Westmont of Santa Barbara

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-202600806115719. During today’s visit, LPA observed a portion of the dining area was roped off denying/excluding residents’ access to a portion of the dining area. LPA observed seven (7) 4-top dining tables were roped off in the dining area between the Concierge’s desk/common area/front entrance. Moreover, the roped off area restricts residents in care direct access to the Concierge’s desk/common area forcing residents to walk around the entire roped off area. During today’s visit, Administrator Shelly Ramos and Staff 1 (S1) stated there is one food server on duty for each meal (breakfast, lunch, dinner) and the Corporate office suggested roping off the area. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued at the time of the visit. Appeal Rights issued.the state’s words, verbatim · CDSS document, Aug 11, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 12, 2026

(a)... (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on observation and interviews conducted, the Licensee did not comply with the regulation above by restricting access to the Concierge's desk and/or denying freedom of choice which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Administrator agrees to no longer rope off areas restricting access and/or freedom of choice in common areas of the facility. Civil Penalty Assessed

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Administrator Shelly Ramos was present at the time of arrival. Resident Services Director was also on duty. Resident Services Director oversees Assisted Living and the Memory Car Unit at this time. During today’s visit, there were 47 residents in care in the Assisted Living unit with one (1) medication technician, one (1) medication technician/caregiver, and two (2) caregivers on duty. In the Memory Care unit, “Compass Rose”, there were eighteen (18) residents with one (1) medication technician and (2) caregivers on duty. Currently, the Resident Services Director oversees the activity programming for the Memory Care unit of the facility. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to residents with a dementia diagnosis, and 99 non-ambulatory residents of which 10 may be bedridden. There are twelve (12) residents currently on hospice. Entrance interview conducted: The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. Throughout the facility, there are approximately 10 fire extinguishers and 5 fire pull alarms. The pull alarms alert the local fire department when activated. Fire inspection was most recently conducted on 9/3/2025. LPA observed the dining areas are clean. LPA observed kitchen cabinets, refrigerator, stove, and counters are clean. Please continue to 809-C, Pg 2. Assisted Living Residents participate in activities such as special occasion celebrations, music entertainment, Bocce ball, physical therapy, and excursions to local eateries and retail businesses. Memory Care residents participate in activities such as special occasion celebrations, music entertainment, and scenic drives. A "Cycling without Age" activity is available for residents in Assisted Living and Memory Care. Due to time restraints, LPA will continue the annual inspection at a later date. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Aug 5, 2026

Allegation investigated: Staff are not trained properly in transferring and repositioning resident

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility to deliver final findings of the allegations. LPA met with Jade Alma-Harris Administrator and explained the purpose of the visit. LPA De Leon conducted the initial 10-day visit on 02/13/2026 and collected records pertaining to the investigation. LPA interviewed staff on 05/12/2026 at 11:47am and 12:01pm. LPA interviewed witnesses on 05/04/26 at 12:56pm and on 05/12/2026 at 4:06pm. LPA received emails from Administrator regarding complaints on 02/20/2026, 05/05/2026, and 05/12/2026. LPA received emails from Complainant on 02/12/2026 and 02/13/2026. On the allegation: Staff are not trained properly in transferring and repositioning resident. It was alleged staff were not properly repositioning residents, had to ask other staff what to do, and were roughly handling residents due to improper technique. Continued 9099-C Substantiated LPA De Leon reviewed the facility training records provided by the Administrator specific to Resident transfers, positioning of bed bound patients, 1 or 2 person assists, and hospice care. On 01/07/2026, 28 Wellness staff participated in an All Staff On-site service training on the topics of Body Mechanics, Positioning, Moving, and Transfers, How to Properly Position Bed Bound Patients, and Get a Lift Buddy. Staff 1 (S1) and Staff 2 (S2) took this training and were listed on the sign in sheets. Twelve Wellness staff took a Competency Verification on Transferring in 2025, Staff 2 was present with a mentor and completed Procedure/Steps/Bed to Chair/Wheelchair/Bed to Walker and Wheelchair to Chair, S2 had a satisfactory completion by a Mentor, S1 did not appear to have a Competency Verification on Transferring based on the records the facility provided LPA. Course Enrollments in online courses were taken by staff with completion dates in 2024-2026 on the Topic of Transferring Safety, 15 staff had completed this course, S2 had completed this course on 06/09/2025, S1 had not completed this course based on records provided. Another course was taken online called Restorative Nursing: Positioning & ROM for Nursing Assistants 14 staff completed this course with completion dates in 2024-2026, S1 completed this training course on 01/05/2026 and S2 completed this course on 06/11/2025. LPA requested Hospice Training records for Resident 1(R1) Administrator could not provide any records of staff training provided by hospice personnel for R1’s hospice care plan, which included transferring and repositioning. R1 was on Hospice services and experienced baseline pain, and sometimes staff used a sheet to help transfer R1 to reduce pain from transfers. R1 was a 2-person assist. A witness stated the staff lacked training to do the repositioning and were not using a sheet so staff would cause R1 pain. Overall, the investigation revealed two staff provided care to Hospice Resident (R1) without Hospice training and records specific to individual R1’s Hospice Care Plan. Based on the evidence this allegation is Substantiated at this time. Exit interview conducted and copy of report emailed tor Administrator per request. Staff would try to do the best job staff could but R1 was clearly in pain and when staff would have to touch R1 to reposition R1 would moan and groan in pain, sometimes the sheet would come down under R1 and one staff would have to touch R1 to hold R1 as the other staff would pull the sheet back up under R1 so that the staff could reposition R1 with a sheet under R1 and not have to physically touch R1 to reduce the pain R1 was in already. R1 was a 2-person assist. A witness stated the staff lacked training to do the repositioning and were not using a sheet so staff would cause R1 pain. Another Witness interview revealed the staff did not handle R1 roughly, R1 was in pain, R1’s family did not want R1 on certain pain medications to help R1’s pain, the facility staff are caring and did not feel staff were under trained or understaffed but felt staff could always use more training. Witness stated the best thing for R1’s care and pain would have been a Hoyer Lift for repositioning and transferring but unfortunately the facility policy does not allow Hoyer Lifts in the facility, and that could have avoided added pain when transferring and repositioning, R1 declined rapidly and in was in pain which had nothing to do with the staffing and more so to do with R1’s transitioning. Based on the lack of evidence this allegation is Unsubstantiated at this time. Exit interview conducted and copy of report emailed to Administrator.the state’s words, verbatim · CDSS document, May 13, 2026 · control 29-AS-20260213094231

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(b)(6)(B) · Plan of correction due date: May 20, 2026

(b)A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:(6)Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan. (B)The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above in 2 staff provided care to Hospice Resident (R1) without Hospice training and records specific to the individual R1’s Hospice Care Plan which poses an potential safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Administrator agreed to read and review 87633, provide a statement of understanding, have hospice agency nurse train a facility lead staff on proper repositioning and transferring for residents on hospice services, then the lead staff can train all wellness staff -Cont. below- working with Hospice residents, provide proof of trainings and materials used with staff signatures and an up to date LIC 500 to CCL.

Allegation investigated: The facility does not respond to residents' calls for assistance in a timely manner due to insufficient staffing The facility does not ensure sufficient staff in the dining room to serve meals timely Licensee did not ensure sufficient staff to provide activities to residents for several months The facility did not provide housekeeping services to common areas or residents rooms with clean linens 1 time per week for the past several months The Licensee/Administrator does not communicate with residents and responsible parties

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Administrator Jade Alma-Harris and explained the purpose of the visit. LPA De Leon conducted the 10-day visit on 06/10/2025, interviewed staff at 11:00 am, interviewed residents at 11:30am and collected records. Witnesses were interviewed on 06/09/2025 in the afternoon and by email on 08/18/2025. LPA De Leon made a subsequent visit on 11/21/2025 to interview staff at 10:30 am, 11:02 am, 11:25 am, 12:20pm, 2:10pm, 2:41pm, interviewed residents at 2:26pm and 3:05pm. LPA De Leon collected further records on 11/17/2025 and 12/08/2025 and reviewed additional records. On 11/25/2026 LPA De Leon conducted a subsequent visit and interviewed residents at 12:55pm, 1:15pm, 1:42pm, 2:20pm, and 3:15pm.. Continued 9099-C Substantiated On the allegation: The facility does not respond to residents' calls for assistance in a timely manner due to insufficient staffing. LPA De Leon reviewed call button logs for the 7 randomly chosen residents at the facility for a 7-day period from June 1, 2025-June 7, 2025, which revealed 3 out of 7 residents reviewed had call button logs over 15 minutes to a maximum of 96 minutes. One Resident had 9 calls over 15 minutes, 1 at 15 minutes, 2 at 16 minutes, 1 at 18 minutes, 1 at 20 minutes, 1 at 21 minutes, 1 at 22 minutes, 1 at 25 minutes and 1 at 48 minutes. The next resident had 1 call at 37 minutes, another Resident had 7 calls with 1 at 15 minutes, 1 at 16 minutes, 1 at 17 minutes, 1 at 19 minutes, 1 at 40 minutes, 1 at 50 minutes and 1 at 96 minutes. LPA reviewed 7 randomly chosen resident care plans which revealed six out of seven (6/7) residents had care plans with additional services needed. Care Plan 1- included Bathing maximum assistance 2 x per week, Dressing maximum assistance daily in the am and pm, Oral Care maximum assistance daily, Hearing moderate assistance with devices from Med-Tech daily am and pm, Toileting maximum assistance several times daily, Meals moderate assistance cutting, preparing and prompting, Engagement minimal assistance needed, Housekeeping services 1X per week. Care Plan 2- included Bathing is now done by Hospice Agency staff, Dressing maximum assistance reminders and preparing items, Toileting maximum assistance stand by assist as needed daily, Transfers moderate assistance standby assist when needed daily, Mobility maximum assistance escort to meals with walker and reminders, Medication Management maximum assistance med pass 2x a day, Coordination of Care moderate assistance with hospice agency, Housekeeping services 1x per week with daily trash pickup. Care Plan 3- included Cognition, Behavioral Expression and Communication minimum assistance prompting and observation, Bathing maximum assistance 1x per week, Mobility minimum assistance walker with daily observation, Care Plan 4- included Bathing is done by Hospice agency, Dressing is maximum assistance daily am and pm, Toileting maximum assistance daily when needed, Transfer maximum assistance daily, Mobility maximum assistance daily, Meals minimum assistance daily reminders, Engagement minimum assistance reminders and observation, Medication Maximum Assistance needed. Housekeeping services 1X per week. Care Plan 5- included Mobility maximum assistance for escorts, walker and wheelchair, Engagement minimum assistance for need and observation, housekeeping services 1X per week. Continued 9099-C Care Plan 6- included Bathing maximum assistance 1 staff 2 x a week, Dressing maximum assistance, Toileting maximum assistance, Mobility maximum assistance with a walker, Medication maximum assistance pass up to 4 or more times per day by a medication technician (Med-tech), Coordination with outside agency moderate assistance Home Health, Housekeeping services 1X per week and Trash assistance daily 7 x a week. Care Plan 7- Resident does not have additional services and is independent of the care plan. Care staff are assigned residents to showers, dressing, and transfers daily and in addition to residents pressing their pendants for help daily. Records reviewed show the residents waiting 15 plus minutes for help with daily Assistance with Assistance with Daily Living (ADL) and on days where the staff are short-handed the wait times can be even longer. Staff interview revealed staff do respond to residents for assistance but at times residents wait so long the resident does the tasks themselves. Witnesses interviewed revealed resident wait times for assistance with ADL’s in much longer than the 10 minutes the facility says it takes and dining times are much longer when the facility is short staffed on that day. Timely assistance was not provided to residents in care based on record review and interviews this allegation is Substantiated at this time. This allegation is the same deficiency as the one cited on Complaint #29-AS-20250604132416 during the same period therefore it will not be duplicated on this complaint. On the allegation: The facility does not ensure sufficient staff in the dining room to serve meals timely. LPA conducted interviews with Caregivers which revealed they had to help in the dining room. Staff stated the dining room has been short staffed, and the facility was using caregivers to help take orders and get food if there were not enough kitchen staff to do so, the facility stopped using care staff for sanitary purposes. The waiting times for taking orders and getting food were longer at times when there were not enough staff. A staff member stated one of the housekeeping staff had to take off work for a while and some of the regular cleaning schedules were not kept up during a period of 1-2 weeks in resident apartments and in the common areas due to not having enough staff to help clean. A staff member said in 09/2025 the facility had hired enough kitchen staff to be fully staffed with servers and the facility asked a server to cover the vacant housekeeper position. LPA interviewed 7 out of 7 Residents which revealed the wait times could be 15-40 minutes for help depending on how many caregivers and servers were scheduled that day. A resident stated if you came early to meal service, then you would get better service but if you came in the middle to the end of service it takes longer. Continued 9099-C A resident stated the desserts were not coming out when the resident was done eating the meal, residents had to wait until all residents were served the meal then staff would serve the dessert at the end of the meal to all the residents at the same time, which took even longer if you came early to eat. Witnesses said the dining room is short staffed, and it takes longer to get meals ordered and delivered to the tables. Based on interviews this allegation is Substantiated at this time. This allegation was cited on Complaint # 29-AS-20250310142840 therefore it will not be duplicated on this complaint. On the allegations: Licensee did not ensure sufficient staff to provide activities to residents for several months. LPA interviewed staff members which revealed activities program director quit, and the new activity staff or director was not hired for several months leaving activities short staffed for a period of 1-3 months, some staff helped run a few activities during this period, but several activities were cancelled. The activities calendar was not followed during this time. Resident interviews revealed residents would attend the activity posted on the calendar and no staff would show up to run the activity. Several residents said they no longer attend activities or certain activities are not the same as they used to be and residents do not care to attend any longer. Witnesses interviewed revealed staff weren't providing the residents with activities. Witness said the facility was having bingo at witness’s request, but the facility expected resident family members to call out the bingo numbers. Based on the evidence this allegation is Substantiated at this time. This allegation was cited on Complaint #29-AS-20250604132416 during the same period therefore it will not be duplicated on this complaint. On the allegation: The facility did not provide housekeeping services to common areas or residents rooms with clean linens 1 time per week for the past several months. A resident interviewed revealed not sure of the activity or housekeeping schedule any longer, not sure if the housekeeper was coming to clean or not, at times the caregivers were helping clean up the room and taking out the trash if they had the time. A witness said the dining room tables are left with food and sticky residue from prior meals. Witnesses interviewed noticed the common areas and apartments were not being cleaned like they normally were for a few weeks due to short staffing. LPA De Leon conducted a tour of resident 10’s (R10’s) room and once LPA entered the doorway the room had a strong urine odor. LPA took photos of R10’s bed and restroom which both needed cleaning and sanitizing. Staff interviews revealed 5 out of 7 staff stated R10’s room had a heavy urine odor. Witness interview revealed resident room had a heavy smell of urine all the time and an odor of feces at times when the bedding had not been changed. Continued 9099-C R10’s care plan revealed that R10 could not clean R10’s own room and restroom and this was to be completed by housekeeping staff. Staff stated that R10’s room was brought to the attention of housekeeping and directors, and the care plan was not updated to accommodate additional services needed to maintain odor, cleanliness, sanitation and disinfection. R10 moved out of the facility, and according to interviews it took several cleanings to get the room back into rentable condition. Witness stated that resident rooms are supposed to be cleaned once per week, staff aren't cleaning the rooms, and resident 1’s (R1’s) room has gone weeks without being cleaned, if Witness calls facility to say the room hasn't been cleaned, staff will send someone to clean it, but it's supposed to be a weekly service, and it's not being done. Witness stated the bedding isn't being washed either. Based on evidence this allegation is Substantiated at this time. This allegation is the same deficiency as the one cited on Complaint #29-AS-20250604132416 during the same period therefore it will not be duplicated on this complaint. On the allegation: The Licensee/Administrator does not communicate with residents and responsible parties. Witness interview revealed Resident 1 (R1) was as breakfast and needed to use the bathroom. R1 pressed pendant R1 needed to go to the bathroom. Staff took R1 to R1’s room and just left R1 in the middle of the room and left without helping R1 to the bathroom. R1 was stuck in the wheelchair because the foot pedals were not in the right position and R1 could not reach R1’s walker. R1 called the front desk using R1’s cell phone and a staff member put the call through to another staff and R1 told staff what happened. Staff walked by and entered R1’s room and helped R1 to the bathroom. This is another situation where the agency staff were unable to communicate with a resident to meet an urgent need to use the bathroom. Witnesses said caregivers should be able to communicate with the residents to meet the care needs and staff not being able to communicate with the residents seems like it could be a very dangerous situation. Staff interviewed revealed the facility has had major turnover in several positions during 2024-2025 when Administrator vacated the position the communication lacked heavily, and several residents and responsible parties did not have questions answered or call back when they made inquiries regarding residents and the facility. Based on the lack of communication to responsible parties (RP) this allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 29-AS-20250604110119

