Willow Oaks Senior Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Agnes Teodoro. During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 4 residents bedrooms. There was no obstruction to block the walkways. The staff area of the facility was also inspected. The front yard and backyard were inspected. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured at 116 degrees F in resident bathrooms. Fire extinguisher was serviced in March 10, 2026. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on May 20, 2026. LPA reviewed facility disaster plan, which was last reviewed/updated on February 1, 2026. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. During the medication audit, LPA observed 2 separate containers dated July 17 and July 18, 2026. LPA noted inside these plastic containers, there was pill boxes inside labeled for each resident. ADM stated she was pre-filling residents medications 2 days in advanced. ADM stated she was pre-filling 2 days in advanced because she has Friday and Saturday off. LPA advised staff and Administrator to ensure medications were not pre-poured in case resident's physician were to change prescription orders. A deficiency and Technical assistance was cited during today's visit. This report was reviewed with Administrator Agnes Teodoro and a copy of the signed report was provided. Appeal rights were providedthe state’s words, verbatim · CDSS document, Jul 16, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Merla Banglayan. During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA observed pool fencing as secured and locked. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 110 degrees F in resident bathrooms. Fire extinguisher was serviced in April 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on June 11, 2025. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 3 staff and 3 residents. No deficiencies cited during today's visit. This report was reviewed with Licensee Irish Ladwig and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Jul 10, 2025

Allegation investigated: Facility staff did not ensure a resident is regularly observed for changes in physical health condition Facility staff did not provide immediate medical assistance to resident

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Agnes Teodoro On June 9, 2023, the Department received a complaint alleging Facility staff did not ensure a resident is regularly observed for changes in physical condition/ Facility staff did not provide immediate medical assistance to resident. On May 22, 2023, the Department received an incident report (IR) that stated, on May 20, 2023, staff observed R1 had no appetite for food, but was able to drink small amounts of liquid. The IR stated, on May 21, 2023 R1 was taken to breakfast and R1 at 80% of his/her meal. Furthermore, the IR stated at 11:30am R1 refused to eat and drink. The IR states the facility called an ambulance and R1 was taken to the emergency room. The IR also states on May 21, 2023, at 6:40pm, the facility was informed that R1 had a Urinary Tract Infection. (UTI). Page 1 Out of 3. Unsubstantiated On June 16, 2024, LPA David Marrufo interviewed ADM. ADM stated R1 had changes in his/her conditions on May 20, 2023. ADM stated on May 21, R1 started to refuse food and at lunch time R1 didn’t want to eat anymore. ADM stated R1 went to the emergency room. ADM noted R1 was not complaining about any abdominal pain. ADM stated he/she notified R1’s physician and R1’s Power of Attorney (POA). ADM stated after two days the facility was informed R1 had a UTI and was transferred to a rehab center. On October 30, 2024, LPA Monter interview staff S1 and S2. Both staff interviewed stated if they see any change to a resident’s condition or baseline, they will inform the ADM about said changes. Both staff interviewed stated they have been working at the facility for 7 months and did not work with R1. LPA interviewed ADM. ADM stated she works at the facility 5 days a week, 8 hours a day. ADM stated she was the one who noticed the change in condition regarding R1. ADM stated she informed R1’s doctor and R1’s POA. ADM stated she called for an ambulance for R1 to be checked. ADM also stated her staff inform her of any changes in the residents’ conditions. Based on a review of R1’s progress notes (PN), on May 14, 2023, R1 has not had a bowel movement. PN stated Medications and prune juice given to manage, but ineffective. Resident R1’s physician was notified and R1’s family members. On May 15, 2023, R1 still has not had a bowel movement & R1’s physician and family members were notified. Facility received a call from clinic stating physician assistant would arrive and administer suppository. R1 had a bowl movement later that evening. Based on a review of R1’s PN, On May 21, 2023, R1 refused to drink liquids at 7:30am. At 11:30am, R1 refused to eat and drink liquids. R1’s doctor and POA was notified. A facetime call done with nurse who assessed R1. The Nurse recommended to take R1 to urgent care/ ER for evaluation. R1’s POA notified and agreed to send R1 to ER. The facility received a call and was informed about R1’s Urinary tract infection. On May 22, 2023, the facility received a call from the hospital and was informed that R1 had been treated for sepsis (bladder infection) and was not ready to come back to the facility. Page 2 Out of 3. Based on a review of R1’s Physician’s Report, dated January 4, 2023, R1 has a neurocognitive disorder. The report states R1 is incontinent in both bladder and bowel. The Report also states R1 is able to communicate his/her needs and is able to feed him/herself. According to Mayo Clinic (https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447), UTIs don't always cause symptoms…In older adults, UTIs may be overlooked or mistaken for other conditions. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 3 Out of 3. END OF REPORT. On June 16, 2024, the Department conducted an initial investigation. Resident R1 was no longer living at the facility, and resident R7 was the new resident to the facility. On November 14, 2024, LPA interviewed ADM and Licensee (LN). ADM and LN stated R1 and R4 can walk and eat by themselves. ADM and LN stated R1 and R4 can also reposition themselves in bed and are able to do Activities of Daily Living (ADL’s) with staff assistance. ADM and LN stated R2 and R3 can eat by themselves and can reposition themselves in bed. ADM and LN stated residents R5-R7 were hospice residents. ADM and LN stated R6 and R7 were still able to feed themselves. A review of R1’s Functional capabilities form, dated March 20, 2023, R1 is ambulatory and able to transfer in and out of bed. A review of R1’s physicians report, dated January 4, 2023, states R1 is able to feed him/herself. A review of R2’s Physicians Report, dated June 5, 2023, states R2 does not require continuous bed care. R2 is able to feed him/herself using special equipment to hold spoons and forks. R2’s Functional Capability Assessment (FCA) dated September 20, 2023, states R1 is able to reposition from side to side. The FCA also states R2 uses a wheelchair. A review of R3’s physicians report dated June 27, 2024, R3 is able to feed him/herself and does not requires continuous bed care. R1’s Functional Capability assessment, dated September 8, 2022, states R3 is able to eat by him/herself. A review of R4’s needs and services plan, dated April 19, 2023, R4 is able to feed him/herself. A review of R4’s Functional capabilities form, dated April 25, 2023, states R4 is able to walk with a walker and is able to reposition him/her self from side to side, and is able to feed him/herself. A review of R5, R6 & R7’s facility file shows these 3 residents were in hospice. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 2 Out of 2the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 26-AS-20230609105059

