Windchime of Marin

Type of visit: Case Management - Other

At approximately 9:05 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection regarding an Incident Report submitted by the facility on 9/16/2026 and met and with Business Office Director (BOD) Ravi Banwait. LPA requested and reviewed documents. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to BOD Banwait. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 18, 2026

Type of visit: Case Management - Other

At approximately 9:35AM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management – Inspection visit, and met with Executive Director, AnneMarie Domizio. The purpose of the visit is to follow up on approved Fire Clearance of facility. Community Care Licensing (CCL) received approved Fire Clearance for facility on 7/7/2026. During today's inspection, LPA observed a handful of resident rooms, they have been checked and approved by fire. On 6/22/2026 while completing annual inspection of facility, LPA Hansen discovered four (4) out of the eight (8) resident showers not being functional. During today’s inspection six (6) out of the eight (8) resident showers were observed to be functioning. Administrator agrees to submit self-certification when final repairs are completed on last showers. LPA conducted interviews and obtained additional documents. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 21, 2026

Type of visit: Office

On 06/29/2026, an informal office meeting was conducted in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager (LPM), Bethany Moellers, Licensing Program Analyst, (LPA) Julie Florio, Mark Mclaine, Regional VP of Ops Integral, and Administrator, Annemarie Domizio. The following joined the meeting virtually: Steve Mellemo/CEO of The Windchime Group LLC, Mike Zeug, Sr. VP of Ops Integral; , Joel Goldman, requested representation, Larry Pasero, Deputy Fire Marshall, Kentfield and Mike Pomi, Fire Chief. The purpose of the informal office meeting was to discuss areas of non-compliance and observed Community Care Licensing (CCL) concerns of the operation of Windchime of Marin. The Administrator was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. LPA Hansen conducted an annual inspection of the facility on 7/24/2025 observing apartment windows/screens/locks not following current Fire Clearance of 2019. 9/4/2025 Deputy Fire Marshal contacted property manager Jason James with expectation of child locks and interior screen locks shall be removed to provide access by first responders from the exterior in a rescue situation. Per Larry Pasero the following are conditional for Fire clearance until 9/18/26. Continued om LIC809C... Continued from LIC809... The following are conditions of approval: 1) At no time shall any lock, device or equipment be added to the existing windows or window screens that requires special knowledge, tools or effort to open from the interior or exterior. 2) Locking hardware and maintenance of existing non-conforming window openings shall be allowed for one year with conditions. Issues discussed during the meeting were: · Administrator’s duties and qualification · Fire Clearance · Buildings & Grounds- 4 out of 8 resident showers not working for over a year · Death of Resident-Death Certificate Administrator and licensee agree to submit the following to CCL and Kentfield Fire Department: · Plan/timeline to resolve and comply with corrections of conditional fire clearance, submit by COB 07/01/2026. · Plan/staffing to ensure safety of residents in care until “fire” plan is complete, submit by COB 7/1/2026. LPA discussed Technical Support Program with Administrator who will let the Department know if interested in participating in the program. Exit interview conducted with Administrator whose signature on form confirms receipt of report.the state’s words, verbatim · CDSS document, Jun 29, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Shannan Hansen returned unannounced to complete the required Annual inspection and was greeted by concierge. LPA met with Administrator Annemarie Domizio & BOD Ravi Banwait. On 6/18/26 LPA arrived at facility to conduct annual inspection. Today, LPA returned to complete inspection. At approximately 9:45 am LPA conducted a review of five (5) staff files, all staff had required training's and requiring CPR & First Aid were current. All staff were DOJ cleared and associated to facility. Facility did not have prominently posted Personal Rights/PUB475/Complaint poster. Facility did have new LTCO poster next to elevator (see LIC809D). LPA issued citation for deficiencies identified on 6/18/26 & 6/22/2026. ****Civil Penalty for repeat citation in less then 12 months for $250. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Continue on LIC809C Continued from LIC809 LIC500- Personnel Report LIC 610 Emergency Disaster Plan-Updated Infection Control Plan-Updated Liability Insurance Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Jun 22, 2026