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Feb 3, 2026

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by: Based on staff turnover and interviews the Licensee did not comply with the regulation above, residents responsible parties did not get responses from Administrator/Licensee which posses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agreed to make a statement of understanding regulation, and how turnover of staffing as directors/Administrator will no longer affect communications, and will timely answers residents and family’s questions, and provide statement to CCL.

Allegation investigated: Staff leave resident unattended for extended periods of time. Staff do not respond to requests for assistance from resident. Resident's room is odiferous. Staff do not provide activities to resident(s). Staff do not ensure that resident receives their mail. Staff do not ensure that resident's bedding is sanitary.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Administrator Jade Alma-Harris and explained the purpose of the visit. LPA De Leon conducted the 10-day visit on 06/10/2025, interviewed staff at 11:00 am, interviewed residents at 11:30am and collected records. Witnesses were interviewed on 06/09/2025 in the afternoon and by email on 08/18/2025. LPA De Leon made a subsequent visit on 11/21/2025 to interview staff at 10:30 am, 11:02 am, 11:25 am, 12:20pm, 2:10pm, 2:41pm, interviewed residents at 2:26pm and 3:05pm. LPA De Leon collected further records on 11/17/2025 and 12/08/2025 and reviewed additional records. On 11/25/2026 LPA De Leon conducted a subsequent visit and interviewed residents at 12:55pm, 1:15pm, 1:42pm, 2:20pm, and 3:15pm.. Continued 9099-C Substantiated On the allegation: Staff leave residents unattended for extended periods of time. LPA De Leon reviewed call button logs for the 7 randomly chosen residents at the facility for a 7-day period from June 1, 2025-June 7, 2025, which revealed 3 out of 7 residents reviewed had call button logs over 15 minutes to a maximum of 96 minutes. One Resident had 9 calls over 15 minutes, 1 at 15 minutes, 2 at 16 minutes, 1 at 18 minutes, 1 at 20 minutes, 1 at 21 minutes, 1 at 22 minutes, 1 at 25 minutes and 1 at 48 minutes. The next resident had 1 call at 37 minutes, another Resident had 7 calls with 1 at 15 minutes, 1 at 16 minutes, 1 at 17 minutes, 1 at 19 minutes, 1 at 40 minutes, 1 at 50 minutes and 1 at 96 minutes. Staff interviews revealed call buttons are usually answered in under 10 minutes if the facility is fully staffed. Staff stated residents use the call buttons for non-emergent matters at times. LPA reviewed records and there is no way for staff to tell if the next call button press is non-emergent or an emergency matter unless staff go to the location and check on the resident. Staff interviews revealed the facility was short staffed for periods of time during 2024-2025 and during those times when the facility was short staffed it took longer to answer the calls while doing regular duties assigned with resident’s showers, dressing, transferring and assistance. Staff stated that when they are with a resident, they must finish taking care of the resident before they can move on to the next call or the next duty assigned. Based on the evidence this allegation is Substantiated at this time. On the allegation: Staff do not respond to requests for assistance from residents. LPA De Leon reviewed call button logs for the 7 randomly chosen residents at the facility for a 7-day period from June 1, 2025-June 7, 2025, which revealed 3 out of 7 residents reviewed had call button logs over 15 minutes to a maximum of 96 minutes. One Resident had 9 calls over 15 minutes, 1 at 15 minutes, 2 at 16 minutes, 1 at 18 minutes, 1 at 20 minutes, 1 at 21 minutes, 1 at 22 minutes, 1 at 25 minutes and 1 at 48 minutes. The next resident had 1 call at 37 minutes, another Resident had 7 calls with 1 at 15 minutes, 1 at 16 minutes, 1 at 17 minutes, 1 at 19 minutes, 1 at 40 minutes, 1 at 50 minutes and 1 at 96 minutes. LPA reviewed 7 randomly chosen resident care plans which revealed six out of seven (6/7) residents had care plans with additional services needed. Continued 9099-C Care Plan 1- included Bathing maximum assistance 2 x per week, Dressing maximum assistance daily in the am and pm, Oral Care maximum assistance daily, Hearing moderate assistance with devices from Med-Tech daily am and pm, Toileting maximum assistance several times daily, Meals moderate assistance cutting, preparing and prompting, Engagement minimal assistance needed, Housekeeping services 1X per week. Care Plan 2- included Bathing is now done by Hospice Agency staff, Dressing maximum assistance reminders and preparing items, Toileting maximum assistance stand by assist as needed daily, Transfers moderate assistance standby assist when needed daily, Mobility maximum assistance escort to meals with walker and reminders, Medication Management maximum assistance med pass 2x a day, Coordination of Care moderate assistance with hospice agency, Housekeeping services 1x per week with daily trash pickup. Care Plan 3- included Cognition, Behavioral Expression and Communication minimum assistance prompting and observation, Bathing maximum assistance 1x per week, Mobility minimum assistance walker with daily observation, Care Plan 4- included Bathing is done by Hospice agency, Dressing is maximum assistance daily am and pm, Toileting maximum assistance daily when needed, Transfer maximum assistance daily, Mobility maximum assistance daily, Meals minimum assistance daily reminders, Engagement minimum assistance reminders and observation, Medication Maximum Assistance needed. Housekeeping services 1X per week. Care Plan 5-included Mobility maximum assistance for escorts, walker and wheelchair, Engagement minimum assistance for need and observation, housekeeping services 1X per week. Care Plan 6-included Bathing maximum assistance 1 staff 2 x a week, Dressing maximum assistance, Toileting maximum assistance, Mobility maximum assistance with a walker, Medication maximum assistance pass up to 4 or more times per day by a medication technician (Med-tech), Coordination with outside agency moderate assistance Home Health, Housekeeping services 1X per week and Trash assistance daily 7 x a week. Care Plan 7-Resident does not have additional services and is independent of the care plan. Care staff are assigned residents to showers, dressing, and transfers daily and in addition to residents pressing their pendants for help daily. Records reviewed show the residents waiting 15 plus minutes for help with daily Assistance with Assistance with Daily Living (ADL) and on days where the staff are short-handed the wait times can be even longer. Staff interview revealed staff do respond to residents for assistance but at times residents wait so long the resident does the tasks themselves, which can be a safety risk for some. Continued 9099-C Timely assistance was not provided to residents in care based on record review and interviews this allegation is Substantiated at this time. This allegation is the same deficiency as the one cited on the previous allegation and will not be cited due to duplication of the same deficiency. On the allegation: Resident's room is odiferous. LPA De Leon conducted a tour of resident 1’s (R1’s) room and once LPA entered the doorway the room had a strong urine odor. LPA took photos of R1’s bed and restroom which both needed cleaning and sanitizing. Staff interviews revealed 5 out of 7 staff stated R1’s room had a heavy urine odor. Witness interview revealed resident room had a heavy smell of urine all the time and an odor of feces at times when the bedding had not been changed. Witness interview stated it had been reported to the care staff and directors and nothing was done about it. R1’s care plan revealed that R1 could not clean R1’s own room and restroom and this was to be completed by housekeeping staff. Staff stated that R1’s room was brought to the attention of housekeeping and directors, and the care plan was not updated to accommodate additional services needed to maintain odor, cleanliness, sanitation and disinfection. R1 moved out of the facility, and according to interviews it took several cleanings to get the room back into rentable condition, therefore this allegation is Substantiated at this time. On the allegation: Staff do not provide activities for residents. LPA interviewed staff members which revealed activities program director quit, and the new activity staff or director was not hired for several months leaving activities short staffed for a period of 1-3 months, some staff helped run a few activities during this period, but several activities were cancelled. The activities calendar was not followed during this time. Resident interviews revealed residents would attend the activity posted on the calendar and no staff would show up to run the activity. Several residents said they no longer attend activities or certain activities are not the same as they used to be and residents do not care to attend any longer. Witnesses interviewed revealed staff weren't providing the residents with activities. A witness said the facility had bingo at witness request, but the facility expected resident family members to call out the bingo numbers due to not having enough staff to run the activities. Based on the evidence this allegation is Substantiated at this time. Continued 9099-C On the allegation: Staff do not ensure that residents receive their mail. LPA observed packages being delivered to the facility, LPA interviewed the front desk staff to see what the procedure was for resident’s package delivery. Staff stated the packages were delivered to the front desk, left on the counter area and when any staff member had time the packages were picked up by staff at the front desk and delivered to the resident’s room. The staff stated they do not log or keep any information regarding delivery of packages received on file or any information about the staff that delivered the packages to the room. According to Witnesses packages were shown as delivered by the carrier but not received by the residents and it was unknown where the packages were at in the facility. LPA recommended a log to be kept so staff could be aware of what was delivered by the carrier and who delivered the package to the residents’ room. The front desk keeps a log of package deliveries now. Based on the lack of resident’s package not getting delivered to the resident’s room, the package not being available for pick up at the front desk and the resident not getting the package after delivery by the carrier to the facility. The facility failed to safeguard the residents mailed packages therefore this allegation is Substantiated at this time. On the allegations: Staff do not ensure that residents’ bedding is sanitary. LPA De Leon conducted a tour of resident 1’s (R1’s) room and once LPA entered the doorway the room had a strong urine odor. LPA took photos of R1’s bed and restroom which both needed cleaning and sanitizing. Staff interviews revealed 5 out of 7 staff stated R1’s room had a heavy urine odor and in need of cleaning. Witnesses interview revealed resident room had a heavy smell of urine all the time and an odor of feces at times when the bedding had not been changed. Witnesses interview stated it had been reported to the care staff and directors and nothing was done about it. R1’s care plan revealed that R1 could not clean R1’s own room and restroom and this was to be completed by housekeeping staff. Staff stated that R1’s room was brought to the attention of housekeeping staff and directors, and the care plan was not updated to accommodate additional services needed to maintain odor, cleanliness, sanitation and disinfection. R1’s linens were only being changed weekly or longer if staff were shorthanded. R1’s linens were not changed after being soiled with urine and feces therefore this allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 29-AS-20250604132416

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 3, 2026

(a)... (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and records the Licensee did not comply with the regulation above, Residents that pushed call buttons for care needs waited prolonged periods of time for assistance which possess a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agreed to higher enough staffing for current residents’ care needs to be met in a timely matter. Provide proof of staffing with an LIC 500 and Call button logs over 15 minutes for the month of February 2026 showing a decrease in wait times for resident care compared to prior months logs.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Mar 3, 2026

(b)... (3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on LPA observation and interviews the Licensee did not comply with the regulations above, R1’s room was not kept clean and free from odors from incontinence which possess a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agreed to make sure all current residents have care plans updated to reflect the current needs and services for those residents, have adequate staffing to keep residents and rooms clean and free from odors of incontinence, See below: send LIC 500, list of incontinent residents and a statement of how the facility will ensure the facility is free from odors of incontinence.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: Feb 3, 2026

(f)...one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities,...staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities....,This requirement was not met as evidenced by: Based on staff and resident interviews, the Activity Director quit, and it took several months to fill the position, activities were not being conducted as the calendar indicated which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agreed to provide LIC 500 with Activity Director name, hours working, and activity calendars for January and February 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Feb 3, 2026

(a)... (25)To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met as evidenced by: Based on interview Licensee did not comply with the regulation above, R1’s package was not found after carrier delivered to the facility which possess a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agreed to safeguard resident’s packages delivered to the facility and log the incoming packages at the front desk when received and name of staff delivered to residents’ room. Provide a copy of the log for resident’s packages delivered to the facility for January 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Feb 3, 2026

(a)…(3)…(C)Clean linen, including... The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times...The requirement was not met as evidenced by: Based on LPA observation and interviews, the Licensee did not comply with the regulation above, R1’s linens were not being changed more often to ensure R1 had clean linen to always use which possess a potential health, safety and person rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agreed to keep enough housekeeping & maintenance staff hired to always maintain the cleanliness and sanitary conditions of the facility, resident’s rooms and bedding, make sure the housekeepers schedule Continued below: accommodated all residents bedding and maintenance, housekeeping and care staff are trained in regulation 87307, provide proof and an up to date LIC 500 to CCL.

