. The purpose of today's visit was to conduct follow up regarding a self reported incident. On May 18, 2024, the Department received an incident report from the facility describing an incident that occurred on May 16, 2024, where staff discovered that Resident 1's (R1's) medication was not being administered as ordered. [Please refer to the LIC811 Confidential Names List to identify individuals]. Interviews with S2 revealed that the resident is not a self-administrator of medications. The health and service plan reflects that R1 is not a self-administrator of medications and R1's medications were ordered from P1. S2 stated that S1 noticed that R1's medication was running low and S1 ordered the medication from P1. R2 directed S1 to call P2 to have the medication delivered to the facility. P2 delivered the incorrect medication, the correct medication was delivered on May 19, 2024 and R1 starting taking the medication on May 19, 2024. Interviews with S2 and review of R1's electronic medication administration record (E-MAR) revealed that the medication was not given to R1 from May 12, 2024 through May 18, 2024. The Physician was notified of the medication error and staff was directed to monitor R1 for no adverse side effects of the missed medication. Interview with S2 revealed that R1 had not been experiencing any adverse effects due to the medication not being administered not as ordered. The following deficiency for medication administration is being cited and noted on the attached LIC809-D page. An exit interview was conducted with Executive Director Sabrina Priesman whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, May 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87645(c)(2) · Plan of correction due date: Jun 29, 2024

87465 Incident Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by: Based on interview and record review, the licensee did not ensure that R1's medication was administered as ordered by the physician. This poses a potential health risk to 1 of 92 residents in care.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: RSD conducted an in-service training for staff on proper medication administration and verification by 6/29/2024 after discovering the medication error.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Sabrina Priesman. According to the facility’s license, the facility has a maximum capacity of one hundred sixty four (164) clients, non ambulatory, of which 12 may be bedridden. Approved for delayed egress and a hospice waiver for 12. During today’s inspection, there were a total of ninety two (92) clients in care, and per medical records, all were ambulatory. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 73 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 112 F, Bathroom #1 sink was 111 F, and Bathroom #2 sink was 112 F. Refrigerator temperature was 31 F and freezer temperature was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Sabrina Priesman Executive Director , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, May 29, 2024

Type of visit: Case Management - Incident

On April 4, 2024, Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced case management visit at the facility. LPA was greeted by Sheryl McCaskill Operation Specialist and granted entry after identifying herself. LPA met with Sheryl McCaskill Operation Specialist and explained the purpose of the visit. The facility self-reported an incident to Community Care Licensing on March 21, 2024 regarding an incident that occurred on March 19, 2024. Reporting indicated that Resident 1 (LIC811 Confidential Names list provided to Administrator to identify R1) had an unwitnessed fall which resulted in a change in condition. R1 refused to go to the hospital the day of the fall on March 19, 2024. On March 20, 2024 at 1:15 pm R1 was sent by ambulance to the hospital for further evaluation and treatment. During today’s visit, LPA conducted a Health and Safety check of R1 and requested facility records. No deficiencies were cited at this time. An exit interview was conducted with Sheryl McCaskill Operation Specialist and a copy of this report and Licensee/Appeal Rights (LIC 9058 03/22) was provided.the state’s words, verbatim · CDSS document, Apr 4, 2024

Allegation investigated: Neglect resutling in serious injury from resident on resident altercation.

