Westmont of Morgan Hill

Allegation investigated: Facility staff did not provide care and supervision of residents without physical or verbal abuse. Facility staff are not appropriately trained.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unnanounced complaint investigation visit. LPA met with Executive Director (ED) Michael Fountain. LPA stated the purpose of the visit. On 4/14/2026 the Department received a complaint with the above allegations. On 4/22/2026 the Department conducted the intial complaint investigation visit and interviewed 5 Staff (S1 to S4), 7 Residents (R1 to R7) and 1 Witness (W1). 5 Out of 5 staff stated he/she is not aware of staff yelling, pushing, pulling or hitting residents in care at anytime. On 4/22/2026 the Department interviewed 7 residents. 6 Out 7 Residents stated he/she is not aware of any staff yelling, pushing, pulling or hitting residents in care at anytime. Page 1 of 2 Unsubstantiated R4 states there was an incident where staff yelled at him/her due to R4 yelling at another resident. R4 states the staff yelled at him/her to stop yelling at the resident. R4 states there was an incident where he/she was trying to get up from his/her wheelchair and staff began to push the wheelchair. R4 states he/she almost fell. R4 did not provide additional information regarding these incidents. On 4/16/2026, 4/20/2026 and 4/22/2026 the Department interviewed Witness 1 (W1). W1 states his/her loved one was pulled by the wrists by facility staff. W1 did not provide additional information regarding this incident. The Department reviewed incident reports for the months of February 2026, March 2026 and April 2026, there were no incident reports regarding physical or verbal abuse of residents in care by staff. Facility staff are not appropriately trained. On 4/22/2026 the Department conducted the initial complaint investigation visit and interviewed 4 Staff (S1 to S4), 7 Residents (R1 to R7) and 1 Witness (W1). 4 Out of 4 staff stated he/she has received training by the facility. On 4/22/2026 the Department interviewed 7 Residents (R1 to R7) 7 residents out of 7 residents stated the staff know what they are doing when assisting him/her with care. On 4/16/2026, 4/20/2026 and 4/22/2026 the Department interviewed Witness 1 (W1). W1 states facility staff are 'not well trained on everything." W1 did not provide additional information regarding how staff are not well trained. On 4/22/2026 the Department reviewed 5 staff records. 5 Out of 5 staff records contain training records for 2023, 2024, 2025 and 2026, to included training topics such as but not limited to dementia care, person centered care, nutrition and hydration. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted with GM and a copy of this report was provided. Page 2 of 2the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 26-AS-20260414103629

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Executive Director Michael Fountain (ED) . LPA toured Compass Rose (Memory Care unit) with ED to include 4 apartments (RM #129, #126, #123, #120), bathrooms, activity room, kitchen, dining room, and patio area. All fire exit routes were free and clear of obstruction. LPA checked 2 common restrooms in memory care unit. One delayed egress exit door of memory care unit was observed in working condition and the other one was under repair. LPA observed a caregiver sit outside if the exit door of the memory care unit to monitor. Room temperature maintained between 76 degrees F. Kitchen refrigerator temperature maintained at 40 degrees F. Freezer temperature maintained at 0 degrees F. Hot water temperature measured at 118 degrees F. Chemicals, disinfectants, and medications observed locked in Compass Rose. During visit, resident's observed participating in various activities. 2 resident files in Compass Rose was reviewed. 2 out of 2 resident files were complete and no issues noted. LPA inspected 2 resident's centrally stored medication and records with staff. 2 out of 2 resident medications were complete and no issues noted. LPA entered in the kitchen with the ED. The facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Items inside the refrigerator and freezer observed covered and labeled. Continue on LIC809-C. LPA toured Assisted Living with ED to include 4 resident apartments (RM #225, #218, #206, and #243) and common restrooms. Hot water temperature was measured at 118 degree F. LPA checked 2 residents file in Assisted Living was reviewed. 2 out of 2 resident's files were complete. LPA inspected 2 resident's centrally stored medication and records with staff. 2 out of 2 resident medications were complete and no issues noted. 4 staff files were reviewed and observed complete. 4 out of 4 staff members are fingerprint cleared. 