Allegation investigated: Staff did not abide by resident's admissions agreement. Staff left resident in wheelchair for an extended period of time.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings to the facility above. LPA met with Administrator Jade Alma-Harris and explained the purpose of the visit. LPA Kontilis conducted the initial 10-day visit on 4/18/2025, interviewed from 12:30 pm to 2:45 pm and obtained documents pertaining to the investigation. LPA De Leon conducted a subsequent complaint visit on 11/21/2025, collected records and interviewed staff at 10:30am, 11:02am, 11:25am, 12:20pm, 2:10pm and 2:41pm. LPA conducted interviews with residents on 11/21/2025 at 2:26pm and 3:05pm. LPA De Leon conducted a subsequent complaint visit on 11/25/2025 conducted interviews with residents at 12:55pm, 1:15pm, 1:42pm, 2:20pm and 3:15pm. LPA De Leon requested additional records from facility on 12/04/2025. LPA De Leon reviewed records on 12/08/2025, 12/11/2025 and 12/15/2025. Continued 9099-C Unsubstantiated On the allegation: Staff did not abide by resident's admissions agreement. LPA emailed the administrator to find out what happened with this perspective resident that did not move into the facility which revealed the perspective resident’s family inquired about placing at community for a respite stay while on vacation. After reviewing LIC 602A the facility asked the family a few more detailed questions regarding the behaviors that were listed on LIC 602A. The facility decided to ask for a 1:1 to be present for the first week of the stay to assist the perspective resident in the transition due to the additional information the facility received back from the family. The TB test had not been completed and was needed before moving in on 03/21/2025 and move in was postponed to 03/22/2025 due to the TB not being completed. The family verbally agreed to the 1:1 so it was coordinated with 1Heart Agency to be here in the community by the time the resident was expected to arrive. On 3/22/2025 the facility was notified the move was postponed to 3/25/25 due to the TB needing to be read and finalized. On the morning of 03/25/25 the family came to the community and told the staff the perspective resident would not be moving in. The original rent quoted for the respite stay of $255 per day with the intention of staying for 30 days at $7650, the fee did not change, and the facility offered to cover the 1:1 for the perspective resident for the one week. The perspective resident did not pay rent; a $500 preadmission fee was paid to hold the room, and the fee was refunded due to the resident not moving in. Based on the admission agreement and the refund issued this allegation is Unsubstantiated at this time. On the allegation: Staff left resident in wheelchair for an extended period of time. LPA interviewed 8/8 staff and 7/7 residents, and no one knew of a male resident being left in a wheelchair for extended periods of time in the front lobby unattended. Based on the lack of evidence this allegation is Unsubstantiated at this time. Exit interview completed and copy of report printed or Administrator.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 29-AS-20250415092141

Allegation investigated: Facility has inadequate staffing.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Administrator Jade Alma-Harris and explained the purpose of the visit. LPA Kontilis conducted the 10-day complaint visit on 03/13/2025, collected records and conducted interviews with residents at 5:20pm, 5:23pm, 5:30pm, 5:37pm, 5:40pm, 5:42pm, 5:45pm, and 5:58pm. LPA conducted interviews with staff on 03/13/2025 at 5:45pm and 6:00pm. LPA conducted interviews with witnesses on 03/14/2025 at 12:11pm, on 08/18/2025 by email and on 05/21/2025 at 3:12pm. LPA conducted additional staff interview on 03/17/2025 at 12:07pm. LPA De Leon conducted a subsequent complaint visit on 11/21/2025, collected records and interviewed staff at 10:30am, 11:02am, 11:25am, 12:20pm, 2:10pm and 2:41pm. LPA conducted interviews with residents on 11/21/2025 at 2:26pm and 3:05pm. LPA De Leon conducted a subsequent complaint visit on 11/25/2025 conducted interviews with residents at 12:55pm, 1:15pm, 1:42pm, 2:20pm and 3:15pm. Cont. 9099-C Substantiated LPA De Leon requested additional records from facility on 12/04/2025. LPA De Leon reviewed records on 12/08/2025, 12/11/2025 and 12/12/2025. On the allegation: Facility has inadequate staffing. LPA’s conducted interviews with 8 out of 8 staff which revealed the facility has been on and off short staffed from summer of 2024 through summer of 2025. A staff stated residents’ needs are more than they used to be in assisted living. It takes longer to provide care to residents that need two-person assistance and transfers. A staff member stated the call buttons are answered as soon as they can be. If staff are with a resident, staff must finish with the resident before moving on to the next resident, some calls do have longer waiting times if staff are busy with a resident. Another staff member stated staffing is short on the weekends when too many staff are off, or the facility gets staff calling off and nobody to fill the vacant shift. A staff member said staff work alone for several hours on a weekday due to not having enough care staff scheduled to work. A staff member stated the facility hires then cuts back hours based on the needs of the current residents; staff feel the care plans are not updated to reflect the actual current needs of the residents. Administrator stated the facility uses a software system to determine the staffing ratios needed to meet residents’ needs. A staff stated if the care plans are not updated to reflect the current needs of the residents in care, then the staffing ratio requirements would not be sufficient at times. Medication Technicians stated they had to help caregivers, Caregivers stated they had to help in the dining room. A staff member stated they helped with housekeeping. Staff stated the dining room has been short staffed, and the facility was using caregivers to help take orders and get food if there were not enough kitchen staff to do so, the facility stopped using care staff for sanitary purposes. The waiting times for taking orders and getting food were longer at times when there were not enough staff. A staff member stated one of the housekeeping staff had to take off work for a while and some of the regular cleaning schedules were not kept up during a period of 1-2 weeks in resident apartments and in the common areas due to not having enough staff to help clean. A staff member said in 09/2025 the facility had hired more kitchen staff and the facility said it was fully staffed with servers, so the facility asked a server to cover the vacant housekeeper position. A staff member interview revealed activities program director quit, and a new one was not hired for several months leaving activities short staffed for a period of 1-3 months, some staff helped run a few activities during this period, but several activities were cancelled. The activities calendar was not followed during this time. 8 out of 8 staff said the facility has been short staffed for several months over the last year in a few departments. Continued 9099-C LPA interviewed 7 out of 7 Residents which revealed the wait times could be 15-40 minutes for help depending on how many caregivers and servers were scheduled that day. A resident stated if you came early to meal service, then you would get better service but if you came in the middle to the end of service it takes longer. A resident stated the desserts were not coming out when the resident was done eating the meal residents had to wait until all residents were served the meal then staff would serve the dessert at the end of the meal to all the residents at the same time, which took even longer if you came early to eat. A resident interview stated if a resident needed assistance to get to and from dining by caregivers it would take longer to get picked up from room and then it would take longer to get picked back up after the meal to get back to the room. A resident interviewed revealed not sure of the activity or housekeeping schedule any longer, not sure if the housekeeper was coming to clean or not, at times the caregivers were helping clean up the room and taking out the trash if they had the time. A resident interview stated that the resident would go to an activity based on the calendar and show up with nobody to run the activity. The communication of the directors with the residents was not good, didn’t really know what was going on except there were not enough staff to handle everything that was needed. A few residents no longer go to activities and were not sure if the activities the residents liked had even began again or not, one resident went back to an activity the resident liked but the new staff did not run it like the prior staff did so the resident no longer liked it and stopped going. A resident interview revealed the staff working at the facility are great, there are just not enough staff to do everything that is needed and to take care of it in a timely manner. A few residents said they do not like to complain about staffing because the staff that are working are great and the staff get in trouble if you complain. Another resident stated the facility is short staffed and has been for a long time, but the facility is not going to do anything about it so why complain. A resident interview revealed the rent fees are increased yearly but no new staff have been hired, and they still have longer wait times. A resident said if the staffing is short on that shift, they may ask for a resident’s shower to be put off till later or the next day. Residents said the communication was not good for a long time and finally now the facility will send someone to your room if you have been waiting awhile to let you know they can help you or if you want to wait for the staff that usually comes to do it, it will be about another 10-15 minutes longer. A resident said communication is better now and it is nice to know what is going on. A resident said the activities are back on again and some of the musicians are great. A residents said the facilities issues could all be fixed with more staffing. Continued 9099-C Witness interview revealed the resident had called about waiting too long, and Witness has gone to the facility when the resident has waited a long time. Witnesses said residents calling for help to take showers or to go to the restroom, or to get escorted to meals and activities, must wait longer when staffing is short that day. Witnesses said the dining room is short-staffed, and it takes longer to get meals ordered and delivered to the tables. A witness said the dining room tables are left with food and sticky residue from prior meals. Witnesses noticed the common areas and apartments were not being cleaned like they normally were for a few weeks due to short staffing. A Witness said the facility has a lack of staffing to meet the timely needs of all the residents in care. Witness interview said dining was short on staff sometimes with only 1 server on the floor and it could take up to 20 minutes to have your order taken and then wait for the food to come out, the tables were dirty, left with sticky residue and not being cleaned after the last meal to be sanitary. LPA reviewed 7 randomly chosen resident care plans which revealed six out of seven (6/7) residents had care plans with additional services needed. Care Plan 1- included Bathing maximum assistance 2 x per week, Dressing maximum assistance daily in the am and pm, Oral Care maximum assistance daily, Hearing moderate assistance with devices from Med-Tech daily am and pm, Toileting maximum assistance several times daily, Meals moderate assistance cutting, preparing and prompting, Engagement minimal assistance needed, Housekeeping services 1X per week. Care Plan 2- included Bathing is now done by Hospice Agency staff, Dressing maximum assistance reminders and preparing items, Toileting maximum assistance stand by assist as needed daily, Transfers moderate assistance standby assist when needed daily, Mobility maximum assistance escort to meals with walker and reminders, Medication Management maximum assistance med pass 2x a day, Coordination of Care moderate assistance with hospice agency, Housekeeping services 1x per week with daily trash pickup. Care Plan 3- included Cognition, Behavioral Expression and Communication minimum assistance prompting and observation, Bathing maximum assistance 1x per week, Mobility minimum assistance walker with daily observation, Special Care Needs maximum assistance daily, Engagement minimum assistance with encouragement daily, Coordination of Care moderate assistance with mental health. Housekeeping services 1X per week. Continued 9099-C Care Plan 4- included Bathing is done by Hospice agency, Dressing is maximum assistance daily am and pm, Toileting maximum assistance daily when needed, Transfer maximum assistance daily, Mobility maximum assistance daily, Meals minimum assistance daily reminders, Engagement minimum assistance reminders and observation, Medication Maximum Assistance needed. Housekeeping services 1X per week. Care Plan 5-included Mobility maximum assistance for escorts, walker and wheelchair, Engagement minimum assistance for need and observation, Housekeeping services 1X per week. Care Plan 6-included Bathing maximum assistance 1 staff 2 x a week, Dressing maximum assistance, Toileting maximum assistance, Mobility maximum assistance with a walker, Medication maximum assistance pass up to 4 or more times per day by a medication technician (Med-tech), Coordination with outside agency moderate assistance Home Health, Housekeeping services 1X per week and Trash assistance daily 7 x a week. Care Plan 7-Resident does not have additional services and is independent of the care plan. LPA De Leon reviewed call button logs for the same 7 residents at the facility for 7-day period from June 1, 2025-June 7, 2025, which revealed 3 out of 7 residents reviewed had call button logs over 15 minutes to a maximum of 96 minutes. Care plan 4 Resident had 9 calls over 15 minutes, 1 at 15 minutes, 2 at 16 minutes, 1 at 18 minutes, 1 at 20 minutes, 1 at 21 minutes, 1 at 22 minutes, 1 at 25 minutes and 1 at 48 minutes. Care Plan 3 Resident had 1 call at 37 minutes, Care Plan 5 Resident had 7 calls with 1 at 15 minutes, 1 at 16 minutes, 1 at 17 minutes, 1 at 19 minutes, 1 at 40 minutes, 1 at 50 minutes and 1 at 96 minutes. Staff stated call buttons are usually answered in under 10 minutes if the facility is fully staffed. Staff stated residents use the call buttons for non-emergent matters at times. LPA reviewed records and there is no way for staff to tell if the next call button press is non-emergent or an emergency matter unless staff go to the location and check the resident. Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 29-AS-20250310142840

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 30, 2025

(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...Additional staff shall be employed as necessary to perform..., cooking, house cleaning, laundering, and maintenance...This requirement was not met as evidenced by: Based on interviews and records the License did not comply with the regulation above due to insufficient staffing did not perform timely care, activities, food service and housekeeping to residents in care which possess a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: Administrator agreed to update care plans and higher enough staff in each department to meet the needs of the residents. Provide an up-to-date LIC 500 with a list of vacancies and staff schedules for January and Februaryto CCL, continued below. after each month is completed send an up to date schedule of staff actually worked.

Allegation investigated: Staff did not provide resident with a reappraisal Staff did not report incidents to appropriate parties Staff did not provide resident with a 60 day notice prior to rate increase