Licensing Program Analyst (LPA), Debbie Correia, conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit and the elements of the allegation with Execuive Director (ED) Kimberly Garcia. The Department’s investigation included staff, resident, and outside source interviews, and facility and outside source records reviews. It was alleged lack of supervision resulted in an altercation between two residents causing one (1) resident to sustain serious bodily injury. Staff, resident, and outside source interviews revealed on August 8, 2022, at approximately 10:00 P.M. Resident 1 (R1) was assaulted by Resident 2 (R2) in R1’s room. Staff and outside source interviews and an outside source records review revealed R1 sustained large lacerations and skin tears. Staff interviews and records reviews also revealed both residents resided in the memory care unit of the facility. [CONTINUED ON 9099C] Substantiated A resident records review revealed R1 was admitted to the assisted living unit of the facility on October 19, 2019, with a diagnosis of Chronic Kidney Disease, Hypertension, AFIB, and Type II Diabetes. A review of resident records dated May 18, 2022, revealed R1 was showing symptoms of confusion, disorientation and wandering behaviors. On July 7, 2022, R1 was transferred from assisted living to the memory care unit of the facility. Staff interviews revealed R1 kept to themselves, and mainly stayed in their room. Staff interviews and a resident records review revealed R2 was admitted to the facility on August 17, 2020, with a primary diagnosis of Alzheimer’s disease, but no signs of aggressive behavior. An interview with Staff 1 (S1) revealed R2 was non-verbal and had a routine of walking in circles around the hall and a tendency to wander into other resident’s rooms. R2 would not show signs of agitation before they became aggressive and assault the caregivers and R2 had only physically assaulted staff, never a resident. The interview with S1 also revealed Outside Source 1 (OS1) hired a Private Caregiver (PC), however the PC opted to be reassigned due to R2’s aggression. An interview with Staff 2 (S2) revealed R2 was difficult to redirect because they would become angry and mean, and on occasion would spit on staff and other residents, although S2 was surprised by R2’s extreme violent behavior against R1 during the current incident. An interview conducted with Staff 3 (S3) revealed when R2 was first admitted they were pleasant but soon had a mental decline and was extremely emotionally unbalanced. S3 corroborated that R2 was a wanderer and had a tendency to wander into other resident’s rooms. A facility records review revealed, in contrast to staff statements, on November 20, 2020, R2 physically assaulted another resident in care and on December 20, 2020, a resident records review revealed R1 was assessed as in need of a Personal Care Attendant (the amount of time was not unspecified) due to their behaviors, and on May 5, 2022, approximately three (3) months prior to the incident under investigation, R2 was assessed as in need of a Personal Care Attendant every day for four (4) times a day. Interviews conducted with the Executive Director (ED) and S3 revealed R2’s Primary Care Physician (PCP) was adjusting their medications to address these behaviors prior to the incident. [CONTINUED ON 9099C] The interview with S3 also revealed on the day of the incident there were four (4) staff working in the memory care unit that housed approximately 28 to 30 residents, and R2 did not have a Personal Attendant or Private Caregiver. An interview with Staff 4 (S4) revealed, on the day of the incident, at approximately 7:00 p.m. they had checked on R1, and they were resting in bed conversing with a visitor. S4 also revealed checking on R2 at approximately 8:00 p.m. and could not locate R2 and asked a staff member regarding R2’s whereabouts and the caregiver pointed across the unit where R2 was observed walking down the hall towards R1’s room, S4 didn’t think anything of it because it was R2’s normal daily routine to walk the unit halls. Approximately 10 minutes later, Staff 5 (S5) came running down the hall towards S4 stating R2 had been injured and R1 was in their room. S4 and S3 ran to R1’s room and found R1 in their bed covered in blood and S4 immediately called 911 and began attending to R1’s injuries, while S5 escorted R2 out of the room. S4 revealed they asked R1 what happened, and they said they walked out of their bathroom and saw R2 was in their room sitting in their recliner. R1 asked R2 why they were in their room and told them to leave. R1 revealed after telling R2 to leave they began attacking them, and when R2 ceased the attack they sat back down in the recliner and R1 called the front desk receptionist for help from their phone, although memory care staff already knew by the time the receptionist tried to notify them Staff interviews revealed both residents were transported to the hospital. An outside source records review revealed R1 had dark blue Ecchymosis (contusions) on the right side of their face, and Ecchymosis and skin tears to their left side of their face, upper chest, bilateral upper and lower arm, and right anterior thigh, requiring wound care. R1’s injuries were caused by scratching and hitting during the assault by R2. R1’s injuries were treated and bandaged and R1 was discharged back to the facility the following day. An interview conducted with the ED revealed R2 remained at the hospital in restraints due to their agitation and was diagnosed with a Urinary Tract Infection (UTI). Upon discharge R2 was relocated to another facility. [See LIC 811 for confidential names] Based on evidence obtained, the allegation is substantiated because the preponderance of the evidence standard has been met. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D. An exit interview was conducted with ED Garcia and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) was provided. ED signature below confirms receipt of the documents. The ED revealed being in communication with R2’s POA regarding what was best for R2. An Outside Source 1 (OS1) record review revealed OS1 had been misinformed and recanted that the ED ever said R2 could not return to the facility upon discharge. An additional outside source records review revealed a meeting with the facility staff and outside sources determined R2 needed a higher level of care. Based on staff and outside source interviews, as well as an outside source records reviews, the above allegation was determined to be unsubstantiated. An unsubstantiated finding means although the allegation could be valid the preponderance of evidence standard was not met. An exit interview was conducted with ED Garcia. A copy of this report and Licensee/Appeals Rights (9058 01/16) will be provided to ED Garcia at the conclusion of the visit. Signature below confirms receipt of the documents.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 08-AS-20220811140908