The state marks this report as 9 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a required Annual inspection and was greeted by concierge. LPA met with Business Office Director (BOD) Ravi Banwait. Administrator Annemarie Domizio arrived later. Administrator certificate # 7015132740 expires 12/19/28. Facility currently has 29 residents in care, five (5) of which are currently on hospice. Facility is full memory care with apartments on the 2nd and 3rd floors containing a total of 36 apartments. The facility has a fire clearance approved for 55 Nonambulatory residents with magnetic locked egress doors and gates on all patios and levels, last effective date of 8/20/2019. During 7/2025 annual inspection LPA observed some resident apartment windows screwed/locked shut and some not functioning, against fire clearance safety regulations. After inspection Fire Department implemented a conditional fire clearance until 9/18/2026 at which time all windows/screens are to be fixed/replaced as per fire inspectors’ guidelines. During today’s inspection none have yet to be replaced. At approximately 9:30am LPA and BOD toured the building and grounds & was accompanied by Administrator shortly after. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food items located in main kitchen were not stored in a safe manner and open items were not covered or closed. Items found uncovered or unsealed or both include: dried green peas & Messa, chicken, hamburger patties out on tray in kitchen, box of frozen peas, mini pies, slices of carrot cake, ice cream containers (deficiency cited, see pics & 809D). Continued on 809C... Continued from 809... LPA, cook, and Admin observed bleach and other toxins stored in main kitchen next to food preparation area (deficiency cited, see pics & 809D). LPA and BOD observed unlocked kitchen cabinet under sink in 3rd Floor MC unit to contain disinfectant cleaning supplies (deficiency cited, see pics & 809D). Laundry soaps are located in a locked closet and inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, closets, and chest of drawers by facility. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident showers (4 on each floor) had required bath mats and grab bars and or shower chairs; although, per staff, 3 showers on the 3rd floor and 1 on the 2nd floor is not working and has not been for a few years due to different issues. Facility is in the process of getting fixed per Administrator. Water temperature in sinks measured at 120.9 degrees F in room #211, 120.5 degrees F in room #203, 119.6 degrees F in room #200, 121.4 degrees F in room #311, and 121.1 degrees F in room #301, finding 6 out of 10 rooms tested not within the allowable range of 105 to 120 degrees F. (deficiency cited, see 809D). Facility has other bathrooms used by staff only. Fire extinguishers were last inspected 9/10/25. Smoke detectors located throughout the facility are hardwired and serviced by vendor. Last date of service was 4/15/26. Deficiencies were cited and cleared per Administrator 6/18/2026. Carbon Monoxide detectors are on each floor and tested. Facility’s last quarterly disaster drill was conducted on 5/18/26. Facility has a backup generator for use during a power outage. LPA observed evacuation chairs present at top of stairwell and by back doors on 2nd & 3rd floor where stairs are on exterior. At approximately 12:30pm LPA conducted a review of six (6) resident files. Resident (R5) does not have current physician reports on file (deficiency cited, see 809D). Resident (R6) did not have TB clearance on file (deficiency cited, see 809D). Resident (R4) does not have a pre-appraisal on file (deficiency cited, see 809D). Continued on 809C(2)... Continued form 809C... At approximately 11:25am LPA, and MedTech began spot check of medication. Facility uses an electronic MAR and medication management system. Signed doctors' orders were on file. Facility utilizes e-MAR for PRNs. LPA advised to MedTech to ensure both reason for administering and outcome of administration are recorded and to provide as much detail as applicable. LPA advised that doctors' ordered must be followed per written instructions. Medication review found resident (R2) was missing 1 Trazadon per count, R3 AM Amlodipine (1 missing) Levothyroxine (3 not given), R4 Benzopril (6 additional pills). (deficiency cited, see 809D). LPA will return at a later date to complete annual inspection. At that time LPA will issue citations for the deficiencies identified today and any identified upon return visit. Exit interview conducted with Admin and a copy of this report given.the state’s words, verbatim · CDSS document, Jun 18, 2026

Type of visit: Case Management - Incident

At approximately 8:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit, and met with Executive Director, AnneMarie Domizio. The purpose of the visit is to follow up on reports that were submitted to the Santa Rosa Regional Office (SRRO). Incident Report 1: The SRRO received a report on 05/07/2026. Report stated that on 05/05/2026, Resident 1 (R1) was eating lunch when they began to exhibit signs of choking. Per report, staff were unsuccessful in dislodging the food particle and CPR was initiated and emergency services were contacted. R1 was transferred to the hospital. Facility made notifications per regulation. Death Report: The SRRO received a death report on 05/08/2026. Report stated that on 05/07/2026, facility contacted the hospital for an update regarding R1. Facility was informed by the hospital that R1 passed away on 05/07/2026. LPA conducted interviews and obtained additional documents. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 22, 2026

Type of visit: Case Management - Incident

04/14/2026; Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met Interim Executive Director, Vivian Villegas. The purpose of the visit was to follow up on a special incident report (SIR) that was self-submitted to Community Care Licensing (CCL). CCL received an SIR on 04/02/2026, stating that on 03/26/2026 during a med pass observation with pharmacy it was discovered that resident (R1) was out of a couple scheduled meds. Upon further investigation by the facility it was determined R1 had two medications that were last administered on 03/16/2026. A third medication was last administered on 03/20/2026 and a fourth medication was last administered on 03/22/2026. Per conversation with Resident Care Director, RCD stated when the med techs noticed R1 was running low on medication they started reaching out to R1s doctor via phone who turned out to not be R1s doctor anymore. RCD stated this previous doctor had done a courtesy refill at one point, causing confusion that he was R1s current doctor. RCD stated that there was a miscommunication with R1s family as to who was R1s real doctor, causing a delay in getting medication refills for R1. Once the facility was able to locate R1s real doctor, they were able to get medication refills. RCD stated they were given two wrong doctors before they were able to contact R1s family and receive R1s current doctor. Although no deficiencies were cited today, facility conducted in-service training and a copy was provided to LPA. Copy of report and LIC811 (Confidential Names) was provided to Interim Executive Director.the state’s words, verbatim · CDSS document, Apr 14, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Lauren Cottman. The purpose of the visit was to follow up on a SOC341 report that was submitted to Community Care Licensing (CCL) on 1/23/26. Per SOC341, on 1/21/26 at approximately 6:30pm, resident (R1) approached resident (R2) touched their shirt, R2 verbalized their dislike and shoved R1 to the floor causing them to hit the back of their head. They were immediately separated by staff. EMS initiated and assessed R1 for injury, R1's responsible party declined transport. Both residents have been placed on alert charting for 48 hours. R2's care plan has been updated. Responsible parties were notified. During today's visit, LPA reviewed resident's records. Based on records review, R2's physician report dated 9/25/24, R2 does have a cognitive condition, but they don't have a history of aggressive behavior. Although, R2 receives frequent visits from a third party agency who indicated in their log dated 11/13/25 that they have noticed some concerns including behaviors and recommended further discussion with R2's responsible party before making any adjustments to antidepressant, which it was reflected in R2's 90-day care plan assessment dated 12/10/25. According to care plan, R2 has active behavioral issues requiring staff to be alert to triggers that could increase behaviors such as noise or crowded areas. On 1/22/26, the facility implemented a behavioral engagement log to identify any trigger situations to obtain more data, one-on-one engagement walks and outing were incorporated to help the resident with behavior issues. Additionally, R2's physician have made adjustments to some of R2's medications. According to Administrator, care plans were not updated for any of the residents because they have implemented the behavioral engagement. Regarding R1, LPA learned that the facility staff called the paramedics 911 immediately, they arrived, assessed R1 and they did the vitals, and reported to R1's responsible party who denied to transport R1 to the hospital for further evaluation. Based on records review and interviews, the facility have followed their protocols. No deficiencies were cited during today's case management visit. Exit interview conducted with the Administrator and copy of this report was given.the state’s words, verbatim · CDSS document, Jan 29, 2026