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility to deliver final findings of the investigation. LPA met with Administrator Jade Alma-Harris and explained the purpose of the visit. LPA Kontilis conducted the initial 10-day complaint visit, interviewed residents around 1:07pm-1:30pm and collected records on 12/06/2024. LPA De Leon conducted a subsequent complaint visit on 11/21/2025, requested a staff roster and a resident roster, interviewed staff that worked in the facility around 11/2024-06/2025 at 10:30am, 11:02am, 11:25am, 12:20pm, 2:10pm, 2:41pm and interviewed residents that lived in the facility during 11/2024-06/2025 at 2:26pm and 3:05pm. LPA De Leon reviewed records on 11/22/2025-11/24/2025. Continued 9099-C Substantiated On the allegation: Staff did not provide residents with a reappraisal. LPA De Leon reviewed the resident appraisal needs and service plan for R1. R1 had care plans done on 03/30/2022, 09/02/2022, 12/11/2023 and 09/16/2024. The plans for 2023 and 2024 were done on a different software program than prior plans completed. R1 suffered a fall with a fracture on 08/23/2024 which initiated the new service care plan on 09/16/2024 done by staff at the facility, R1 signed the plan, and it was emailed to R1’s Responsible party (RP) on 09/16/2024 for approval and signature. RP never received the email but in October R1’s fees increased, and the RP questioned why and how when there was no reappraisal, a new LIC 602A physicians report, or a meeting set up to discuss the changes. The facility said they had emailed her an updated service plan with the changes on 09/16/2024. The RP did sign the new service plan on 11/26/2024 and a new LIC 602A was done on 12/04/2024 to verify the changes being made to R1’s care fee increase. The facility did not follow the regulation for reappraisals, RP was not contacted, or a meeting arranged for R1’s change in condition and review of a new service plan before the facility billed for the increase therefore this allegation is Substantiated at this time. On the allegation: Staff did not report incidents to appropriate parties. LPA De Leon reviewed records for R1 which revealed several incidents of R1’s confusion were faxed and sent to R1’s doctor on 1/13/2024, 04/04/2024, 06/01/2024, 06/18/2024, 07/16/2024 and 11/11/2024 but not all the incidents were reported to R1’s RP’s based on interviews. RP’s said the communication with the facility was not good and when the RP’s reached out to the facility and left messages, no one from the facility replied. On 12/05/2024 R1 was moved into the memory care (MC) unit, when R1’s family went to visit the facility R1 could not be found and staff said R1 was now in MC. R1’s belongings were not with R1 in the MC unit and family took R1 back to R1’s apartment in the assisted living portion of the facility. The facility moved R1 without notification to the family into the MC unit due to R1’s increased confusion. The facility said R1 could stay in AL during the day for meals but needed to go to MC in the evening, R1’s RP’s didn’t agree to this arrangement or get an eviction notice that R1 could no longer live in the AL portion of the building and only learned of it through a family member that tried to visit. The RP’s said the facility had all updated information and phone numbers for the RP’s and made no contact to discuss the movement of R1 therefore this allegation is Substantiated at this time. Continued 9099-C On the allegation: Staff did not provide residents with 60-day notice prior to rate increase. LPA De Leon reviewed records which revealed the facility did a rent and care level fee increase to all residents on 11/01/2024 to be effective 01/01/2025. The facility mailed out the information to the residents and the RP’s on 11/01/2025. R1’s RP did not get anything from the facility for the increase effective 01/01/2025.R1’s RP’s decided with the lack of communication and R1 was not getting any more services for the increase R1 would move out before the new increase took effect. Resident 2 (R2) received a notice for increase of rent and care fees dated 11/14/2024 with an effective date of 01/01/2025 not a full 60-day notice therefore this allegation is deemed Substantiated at this time. Exit interview conducted, deficiencies issues, copy of report and appeal rights printed for Administrator. According to the Resident Service Plan dated 12/11/2023 R1 had facility doing medication management and observation of cognition and orientation. Incident Report submitted to the department on R1 for 08/23/2024 Caregiver heard a loud noise went to check and found R1 on the ground, 911 was called and R1 was transported to the hospital. According to the Hospital Discharge R1 had a fall on 08/23/2024, went to the ER and was diagnosed with a fracture to the upper extremity, face laceration with stitches, and discharged back to the community. R1’s LIC. 602 A dated 03/05/2024 R1 has MCI, exiting does not prevent a hazard, does not require additional monitoring while in the community and is Ambulatory. Staff 1 (S1) interview revealed S1 heard a loud noise and went to check R1 had a fall and staff called 911, and R1 was transferred to the hospital, it was not neglectful on the facility or the staff, it was an accidental un-witnessed fall. Based on the evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 29-AS-20241205123921

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(i) · Plan of correction due date: Dec 2, 2025

(i)When there is significant change in condition,...or once every 12 months,...the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's rep,... facility staff,...,Resident Participation.... This requirement was not met as evidenced by: Based on records and interviews the licensee did not comply with the regulation above Staff conducted a reappraisal Service Plan and did not make contact with R1’s RP to go over or have a meeting to discuss, letting R1 sign and putting the new fees in effect which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Administrator agreed to read, review and train staff doing pre-appraisals, re-appraisals, generating new LIC 602A to the doctor and updating Service plans on Regulation 87463, provide proof of training with a list of staff to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Dec 2, 2025

...residents are regularly observed for changes in physical,...social ...functioning...assistance is provided...observation reveals unmet needs.... attention of the resident's physician and the resident's person responsible,... This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the regulation above Staff did not report to R1’s RP several dates and incidents that were faxed to the physician which possess a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Administrator agreed to train the staff that notifies doctors and RP’s in regulation 87466 and the facility policy and procedures for notifications, send proof of training and provide a current list of those staff to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: Dec 2, 2025

(a) ...increases the rates of fees for residents or makes increases in any of its rate structures for services,...90 days’ prior written notice to the residents or the residents’ representatives...amount of the increase and the reason or reasons for the increase,,...This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the H&S code above. Facility mailed out notices, not all notives were received by the RP’s and some notices were not a full 60days notice which possess a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Administrator agreed to train staff that handle rent and care increases in H&S code 1569.655, provide proof of training and list of staff who do the increases at the facility.

Allegation investigated: Staff are not being properly trained Staff mishandled a resident's medication Staff interfered from reporting incidents involving a resident

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Administrator Jade Alma-Harris and explained the purpose of the visit. LPA Kontilis conducted the original 10-day complaint visit to the facility on 11/08/2024, requested records and interviewed staff at 11:21am and 2:38pm. LPA Kontilis conducted additional interviews with witnesses on 11/12/2024 at 12:06pm, 11/13/2024 at 8:47am, and with Administrator on 08/29/2025 at 11:13am. LPA De Leon reviewed the complaint, interviews and records and conducted further investigation from 11/05/2025-11/19/2025. LPA requested additional records on 11/13/2025 from Administrator, partial records were received. On the allegation: Staff are not being properly trained, LPA Kontilis requested training records for staff handling medications on 11/08/2024, only emails were provided. Cont. 9099-C Substantiated LPA De Leon reviewed the emails which revealed the previous Administrator was setting up medication training for a list of staff handling medications. The email chain did not have set dates for training to be held or completed, and the emails were dated 09/2024. The prior administrator no longer works at the facility as of 11/2024. LPA Kontilis never received staff medication training records during the investigation. LPA De Leon requested 2024 medication training records on 11/13/2025 from the new Administrator as of 10/19/2025 no medication records were produced. Due to the lack of evidence with training records for medication staff this allegation is Substantiated. On the allegation: Staff mishandled a resident's medication, LPA Kontilis was provided with the facility’s internal investigation report, at the time the investigation was ongoing and had not been completed. LPA De Leon requested the completed investigation report and any staff disciplinary records on 11/13/2025, Administrator provided one staff members disciplinary record which did not involve a medication error. LPA De Leon reviewed the emails, medication records and photos which revealed the Resident 1 (R1) handled and stored R1’s own medications when moving into the facility on 09/27/2024, the medication order was for Amiodarone HCL 200mg – 1 tab by mouth twice a day and was prescribed by R1’s Cardiologist. On 10/09/2024 Staff notes communicate that R1 was having confusion with medications and staff felt it should be centrally stored by the facility. On 10/12/2024 the facility took over R1’s medication and Staff 1 (S1) took a telephone order from another doctor for Amiodarone HCL 400mg – 1 tab by mouth twice a day. The doctor’s office was contacted by the facility during the investigation to ask if the telephone order was correct, the office told the facility that they did not do a phone order for that medication for R1. On 10/22/2024 the cardiologist wrote an order for the medication Amiodarone 200mg – 1 tab by mouth twice a day. The medication Amiodarone 400mg – 1 tab by mouth twice a day was provided to R1 from 10/12/2024 until 10/23/2024. The record keeping of medications and orders was not being done timely and several orders were not confirmed by the prescribing physician which was a communication breakdown between the facility and the providers which is required when the medications for the residents are being centrally stored, and the staff are aiding the residents with taking medications. Residents pay additional fees to have the medication managed by the facility and the lack of communication was the issue with this medication being given. Based on the evidence this allegation is deemed Substantiated at this time. Continued 9099-C On the allegation: Staff interfered with reporting incidents involving a resident, LPA De Leon reviewed records and interviews which revealed Resident 1 (R1) had medication changes in October which increased the medication dosage. On 10/22/2024 the cardiologist wrote an order for the medication Amiodarone 200mg – 1 tab by mouth twice a day. The medication Amiodarone 400mg – 1 tab by mouth twice a day was provided to R1 from 10/12/2025 until 10/23/2024. The doctor’s office that increased the medication to 400mg was contacted by the facility and the facility was told that doctor did not change the medication by telephone order. Due to the record keeping showing the medication was give at 400mg twice a day and the cardiologist confirmed the medication was to be given at 200mg twice a day, the facility made an error by providing the higher dosage to the resident from 10/12/2024-10/23/2024. CCL did not recieve an incident report for these error therefore based on the evidence this allegation is Substantiated at this time. Exit interview conducted, Deficiencies cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 29-AS-20241104104759

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a)(1) · Plan of correction due date: Nov 26, 2025

(a)...:(1)...the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training,...and 8 hours of other training or instruction,...which shall be completed within the first four weeks of employment. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above staff did not take initial /or annual medication training which possess a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: Administrator agreed to hold training for all staff on H&S code 1569.69 and provide staff missing any of these requirements with medication training, provide proof of training and an up to date LIC 500 with all staff and positions listed to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 26, 2025

(a)...(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and records the Licensee did not comply with the regulation above, staff were not competent in handling the centrally stored medications and assistance to residents, without errors which possess a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: Administrator agreed to hold personal rights training with all staff to include regulations 87468.1 and 87468.2. Provide proof of training and an up-to-date LIC. 500 for all staff to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 26, 2025

(a)...(1)...(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Based on incident reporting the Licensee did not comply with the regulation above The facility did not report any medication errors or discrepancies for R1 which possess a potential Health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: Administrator agreed to train all staff in reporting requirements 87211 and send proof of training with an up to date LIC 500 will all staff to CCL.

Type of visit: Case Management - Deficiencies

LPA Kristin Kontilis conducted a Case Management visit to address deficiencies noted during a Case Management – Incident visit on this day. LPA met with Jade Alma, Administrator and explained the purpose of the visit. At approximately 2:15 pm, during record review of Resident 1’s (R1’s) records, LPA obtained a confidential document pertaining to Resident 2’s (R2’s) care. Administrator Jade Alma stated the confidential document should not have been in R1’s file and immediately removed the document from R1’s file. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued. Appeal Rights issued.the state’s words, verbatim · CDSS document, Sep 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c) · Plan of correction due date: Sep 10, 2025

87506(c) Residents Records: (c) All information and records obtained from or regarding residents shall be confidential. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as a confidential document of one resident was found in another resident's record which poses a potential safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2025

Plan of correction: Administrator immediately removed the confidential document from the file. Deficiency cleared at the time of the visit.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management – incident visit to the facility regarding a self-reported incident and a self-reported death that occurred on 8/31/2025. LPA Kontilis met with Jade Alma, Administrator to explain the purpose of the visit. On 9/3/2025, CCLD received LIC624 Unusual Incident/Injury Report stating 9-1-1 was called on 8/31/2025 for Resident 1 (R1) when R1 was observed to have “increased confusion found eating balmex”. The incident report states Staff 1 (S1) noted “pale skin and not at baseline…upon Paramedics’ assessment resident blood pressure was very low. Resident was sent out to ER by ambulance for further evaluation.” On 9/3/2025, CCLD received LIC624A Death Report stating R1 passed away at the hospital on 8/31/2025 at approximately 3:15 PM. The death report states R1’s responsible party reported R1’s passing to facility personnel. Death Report states cause of death is “Unknown at this time…” R1 was not on hospice. Per the information received, the circumstances surrounding R1’s death may be questionable, and an investigation is required. During today’s visit, LPA Kontilis obtained documents pertaining to the investigation and conducted in-person interviews. Due to time restraints, LPA will return at a later date to continue the investigation. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Sep 10, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Administrator Jade Alma was present at the time of arrival. There were 48 residents in care in the Assisted Living unit with 1 medication technician, 2 caregivers from home health agencies on duty. Resident Services Director was also on duty. In the “Compass Rose” Memory Care unit, there were 16 residents with 1 medication technician and 2 caregivers on duty. The Compass Rose Coordinator who currently oversees the activity programming for the Memory Care unit of the facility was also on duty. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to residents with a dementia diagnosis, and 99 non-ambulatory residents of which 10 may be bedridden. There are 11 residents currently on hospice. Entrance interview conducted: The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. Throughout the facility, there are approximately 14 fire extinguishers and 5 fire pull alarms. The pull alarms alert the local fire department when activated. Fire inspection was most recently conducted on 5/20/2025. LPA observed the dining areas are clean. LPA observed kitchen cabinets, refrigerator, stove, and counters are clean. Please continue to 809-C, Pg 2. Assisted Living Residents participate in activities such as special occasion celebrations, music entertainment, Bocce ball, physical therapy, and excursions to local eateries and retail businesses. Memory Care residents participate in activities such as special occasion celebrations, music entertainment, and scenic drives. A "Cycling without Age" activity is available for residents in Assisted Living and Memory Care. At approximately 2:19 pm, LPA reviewed medication records and incident reports. On 6/19/2025, the facility self-reported an incident that occurred on 6/15/2025 wherein at approximately 5:50 am, Resident 1 (R1) was administered their first dose Hydromorphone 2mg. At approximately 6:00 am, Staff 1 (S1) administered a second dose of Hydromorphone 2mg to R1 in error. Administrator stated they were trying to obtain additional information as to how the error happened, however S1 did not report to work after the incident and therefore the administrator was unable to determine how or why the incident occurred. Administrator stated most likely S1 did not review the Electronic Medication Administration Record (EMAR) or the Narcotics book before administering the second dose to R1 and if S1 had reviewed the records, S1 would have seen the medication had been administered about 10 minutes before the second dose was administered. Administrator further stated although the incident report states S1 was administered corrective counseling and re-training of medication administration, S1 ‘terminated’ themselves before further investigation and re-training could be conducted. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Due to time restraints, LPA will continue the annual inspection at a later date. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Aug 26, 2025

Allegation investigated: Staff do not communicate effectively with authorized representatives. Staff do not properly reassess a resident while in care. Staff do not ensure a resident is being properly fed.