4 out of 4 staff have over 20 hours of annual training. Fire extinguishers observed throughout the facility, last service date was 06/26/2025. Facility has carbon monoxide and smoke detectors present. Carbon monoxide detector was tested and was observed functional. Facility has an emergency disaster plan and emergency non-perishable foods. LPA observed the facility has a box that contains emergency supplies to include (but not limited to) flash lights, batteries, radio, reflector vests, and band aids. The last time of the facility emergency drill was done on 1/30/2026. Elevator observed in working condition. LPA observed the facility has a first aid kit. 3 stairwells were observed with an evacuation chairs. LPA toured 2 court yards and side yard with ED. The court yard of memory care unit with 2 delayed opening doors and were observed in operational condition. No citation were cited today. This report was reviewed with Executive Director, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 24, 2026

Allegation investigated: Facility staff are not adhering to residents' care plan. Facility staff are not addressing the issue of ants in resident's rooms and kitchen area.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Executive Director, Michael Fountain and Resident Service Director, Jmy Ramos and stated the purpose of today’s visit. On 11/12/2025, the Department received a complaint with the above allegations. On 11/20/2025, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 3. Unfounded Page 2 of 3. Facility staff are not adhering to residents’ care plan. It was alleged residents are being left in their wheelchairs “all day”, staff are not meeting resident’s care needs in memory care and assisted living. On 11/20/2025, LPA Rai interviewed four staff (S1-S4). Three out of four staff (S1-S3) are involved in the resident’s care. Three out of three staff stated the facility has an electronic system to generate residents’ care plan and staff initial as acknowledgment for providing care and supervision to the residents in a timely manner. The staff are able to make notes if the resident was delayed care or if resident refused care services. Three out of three staff stated they do not see residents in their wheelchairs all day as residents are transferred by staff. They stated there is one resident (R1) who sleeps in the assisted living side of the facility but spends the day on the memory care side of the facility for activities and meals. R1 stated the facility staff is able to provide care and supervision to the resident and the residents’ needs and services have been updated. Based on review of at random five resident’s records, LPA Rai reviewed 5 service plans which address resident’s care and attached care plans which show staff’s initials acknowledging providing care and supervision to the residents in a timely manner. LPA Rai reviewed R1’s care plan before and after moving to assisted living unit and the facility staff addressed resident’s care and supervision. On 2/4/2026, LPA Rai interviewed three staff (S5-S7). Three out of three staff stated the facility staff do not leave the residents in the wheelchair “all day”. The facility staff will assist the residents back to their bed for naps or help assist them in the dining room and activity room. Three out of three staff stated they are meeting the residents’ care needs in a timely manner and they acknowledge providing care and supervision by placing an initial in the resident’s care plan for each service for each shift of the day. Three of the three staff stated the facility staff did assist resident R1 in assisted living side and memory care side and they are able to meet the resident’s care and supervision needs. On 2/4/2026, LPA Rai interviewed five residents (R1-R5). Five out of five resident stated the facility staff do not leave the residents in the wheelchair “all day”. Five out of five residents stated the staff are meeting the residents’ care needs in a timely manner and they have no issues of staff not responding to their care needs in a timely manner. Page 3 of 3. Facility staff are not addressing ants in the facility in resident's rooms and kitchen area. It was alleged that there are ants in the kitchen and resident rooms and the facility staff are not addressing the issue. On 11/20/2025, LPA Rai interviewed four staff (S1-S4). Four out of four staff stated the facility staff do address ant issues in the facility. Four out of four staff stated there is a third-party vendor that comes out to the facility twice a month as maintenance care to ensure there are no issues in the facility. Four out of four staff stated the maintenance team at the facility do have commercial spray to address ant issues in the facility right away and if there are repeat issues