Allegation investigated: Facility staff are not meeting resident care needs Responsible party not notified of resident fall Facility staff not giving prescription medications as prescribed by doctor

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint investigation findings regarding the above allegations and met with Administrator, Lauren Cottman. During investigation LPA made 3 visits (9/18/25, 10/14/25, & 10/30/25), conducted 11 interviews with staff and outside parties, made observations and reviewed records. Facility staff are not meeting resident care needs -- Reporting party alleges resident has not had a shower since they were admitted, general lack of care of patient and lack of activities. R1’s pre-placement appraisal signed by Administrator on 8/26/2025 indicates, needs help with bathing, hair care, personal hygiene. Care appraisal dated 8/19/2025 completed by RCD indicates- requires assistance from one (1) person two times a week for bathing. Record review revealed facility did not have a shower log indicating when R1’s showers were scheduled for, days of the week, and times, or any shower sheet that indicates if there is a skin problem/break down of skin/injury, etc. Continue on LIC9099C Substantiated Continued from LIC9099: Interviews with 3 staff (S1, S2, & S3) who care for residents on 3rd floor revealed none of them had given R1 a shower/bath, for the approximate 3 weeks R1 was at facility. Interview with R4 revealed protocol is, when a resident is admitted to the facility, staff put them on a shower schedule 2 times a week (unless otherwise requested) and then sign log each time a shower is given or indicate a refusal or indicate refusal in daily notes, which was not completed in this case. There is sufficient information obtained to support that a violation has occurred regarding the reported allegation of "facility staff are not meeting residents’ care needs", therefore, the allegation is Substantiated. Responsible party not notified of resident fall- Reporting party alleges facility did not notify/call responsible party of residents fall until in person, hours later when resident was at the hospital. Incident report received indicates facility was aware at approximately 7:45 am but POA/Responsible Party told in person at 10am when arrived at facility for regular visit. Interview with S5 informed the processes of inputting new resident information: obtain residents information from POA then S5 types it up on Emergency contact forms (attachment #5) & Resident & responsible party information form (attachment #6) etc. then provide to RCD their portions who then implements into their computer system. Documents obtained revealed the Identification document handwritten from the POA is the same on the emergency contact form but on the responsible party information form the last number of the phone number was turned from 9 to 3. S4 typed in the number from the responsible party information which was wrong as indicated on the facility online resident contact number for their POA. 9/11/25 at 10am Progress Notes & Incident report submitted to CCL on 9/16/25 of 9/11/25 incident for R1 indicates Med Tech called POA 3 times starting at 7:45am not getting any answer and finally left a message. Progress notes also indicated S4 notified POA at 10am when they came into the facility to visit. Interview with S1 informed when there is a fall or emergency and they need to contact the family they go to the online information. Investigation revealed S1 called R1’s POA when incident occurred on 9/11/2025 at approximately 7:45am, although they were dialing the wrong number that had been inputted into the computer for the responsible party. On 9/22/25 responsible party informed LPA, they also never received any written notification of incident. Regulation 87211(a)(1)(D) indicates :Reporting Requirements: Each licensee shall furnish ..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...(D)Any incident which threatens the welfare, safety or health of any resident. Continue on LIC9099C2 Continued from LIC9099C: There is sufficient information obtained to support that a violation has occurred regarding the reported allegation of "responsible party not notified of resident fall". Therefore, the allegation is Substantiated. Facility staff not giving prescription medications as prescribed by doctor- Reporting party alleges facility may not have been giving R1 the correct dosages of medications that were prescribed by physician. Facility only had paper Medication Administration Record (MAR) of August for R1 which indicated prescription Rexulti was to be given every AM although does not show was given 8/29- 31/2025. Further review of medications indicated 10 of R1’s daily medications from 8/28-31/2025 were not given consistently. LPA interview with S4 revealed R1 did not have any medication refusals. Interview with Med tech and Administrator informed, with the documents provided they could not confirm medications were provided on said days. As there was no proof medications were provided to the resident, there is sufficient information obtained to support that a violation has occurred regarding allegation Facility staff not giving prescription medications as prescribed by doctor is SUBSTANTIATED. Additionally, Community Care Licensing (CCL) received an incident report on 10/20/2025 indicating on 10/14/2025 while inputting narcotics into new EMAR system discovered R2 had discrepancy in log record. From 8/18/2025 to 10/13/2025 (except on 6 correct occasions) multiple PM med techs had inadvertently been giving R2 PRN Geri-tussin instead of physician ordered routine Guaifen-Codeine. No adverse side effects observed, Responsible party and Hospice physician notified. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of evidence standard has been met. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 21-AS-20250909105915