At 3:00pm on 08/13/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to issue final findings to the allegations to this complaint. LPA met with Business Office Director, Carolina Nava announced who he is and the reason for the visit. The findings to the allegations to this complaint are as follows: As to the allegation of, “Staff do not communicate effectively with authorized representatives.” It was alleged that, “facility has absolutely no communication with families.” It was discovered through interviews, documentation and observations that on 06/03/2025, Licensing Program Analyst (LPA) Jeffries conducted interviews with 4 direct care staff (S1, S2, S3, and S4). S1, S2, S3, and S4 all stated that Resident 1’s (R1) Family Member (F1) visit R1 daily and communicate with staff on R1’s condition daily. On 06/18/2025 LPA Jeffries conducted an interview with Facility Administrator, Jade Alma, who stated that they have been in daily contact with F1, in person and on the telephone with updating R1’s condition, appraisals, and care assessments. CONTINUED on LIC9099-C Unsubstantiated On 06/11/2025 LPA contacted F1 by phone, F1 stated that they were not happy with the transition from the old Administrator to the new Administrator. F1 stated on one occasion (date not known) the interim administrator failed to return F1’s call. On 06/03/2025, LPA reviewed R1’s Physicians Report (LIC602) dated 04/03/2025, which indicated there is no cognitive impairment of R1. LPA reviewed facility most current assessment of R1 dated 01/16/2025, which shows 0 acuity in cognitive/orientation, communications, and psycho-social engagement. (0 acuity translate to no issue.) LPA requested any power of attorney, conservatorship or contract indicating requirement of facility to communicate with R1’s representatives. LPA observed R1’s admission agreement with F1’s digital signature. On 06/03/2025 LPA conducted interviews of 5 Residents (R1, R2, R3, R4, and R5) who all stated they have had no problems with communications with facility and had no issues with facility. At this time there is no evidence to support the allegation of, “Staff do no communicate effectively with authorized representatives.”, and is unsubstantiated at this time. As to the allegation of, “Staff do not properly reassess a resident in care.” It was alleged that R1 has not been able to get a service plan meeting in 3 years. It was discovered through documentation and interviews that, on 06/03/2025 LPA Jeffries reviewed R1 service plan dated 01/16/2025. On 06/11/2025, LPA interviewed F1, who stated that, “due to falls and recent weight loss of R1, they have been trying to get a service plan meeting, but due to the transition of Administrator it has taken longer than desired but has a service plan meeting scheduled for the end of June 2025.” On 06/03/2025 LPA conducted interviews of 5 Residents (R1, R2, R3, R4, and R5) who all stated they have had no problems with communications with facility and had no issues with facility. At this time there is not enough evidence to support the allegation of, “Staff do not properly reassess a resident while in care.” and I unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Staff do not ensure a resident is being properly fed.” It was alleged that, “R1 seems to have lost a significant amount of weight, and the food is terrible” It was discovered through interviews, observations and documentation that on 06/03/2025, LPA Jeffries reviewed R1’s monthly weight record that dates from July 2, 2023, through June 2, 2025. LPA also reviewed one report of weight variance Physician Notification for R1 dated 03/14/2025. LPA noted that the facility weight reporting policy as follows: 1. A weight gain or loss of 5 lbs. in 1 month and or a 05% variance. 2. A weight gain or loss of 7.5% in 3 months. And 3. A weight gain or loss of 10% in 6 months. This report compared to R1’s monthly weight report shows that the report of 03/14/2025 indicated the only time, within the standards pointed out in 1-3 were required for a physician’s notification, of which the facility sent to R1s physician and was signed and dated by R1s Physician on 04/01/2024. LPA noted that R1 has been losing weight but within the parameters of the standards 1-3. On 06/03/2025 and 06/18/2025, LPA Jeffries observed sample breakfast and sample lunch made by facility noted all food served look to be of quality and good portions. On 06/03/2025 LPA conducted interviews of 5 Residents (R1, R2, R3, R4, and R5) who all stated the facility has food of good quality, choice and proportions, all stated they have had no problems with communications with facility and had no issues with facility. At this time there in not enough evidence to support the allegation of, “Staff do not ensure resident is being properly fed.” and in unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 29-AS-20250530141639

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20241104104759 investigation visit conducted on 11/8/2024. At approximately 11:21 am during a tour of the facility, LPA observed the carpet in a resident’s room is stained and soiled. Administrator stated on 10/22/2024, he learned from the Residents’ Council meeting that there are five residents’ rooms that need carpet cleaning service. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in additional civil penalties.the state’s words, verbatim · CDSS document, Nov 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 15, 2024

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times… This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as the carpet in a resident’s room was observed to be stained and soiled which poses/posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 8, 2024

Plan of correction: Administrator agrees to have carpets cleaned in five (5) resident's rooms no later than POC due date (11/15/2024). Administrator agrees to provide photographs of cleaned carpets via email on or before POC due date (11/15/2024).

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management - Annual Continuation visit to the facility above. LPA met with Ernest “EJ” Lewis, Acting Executive Director and explained the purpose of the visit. Entrance interview conducted: LPA completed medication inventory and continued to review residents’ records for health screenings, Serious Illness/Injury reports, death reports, medication administration, appraisals, re-appraisals, admission agreements, and Physician’s reports. Centrally Stored Medication Record: Record review and interviews revealed two prescribed medications were not listed on R1's Centrally Stored Medication Record. Record review and interviews revealed the facility self-reported the following medication errors: On 9/15/2023, Staff 1 (S1) discovered on 9/12/2023 PRN Acetaminophen bubble back was mixed into Resident 8’s (R8’s) routine medications. R8 was prescribed two tablets 3x/daily of Acetaminophen 500mg. S1 discovered R8 was administered 650mg of Acetaminophen instead of 1,000mg. On 1/11/2024, CCL received an incident report stating on 1/4/2024 S1 removed R8’s Fentanyl 12mcg Patch that was applied on 1/2/2024 at 8:00 pm. Doctor's order states the patch is a 72-hour patch and should have been removed on 1/5/2024 at 8:00 pm. Per the incident report, S1 was "counselled with a Corrective Counseling Documentation, and was retrained on the process of administering fentanyl patch and was counseled to review of the physician order". On 5/16/2024, CCL received an incident report stating on 5/7/2024, Resident 9 (R9) was transported via ambulance to the hospital due to being unresponsive. LIC624 states R9 received a diagnosis of “morphine overdose”. Please continue to 809-C, Pg 2. During today's visit, a tour of the facility revealed the east patio area between the Assisted Living and Memory Care patios were unclean and unsanitary. Acting Executive Director stated the Licensee has approved an estimate/quote for a "spray wash" to be conducted on the patio areas. Acting Executive Director stated the facility currently does not have a maintenance director and a maintenance technician is available two days a week to assist with maintenance needs. Record review and interviews conducted revealed on or about 5/10/2024 the previous administrator resigned as administrator from the facility. In the interim, Sheryl McCaskill, Operations Specialist was present in the facility. On or about 6/24/2024 Acting Executive Director Ernest "EJ" Lewis began his tenure at the facility. As of today's visit, Licensee has not submitted required paperwork to CCLD naming Acting Executive Director as the current administrator. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jul 25, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management - Annual Continuation visit to the facility above. LPA met with Ernest “EJ” Lewis, Interim Administrator and explained the purpose of the visit. Entrance interview conducted: LPA reviewed residents’ records for health screenings, Serious Illness/Injury reports, death reports, medication administration, appraisals, re-appraisals, admission agreements, and Physician’s reports. Due to time restraints, LPA will return at a later date to continue the inspection. Exit interview conducted. No deficiencies noted. Copy of report provided at the time of the visit.the state’s words, verbatim · CDSS document, Jul 24, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Interim Administrator Ernest “EJ” Lewis was present at the time of arrival. There were 41 residents in care in the Assisted Living unit with 1 medication technician, 3 caregivers on duty, and 1 activities coordinator on duty. In the “Compass Rose” Memory Care unit, there were 27 residents with 1 medication technician and 3 caregivers on duty. The Compass Rose Lifestyle Assistant Director who currently oversees the activity programming for the Memory Care unit of the facility was also on duty. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to residents with a dementia diagnosis, and 99 non-ambulatory residents of which 10 may be bedridden. There are 7 residents currently on hospice. Entrance interview conducted: The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. Throughout the facility, there are approximately 18 fire extinguishers and 5 fire pull alarms. The pull alarms alert the local fire department when activated. Fire inspection was most recently conducted on 6/20/2024. There are approximately 81 dual carbon monoxide detectors and smoke alarms throughout the facility. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. LPA observed the dining areas are clean. LPA observed kitchen cabinets, refrigerator, stove, and counters are clean. Assisted Living Residents participate in activities such as special occasion celebrations, music entertainment, Bocce ball, physical therapy, and excursions to local eateries and retail businesses. Memory Care residents participate in activities such as special occasion celebrations, music entertainment, and scenic drives. A "Cycling without Age" activity is available for residents in Assisted Living and Memory Care. Please continue to 809-C, Pg 2. The facility has various sitting areas throughout the first and second floors including a library/reading area, faux fireplace, computer/business center for residents and staff, beauty salon, physical therapy center, and a laundry room. The facility grounds are well maintained with walkways, sitting areas with covered tables and chairs, and raised garden areas. Throughout the interior area and outdoor area, the facility is conducive for socially distanced visitation. Chemicals and cleaning supplies are kept in two locked closets with no access to residents in care. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Due to time restraints, LPA will return at a later date to continue the inspection. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jul 23, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management visit to issue additional deficiencies discovered while investigating complaints at this facility. LPA met with Ernest “EJ” Lewis and explained the purpose of the visit. During the investigation, LPA Kontilis reviewed relevant documents and interviewed staff. During the investigation of complaint 29-AS-20240515122500, it was alleged that Resident 1 (R1) did not receive their eyedrops as prescribed. Staff interviewed indicated R1 sometimes refused their eyedrops. LPA reviewed Medication Administration Records (MARs) for R1 from September 2023 to March 2024. LPA observed different reasons documented for resident not receiving medications. For eyedrops specifically, LPA observed several dates where R1 did not receive their eyedrops as prescribed, and reasons included “resident very sleepy,” “resident refused,” “physically unable to take – resident very sleepy,” “physically unable to take – resident in a deep sleep.” LPA asked for documentation showing that the prescription eyedrop refusals were communicated to R1’s physician. LPA was provided only two documented cases where R1’s physician was notified of refused eye drops, on 4/18/2023 and 10/30/2022. The refusals also included other medications, and the refusal notice was sent to R1’s primary care physician, where they notated “thank you, no new orders.” Regulations require that any changes in the resident are documented and brought to the attention of the “resident’s physician.” The facility only notified R1’s primary care physician of two cases where the resident refused the medication, due to agitation per interviews. The facility did not notify R1’s physician when R1 did not take their medications due to being asleep, which occurred more times. Although the regulation does not specify which physician the changes should be brought to, Technical Assistance is provided to the facility to recommend that relevant specialists and prescribing physicians should also be notified of changes including medications not given, in addition to primary care physician’s. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were providedthe state’s words, verbatim · CDSS document, Jul 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jul 15, 2024

87466 Observation of the Resident. When changes…are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when R1’s missed medications were not communicated to their physician, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 12, 2024

Plan of correction: Interim Administrator agrees to provide a written plan to ensure residents’ physicians are notified of medication refusals promptly and appropriately. Interim Administrator agrees to conduct in-service with staff to include procedures to follow with residents' medications refusals. Interim Administrator will inform CCLD as to date(s) in-services will be conducted.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management visit to issue additional deficiencies discovered while investigating complaints at this facility and reviewing incident reports. LPA met with Ernest "EJ" Lewis, Acting Executive Director and Jessica Zebroski, Resident Services Director Specialist, Westmont Living, San Diego, CA. LPA explained the purpose of the visit. During the investigation, LPA Kontilis reviewed relevant documents and interviewed staff. On 5/29/2024, LPA Kontilis received a call from interim Administrator Sheryl McCaskill, who reported medication errors. McCaskill reported a new staff (Staff 1 – S1) did not provide morning medications to 21 residents on 5/27/2024, due to “being overwhelmed.” McCaskill stated S1 did not reach out to the facility management for assistance or for notification. On 6/1/2024, CCL received 10 incident reports for the medication errors. The following medication errors were noted on 5/27/2024: -R1 did not receive their 8:00 am dose of Citalopram 10 mg, or Preparation H cream. -R2 did not receive their 8:00 am dose of Escitalopram 5mg.| -R3 did not receive their 8:00 am dose of Acetaminophen 325mg, Metoprolol 25mg, or Risperidone 0.5mg. -R4 did not receive their 8:00 am dose of Famotidine 20mg, Nitrofurantoin Mono MCR 100 mg, Pravastatin 40mg, Quetiapine Fumarate 25mg, or Valsartan 80mg. -R5 did not receive their 8:00 am dose of Astrovastin 20mg, Furosemide 20mg, Jardiance 10mg, Metoprolol 25mg, Mirtazapine 7.5mg, Spironol Actone 25mg, or Xarelto 15mg. -R6 did not receive their 8:00 am dose of Naproxen 500mg. -R7 did not receive their 8:00 am dose of Pantoprazole 20mg, Aripiprazole 5mg, Aspirin 81mg, Calcium Citrate 200mg, Carvedilol 3.125mg, Ferrous Sulfate 325mg, Finasteride 5mg, Januvia 25mg, Jardiance 10mg, Multivitamin/Minteral, Pioglitazone HCL 30mg, Sertraline HCL 50mg, or Vitamin D3 1000 unit. -R8 did not receive their 8:00 am dose of Senna 8.6mg, or Tramadol 50mg. -R9 did not receive their 8:00 am dose of Donepezil HCL 10mg, Glimepride 4mg, Lisinopril 2mg, Metformin HCL 500mg, or Simvastatin 20mg. -R10 did not receive their 8:00 am dose of Donepezil 10mg, or Eliquis 2.5mg. Please continue to 809-C, Pg 2. The incident reports indicate all resident’s physicians and responsible parties were contacted regarding the medication errors. Additionally, all affected residents were placed on alert charting for a minimum of three days for adverse reactions. S1 received a corrective counselling memo and was retrained on the medication process. Interview with Interim Administrator revealed no severe adverse reactions occurred that required further medical treatment. A deficiency will be issued for failure to provide medication as prescribed. On 7/2/2024, LPA Kontilis confirmed 21 residents were not prescribed morning medications on 5/27/2024 and only 10 of the 21 were reported to CCLD. Additionally, During the investigation, LPA was also informed that the facility’s bus was involved in an accident on the afternoon of 3/8/2024. On 6/13/2024, LPA briefly discussed the accident with acting Administrator McCaskill. McCaskill asked if they should submit an incident report still, even though it was late, and LPA informed McCaskill they should submit the incident report to the Department. McCaskill acknowledged the incident should have been reported, as three residents were on the van at the time. As of 7/2/204, no incident report has been received. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. Due to technical difficulties, a copy of the report and appeal rights issued via email.the state’s words, verbatim · CDSS document, Jul 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465 · Plan of correction due date: Jul 3, 2024

87465 Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when multiple residents did not receive their medication as prescribed, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2024

Plan of correction: Acting Executive Director agrees to provide proof S1 was retrained in mediation procedures. Acting Executive Director agrees to submit a written plan to ensure residents will receive their medication as prescribed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211 · Plan of correction due date: Jul 8, 2024

87211 Reporting Requirements. A written report shall be submitted to the licensing agency…Any incident which threatens the welfare, safety, or health of any resident… This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when they failed to report a bus accident involving residents and medication errors, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2024

Plan of correction: Acting Executive Director agrees to provide a written incident reports, as well as a written statement of understanding of 87211 Reporting Requirements.