with the resident rooms, then the third-party vendor will address the issue during the monthly spray schedule. Based on review of facility system of recording maintenance issues at the facility, LPA Rai reviewed 6 incidents between May 2025 to November 2025 wherein there were ants present in resident rooms. LPA Rai did not observe any records wherein there were any incidents recorded of ants present in kitchen area. LPA Rai reviewed the third party vendor services from September 2025 to November 2025 and LPA Rai did not observe any records where technician observed any pests at the facility and technician provided the semi-monthly treatment in the kitchen, resident rooms, and exterior areas of the facility. On 2/4/2026, LPA Rai interviewed three staff (S5-S7). Three out of three staff stated they have brought up issues of ants being present in resident rooms, but the maintenance team has addressed it right away. Three out of three staff stated they have observed the third-party vendor present at the facility addressing the concerns in the kitchen and resident rooms and the facility staff have addressed the ant concerns right away. On 2/4/2026, LPA Rai interviewed five residents who reported incidents of ants in their room between May 2025 to November 2025. Five out of five residents stated they brought up the concerns of ants to the facility staff and they addressed the issue right away by spraying the area or bring in the third-party vendor to address the issue. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Michael Fountain and Resident Service Director, Jmy Ramos and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 26-AS-20251112160202

Allegation investigated: Facility did not provide proper care and supervision to resident in care. Resident was physically assaulted while in care.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Resident Services Director Jmy Ramos On August 21, 2025 the Department received a complaint alleging resident was physically assaulted while in care. On August 26, 2025, the Department received an incident report regarding R1. The incident report stated on August 19, 2025, at 3:00pm, R1 appeared confused and disoriented. R1 stated he/she had been having hallucinations and he/she believed that he/she had been given a “date rape drug” and had been molested. 911 was contacted. Page 1 Out of 5 Unfounded LPA Tarin interviewed staff S1 & (Former) Resident Services Director Gladys Desmarais, referred to as S2. S1 stated he/she isn’t aware of any incident of alleged physical abuse from any resident by staff. Staff S2 stated S2 states not aware of any incidents of physical abuse. S2 stated R1 was confused and having hallucinations and believed he/she was drugged and told S2 that he/she believed someone gave him/her date rape drug and someone molested him/her. S2 stated R1 said it was 2 male staff members, and R1 didn’t know their names. S2 stated paramedics came to assess him/her and paramedics called the R1’s responsible party, referred to as FM to inform. S2 stated the paramedic told him/her that FM stated R1 has been making this allegation about being molested for years. On October 30, 2025, LPA Manuel Monter interviewed staff S3-S6. 4 Out of 4 staff are not aware or didn’t observe any physical altercations between staff and or residents on the assisted side of the facility in the past 6 months. LPA Manuel Monter interviewed current Resident Services Director (RSD) Jmy Ramos. RSD stated R1 was not physically assaulted. RSD stated there was no observed bruising, bleeding or marks on R1. RSD stated there were no incidents of residents physically assaulting R1. On November 3, 2025, LPA interviewed Witness W1. W1 stated he/she became aware of the allegations based on his/her conversation with R1’s responsible party, referred to as FM. W1 stated FM stated, that R1 has been stating he/she has been molested for multiple years. W1 stated he/she also spoke to R1, who told W1, that after he/she was given his/her UTI medication, R1 expressed to W1 that he/she was just hallucinating and the assault didn’t occur. On November 10, 2025, LPA Monter interviewed residents R13-R17. 5 Out of 5 residents (R13-R17) stated there are not aware of or have not heard about any physical altercation occurring between residents in the facility. 5 Out of 5 residents (R13-R17) stated they are not aware of or have not heard about any physical altercation occurring between staff and residents in the facility. Page 2 Out of 5 LPA Monter interviewed staff S7-S10. 4 Out of 4 Staff (S7-S10) stated there are not aware of or have not heard about any physical altercation occurring between residents in the facility. 