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Oct 31, 2025

87464(f)(4). Basic Services. Basic services shall at a minimum include:...Personal assistance and care as.. indicated in the pre-admission appraisal, …such as dressing, eating, bathing..***Based on documents reviewed and interviews conducted, this requirement was not met as evidenced by: Care report-appraisal for 8/26/2025 indicate R1 was to have 2 showers per week although, there were no shower logs for time frame or notes indicating shower refusals, along with 4 staff interviews indicated R1 not showered 8/26 thru 9/11/2025. This posed an immediate risk to the health and personal rights of R1the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Administration to provided refresher training to staff on the subject of showers provided to residents regarding Regulations 87464(f)(4) and submit by 10/31/2025 type of training and date training will be conducted. Logs and scope of training with signatures to be submitted to CCL/LPA by 11/7/25 to clear citation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 7, 2025

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...(1)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...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement has not been met based on document review and interviews revealing due to facility writing wrong number of responsible party they were not reached, as well responsible party indicated they never receive written notice of incident report. This is a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Facility Administrator agrees to have staff who are responsible for inputting contact information and reporting incidents, complete an in-service training regarding regulation 87211 no later than POC due date, 11/7/2025 and submit a copy of signed and dated log.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 31, 2025

87465 Incidental Medical and Dental Care:(a)A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review, Licensee did not comply with the section cited above and did not ensure that medication was administered to R1 as required. R2 Incident Report stated that PM Med Tech provided wrong medication ??times. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Licensee provided proof of training that was conducted on 10/16/2025 on "The Six Rights", central storage of medications, & medication destruction process when an order is discontinued, for all med techs that administer medications. Deficiency cleared during visit.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and conducted a case management regarding fire clearance issues. During annual inspection on 7/24/2025 LPA observed some resident room windows on the 2nd and 3rd floors : that were screwed in closed, and or had safety crank off, not having ability to open if there was an emergency, 90% having infant security locks on screens, and many infant security locks broken off of the screens, not functional at all. Fire clearance at time of inspection (7/24/2025) STD850 approved by Kentfield Fire District dated 8/2019 indicates Window screens shall remain free of keyed locking mechanisms and shall remain readily accessible by First Responders from the exterior. Issues were cross reported to Kentfield Fire District requesting updated STD850. On 9/4/2025 Deputy Fire Marshal Larry Pasero conducted a visit at facility informing facility child locks and screen locks shall be removed to provide access by first responders from the exterior in a rescue situation. On 10/9/2025 Kentfield Deputy Fire Marshal submitted to Community Care Licensing (CCL) Conditional Fire Clearance until 9/18/2026 when window issues must be resolved by. Conditions being; 1) At no time shall any lock, device or equipment be added to the existing windows or window screens that requires special knowledge, tools or effort to open from the interior or exterior. 2) Locking hardware and maintenance of existing non-conforming window openings shall be allowed for one year with conditions. During today’s (10/30/2025) visit, LPA is citing facility for not following their Fire Clearance conditions per regulation 87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. **** Immediate Civil Penalties of $500. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Oct 30, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Oct 31, 2025

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...This requirement is not met as evidenced by: Based on observation during Annual inspection and information... received from Local Fire Department, Licensee did not comply with the section cited above by not following fire clearance regarding windows and screens resulting in the fire department providing conditional fire clearance until 9/18/2026 or if prior windows and screens fixed to notify CCL & Fire Dept. This is an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Licensee has initiated the replacement of all residents’ window locks and unapproved screen locks etc., by having two glass companies out (10/29/25 & 10/30/25) who are submitting quotes with the final third soon. Once quote is approved, Licensee/Admin will.. .. provide to CCL and update with progress until complete. **** Immediate Civil Penalties of $500.

Type of visit: Case Management - Incident

At approximately 12:00 PM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Lauren Cottman. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 08/27/2025. The report stated that on 08/25/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community shortly after 5:30 PM, by exiting emergency exit door on the right side of the 1st floor elevator as staff was returning residents to 2nd and 3rd floor apartments after dinner. At approximately 7:30 PM staff was unable to locate R1 and notified ED, while interior & exterior search was conducted. At approximately 8:15pm Med Tech contacted EMS and was informed fire department brought R1 to hospital after finding near fire house confused. R1 was assessed at hospital, finding no injuries and discharged back to community same evening. After further check of facility, two doors on the 1st floor were found unlocked and one alarm found on emergency exit turned off. PCP and family were notified. LPA was provided; staff signed training for elopements, plan to keep residents safe from future risk, and investigation documents. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited) LPA also obtained updated service plan and notes from care conference. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Sep 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Sep 5, 2025