Allegation investigated: Facility staff did not meet the needs of resident(s) in care. Facility has insufficient staffing. Facility staff did not respond to residents’ call for help. Facility staff are not adequately trained. Facility staff did not treat resident with dignity and respect.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sheryl McCaskill, Interim Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 11/30/2023 from 12:35 pm to 6:10 pm, toured the facility, conducted interviews, and obtained documents. LPA also interviewed staff and residents on 6/13/2024 and 6/17/2024 and obtained additional documents. On the allegation: Facility has insufficient staffing. It was alleged the facility had insufficient staffing. LPA observed staffing schedules for July 2022 through November 2022. LPA also observed additional agency staff the facility contracted from July 2022 through November 2022, that coincided with days when less facility staff were present. LPA observed a large number of agency staff used in October and November 2022. Residents interviewed indicated sometimes the staff are spread thin, but they work hard to provide care. Residents noted during the COVID-19 outbreak, staff routinely checked on them in their rooms. Please continue to 9099-C, Pg 2. Substantiated Interviews revealed in 2022, the facility did not have a chef for approximately 6 weeks, and management helped with cooking. Residents indicated there were multiple current vacancies at the facility, including administrator (which is being filled by interim corporate managers), activities director, facilities maintenance director, and personal services director. Staff interviewed stated caregivers were serving food in the kitchen without having a food handling certificate. Staff did not believe there were enough staff, especially if staff call out. Multiple residents interviewed stated the meal service is very slow due to a lack of staffing. LPA reviewed staffing scheduled for May and June 2024. LPA observed some days have 3 dining staff total, while other days have 7 dining staff total. LPA observed on 5/17/2024, 5/18/2024, 5/25/2024, 2 staff at breakfast and lunch, but only 1 staff for dinner. On 6/13/2024, LPA observed 5 staff at breakfast, 4 staff at lunch, and 2 staff at dinner. Interim administrator stated they have 1 server and caregiver assigned for breakfast and at lunch. Residents indicated breakfast took 1.5 hours recently, and noted coffee and tea are no longer on the counter so servers have to bring the beverages, adding to the long service times. Some residents stated they don’t eat breakfast anymore because the wait was so long. One resident interviewed indicated they complained about the long service time to a server, and the server stated they were only one person. Multiple residents interviewed indicated they believe the staff are overworked and are not getting the help they need, as evidenced by the long wait times. Responsible party 3 (RP3) stated if the resident’s food is not ready when they take medication, they are unable to take their medication on time. Based on the information obtained the allegation is deemed Substantiated at this time. On the allegation: Facility staff did not respond to residents’ call for help. It was alleged staff do not respond timely to residents’ call buttons. Administrator at the time indicated the maximum response time should be 10-mintes. LPA reviewed call button logs for October 2022. LPA reviewed 295 pages of call log summaries, with hundreds of entries. LPA observed many calls that were under the 10-minute target response time. However, LPA observed 19 calls that were 30-39 minutes; 12 calls that were 40-49 minutes; 3 calls 50-59 minutes; 4 calls 60-79 minutes; 3 calls 80-99 minutes; 3 calls 100-149 minutes; one call that was 151 minutes; one call was 1,387 minutes; and one call was 2,838 minutes. LPA reviewed an on-site in-service training sheet dated 11/10/2022 conducted my administrator at the time. Topics discussed include “pendant response times.” Another training dated 10/19/2022 reminded staff the pendant logs can be printed. It states staff cannot have calls unanswered for more than 10 minutes and notes the average response time is 7 minutes. Based on the information obtained, the allegation is deemed Substantiated at this time. Please continue to 9099-C, Pg 3. On the allegation: Facility staff are not adequately trained. It was alleged that due to a high staff turnover, staff were not properly trained. LPA reviewed training transcripts from 2022. Care staff training requirements include 40 hours training for new staff and 20 hours annual training for existing staff. LPA observed staff to have 6 hours, 5.25 hours, 4.75 hours, 25.5 hours, and 16.50 hours. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility staff did not treat resident with dignity and respect. It was alleged staff were not respectful to residents. RP2 stated on 11/9/2022 they emailed a staff that R2 gets agitated when they feel the staff are disrespectful or aggressive toward them. RP2 stated some of the staff were “not kind.” Responsible Party 1 (RP1) stated they observed the business office manager speak inappropriately to a resident. It was alleged on 11/4/2022, that R2 was agitated after an interaction with staff. R2 told the staff they did not get breakfast, and the staff took the box for breakfast out of the trash and threw it at R2, stating R2 did eat breakfast but they are not remembering. LPA reviewed an on-site in-service training sheet dated 11/10/2022 conducted my administrator at the time. Topics discussed include “sensitivity training.” In the training notes, administrator discussed standards/expectations including “customer service,” and “exercise patience and slow down with resident interactions so you are better understood and so are they.” Administrator also notes “communication between staff should always be respectful and professional.” Another training dated 10/19/2022 states to be respectful and be kind. Residents interviewed indicated they had heard staff speak inappropriately to others. One resident interviewed stated a while ago a staff was “a little huffy” responding to residents when they complained about slow meal service. Based on the information obtained, the allegation is deemed Substantiated at this time. A citation for this was already issued on complaint 29-AS-20221215114140 on 6/13/2024 so a duplicate citation will not be issued. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit. respond sooner because they were short-staffed and were helping deliver meals to residents’ rooms. RP1 stated again on 10/23/2022, they found R1 on a urine-soaked pad, with their shirt wet. R1 stated no staff came to check on them all morning. RP1 pushed R1’s call button and staff provided care to R1. LPA reviewed call button logs for 10/23/2022 and observed quick response times to R1. Staff interviewed stated caregivers were on top of things, and they attend to soiled residents right away. Staff stated residents are checked every two hours if they need restroom assistance or incontinence care, or if they need repositioning. Staff all stated they worked to ensure residents are not soiled for an extended period of time. Staff stated some residents are combative when trying to be changed, but staff do their best and may provide residents PRNs for agitation. Resident 2 (R2) received showers twice a week. Responsible Party 2 (RP2) stated on 10/31/2022, R2 missed their scheduled shower due to a medical appointment, but RP2 asked staff to make sure R2 got their shower. On 11/4/2022, R2 had not had a shower still, and staff stated R2 refused multiple showers. On 11/6/2022 R1 received a shower, 9 days after their last shower. Facility shower logs were unavailable for review. Staff stated they try to meet residents’ care needs but some residents are combative to care. Residents interviewed stated the staff are busy, and sometimes they don’t show up to provide the residents their showers on time/as scheduled. However, Residents interviewed indicated they believe overall staff are meeting residents’ needs. However, some noted they had difficulty communicating with the staff because they do not speak English, but they try to communicate through gestures. Technical assistance is provided to remind the licensee of their responsibility to have competent staff that can communicate appropriately with residents. Although the allegation may have occurred, there was insufficient evidence to prove it; therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility staff mismanaged resident’s medication. It was alleged the facility mismanaged a resident’s medication. A responsible party (RP3) stated in June 2022, Resident 3 (R3) received the wrong medication for three days. RP3 also stated on 11/26/2022, during a COVID-19 outbreak, staff dropped off R3 and R4’s medication cups in their shared room, but did not ensure the residents took the medication. RP3 was concerned the medication cups could get mixed up and did not feel the facility was handling the medication properly. LPA reviewed incident reports submitted by the facility in 2022, and noted no medication issues were submitted. LPA reviewed R3’s file and did not observe medication issues in June 2022. However, LPA observed medication issues in July and August 2023. These were cited on complaint 29-AS-20230711113736. There was insufficient evidence to prove the allegation occurred in June 2022. Therefore, the allegation is deemed Unsubstantiated at this time. Please continue to 9099-C, Pg 3. On the allegation: Facility staff mishandled residents. It was alleged that due to improper training, staff handled residents roughly. LPA reviewed an on-site in-service training sheet dated 11/10/2022 conducted by administrator at the time. Topics discussed include “sensitivity training.” In the training notes, administrator discussed standards/expectations including “customer service,” and “exercise patience and slow down with resident interactions so you are better understood and so are they.” Some residents interviewed indicated they had never had an issue with handling them roughly. One resident stated they were aware of a resident who mishandled another resident but did not have an issue with staff. Staff interviewed indicated they were unaware of any staff mishandling or roughly handling residents. Although the allegation may have occurred, there was insufficient evidence to prove it. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility is in disrepair. It was alleged the facility was in disrepair. Responsible Party 1 (RP1) stated they asked staff to repair R1’s toilet paper holder, and later asked the marketing director. Both staff and marketing director indicated they would put in a work order. RP1 stated despite multiple follow-ups, it took 5 weeks to get the repair complete. LPA observed the work order report for 7/15/2022 to 12/1/2022, and 168 work order requests. LPA observed the broken toilet paper holder reported twice with “medium” priority given. During the facility’s annual inspections on 8/4/2022, 8/9/2023, 9/8/2023, and 9/13/2023, LPA did not observe the facility to be is disrepair. LPA also did not observe any physical plant issues on 6/13/2024 or 6/17/2024. Based on the information obtained, the allegation is Unsubstantiated at this time. Technical assistance is provided to remind the facility to address any necessary repairs timely and appropriately. On the allegation: Facility staff did not follow COVID-19 guidelines. Multiple responsible parties confirmed on 11/8/2022, the front lobby of the facility, adjacent to the dining room, was used as a public polling place for an election. It was alleged that as a result of the public in the building, the facility experienced a COVID-19 outbreak, with 9 cases by 11/14/2022, 25 cases by 11/17/2022, and 38 cases by 11/19/2022. Responsible parties feel that that it was dangerous and negligent of the facility to allow the public into the facility, near the resident’s dining room. CCL reviewed records and verified the facility reported the COVID-19 outbreak to CCL and local public health. The origin of the COVID-19 cannot be conclusively proven, and no guidance at the time of the complaint formally prohibited the facility from acting as a polling site. However, Technical Assistance is provided to the facility as a reminder of their responsibility to use good judgment to ensure resident safety and follow applicable public health guidelines. Based on the information obtained, the allegation is Unsubstantiated at this time. Please continue to 9099-C, Pg 4 On the allegation: Facility is unkempt. It was alleged resident’s rooms were not being cleaned. It was alleged a resident’s room did not get cleaned for 11 days. During the facility’s annual inspections on 8/4/2022, 8/9/2023, 9/8/2023, and 9/13/2023, LPA did not observe the facility to be unkempt or dirty. LPA also did not observe any physical plant issues on 6/13/2024 or 6/17/2024. Based on the information obtained, the allegation is Unsubstantiated at this time. On the allegations: Facility staff did not communicate with resident's responsible parties, and Facility did not report incidents. It was alleged an incident where a resident sustained injury was not reported to the responsible party. Responsible Party 1 (RP1) stated on 11/16/2022, Resident 1 (R1) sustained an injury in their bathroom that resulted in substantial bleeding; however, RP1 was not notified. RP1 arrived and observed R1’s injury, pressed R1’s call button, and staff bandaged R1’s bleeding. RP1 noted R1 needed assistance in the bathroom, so staff should have been with R1 when it happened. RP1 stated on a subsequent interview, RP1 arrived at the facility on 11/6/2022 and observed R1 had a bandage on their arm. R1 got their arm stuck on a grab bar while toileting with staff, and R1 stated they bled a lot and a bandage was applied. RP1 asked the facility’s nurse for more information and why they were not informed, but the nurse was not aware of the incident. RP1 stated on 11/8/2022 a nurse visited R1, told R1 they had a vaginal infection and attempted to do a pelvic exam. RP1 was unaware of R1’s symptoms or the medical attention R1 was receiving. RP1 confirmed with R1’s doctor the facility faxed them about the symptoms. On 11/9/2022, RP1 stated they emailed the facility nurse about the lack of communication. LPA did observe incident reports submitted for these dates, but the incidents did not meet reporting requirements for CCL. LPA did not find sufficient evidence to corroborate the allegations although RP1 kept detailed notes of the issues. There was insufficient evidence to conclusively prove the allegation happened, therefore the allegation is deemed Unsubstantiated at this time. However, LPA reminded administrator of the requirement and importance of reporting incidents to both CCL and responsible parties, and keeping responsible parties informed. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jun 17, 2024 · control 29-AS-20221121125215

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jun 24, 2024

87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform…cooking… This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited when they did not employ sufficient dining staff, which posted a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Administrator agrees to submit a plan to ensure sufficient dining staff and decrease resident wait times for food. Administrator will submit by 6/24/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i) · Plan of correction due date: Jun 24, 2024

87303(i) Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria… This requirement was not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when staff did not answer calls timely, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Administrator agrees to provide training to all staff of call button response time expectations. Administrator will submit by 6/24/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Jun 24, 2024

87411(c) Personnel Requirements. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625… This requirement was not met as evidenced by: Based on record reviews, the licensee did not comply with the section cited above when staff did not have adequate training in 2022, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Administrator agrees to provide a plan to ensure all staff receive adequate training going forward. Administrator will submit plan by 6/24/2024.