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee (LN) Irish Ladwig. During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with LN which included the Living room, kitchen, dining room, 3 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. LPA observed the backyard pool locked and inaccessible to residents in care. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 112 degrees F in resident bathrooms. Fire extinguisher was serviced in March 8, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by LN, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 29, 2024. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 2 residents. No deficiencies cited during today's visit. This report was reviewed with Licensee Irish Ladwig and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2024

Type of visit: Case Management - Other

Licensing Program Analyst Manuel Monter & Mita Partoza conducted an unannounced case management to amend a complaint investigation LIC9099 and LIC9099-D issued on November 16, 2023.(26-AS-20230308155736) LPAs met with (LN) Licensee Irish Ladwig explained the purpose of the visit. On March 15 & November 16, 2023, LPAs interviewed ADM, S1 and Licensee (LN). ADM, LN and S1 stated R1’s shared bathroom was locked due to R1’s fecal smearing behavior. Staff also stated, although R1’s shared bathroom was locked, he/she still had access to the other two bathrooms with supervision. ADM also stated that they found R1's clothes in shower and staff feared fall risk at night. ADM stated R1 would hide used toilet paper around his/her bedroom. ADM stated they have found R1's diaper hidden under his/her roommate’s bed. The licensee stated R1's bathroom is locked, due to R1’s behaviors. Based on a review of R1’s physician’s Report January 4, 2023, R1 has a neurocognitive disorder. R1 is incontinent on both bowel and bladder. Furthermore, under ‘mental condition,’ R1 has fecal smearing behavior and wandering behavior. R1 requires assistance with ADLs such as, but not limited to bathing and toileting. Based on a review of R1’s Appraisal/Needs and Services plan, LIC625 dated December 23, 2022, R1 has a rummaging behavior evidenced by digging though cabinet drawers, bathroom and taking items from one place and hiding them all over the house. R1 also had a behavior of by digging out his/her bowel movement through his/her undergarment. In addition, ADM also noted on LIC625 that R1 requires a toilet scheduling every 2-3 hours and R1 needs to be supervised when he/she enters the bathroom on his/her own at all times. Page 1 out of 3. ADM and staff stated R1 has been found smearing early hours of the morning. ADM stated the facility does not have an awake night staff. A review of the facility’s LIC500 dated September 25, 2023, shows there is no wake night staff. Further review of R1’s LIC625, the ADM’s objective plan under the following areas “Mental, Physical/Health, functioning skills” does not address R1’s behaviors. ADM wrote under “evaluating progress,” the facility staff is to put R1 in a toileting schedule and supervise R1 when he/she is going to the bathroom on his/her own. According to Title 22 code of regulations, 87625 Managed incontinence (a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances…(B) a structured bowel and/or bladder retraining program to assist the resident in restoring a normal pattern of continence. (C) a program of scheduled toileting at regular intervals. A review of R1’s file does reveal the facility did not have documentation on R1’s toileting. ADM stated that they do not have a log on toileting and notes regarding R1 behavioral episodes. In addition, a review of R1’s LIC625, locking of R1’s shared bathroom (located in bedroom #1, based on the floor plan) is not written on the agreed upon plan, dated December 23, 2022. Based on interview staff S1 and ADM, staff interviewed were unable to provide of how they are adhering to the plan in place. Staff were not aware of the toileting plan and always supervise R1 when he/she goes to the bathroom on his/her own. Based on interview with ADM, there is no awake night staff and there is no toileting log. ADM and licensee stated R1’s shared bathroom was locked as a solution to prevent resident from smearing feces which also violates R1 and R5’s personal rights under code section 87468.1(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. R1 shared a bedroom with R5. Staff stated that R5 gave permission to lock bathroom. R1 has neurocognitive disorder. Page 2 out of 3. ADM stated, “…sometimes when we are busy, that's when he/she’s doing it, the smearing.” ADM stated that R1 behaviors occurs during sleeping hours. Staff stated that they would at times hear movements from R1’s bedroom, and also during waking hours at 6:30AM wherein R1 was found with feces in bed, clothing and bedroom walls. ADM stated the smearing behavior always happened when he/she was alone. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Licensee Irish Ladwig and a signed copy of this report was provided along with appeal rights. On 11/20/2023, at approximately 4:45pm. The report was presented to the Licensee and Licensee refused to sign. A copy of the report was printed and was handed to ADM. Appeal rights were printed and handed to ADM. Page 3 out of 3.the state’s words, verbatim · CDSS document, Nov 20, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Nov 27, 2023

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate... This requirement was not met as evidenced by: Based on a review of R1’s LIC625, R1 has a rummaging, wandering behavior& incontinence wherein R1 smears his/her feces on bathroom walls and self. R1’s behavior has not been addressed other than locking R1’s bathroom. The facility locking the bathroom door was not written on the plan of care.the state’s words, verbatim · CDSS document, Nov 20, 2023

Plan of correction: ADM stated he/she will send letter of understanding regarding the regulation to LPA by POC date, 11/27/2023.

Allegation investigated: Resident sustained bruises from falling but staff are not aware of injuries. Facility is not providing activities for the residents.