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement... This requirement not met by licensee as evidenced by: R1 eloped from facility and was found by Fire Dept approximately 2 hrs later alone outside of facility property, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Administrator submitted staff training on elopement prevention and procedures. Citation cleared at visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection of this 3 story 36 apartment (some shared) RCFE with a plan of operations for Dementia and was greeted by staff. LPA met with Administrator Lauren Cottman and Business Office Director (BOD) Ravi Banwait. The facility has a fire clearance approved for 55 Nonambulatory residents on the 2nd and 3rd floors with magnetic locked egress doors and gates on all patios and levels, last effective date of 8/20/2019. A Hospice Waiver approved for 12. There is a total of 26 residents of which 4 are under Hospice care. At approximately 8:45AM, LPA toured the community with staff & BOD. The tour of the facility included ten resident apartments, activity rooms, salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstruction. Delayed egress doors have audible alarms when doors are opened without access codes. Facility serves residents with dementia and has special care plan of operation and programming. Hot water temperature measured between 115.3 degrees F and 121.2 degrees F not within regulation of 105 to 120 degrees F in six of ten rooms tested (see LIC809D). Bathrooms contained necessary grab bars and slip-resistant mats, strips, or flooring in all bathtub and or shower floors as required by Title 22 Regulations. There was a supply of cleaners, hygiene products and paper products available for residents. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchenettes were inspected. Menus with snacks and beverages are available to residents. Activity schedules are posted and at approximately 9am LPA observed activities director conducting morning activity and at approximately 4pm observed live music being played for monthly birthday party. Continue on LIC809C Continue from LIC809 LPA was informed there was only 1 med tech and 2 caregivers for entire facility during morning shift of 26 residents of which 10 are two person assist and 16 one person assist which is a violation of personal right 87468.2(a)(4) see LIC809D. Facility has multiple indoor and outdoor sitting areas and a private dining area. Toxins are stored in a locked laundry and housekeeping closet; although at approximately 9:15am Housekeeping closet was found unlocked with toxic cleaning chemicals including Mold Armor Rapid clean remediation (see pics & LIC809D). Also in resident (R3’s) room LPA observed unlocked bathroom cabinet with razors and supplies (see pics). A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. A sample review of six resident & five staff records as well as three resident’s medications was conducted. LPA reviewed resident’s files at 10:45 AM on 7/24/2025 and learned that 6 out of 6 residents have an updated reappraisal/needs & care plan on file. Medical assessments of 1 out of 6 residents was absent during inspection, as required by Title 22 Regulation (see LIC809D). In addition, as per ED facility has no residents with pressure sore as of 7/24/2025. Medications were centrally stored in a locked medication cart in the facility medication room. The Medications of 3 out of 3 residents were found to be given according to physicians’ directions on 7/24/2025 at 10:20 AM. Centrally Stored Medication Record (CSMR) of 3 out of 3 residents were found to be accurate. LPA conducted a sample review of staff records at 1:15 PM on 7/24/2025 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1st Aid certification for all staff. Lauren Cottman Administrator Certificate # 7028976740 expires 9/21/2026. Fire Extinguisher was found to be last charged on 9/10/2024 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 4/14/2025. LPA & Administrator were unable to locate Carbon monoxide detectors or records indicating they were attached to smoke detector system (see LIC809D). There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Continue on LIC809C2 Continued from LIC809C In addition, LPA advised to ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted monthly in different shifts with the last one on 6/6/2025. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. LPA Hansen is requesting Licensee to update and submit the following documents by 8/14/2025: LIC 308 Designated LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Jul 24, 2025

Allegation investigated: Facility staff are not meeting resident’s incontinence care needs

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint investigation findings regarding the above allegations and met with Business Office Director, Ravi Banwait as Administrator Lauren Cottman was at annual trainings. Complainant alleges facility staff are not meeting the resident’s incontinence care needs. Complainant alleges on 3/20/25 and 3/21/25, midafternoon resident was observed in “Depends” that were "completely saturated" with urine. Reporting party stated it had to have been several hours since staff had changed resident. As well, on 3/20/25, resident's bed linens were "soaked with urine" and had to be changed. Documents obtained from facility: Care appraisal dated 2/16/2025 of toileting -requires prompting/assistance with toileting but can be left alone, (progress notes) of daily routines for R1 (3/20/2025 & 3/21/2025) do not indicate R1’s bed had been urinated in or had depends full of urine. Continued on LI9099-C Unsubstantiated Continued from LIC9099 LPA interview of witness’ (W1 & W2) revealed R1 is able to use the bathroom on own and other than observing some remnants of urine on R1’s shirt or pants after using the restroom, neither W1 or W2 have observed R1’s bed urinated in or R1 wearing urine-soaked adult briefs. LPA conducted facility visit on 3/27/2025, observed R1’s room not having mal odors/no urine smell and R1 to have adequate hygiene. There was no information obtained that supported a violation had occurred. Based on record review, interviews conducted, and observations made, the allegation facility staff are not meeting the resident’s incontinence care needs is UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 21-AS-20250324084022

Allegation investigated: Staff did not safeguard resident's personal belongings Staff did not bathe a resident in care Staff obtained care giving services for a resident without consent from resident's responsible party