Allegation investigated: Staff are mismanaging resident's medication. Staff are not ensuring residents medication are refilled timely.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sheryl McCaskill, Interim Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 7/18/2023 from 11:40 am to 3:30 pm, toured the facility and obtained documents. LPA also conducted a medication audit on 8/9/2023 at 12:35 pm. On 6/13/24, LPA collected additional documents. On the allegation: Staff are mismanaging resident's medication. On 6/30/2023, R1 stated they had not received their Colchicine for two days. Although Responsible Party 1 (RP1) provided the facility R1’s medication on 6/26/2023, staff could not find the medication and called RP1 twice asking for the refills. RP1 brought up the issue to facility management, who indicated via email they found the Colchicine in their ‘overflow’ area once it was brought to their attention, and addressed the issue with staff. Please continue to 9099-C, Pg 2. Substantiated LPA reviewed an email from 7/31/2023 from RP1 to facility management. It states over the weekend, RP1 received a call asking for Colchicine and Miralax for R1. RP1 asked when the medications were needed, and was told R1 was completely out and missed the morning dose. RP1 stated they never received a request to refill the medications prior to running out. On 8/9/2023 at 12:35 pm, LPA conducted a medication audit of R1’s medications with administrator at the time present. LPA observed the following errors: · Amlodipine Besylate 5.0mg started 7/18/2023; Med count: 21; should have been 22 count. · Amlodipine 2.5mg started on 7/29/2023; Med count: 77; should have been 78. Administrator believes the med tech wrote down the wrong start date. · Aspirin 81mg/day in AM; 500 tablets, started 9/19/2022; 324 days elapsed. Med count: 51; Short 125 tablets. · Colchicine: 0.6 mg/1 tab/day AM: Started 7/31/2023; 90-day supply; 10 days from 7/31/2023 to 8/9/2023; Med count: 79; Should have 80; count is short one tablet. · Ezetimibe: 10mg 1/day in AM; started 6/17/2023; 90 tablets; 54 days between 6/172023 & 8/9/2023; Med count is 36 tablets, 2 tablets short. · 2 orders of Famotidine at 20mg/each order: Started 6/10/2023; 125 tablets to start; 1/day in AM, 1/day at bedtime; 61 days from 6/10/2023 to 8/9/2023; (61 x 2 = 122 tablets/day); Med count: 8 tablets; (On 8/9/2023, one tablet given in AM; bedtime tablet not yet given on 8/9/2023); Med count: 8 tablets; Over 4 tablets. · Furosemide 40mg: Started 6/1/2023; 1 tab/day in AM; Bottle count: 90 at start; med count: 19 tablets; 1 tablet short. · Hydralazine 25mg; Qty at start: 270; Start date: 5/31/2023; 1T/2x day at 9 am & 5 pm; 5/31/2023 – 8/9/2023 am: is 71 days; 5/31/2023 – 8/9/2023 pm is 70 days. Total of 141 disbursements; Med count: 130; Should be 129; One tablet over. Administrator stated he believed the start dates were incorrect. Please continue to 9099-C, Pg 3. · Leg cramps (quick dissolve): no mg stated; 1T/bedtime; Start date 6/12/2023: Qty at start: 100; 1T @ bedtime; 58 days from 6/12/2023 to 8/8/2023 (not 8/9/2023 because it is a bedtime med); Med count: 48; four tablets over. · Levothyroxine 112 mcg: Started on 6/11/2023; 90 qty at start; 29 remaining; 1/day in AM; 59 days from 6/11/2023 – 8/9/2023; Med count: 29 tablets; 12 short. · Melatonin: 250 count; started 1/16/2023 – 8/8/2023 = 204 days; no mg stated; 1 day/night; OTC; Med count: 46; Accurate. · Potassium Chloride: 10mek (microtab); Started 5/19/2023; Qty at start: 90; 1/day in AM; 1 remaining in bottle; Short 7 tablets. · Pravastatin (Sodium): Started 7/16/2023; 40mg; Qty at start: 90; 1/day at bedtime; 7/16/2023 – 8/8/2023 = 24 days; 67 remaining in bottle; 1 extra. · Methenamine: 1T/day 2x daily at meals (breakfast & dinner); Start date 7/20/2023; Qty at start: 60; 7/20/2023 – 8/9/2023 (AM): 20 days; 7/20/2023 – 8/8/2023 (PM) 19 days; Med count: 19 tablets; Short 2 tablets. · Metoprolol Tart: 25mg; 1T/2x daily (AM & PM) Start date: 7/5/2023: 7/5/2023– 8/9/2023 = 36 days (AM); 7/5/2023 – 8/8/2023 = 35 days; Qty at start: 180 tablets; Med Count: 110 tablets; 1 over (extra). LPA observed no records of R1’s medications being refused or destroyed. Per Administrator, an in-service for med techs was held on 8/10/2023. RP2 stated R2 had eye ointment prescribed for styes 4x per day, including one midnight dose that staff did not provide when resident was sleeping. RP2 asserts that R2 may not have received the ointment as prescribed during the other dosages because the tube was full. LPA was unable to determine whether this ointment was given as prescribed or not given as prescribed. LPA recommends in the future, facility clarify orders that state “X times per day” to ensure resident’s physician agrees with the times the medication is given and if the medications will be given to the residents in the middle of night. The facility should clarify the orders so that residents do not need to be woken up for medications, unless necessary per the physician, and may be less likely to refuse or miss them. Please continue to 9099-C, Pg 4. Based on the information obtained, R1’s medications were not given as prescribed. The facility was already cited for R1’s medication errors on 9/13/2023. A duplicate citation will not be issued but the facility is encouraged to provide staff additional medication training regularly and as-needed to ensure medications are given as prescribed. On the allegation: Staff are not ensuring residents medication are refilled timely. RP1 stated staff did not notify RP1 in order to get refills timely. LPA observed a screenshot of a text message from Mariposa at Ellwood Shores that shows medication bottles and indicates they need more of this medication, stating “We don’t have none. A soon as possible please [sic].” RP1 stated in June 2023, they dropped off R1’s refill of Colchicine at the front desk. However, the medication bottle went missing and R1 did not receive the medication for two days as a result. RP1 stated after that incident occurred, they now bring R1’s refills to the medication room or hand them to a med tech. LPA reviewed an email chain that started 6/26/2023, with the facility asking RP1 for 7 of R1’s medications to be refilled. On 7/3/2023, RP1 wrote to facility management that they dropped off all the medications requested on 6/26/2023. Later in the week, med techs called RP1 to ask for the Colchicine medication, which RP1 stated had already been dropped off. On 6/30/2023, RP1 brought the issues to management’s attention verbally. On 6/30/2023, RP1 spoke to a med tech who indicated R1 received the Colchicine, which was confirmed via email on 7/1/2023. Facility management indicated via email they found the Colchicine in their ‘overflow’ area once it was brought to their attention, and addressed the issue with staff, admitting there was an issue. LPA reviewed an email from 7/31/2023 from RP1 to facility management. It states over the weekend, RP1 received a call asking for Colchicine and Miralax for R1. RP1 asked when the medications were needed and was told R1 was completely out and missed the morning dose. RP1 stated they never received a request to refill the medications prior to running out. Administrator at the time stated they would look into the issue. Based on the information obtained, the allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit. daily but “facility must verify directions.” LPA observed in July 2023, R1 had changes to their Allopurinol order. From 7/1/2023 to 7/7/2023, R1 took 1.5 tablets (150mg) by mouth daily. Then the order effective 7/8/2023 became two separate orders. One order stated take 1 tablet (no mg) by mouth daily. The MAR indicated 0.5 tabs were given, although the order did not say to give a half tab. The second order stated take 0.5 tablet (50mg) by mouth on Sat, Tues, Thurs for 150mg total. The MAR shows the medication was still given on days that were not Sat, Tues or Thurs (Monday 7/92023, Wednesday 7/12/2023, Friday 7/14/2023). Based on the information obtained, the medication was not given as prescribed, and the facility was already cited for this issue. R1’s MAR was up to date with the changed orders, but it appears it was implemented incorrectly by staff. Therefore, this allegation is deemed Unsubstantiated at this time. On the allegation: Staff are not following doctor's orders. Since March 2023, R1’s doctor requested staff to check R1’s blood pressure. RP1 stated staff did not fulfill the doctor’s request, so the doctor is unable to prescribe proper medication for R1. LPA observed R1’s Medication Administration Record (MAR) for March 2023 through July 2023. LPA observed March 2023 indicates to check the blood pressure twice per week, and the MAR notes this was completed. April 2023’s MAR shows R1’s blood pressure check changed from twice per week, to three times per day, to once per day, to check daily before and after a medication. The MAR indicates all blood pressure checks were completed for April 2023, May 2023, June 2023, and July 2023 show daily blood pressure checks were given before and after a medication as prescribed. R1’s physician’s orders dated July 2023 state to check R1’s blood pressure in the morning and after a medication dose, and fax the blood pressure records to the physician every Thursday. LPA observed a similar order to take R1’s blood pressure in April 2023 and log it, but the instructions do not say to provide the results to R1’s doctor on a certain basis. LPA was unable to find sufficient information proving the allegation was true and/or occurred. Based on the information obtained, the allegation is deemed Unsubstantiated. The facility is reminded they are responsible for meeting the needs of the residents and must follow all doctor’s orders. On the allegation: Facility has not provided residents emergency preparedness training. The complainant alleged that the facility did not provide residents with emergency preparedness training. While facility staff are required to have emergency preparedness training and participate in quarterly drills, the regulations do not require residents to participate in the drills, and do not require facilities to allow residents to participate in the drills. A best practice is recommended to the facility to include residents in appropriate emergency Please continue to 9099-C, Pg 3. preparedness training. LPA reviewed facility disaster training held on 4/29/2023, 3/20/2024, 2/21/2024. LPA observed disaster drills covering different shifts completed on 2/28/2023, 4/13/2023, 4/30/2023, 7/31/2023, 9/11/2023, 9/19/2023, 9/20/2023, 9/26/2023, 1/10/2024, 1/15/2024, 1/17/2024, 1/18/2024, 1/30/2024, 3/2/2024, 3/3/2024, 3/4/2024, 3/11/2024, 3/25/2024, 4/10/2024, 4/12/2024, 4/14/2024, 4/30/2024, 5/11/2024, 5/12/2024, 5/15/2024, and 5/22/2024. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report given issued at the time of the visit.the state’s words, verbatim · CDSS document, Jun 17, 2024 · control 29-AS-20230711113736

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jun 19, 2024

87465(a)(2) Incidental and Medical Care: A plan for incidental medical and dental care shall be developed by each facility. The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when not asking for R1’s refills timely, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Administrator agrees to develop a written procedure/plan for staff to ensure refills are obtained timely. Administrator will submit plan to CCL by 6/19/2024.

Allegation investigated: Staff did not provide residents personal representative with copy of resident's records. Staff did not ensure residents room was kept in clean sanitary conditions. Staff did not ensure residents room was free of mal odors. Facility staff did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced complaint visit to issue final findings on the allegations above. LPA met with Sheryl McCaskill to issue the final findings. During the investigation, LPA Kontilis conducted a visit on 5/21/2024 from 10:00 am to 5:30 pm to interview staff and residents and obtain relevant documents. LPA also conducted interviews on 6/14/2024 and 6/17/2024. On the allegation: Staff did not provide residents personal representative with copy of resident's records. It was alleged that a personal representative was not provided a copy of the resident’s records. Responsible Party (RP) for Resident 1 (R1) stated they asked the now former administrator for a copy of R1’s resident records multiple times via email and once in person. Per RP, the former administrator indicated the facility no longer releases records in order to protect the identify of the caregivers. LPA observed an email dated 1/22/2024 to facility management asking for R1’s records, and additional emails dated 1/30/2024 and 3/19/2024 asking for the records. An email from 3/4/2024 from RP to facility management indicates the Please continue to 9099-C, Pg 2. Substantiated facility provided R1’s recent history, physician’s reports, medication list, and advanced healthcare directive. However, the facility did not give a complete copy of R1’s records to their responsible party as requested. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegations: Staff did not ensure resident’s room was kept in clean sanitary conditions, and Staff did not ensure resident’s room was free of mal odors. LPA reviewed photographs obtained by Resident 1’s (R1’s) responsible party (RP). RP stated when RP visited R1 in R1’s room on 12/31/2023, feces were observed on the wall of R1’s room. RP indicated R1 had a behavior of throwing their brief at the wall. LPA observed photographs of numerous brown marks all over a wall but did not observe any during the visit on 5/21/2024. RP stated feces was observed in R1’s room on 12/31/2024 which caused a mal odor in the room. RP stated they conducted a walk through with now former Administrator on 4/23/2024 at which time RP observed the feces on the wall was “dried and still present” and stated the feces seemed to be dry enough to not present a mal odor. During the visit on 5/21/2024, LPA toured the “Compass Rose” memory care unit of the facility with Staff 1 (S1). At approximately 2:00 pm, LPA observed a mal odor in the common area of the memory care unit, of urine and feces. LPA brought the odor to S1’s attention, and S1 stated “I smell it too.” Based on interview conducted and documents obtained, the allegation that Staff did not ensure resident’s room was kept in clean sanitary conditions is deemed Substantiated at this time. On the allegation, facility staff did not safeguard resident’s personal belongings, RP stated R1 had many personal belongings such as but not limited to scarves, clothing, sheets, bedspread, a doll, and pillows. RP noted one scarf that was missing was worn by a staff member, who stated a resident gave them the scarf. RP further stated when R1’s coats, jackets, and other clothing articles were returned from being laundered, many of the items had been “ruined” due to having been put through a washer and/or dryer when they were not the type of fabrics that should have been washed and/or dried. RP provided email communications between facility staff and RP inquiring about missing and damaged items. RP also noted when R1 was moving out, RP discovered several items in R1’s room that did not belong to R1. During the visit on 5/21/2024, LPA conducted interviews with residents. Resident 2 (R2) stated their clothing and laundered items were not returned after several days. Resident 3 (R3) stated personal clothing items such as shirts were either being washed in too hot of water or dried at too hot of a temperature because the shirts are getting “shorter and shorter”. R3 also stated a furniture item was damaged when facility staff moved R3 into a different room. During today’s visit, LPA conducted an interview with R3’s Responsible Party. R3’s Please continue to 9099-C, Pg 3. Responsible Party confirmed R3’s chair was broken as a result of R3’s move. The investigation revealed that some items went missing; and also that facility staff damaged multiple items belonging to residents. Based on records reviewed and interviews conducted, the allegation “Facility staff did not safeguard resident’s personal belongings” is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit. residents are checked every two hours and changed as needed. Some residents noted they had difficulty communicating with the staff because they do not speak English, but they try to communicate through gestures. Technical assistance is provided to remind the licensee of their responsibility to have competent staff that can communicate appropriately with residents. Although the allegation may have occurred, there was insufficient evidence to prove it; therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not ensure medications were dispensed as prescribed to residents in care. It was alleged that staff did not provide R1 their eye drops to them as prescribed. It was alleged R1 moved out of the facility and had 3 to 5 extra bottles of eye drops. If R1 had received them as prescribed, they should not have so many extra bottles. Staff stated sometimes R1 refused the eye drops, which could account for the extra bottles over the years R1 lived at the facility, as the eye drops were auto-refilled by the pharmacy regardless if they were empty or not. LPA reviewed centrally stored medication records for the facility and medication lists that showed R1’s eye drop medications. However, R1 moved out of the facility in April 2024, and the eye drops were no longer at the facility and could not be reviewed. Based on the information obtained, there was insufficient evidence to prove the allegation occurred. Therefore it is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jun 17, 2024 · control 29-AS-20240515122500

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jun 24, 2024

87468.2(a)(19) Personal Rights. To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days…This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when they did not provide R1’s responsible party access to all of R1’s records, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Administrator agrees to provide R1’s responsible party a complete copy of R1’s records by 6/24/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 24, 2024

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on interview and observation, the licensee did not comply with the section cited above when the facility had a mal odor and feces on R1’s wall, which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: R1’s wall has been cleaned. Administrator agrees to provide proof of deep cleaning in memory care by 6/24/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(2) · Plan of correction due date: Jun 24, 2024

87218(a)(2) Theft and Loss: A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. This requirement was not met as evidenced by: Based on interview, the licensee did not comply with the section cited above, as they were unable to properly safeguard resident property, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Administrator agrees to reimburse residents for damaged items. Administrator agrees to submit a written statement of understanding of 87218 to CCL by 6/24/2024.