4 Out of 4 Staff (S7-S10) stated they are not aware of or have not heard about any physical altercation occurring between staff and residents in the facility. he Department reviewed R1's Service Plan, dated July 23, 2025. Under behavioral expressions, the plan states "resident has a history of hallucinations as a medication reaction." The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Facility did not provide proper care and supervision to resident in care. On August 21, 2025 the Department received a complaint alleging Facility did not provide proper care and supervision to resident in care. It has been alleged that resident R1 was not being given their medication, not being bathed and are not being assisted with escorting. On August 25, 2025, LPA Tarin conducted the initial complaint investigation visit. LPA interviewed residents R2-R12. 8 Out of 11 residents (R2, R4-R6,R8,R9,R11) stated they receive their medications on time and have not had any issues with medications. 4 Out of 11 residents (R3, R7, R10, R12) interviewed stated they don’t need staff assistance with medication administration. 11 Out of 11 residents (R2-R12) stated they don’t have any issues with the care they are receiving at the facility. LPA Tarin (Former) Resident Services Director Gladys Desmarais, referred to as S2. S2 stated to her knowledge, he/she is not aware of any issues with R1 not receiving his/her medications on time. On October 30, 2025, LPA Manuel Monter interviewed Staff S1, S3-S6. 5 Out of 5 staff (S1, S3-S6) stated isn’t aware of any issues regarding medication errors. 5 Out of 5 staff (S1, S3-S6) stated there hasn’t been a time when a resident who needed to be escorted, wasn’t escorted. 5 Out of 5 staff (S1, S3-S6) stated there hasn’t been a time when a resident who needed assistance with showers, wasn’t assisted. Page 3 Out of 5 On, October 30, 2025, LPA Manuel Monter randomly audited 4 resident’s medications. LPA audited the medications by cross referencing the medication bottles/ containers and cross referencing with the Centrally Stored Medication Record and Medication Administration Record. No discrepancies were noted during review. On November 10, 2025, LPA Monter interviewed residents R13-R17. 5 Out of 5 residents (R13-R17) stated they have not had any issues with their medication administration. 3 Out of 5 residents (R13, R14, R16) stated they do not need assistance with showers. 4 Out of 5 residents (R13-R16) stated they do not need assistance with escorting. 2 Out of 5 residents (R15, R17) stated they need assistance with showers and there hasn’t been a time when they were neglected their shower. Resident R17 stated he/she does need assistance with escorting and stated there hasn’t been a time when he/she was neglected his escorting needs. LPA Monter interviewed staff S7 – S10. 4 Out of 4 staff (S7-S10) stated they have not heard about or observed a resident who was neglected their shower. 4 Out of 4 staff (S7-S10) stated they have not heard about or observed a resident who was not escorted and neglected. 4 Out of 4 staff (S7-S10) stated they have not heard about or observed any instance of a resident not getting their medication. On November 13, 2025, LPA Monter interviewed Resident Services Director (RSD) Jmy Ramos. RSD stated on care track, they have the days the residents are scheduled to have a shower. RSD stated once it has been completed, it will be updated on care track. RSD stated there hasn't been an instance where a resident was neglected, and not given their shower. RSD stated there hasn't been any instance of R1 being neglected and not escorted. RSD stated in terms of medications for R1, there hasn't been any instance of R1 not receiving their medication and/or the facility not administering R1 medication per physician's order. The Department reviewed R1's Service Plan, dated July 23, 2025. Under Mobility, the service plan states R1 does need escorting to meals as needed / As requested. The Department reviewed R1's Medication Administration Record for the month of July and August 2025. Based on a review, there was no discrepancies noted. Page 4 Out of 5 The Department reviewed R1's Care Summary for July October 2025. Based on a review, the summary notes detail all the instances of R1 receiving assistance with his/her bathing needs. LPA did not note any discrepancies. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 5 Out of 5. END OF REPORT.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 26-AS-20250821101231