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint investigation findings regarding the above allegations and met with Business Office Director, Ravi Banwait as Administrator Lauren Cottman was at annual trainings. Staff did not safeguard resident's personal belongings- Complainant alleges facility staff lost the resident's electric razor, glasses, and clothing, also they were not labelled and R1 never created an inventory of their personal belongings when they moved into the facility. Investigation revealed Admission Agreement of R1’s personal property and valuables, dated 10/25/2024, only identifies wedding band. Administrator informed that if the facility is advised something has gone missing it will be relayed to the rest of the staff and they will look. Most razors have the residents’ name on them to identify and are put in a box in the med room until using. There is a lost and found box on the 2nd floor med room that keeps glasses and razors, etc… (due to safety purposes all razors are kept in Med room until needed for use). When asked of the brand etc... complainant was unable to provide. Continue on LI9099-C Unsubstantiated Continued from LIC9099 Complainant looked through box and could not locate any of R1’s alleged missing items. Interview with witnesss (W1 & W2) indicated they were unaware of any missing items or that R1 wore glasses. LPA conducted facility visit on 3/27/2025 and observed R1 to have adequate hygiene. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff did not safeguard resident’s personal belongings is Unsubstantiated. Staff did not bathe a resident in care- Complainant alleges resident went ten days without having a shower. Follow up interview with complainant informed it was after R1 returned from the hospital in either January 2025 or February 2025 when staff informed it has been 10 days since R1 had a shower due to R1’s refusal to take a shower. Resident progress notes indicated R1 returned from the hospital on 1/23/2025 and had a shower that day. Shower log for R1 indicates they have showers on Sunday’s and Friday AM’s and had one on 1/23/2025 after returning from the hospital, the following shower was given on Sunday 1/26/2025 as scheduled. Refused on 1/31/25 but given on February 2, 2025. Interview with S2 revealed they would mention to the family/POA that there were days where R1 would refuse baths/showers, there was never a time they indicated there had been 10 days since a shower had been given. LPA was informed, if a shower cannot or resident refuses to have a shower on designated shower day’s staff will attempt the follow day and night. LPA conducted interviews, record reviews, and made observations of R1 having satisfactory hygiene. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff did not bathe a resident in care is Unsubstantiated. Staff obtained care giving services for a resident without consent from resident's responsible party- Complainant alleges after R1 returned to the facility from the hospital on 1/23/2025. The following week the complainant informed they received a phone call that R1 pushed a resident, at which point the facility requested for R1 to be put back on a medication that was recently d/c’d and/or 1:1 staff to be implemented. CCL received SOC341 (2/18/25) (smacked R2 in the chest (female resident) on (2/19/25) hit R2 again, this time on left arm. On 2/14/25 2nd SOC341 R1 pushed R3 (female resident against the med tech office door) Resident agreement references pg 10 paragraph F regarding One on one care “ If it is determined by the Community staff that you are a danger to yourself or others, you may be required to receive one-on-one care and supervision for an additional charge as set forth in Appendix A, or for the cost of all services provided by Outside Provider and billed directly to you. Continue on LIC9099-C2 Continued from LIC9099C1 Interview with Administer informed family was advised by Nurse of the possible 1:1 being needed. LPA obtained email correspondence with RP and facility, dated 2/21/2025, email states that R1 due to behaviors requires a 1:1 caregiver. Care conference was held on 2/20/2025. R1 moved out of the facility 4/11/2025. Based on interviews conducted and record review, the facility communicated R1’s care needs with RP prior to implanting. Therefore, the allegation Staff obtained care giving services for a resident without consent from resident’s responsible party is UNSUBSTANTIATED. A finding of Unsubstantiated means, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documents Continued from LIC9099-A This agency has investigated the complaint alleging staff did not allow resident’s responsible party to use a medical pharmacy of their choice. We have found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documentsthe state’s words, verbatim · CDSS document, Jun 3, 2025 · control 21-AS-20250319115051

Type of visit: Case Management - Incident

On 1/7/2025 at 2:00pm, Licensing Program Analysts (LPAs) Frank and Felias arrived unannounced to conduct a Case Management inspection and met with Executive Director, Lauren Cottman and Resident Care Director, Parinda Kleinberg. The facility submitted an Incident Report (IR) for Resident 1 (R1) for a medication error. The IR stated that on Sunday 12/8/2024 Resident Care Director reviewed medications orders and found new orders from the resident's doctor. The new orders received stated that facility was to stop one medication and start a new medication once it was received by the facility. The med tech on duty (S1) faxed orders to the pharmacy the same day but gave both medications to the resident on the 12/6/24 and 12/7/24 PM shifts. Resident Care Director faxed details of the incident to R1's primary physician and notified the resident's responsible party. LPAs reviewed documentation. Correspondence between facility and R1's primary care physician showed that R1's new medication was not sent by the pharmacy until 12/6/24. Facility received the new medication on 12/8/24. R1's Medication Administration Records (MAR) shows that R1's old medication was given on 12/6/24, 12/7/24, and the morning of 12/8/24. R1's new medication arrived the evening of 12/8/24. Review of R1's MAR showed that when the new medication arrived to the facility, the old medication was discontinued and the new medication was administered appropriately. Review of records showed that there was no overlap in medications. No deficiencies cited. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Jan 7, 2025

Allegation investigated: Facility allows untrained staff to dispense medications to residents in care Staff do not ensure facility is kept free of mal odors

Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver findings regarding the above complaint allegations and met with Mary McClure, Administrator. Facility allows untrained staff to dispense medications to residents in care – Complainant alleges staff (S1) was hired as a caregiver, received some med tech training and was working as a medtech, then did not pass med tech exam and was relieved of duties on 6/15/2024. S1 was required additional training but did not retake the test and administrator placed S1 back on med tech schedule. LPA obtained training documents for S1 that indicate per Title 22 Regulation has not obtained required hours of initial medication training. Due to LPA’s record review of trainings for S1 regarding Facility allows untrained staff to dispense medications to residents in care, allegation is found to be SUBSTANTIATED. Continue on LIC9099-C Substantiated Continue from LIC9099-C Staff do not ensure facility is kept free of mal odors- Complainant alleges due to lack of housekeeping resident’s rooms smell badly as the majority of residents are incontinent and the smell travels through the hallways as you enter the facility. On 7/22/2024 (Monday) LPA toured the facility at aprox 8:54am starting on the 3rd floor and when entering the floor when door opened - there was a pungent smell of urine/mal. LPA & S2 toured 5 rooms finding 2 bedrooms having strong urine/mal odors which S2 opened windows and removed soiled clothing in laundry basket. LPA was informed from staff interviews there are 2-3 residents who have incontinent issues and behaviors of urinating on the floor in their rooms & in the hallways. Per staff interviews regarding June & July, 2024 the facility does not have housekeeping cleaning on Sunday. Staff schedule obtained supports lack of housekeeping staff on Sunday. The facility just hired a new housekeeper, but staff believe the smell is due to the floors not being cleaned over the weekend. Due to LPA’s observations & interviews regarding Staff do not ensure facility is kept free of mal odors allegation is found to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of evidence standard has been met. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Allegation of Staff do not ensure facility is kept free of mal odors is Substantiated due to odor and lack of housekeeping on sight. Although, LPA was unable to obtain or observed additional evidence to support facility is not safe and sanitary citation issued under reference allegation. Although it was alleged Staff do not ensure residents rooms are kept in safe, clean, sanitary condition may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 21-AS-20240620093300

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a)(1) · Plan of correction due date: Aug 20, 2024