Allegation investigated: Staff did not respond to resident's request for assistance as necessary. Staff did not report an incident involving resident to their Responsible Party as required.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sheryl McCaskill, Interim Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 10/25/2023 from 11:00 am to 4:15 pm. LPA conducted staff interviews and obtained documents. On the allegation: Staff did not respond to resident's request for assistance as necessary: It was alleged that Resident 1 (R1) fell and broke their hip on 10/4/2023. It was alleged R1 pushed their call button for an extended period of time and cried for help. However, R1 did not receive assistance until a visitor opened their door and called 9-1-1. R1’s family member stated R1 typically goes to dinner between 4:45 pm and 5:00 pm. R1 stated on 10/4/2023, they were in their bathroom changing their clothes for dinner, and suddenly fell. R1 stated they pushed their call button, and it took the staff a “long time” to get there, estimating approximately Please continue to 9099-C, Pg 2. Substantiated 45 minutes. R1 stated they were banging on the door to let someone know they needed assistance. R1 stated their hand was getting numb from hitting the door and they had bruises on their hand, arm, and legs from trying to signal for help. R1 stated a visitor found them and summoned staff. R1 stated they have only pressed their pendant once or twice in the past. R1’s visitor signed into the facility at 5:39 pm, which was confirmed by visitor logs. Visitor went upstairs to R1’s room, where they heard R1 yelling for help. Visitor stated they went back downstairs to the front desk and asked for staff to open the door immediately. Staff told the visitor there was another emergency on the same floor. Visitor went back to the second floor and searched for another staff, who opened R1’s door and then left. Visitor stated R1 was in the bathroom, behind two closed doors, banging for help. Visitor left to find help and found a staff in the kitchen. The staff immediately called for help on the walkie talkie and went to R1’s room with the visitor. Staff called 9-1-1. Information from visitor and R1’s family member confirmed the visitor first called family at 5:58 pm, then 6:00 pm and 6:11 pm. The incident report submitted by the facility indicates R1 was discovered around 5:45 pm. Former administrator indicated the facility has a 10-minute response time to their call buttons. LPA reviewed facility call button logs. LPA observed an entry for 10/4/2023 at 5:12:46 pm where R1 pressed their pendant. It states it took 35 minutes and 3 seconds for staff to respond, at 5:47:49 pm. For the time period of 10/3/2023 to 10/4/2023, LPA observed 3 calls that were between 20 and 40 minutes, and 3 calls that were over 40 minutes. LPA also observed one call for a resident was listed at 117 minutes 4 seconds. An interview with a credible witness revealed they discussed call button times with the former administrator on 10/24/2023. Witness stated the staff have just been saying “Copy” but then do not respond to the call. Per witness, former administrator was going to change the policy to ensure staff responded promptly, or else another staff would be notified to respond. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Staff did not report an incident involving resident to their Responsible Party as required: It was alleged that the facility refused to provide R1’s responsible party a copy of the incident report. R1’s family member stated family met with the former administrator on 10/24/2023 to discuss the incident with R1. Former administrator indicated they were not able to release the written incident report to them due to corporate policy. A credible witness also indicated they were not able to obtain call button logs due to ‘corporate policy.’ Please continue to 9099-C, Pg 3. LPA reviewed the incident report for R1’s fall on 10/4/2023. The incident report states R1’s responsible party was called and notified but does not indicate they were notified in writing as required per regulation. Based on the information obtained, the allegation is deemed Substantiated at this time. Technical Assistance is also provided to remind the Administrator of section 87468.2(a)(19) Personal Rights, which states residents have the right “To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.” The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 29-AS-20231020165322

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Jun 14, 2024

Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they failed to respond to R1’s call button for assistance, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Administrator agrees to provide staff training on call button response expectations. Administrator will provide proof training is scheduled by 6/14/2024, and administrator will provide proof of training by 6/21/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 17, 2024

87211(a)(1) Reporting requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when they did not notify R1’s RP of a fall in writing, which posed a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Administrator agrees to provide R1’s responsible party a copy of the incident report. Administrator stated a copy of the report will be sent via USPS Certified Mail with Return Receipt.

Allegation investigated: Staff speak inappropriately to residents in care.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sheryl McCaskill, Interim Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 12/12/2023 from 1:05 pm to 4:00 pm, and toured the facility and obtained documents. LPA also interviewed staff and residents on 6/13/2024 and obtained additional documents. On the allegation: Staff speak inappropriately to residents in care. It was alleged that a staff spoke inappropriately to a resident. Responsible Party 1 (RP1) stated they observed the business office manager speak inappropriately to a resident. Responsible Party 2 (RP2) stated on 11/9/2022 they emailed the facility nurse that R2 gets agitated when they feel the staff are disrespectful or aggressive toward them. RP2 stated some of the staff were “not kind.” RP2 stated on 11/4/2022, R2 told the staff they did not get breakfast and Please continue to 9099-C, Pg 2. Substantiated the staff took the box for breakfast out of the trash, threw it at R2, and stated R2 did eat breakfast but they are not remembering. LPA reviewed an on-site in-service training sheet dated 11/10/2022 conducted by administrator at the time. Topics discussed include “sensitivity training.” In the training notes, administrator discussed standards/expectations including “customer service,” and “exercise patience and slow down with resident interactions so you are better understood and so are they.” Administrator also notes “communication between staff should always be respectful and professional.” Another training dated 10/19/2022 states to be respectful and be kind. Residents interviewed indicated they had heard staff speak inappropriately to others. One resident interviewed stated a while ago a staff member was “a little huffy” responding to residents when they complained about slow meal service. Based on the information obtained, the allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit. On R1’s physician’s report dated 8/18/2022, it indicates R1 had a history of a kidney transplant and diabetes. The report is incomplete, with no marks about R1’s ability to complete Activities of Daily Living, including bathing self, dress/groom self, feed self, care for own toileting needs, and able to manage own cash resources. R1’s service plan dated 9/21/2022 states R1 may require stand-by assistance for ambulation, needs assistance with bathing twice a week, and needs assistance with application and removal of support stockings. There is no indication R1 needed assistance with toileting. R1’s updated assessment dated 10/20/2022 indicates they are alert and oriented, had no neurocognitive issues, and do not require additional status checks. R1 also handled some of their own medications, including insulin. LPA reviewed incident reports for the facility for November and December 2022. LPA observed an incident report notifying CCL that R1 had COVID-19, but did not observe any other incident reports. LPA reviewed documentation from R1’s facility. The facility notified R1’s Primary Care Physician (PCP) of a fall on 11/1/2022 where the resident had no injuries, nor complaints of pain or discomfort, so they were not sent to the hospital. On 11/4/2022, R1 slid off their bed but stated they did not hit their head. On 11/7/2022, R1 had a fall and refused to go to the hospital. On 11/3/2022, 11/10/2022 and 11/16/2022, R1 was seen by home health where they provided bladder irrigation. The facility notified R1’s Primary Care Physician (PCP) that R1 tested positive for COVID-19 on 11/17/2022. R1 isolated in their apartment at the facility for 10 days. Charting notes for R1 indicate on 11/7/2022 on the PM shift R1 was weak, sleepy, with body aches, cough and runny nose. R1 went to the hospital to receive an IV infusion and returned. On 11/19/2022 R1 stated they “feel okay.” On 11/22/2022 R1 did not have any complaint of pain or discomfort. The other entries between 11/17/2022 and 11/26/2022 indicate R1’s temperature, heart rate, and oxygen saturation. Charting notes for R1 indicate on 11/28/2022 during the PM shift, a visitor observed R1 to be more confused than normal. Staff checked on R1 and found them shaky with swollen feet and feeling nausea; 911 was called and paramedics found R1’s blood sugar to be high. Paramedics instructed R1 to take their insulin, which they forgot to do at lunchtime. R1 and paramedics agreed not to send R1 to the hospital, and R1 felt better after taking insulin. R1 was checked on multiple times during the shift. The overnight shift reported R1 stated they were doing better. On the morning of 11/29/2022, R1 woke up late and staff reminded R1 to take their medications and food. In the evening, R1 was wheeling self around the room putting clothes away. Please continue to 9099-C, Pg 3. Staff asked R1 why they hadn’t touched their meals that were at their table. R1 stated they did not want the food. Staff offered for the cook to make a sandwich or hot dog, but R1 stated they would make food themselves. R1 was recovering from COVID-19, but staff noted R1 had a stuffy nose but stated they always had sinus issues due to allergies and were in good spirits. Later, R1 complained of a stomach ache and asked for pepto bismol, which they took and felt better. On 11/30/2022, R1 was found on the floor and taken to the ER. The facility also notified PCP of the fall. There were no documents in R1’s file indicating they had a urinary tract infection (UTI) or symptoms of a UTI. There was also no documentation that R1 was seen by a medical professional between 11/23/2022 and 11/25/2022. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff do not serve nutritious meals for residents. It was alleged that the facility’s chef had quit and non-nutritious food was served. Two residents’ responsible parties both indicated the facility food was “not good” and “non-nutritious.” The Administrator at the time stepped in and assisted with cooking and serving meals. During the facility’s annual inspections on 8/4/2022 and 8/9/2023, the kitchen was inspected. LPA did not observe any spoiled or expired food during the inspections. Responsible Party 2 (RP2) stated Resident 2 (R2) was excited for hot dogs which were available on the “all day menu,” but R2 was told their responsible party did not want them eating hot dogs and was told they were out of hot dogs. Menu for 2022 was unavailable to review; however LPA reviewed menus from early 2023, which appear balanced. Residents interviewed stated the food was non-nutritious and the meals were “imbalanced.” Resident stated macaroni and rice were served together at a meal, so the meal was all starches and no vegetables. Residents stated they would agree there are some “nutrition drawbacks or inadequacies.” For example, the menu will say “ham slice” for dinner but the ham is very processed and is more like bologna. Resident noted many of the foods served are high in sodium, but the vegetables are getting better and salads are always available. Residents stated the meals were not great, and the food service is slow. Resident stated meatloaf was the meal today, but it was just ground meat and was not meatloaf. There was insufficient evidence to prove that the food did not meet Title 22 requirements, therefore the allegation is deemed Unsubstantiated. However, technical assistance is provided to notify the administrator that many residents interviewed were dissatisfied with the food, and communicated meals may be imbalanced or not as nutritious as they could be. In addition, some noted meat was tough or not cooked appropriately. Facility is advised to reconsider their menu and food offerings, and ensure kitchen staff have sufficient training to adequately serve the large number of residents in this facility. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 29-AS-20221215114140

From the deficiency page — Deficiency type: Type B · Section cited: CCR 878468.1(a)(1) · Plan of correction due date: Jun 20, 2024

87468.1(a)(1) Personal Rights. Residents…have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when staff spoke inappropriately to residents, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Administrator agrees to conduct personal rights training with all staff and provide proof of training by 6/20/2024. Administrator agrees to submit proof of training via email including description of training, first and last name(s) of trainer(s) and trainees. Trainee signatures required.

Allegation investigated: Staff did not meet a resident's health needs while in care.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced complaint visit to issue final findings on the allegation above. During the investigation, LPA Kontilis conducted a visit on 5/17/2023 from 11:40 am to 4:00 pm to interview staff and obtain relevant documents. LPA Kontilis conducted a subsequent visit on 8/2/2023 from 2:00 pm to 5:15 pm to conduct staff interviews and obtain additional documents. On the allegation: Staff did not meet a resident's health needs while in care. It was alleged that Resident 1 (R1) did not receive appropriate wound care, which lead to R1 developing osteomyelitis in their right great toe. LPA interviewed Administrator, facility nurse, and hospital nurse. LPA reviewed R1’s facility records and medical records. Please continue to 9099-C, Pg 2. Unsubstantiated On 2/26/2023, R1 was sent to Santa Barbara Cottage Hospital after developing aphasia and was found to have cellulitis on their right second toe, which had to be amputated. R1 was diagnosed with having a stroke and was discharged from the hospital to a Skilled Nursing Facility (SNF). R1 saw a podiatrist and was diagnosed with a foot fungus as well. Facility nurse visited R1 at the SNF and observed R1 appeared to be declining. R1 did not return to the facility until 4/17/23. R1 returned to the facility on home health because R1 was not participating in physical therapy. Central Coast Home Health regularly visited R1 and did not consider the wound to be a pressure injury. The facility nurse contacted the SNF, who also stated the wound was not a pressure injury and was healing. LPA interviewed the case manager nurse from the hospital, who disclosed based on hospital records, when R1 was seen in the hospital on 2/27/2023, R1 did not have black necrotic tissue or the wound that was observed 5/9/2023. Case manager nurse indicated the wound developed between 3/29/2023 and 4/11/2023, when R1 was at the SNF. Facility nurse stated after R1 returned to the facility, they asked for hospice to be considered for R1, and also asked for a swallowing evaluation. Facility nurse also asked for palliative care as a bridge between home health and hospice. On 5/9/2023, a home health nurse visited R1 at the facility. Home health nurse observed R1’s right great toe and observed an unstageable necrotic (black) wound to the right great toe. On 5/9/2023, home health nurse notified facility nurse of the unstageable necrotic wound. Facility nurse stated she was unaware of the necrotic toe until 5/9/2023. R1’s PCP was in the building at the time of discovery, and PCP’s nurse observed R1’s toe. PCP believed the tissue could be a basal cell carcinoma. R1 was taken to Goleta Valley Cottage Hospital and was diagnosed with osteomyelitis. Additionally, hospital notes indicate on 5/10/2023, R1 was found to have MRSA and E.coli, and the skin of the bone reached the toe and caused osteomyelitis. Hospital notes indicate R1’s course of treatment was IV antibiotics. Facility nurse stated home health was brought in for wound care and was supposed to communicate with the facility staff or herself if there was anything concerning. Facility nurse stated they questioned how the condition of R1’s great toe could have been missed if home health was providing wound care for the amputated second toe on the same foot. However, facility nurse stated when R1 was first brought back from the hospital, there was a bandage on the toe, so the condition was not visible. Please continue to 9099-C, Pg 3. Based on interview with facility nurse and R1’s physician’s report and care plan, the facility showered R1. After R1 returned to the facility, they obtained a Hoyer lift to assist with showers, but R1 began refusing showers. Eventually R1 received bed baths due to refusing showers and refusing to use the Hoyer lift. LPA interviewed staff who assisted R1 between 4/17/2023 and 5/9/2023 about R1’s care needs and the condition of R1’s right great toe. Staff interviewed indicated R1’s feet were always wrapped in compression socks and/or had bandages covering the toes, so they did not look at R1’s feet. Staff interviewed indicated the Home Health nurses would check R1’s feet, and that task was not assigned to facility staff. Based on the information obtained, there was insufficient evidence to prove the allegation occurred. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 29-AS-20230512135542