Licensing Program Analysts (LPA) Monter and Partoza conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with (LN) Licensee Irish Ladwig. Resident sustained bruises from falling but staff are not aware of injuries. The department review of Willow Oaks Senior Living internal fall report stated R1 had a witnessed fall on February 22, 2023, in the living room and after minor assistance R1 was able to walk without any discomfort. The report states R1’s Power of Attorney (POA) and doctor was informed about the fall. On a follow up report dated, February 23, 2023, R1 was assessed and was able to walk without pain and discomfort. On March 15, 2023, LPA David Marrufo interviewed resident R1. R1 stated he/she “doesn’t believe in falling. I tripped. I did it and fixed it.” Based on R1’s physicians report, dated January 4, 2023, R1 is diagnosed with a neurocognitive disorder. Page 1 out of 3 Unfounded On March 15, 2023, LPA David Marrufo interviewed R1’s Power of attorney, (POA). POA stated the following, “they called me as soon as R1 had a fall and called me and made a record of it. They checked R1 the next morning and there was no problem.” POA stated the facility staff informed him/her that R1 had a bad step and lost his/her balance. On March 15, 2023, LPA Marrufo interviewed administrator (ADM) and Licensee (LN). ADM & LN stated R1 had a fall on February 22, 2023 & notified the POA regarding the fall and recorded it in internal records. ADM & LN stated it he/she wouldn’t describe it as a fall, but more of a trip and R1 only hit their knee. ADM stated the resident was assessed and no bruises or injury was observed. ADM stated R1 was assessed the following day as well, and no injury was observed. On November 16, 2023, LPA's Monter and Partoza interviewed ADM regarding the fall. ADM re-enacted R1 stumbled and fell on his/her knee. ADM stated R1 lost balance due to losing her footing in the living room. ADM stated R1 then slowly fell on his/her knee and then laid on his/her side. ADM stated R1 then used the recliner next to him/her to lift themselves up. The Department has completed the investigation of the above allegations. Based on interviews conducted and record review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Facility is not providing activities for the residents. On March 8, 2023, the Department received a complaint alleging the facility is not providing activities for the residents. On March 15, 2023, LPA Maruffo & Monter toured the facility. LPAs observed resident R1 participating in a puzzle activity in the morning and was later escorted with a staff member for a walk outside. A review of Willow Oaks Senior Living’s Policy & Protocol for activities states the following: the ADM is responsible for planning the daily schedule for activities and residents are encouraged to contribute to the planning, preparation, and critique of planned activities. A monthly calendar of activities was observed during the visit. Page 2 out of 3 On March 15, 2023, LPA interviewed residents R1-R3. R1 stated the facility provides him/her with things to do. R2 stated he/she did not want to be interviewed. R3 is nonverbal and could not answer LPA’s questions. On March 15, 2023, LPA interviewed R1’s Power of attorney, (POA). POA stated “they do provide activities for R1. The activities that they have is that they get together at the table and do scrabble. When the weather is nice, they walk R1. They do have activities. I have seen them walk R1.” On March 15, 2023, LPA interviewed ADM, S1 and Licensee. ADM stated the facility does provide activities such as walking, television, scrabble, listening to music, and arranging flowers. S1 stated the facility provides activities for the residents. S1 stated they assist residents with walking by holding their hands. The licensee stated the facility provides multiple activities such as; watching television, bingo, cards, walking. On November 16, 2023, LPA's Monter & Partoza interviewed R2, R4, R6-R8. R7 and R7 stated the facility does provide activities such as walking dominos, and bingo. R6 and R7 stated the facility does offer but they choose to to other things. R2 stated the home does have activities but he/she prefers to stay and watch television. R3 and R8 was unable to answer LPA questions due to inability to speak. The Department has completed the investigation of the above allegations. Based on interviews conducted and record