From the deficiency page — Deficiency type: Type A · Section cited: CCR 84761(A) · Plan of correction due date: Mar 29, 2024

The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1)tends to wander; (2) is confused or forgetful (5) has a documented history of behaviors which may result in harm to self or others. This requirement was not met as evidenced by: Based on records reviews and interviews, the licensee did not ensure the amount of supervision determined necessary by assessments for one (1) Resident 1 [R1] in care which posed an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Executive Director agreed to have all staff attend a CCL approved training on assessing changes in behavior/conditions to determine appropriate level of care. Proof of training will be provided by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Kimberly Garcia. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 01/29/2024). According to the LIC624: on 01/27/2024, Resident #1 (R1) eloped from the facility (meaning they left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] Staff responded to a door alarm, located R1 in the facility’s parking lot, and brought R1 back inside, unharmed. During today’s visit, LPA performed a brief facility tour and welfare check, verifying that R1 was indeed unharmed. LPA inspected the facility’s delayed-egress doors in its memory care section, finding them audible and operational. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 03/31/2023), R1 was diagnosed with Dementia and their doctor determined that they were not able to safely leave the facility unassisted. The LIC603 Preplacement Appraisal, Care Assessment, and Plan of Care which Licensee performed on R1 corroborated these same points. Due to their baseline memory-loss and language impairment, R1 was not able to participate as a reliable historian/interviewee in this case. Per LPA observation and corroborated by staff interviews: R1 lived in the facility’s secured “Compass Rose” memory care section. This section features four (4) delayed-egress doors, which unlock and open 30 seconds after the panic bar is pressed (assuming staff do not first enter a code to reset/rearm the door and its associated alarm). [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] According to date and time stamped records, which were corroborated by staff interviews: On 01/27/2024 around 4:35 PM, staff heard one of the Compass Rose delayed-egress door alarms go off. When staff arrived at this specific door, no resident was near it. Staff, per their training, performed a team search of the interior and exterior of the facility building. Staff located R1 in the facility’s parking lot at 4:46 PM, unharmed. Per manager interviews: The Compass Rose PM Shift is considered “fully staffed” with one (1) Medication Technician and four (4) Caregivers. According to the staff work schedule, and corroborated by staff interviews: During the incident, Compass Rose had two (2) Medication Technicians and four (4) Caregivers on duty. No deficiencies were cited during today’s visit. However, LPA issued two (2) Technical Violations (TVs), regarding signage affixed to delayed-egress doors and reporting requirements (see the LIC 9102-TV pages). LPA also issued Technical Assistance (TA) regarding electronic equipment issued to care staff (see the LIC 9102-TA page). An exit interview was conducted with Garcia, to whom a copy of this report, the LIC9102-TV, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 30, 2024

Allegation investigated: Staff do not ensure that the facility remains free of odors Staff do not assist resident with incontinence needs Staff do not ensure resident's hygiene needs are being met Staff are not providing adequate food service to resident

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to open a complaint and deliver findings. LPA was allowed entry by Kimberly Garcia, Director. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Director. On December 28, 2023, a complaint was received regarding Staff do not ensure that the facility remains free of odors; Staff do not assist resident with incontinence needs; Staff do not ensure resident's hygiene needs are being met; Staff are not providing adequate food service to resident. The purpose of this investigation was to determine the validity of the allegations and take appropriate actions if necessary. The following were reviewed and observed as part of the investigation: Residents' records, Incident reports, and meal plan/menu and a tour of the facility. Continued on 9099c Unsubstantiated Allegation 1: Staff do not ensure that the facility remains free of odors. The investigation revealed that there were no instances where staff members failed to keep the facility free of odor. No odors were present at the time of visit. Allegation 2: Staff do not assist resident with incontinence needs. The investigation found that staff members had followed policy and procedures for changing incontinence wear. Allegation 3: Staff do not ensure resident's hygiene needs are being met. The investigation revealed that there were no instances where staff members failed to meet residents' hygiene needs. Staff followed schedule for bathing/showering of resident. Allegation 4: Staff are not providing adequate food service to resident. The investigation revealed that resident would skip meals because they did not want to be awaken to eat. However, staff will provide a snack prior to the next meal served. Based on the findings of this investigation, the allegations of Staff do not ensure that the facility remains free of odors; Staff do not assist resident with incontinence needs; Staff do not ensure resident's hygiene needs are being met; Staff are not providing adequate food service to resident were found to be unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Kimberly Garcia, Director. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Director and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jan 4, 2024 · control 08-AS-20231228102541