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit to follow up regarding an incident report, which stated a resident had eloped from the facility. LPA met with Administrator (ADM) Michael Fountain. LPA explained the purpose of the visit. On October 16, 2025, the Department received an incident report (IR) from the facility. The IR stated, on October 15, 2025, around 7:20pm, medtech noticed R1 was not in their bedroom. After double checking the room, medtech alerted staff and initiated a thorough search of the community. The resident was located outside the community by a care giver and was safely escorted back inside. No injuries were observed. On October 17, 2025, LPA Manuel Monter interviewed Resident Services Director (RSD), Jmy Ramos. RSD stated R1 was found at target. (Based on a google Maps search, Target is 0.4 miles away from Westmont of Morgan hill.) RSD stated one of the care givers found him/her. RSD stated the care giver, Staff S4 had already clocked out, and happened to be at target, he/she recognized R1, at around R1 was found. RSD stated S4 saw R1 and recognized him/her. RSD stated R1 was found around 8:10pm. RSD stated R1 has wandering behavior. RSD stated, based on what she knows, R1 used to live at assisted living, and moved to memory care in July 2025. RSD stated R1 cannot leave the facility unassisted. RSD stated she isn't sure how R1 got out of the memory care, or which door, RSD stated the staff claimed they didn't hear the door alarms make a sound. RSD stated she tested the doors the next day, and the alarms did sound. RSD stated the executive director also tested the same day of the elopement and the alarm sounded. Page 1 Out of 3. On October 20, 2025, LPA Manuel Monter interviewed staff S1-S3. All staff interviewed stated R1 has exit seeking behavior. All staff interviewed stated they did not hear the delayed egress alarm activate/ring. S1 stated the day of the elopement, after taking R1 for a walk he/she took R1 back to his/her bedroom. S1 stated he/she went to pass out medications for the residents. S1 stated she started from the entrance of the memory care unit. S1 stated while she was going through her routine, she eventually got to R1, and R1 wasn’t there. S1 stated he/she doesn’t know how R1 exited the memory care unit. S2 stated on October 15, 2025, staff S1 and R1 went walking. S2 stated they came back around either, 6:40pm or 6:20pm. S2 stated S1 took R1 back to her room. S2 stated that is the last time he/she saw R1. S2 stated he/she was assisting a resident to bed when the elopement occurred. Staff S3 stated resident R1 is an exit seeker. S3 stated R1 is one of the main residents that tries to exit seek. S3 regarding the elopement: Around 7pm, was the last time he/she saw R1. S3 stated when he/she saw R1 in hallways, passing the dining room, headed to the TV. S3 stated he/she was going to use the restroom. S3 stated when he/she exited the bathroom, S1 asked if he/she has seen R1. LPA Monter interviewed Memory Care Coordinator, Rohit Singh, referred to as MCC. MCC stated R1 has sun downing and exit seeking behavior everyday. MCC stated R1 was assigned, in terms of groupings, to staff S1. MCC stated staff are supposed to supervise residents they are assigned to. The Department reviewed R1's Service plan, dated March 24, 2025. The service plan states, under the section, Wandering and Elopement, that R1 needs frequent supervision and redirection due to wandering outside and/or off community premises. Exits must be monitored due to elopement risk. Further more, the service plan states R1 has exit seeking behavior during the day and night; and R1 has prior history of elopement. Page 2 Out of 3. The Department reviewed R1's Physician's Report, dated April 8, 2025. The report states R1 has a neurocognitive disorder and cannot leave the facility unassisted. As a result, the department issued an immediate civil penalty of $500 for the absence of supervision, which resulted in R1 eloping from the facility. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Administrator Michael Fountain and a copy of the report was provided. Appeal Rights was provided. END OF REPORT Page 3 Out of 3the state’s words, verbatim · CDSS document, Oct 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 23, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) (4) To care, supervision, and services that meet their individual needs and are delivered by staff … to meet their needs. This requirement was not met as evidence by: Based on interview and records reviewed, on October 15, 2025, R1, who has a neurocognitive disorder left the memory care unit unassisted and was found 0.4 miles away from the facility. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 22, 2025