review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 3 out of 3 On March 15, 2023, LPA David Marrufo interviewed R1’s Power of attorney, (POA). POA stated the following: “They generally lock the bathroom door. They check R1 about every hour or so.” POA added, “I know that on several times, R1 has been in there by himself/herself and took his/her pants off and put his/her feces all over the walls and that happened several times. That is the reason that they shut the door. R1 tries to get rid of his/her feces.” POA stated he/she gave verbal permission to lock the bathroom door. On March 15, 2023, LPA interviewed ADM, S1, & Licensee. ADM and S1 stated R1’s bathroom was locked due to R1 “digging out feces and putting on the walls." ADM also stated that they found R1's clothes in shower and staff feared fall risk at night. ADM stated R1 would hide used toilet paper around his/her bedroom. ADM stated they have found R1's diaper hidden under his/her roommate’s bed. The licensee stated R1's bathroom is locked, due to feces smearing that occurred in the first week. ADM and Licensee stated they had a verbal agreement with R1's family member regarding locking the bathroom door during the admission of R1. On November 13, 2023 LPA interviewed R1’s POA. POA stated the facility locked R1’s bathroom door due to smearing behavior and to keep R1 out of that bathroom for his/her safety, and to keep him/her going to one bathroom. On November 16, 2023, LPA's Monter and Partoza interviewed ADM and Licensee. ADM stated R1's behavior was an ongoing issue in the first occurred frequently. ADM stated the facility does not have a toileting log for R1. ADM stated the facility does not have a wake night staff. ADM stated that sometime when we are busy, that's when she's doing it, the smearing. ADM stated that the behaviors incidents regarding would eventually become once a week. ADM stated before R1 left the facility, R1 continued to have behaviors regarding hiding his/her feces and diaper. ADM stated the bathroom door was locked when R1 was unsupervised. ADM stated " we didn't want her to go to the bathroom alone." ADM stated " it didn't happen in the other bathroom because she was supervised." Licensee stated R1 did not smear in the other bathroom because some one was with him/her. Licensee and ADM stated R5 was agreeable to having the private bathroom door locked. Licensee stated the reason the facility locked the door was because R1 was washing their diapers in the toilet. Licensee stated he/she feared risks around water in the toilet bowel without supervision. Licensee stated the other bathrooms are available to R1. Page 2 out of 3. A review of the facility floor plan shows that R1’s bedroom is bedroom #1, which has a private bathroom. Bedroom #1 is a shared bedroom, for R1 and R5. In addition, ADM also noted on LIC625 that R1 requires a toilet scheduling every 2-3 hours and R1 needs to be supervised when he/she enters the bathroom on his/her own at all times. Based on interview with ADM, there is no awake night staff and there is no toileting log. ADM and licensee stated R1’s shared bathroom was locked as a solution to prevent resident from smearing feces which also violates R1 and R5’s personal rights under code section 87468.1(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. R1 shared a bedroom with R5. Staff stated that R5 gave permission to lock bathroom. R1 has neurocognitive disorder. ADM stated, “…sometimes when we are busy, that's when he/she’s doing it, the smearing.” ADM stated that R1 behaviors occurs during sleeping hours. Staff stated that they would at times hear movements from R1’s bedroom, and also during waking hours at 6:30AM wherein R1 was found with feces in bed, clothing and bedroom walls. ADM stated the smearing behavior always happened when he/she was alone. ADM also stated R1 would hide used toilet paper around his/her shared bedroom. ADM stated they have found R1's diaper hidden under R1's roommates bed. The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Licensee Irish Ladwig and a signed copy of this report was provided along with appeal rights. Page 3 out of 3. On 11/20/2023, at approximately 4:45pm. The report was presented to the Licensee and Licensee refused to sign. A copy of the report was printed and was handed to ADM. Appeal rights were printed and handed to ADM.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 26-AS-20230308155736