1569.69(a)(1) Medication Administration Training (a)Each residential care facility for the elderly shall ensure that each employee …who assists residents with the self-administration of medications meets all the following training requirements: (1)In facilities licensed for 16 or more.. employee shall complete 24 hours of initial training…consisting of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction..which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Based on: Record review & interview with Administrator, S1 lacks proof of required HSC 1569.69(a)(1) medication training, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2024

Plan of correction: Licensee to ensure that all staff obtain the H&S Code initial medication training as required; Submit proof of S1’s, medication training (16 hrs of hands on shadowing training) by POC due date of 8/20/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Aug 20, 2024

87625(b)(3) Managed Incontinence (b)In addition to Section 87611, General .., the licensee shall be responsible for :(3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on statements and observation, this requirement is not met as evidenced by: On 8/22/24 LPA & staff observed 3rd floor of facility and R1 & R2’s rooms having strong incontinence odors. This poses a potential health & safety risk to R1, R2 & other residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2024

Plan of correction: Licensee to ensure an in-service is conducted with all staff regarding incontinent care services to residents. Submit plan of future compliance with this regulation, ensuring staff are checking on resident and changing resident timely... & staff are cleaning floors to keep facility free of odors from incontinence. Submit proof of training. All POC documentation is due 8/20/24.

Allegation investigated: Staff do not ensure residents rooms are kept in clean sanitary conditions Staff do not ensure residents receive adequate incontinence care Staff do not ensure safe food service practice is followed

Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver findings regarding the above complaint allegations and met with Business Office Director Ravi Banwait as Administrator was unavailable. Staff do not ensure residents rooms are kept in clean sanitary conditions- Complainant alleges there is not enough housekeeping staff for the residents, resulting in resident’s rooms being left dirty. LPA conducted visits at facility on 5/29/2024 & 5/30/2024 inspecting 5 resident rooms on the 3rd floor and 4 resident rooms on the 2nd floor. LPA’s observations revealed all bedrooms inspected were clean on both days. Documents obtained revealed only 1 housekeeper. Interviews conducted with 4 staff and a hospice employee revealed although all housekeepers left the week of 5/20/2024 other then one who is in charge of the laundry, caregivers are helping with housekeeping manager to clean the facility while new staff are being hired. Although it was alleged staff do not ensure residents rooms are kept in clean sanitary conditions may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Continue on LIC9099-C Unsubstantiated Staff do not ensure residents receive adequate incontinence care- Complainant alleges residents are not being cleaned properly after being changed out of their soiled incontinent products and there is not enough incontinent products. LPA made unannounced inspections of facility on 5/29/2024 & 5/30/2024 and observed most of the 9 resident rooms inspected had supplies of incontinence products in their bathrooms or bedrooms. LPAs interview with staff revealed they check all rooms that use these products every Friday and if a resident is low on supplies staff calls the families or if they are on Hospice, they call the hospice company. There is also a storage room on the 2nd floor that LPA observed to have extra supplies of incontinence products (wipes, depends, gloves) and was told by staff if a resident runs out before their supplies are replaced, they can use these. The house supplies are also checked every Friday. LPAs interviews with 4 staff and one hospice employee who cares for a resident with incontinence issues revealed there has not been any issue with incontinence care supplies. Although it was alleged Staff do not ensure residents receive adequate incontinence care may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Staff do not ensure safe food service practice is followed- Complainant alleges kitchen staff do not practice safe food service by wearing hair nets. LPA conducted annual inspection on 5/29/2024 & 5/30/2024 of facility which included inspection of the kitchen area on dates inspected. The kitchen appeared to be clean as well as organized. Title 22 does not enforce kitchen staff to wear hair nets. Although it was alleged Staff do not ensure safe food service practice is followed may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Jun 5, 2024 · control 21-AS-20240520093428

Type of visit: Case Management - Annual Continuation

License Program Analyst (LPA) Shannan Hansen arrived at 8:45 AM to complete an unannounced annual inspection and met with Mary McClure, Administrator. There is a total of 26 memory care residents. During inspection 5/29/24 LPA observed 3rd floor west fire exit obstructed by bedframe across interior of both exit doors, and a full bed in front of one of the exit doors on the east side of the 3rd floor, which is a violation of Fire Safety regulation 87203 (see pics & LIC809-D). During today’s inspection 5/30/2024 both bed & bedframe have been removed. During inspection on 5/29/24 at approximately 9:30am LPA observed unwrapped quiche in 3rd floor kitchenette drawer, unwrapped/uncovered ice cream in freezer & uncovered pie from previous day in refrigerator (see pics LIC809-D). LPA also observed on 3rd floor, black coloring on floor under kitchenette sink where water leak use to be, a missing bedroom door to room 314 & bathroom wall to resident (R1)’s room (see pics & LIC 809-D). Razors & a pair of scissors were observed by LPA & BOD on 5/29/2024 at aprox 9:45 am in R2’s unlocked bathroom cabinet. BOD moved immediately (see pics & LI809-D). At approximately 11:30 pm, LPA reviewed 5 staff records. 2 of 5 staff Dementia training records were not complete & 2 of Medication training records did not contain required hours of training (see LIC 809-D) Evidence of current first aid and CPR training were present for required staff. All staff had required criminal record clearance and were associated. LPA reviewed centrally stored medication records of 2 of 2 residents finding to be complete to complete this annual inspection. Continued on LIC 809-C Fire extinguishers were last serviced 9/25/2023. Fire safety system including smoke detectors and carbon monoxide detectors are checked quarterly by facility staff and are on a regular service schedule with a vendor, is current. Disaster Drill are conducted monthly in shift rotation with the last drill being conducted on 5/22/2024. Facility is being cited today for 87203 Fire Safety violation with an immediate Civil Penalty in the amount of $500. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.. LPA Hansen is requesting Licensee to update and submit the following documents by 6/13/2023 to SRRO: LIC 308 Designation of Facility Responsibility LIC 610 Emergency Disaster Plan (if changes) Proof of Liability Insurancethe state’s words, verbatim · CDSS document, May 30, 2024