Plan of correction: ADM they have provided in-service for daily door checks. ADM stated they also updated the delayed egress doors codes. ADM stated they had the do company inspect the doors as well. ADM stated they also did an in-service regarding elopement. ADM stated he would send LPA the plan of correction by POC due date, October 23, 2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards an incident report, which stated a resident had eloped from the facility. LPA's met with Business office director Brianne Merritt. LPA's explained the purpose of the visit. On October 16, 2025, the Department received an incident report from the facility. The incident report stated, on October 15, 2025, around 7:20pm, medtech noticed R1 was not in their bedroom. After double checking the room, medtech alerted staff and initiated a thorough search of the community. The resident was located outside the community by a care giver and was safely escorted back inside. No visible injuries were observed upon return. During the visit LPA interview 4 staff. LPA requested staff schedule for October 15, 2025, and a copy of R1's care plan prior to October 15, 2025. LPA determined this incident requires further investigation. This report was reviewed with Brianne Merritt. A copy was provided.the state’s words, verbatim · CDSS document, Oct 20, 2025

Allegation investigated: - Facility staff tells resident to use their diaper rather than assist the resident to the bathroom - Facility staff does not offer resident water resulting in dehydration - Facility does not safeguard resident's personal belongings - Facility staff handled a resident roughly

On 05/20/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with Resident Services Director - Ria Hernandez and explained the purpose of today's visit. During the investigaiton documents are reviewed, interviews are conducted, and observations are made. It cannot be determined if the allegations took place as described. Contridicting information cannot confirm if they took place. Facility has toileting plans for all residents. Water is encouraged, sometimes juice, to residents as well as snacks. Staff do are not aware of how or if the resident's belongings went missing. Staff indicate that residents tend to take off clothing such as sweaters and leave them behind. Or, residents due to their diagnosis' of dementia may take another resident's clothes unintentionally. No staff or residents indicate seeing staff handle resident's roughly as described. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Resident Services Director - Ria Hernandez and a copy is provided during today's visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 20, 2025 · control 26-AS-20250129152555

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Executive Director (ED), Jolie Higgins and Resident Services Director Ria Hernandez. LPA toured Compass Rose (aka Memory Care) with ED to include 4 apartments (RM 138B, 133, 134, and 129), bathrooms, activity room, kitchen, dining room, and patio area. All fire exit routes were free and clear of obstruction. Delayed egress exit doors observed in working condition. Temperature maintained between 72 - 74 degrees F. Kitchen refrigerator temperature maintained at 26 degrees F. Freezer temperature maintained at 0 degrees F. Hot water temperature measured between 109.4 - 111.2 degrees F in RM 133 and 138B. Chemicals, disinfectants, and medications observed locked in Compass Rose. Activities calendar observed posted for the month. During visit, resident's observed participating in various activities. 2 resident files in Compass Rose was reviewed. 2 out of 2 resident files were complete and no issues noted. LPA inspected 2 resident's centrally stored medication and records with staff. 2 out of 2 resident medications were complete and no issues noted. LPA entered in the kitchen with the ED. The facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Walk-in refrigerator temperature maintained at 36 degrees F. Walk-in freezer temperature maintained at 0 degrees F. Items inside the refrigerator and freezer observed covered and labeled. LPA observed a menu posted in the Compass Rose and Assisted Living section. See LIC809-C. LPA toured Assisted Living with ED to include 4 resident apartments (RM 223, 219, 206, and 248). Hot water temperature was measured between 109.4 - 111.5 in RM 219 and 248. 2 residents file in Assisted Living was reviewed. 2 out of 2 resident's files were complete. LPA inspected 2 resident's centrally stored medication and records with staff. 2 out of 2 resident medications were complete and no issues noted. 4 staff files were reviewed and observed complete. 4 out of 4 staff members are fingerprint cleared. 4 out of 4 staff have over 20 hours of annual training. Fire extinguishers observed throughout the facility, last service date was 06/28/2024. Facility has carbon monoxide and smoke detectors present. Facility has an emergency disaster plan and emergency non-perishable foods. LPA observed the facility has a box that contains emergency supplies to include (but not limited to) flash lights, batteries, radio, reflector vests, and band aids. Emergency drills are being completed monthly and the last drill was completed in January 2025. Elevator observed in working condition. LPA observed the facility has a first aid kit. 3 stairwells were observed with an evacuation chair. Activities calendar posted in the elevator in assisted living. Based on resident interviews, the activity calendars are also provided to the residents weekly. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Jolie Higgins and Resident Services Director Ria Hernandez and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 19, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1- year annual inspection. LPA met with Executive Director (ED) Jolie Higgins. LPA entered the kitchen with the ED. Refrigerator temperature maintained at 32 degrees F and freezer temperature maintained at 1 degree F. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. Items inside the refrigerator observed covered and labeled. Fire extinguisher last serviced on 05/30/2023. Facility has sufficient amount of silverware and dishes. LPA toured Compass Rose (aka Memory Care) with ED to include 6 resident apartments (RM 137B, 133, 130, 128, 124, and 123), bathrooms, activity room, dining room and exterior. Temperature in memory care maintained at 74 degrees Fahrenheit. Hot water temperature in RM 133 maintained at 110 degrees Fahrenheit. Oxygen in use signs posted in appropriate areas. All chemical, disinfectants, and hygiene items observed secured. Residents observed participating in activities during visit. 1 out of 2 egress doors in the patio observed in disrepair as the egress door does not open or alarm. The facility has another fire exit egress door in the patio area in case of emergency. 1 egress door inside memory care observed in disrepair and does not alarm. Facility initially had a latch lock on the door installed at the very top of the door that is not within arms length. LPA advised to remove the latch lock on the door in case of emergency. Facility staff immediately removed the lock and taped multiple caution tape signs on the door. Facility placed the lock temporarily to avoid resident elopements while they wait for the door to be repaired. The facility scheduled technicians to repair the egress doors this week. SEE LIC809-C. LPA reviewed 4 resident files in memory care contained a signed admission agreement, updated medical assessment, TB result, service plan, consent form, and personal rights form. 3 out of 4 residents uses oxygen and has a physician order for oxygen on file. 2 out of 4 residents uses half rails and has a physician's order for half rails on file. LPA reviewed 4 resident centrally stored medication records and centrally stored medication. 1 out of 4 resident was missing 1 PRN medication that was not written in the centrally stored medication record. LPA observed the facility has the physician's order on file along with the PRN log. LPA toured Assisted Living with ED to include 6 resident apartments (RM 247, 239, 236, 229, 226, and 225) bathrooms, and common areas. Temperature maintained at 74 degrees F. Hot water temperature in RM 247 AND 236 observed at 112 degrees F. LPA observed the residents are provided with an activity schedule weekly. 1 stairwell observed free and clear of obstruction with a stairwell chair. LPA reviewed 4 resident files in Assisted Living contained a signed admission agreement, medical assessment, TB result, service plan, consent form, and personal rights form. LPA reviewed 4 residents centrally stored medication records. LPA observed 2 medications were not part of the centrally stored medication records for 2 out of 4 residents. LPA observed the physician's order for each medication. Staff immediately inputted the medication on the centrally stored medication record. 5 residents were interviewed in their apartments. LPA reviewed 6 staff records to include a fingerprint clearance, health screening, TB result, employee rights, and job application. 1 out of 6 staff members had a 1st Aid Certification. Facility has at least one person per shift who has a first aid certification. Facility has a scheduled 1st Aid certification course scheduled on 02/26/2024. LPA reviewed staff training records included training on topics to include but not limited to medication, dementia/Alzheimer, postural supports, and hospice care. LPA recommended to document the hours for each in-service training. Facility has an updated emergency disaster plan. Fire drills are being conducted quarterly with the drills dated on 11/2023, 12/2023, and 01/2024. No deficiencies are being cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Executive Director, Jolie Higgins, Resident Care Director, Ria Hernandez and Memory Care Director, Myrene Carasi and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 20, 2024