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 23, 2023

87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interview and record review; R1’s lack of supervision and absence of care plan to address R1’s behavior leads to feces smearing, which is unsanitary for R1 and R5. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: ADM stated they will send a letter of understanding regarding the regulation to LPA by POC date, 11/23/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 23, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, ... 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 interview with ADM & LN; R1's shared bathroom was locked due to R1's behaviors. ADM & LN stated R1 had multiple instances of smearing when he/she was left unsupervised in bedroom #1's bathroom. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: ADM stated they will send a letter of understanding regarding the regulation to LPA by POC date, 11/23/2023.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee Irish Ladwig. LPA explained the purpose of the visit. LPA toured the facility inside out which included; the living room, kitchen, dinning room, 3 restrooms and 4 residents bedrooms. Front yard and backyard were inspected. LPA observed the backyard pool locked an inaccessible to residents in care. There was no obstruction to block the walkways. Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication cabinet, knives storage cabinet, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured in the 3 facility bathrooms to range from 106 degrees to 108 degrees in the facility bathrooms. LPA observed two Fire extinguishers, that were on serviced on 03/08/2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by licensee, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 09/22/2023. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 3 staff (S1 to S3) and 3 residents (R1-R3). No deficiencies cited during today's visit. This report was reviewed with Licensee Irish Ladwig and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Sep 29, 2023