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

License Program Analyst (LPA) Shannan Hansen arrived at 8:45 AM to conduct an unannounced annual inspection and was greeted by staff. Business Office Director (BOD) Ravi Banwait arrived shortly after. LPA spoke with administrator on the phone, who was unable to attend inspection, authorized BOD to sign report. There is a total of 26 dementia residents and 5 residents under Hospice care. Beginning at approximately 9:00 AM, LPA toured the community with Care Coordinator, Gisselle Benavides & BOD. The tour of the facility included nine resident apartments, activity rooms, salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstructions other then third floor east fire exit door. Delayed egress doors have audible alarms when doors are opened without access codes. Hot water temperature measured within regulation of 105 to 120 degrees F in nine of nine rooms tested. Bathrooms contained necessary grab bars and showers contained non-slip floor/mats. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchenettes were inspected. Menus with snack and beverages are available to residents. Activity schedules are posted. Facility has multiple indoor and outdoor sitting areas and a private dining area. LPA initiated a file review of five resident files and five personnel files but were unable to complete. LPA was also unable to review medication, and conduct remaining interviews and will return at a later date to complete annual inspection. No citations given at today's inspectionthe state’s words, verbatim · CDSS document, May 29, 2024

Allegation investigated: Staff does not ensure residents allowed to leave their rooms at the facility Licensee does not ensure that staff are able to communicate with residents in care Staff do not ensure care needs are being met for residents

Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver findings regarding the above complaint allegations and met with Administrator, Kari Oxford. Staff does not ensure residents allowed to leave their rooms at the facility – Complaint alleges facility locks all of the residents in their rooms. Per Interview with staff (S1), residents’ doors are locked as a safety precaution due to memory issues, so that other residents don’t come into other resident’s room and take things or think it is their room. S1 also indicated residents are only locked on the outside, but if residents are inside of a locked door they can get out. On 12/28/2023 while touring third floor of facility, LPA found an unlocked room, locked the door prior to closing on the inside handle, tested the outside handle that did not move and shut the door. LPA was able to open the locked door from the inside by pushing the handle down. Follow up call with reporting party informed they do not have additional evidence or information to provide. Continue on LIC9099-C Unsubstantiated Although it was alleged that residents are unable to leave their rooms, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Licensee does not ensure that staff are able to communicate with residents in care – Reporting party (RP) alleges many staff who work at facility do not speak or understand English and therefore cannot communicate with residents. Reporting party could not give specific name of staff or residents who allegations were referring to. On 12/28/2023 while opening complaint, LPA went to both second and third floors where residents reside of this full dementia facility and spoke with 2 housekeepers, 3 medication technicians, 2 caregivers, and the activities director. LPA observed exercise activities being conducted and residents talking with and being directed by activities director. LPA also observed the other 5 staff speaking with residents without any communication problems other than possible dementia issues. Also, while LPA was conducting interview with R1, S2 was delivering their meal and was requested by R1 of S2 to give LPA a message, which S2 did. Although it was alleged that the licensee does not ensure that staff are able to communicate with residents in care may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Staff do not ensure care needs are being met for residents – Complaint alleges residents care needs are not being met as they are not being checked on per resident (R1) to reporting party. Reporting party also indicated R1 does not have a diagnosis of dementia. Conflicting to reporting parties’ statement, LPA’s file review revealed, the residents (R1) physician report (602) dated 9/2023 shows a diagnosis of dementia. Progress notes of 12/23/2023 to 12/25/2023 do not indicate due to care needs not being met, there was negative effects. End of Shift reports for same time period show residents slept all night and no issues or concerns during checks. LPA’s interview with S1 on 12/28/23 revealed bed checks are conducted every 2 hours and there is a log sheet that staff will notate in when they do something for the resident or if the residents are not eating or need a shower, have a bowel movement, etc. LPA conducted interview with S3 on 1/2/2024, that corroborated with S1, stating that if the resident doesn’t need help they do not write anything on the report. S3 was on shift during stated time period and end of shift report is notated as, residents slept all night and no issues or concerns during checks. LPA also obtained call logs from facility for time period in question that revealed only 1 resident requested attention, that was not R1. Therefore, the allegation, staff do not ensure care needs are being met for residents is Unsubstantiated. Based on LPAs observations, record reviews, interviews with staff, resident, and conflicting information obtained from party’s, there is insufficient information to prove or disprove the allegations listed above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 21-AS-20231226140340

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a case management on mandated reporting requirements at facility and was welcomed by staff Maryellen. Administrator Kari Oxford was contacted and arrived an hour and a half later. On 12/8/2023 Community Care Licensing (CCL) received information from an outside agency involving resident (R1), being assaulted by a caregiver. The facility has not notified licensing agency as required by regulation 87211(a)(1)(D), within 7 days of incidents. LPA was informed by Administrator, CCL had not been provided required SOC 341 documentation due to lack of communication within facility. LPAs interview with administrator and additional documents obtained regarding incident and involved parties, learned agency caregiver/individual (I1) had worked at facility for approximately three months with November 27, 2023 being the last day at facility. LPA located I1 on guardian check list, showing I1 has not been background cleared by DOJ. LPA is issuing citation for not having I1 background cleared by DOJ 87355(e)(1). Based on records review, LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. Last incident report submitted 11/21/2023. Administrator could not provide proof that incidents were reported to CCL. *****Civil Penalties for $500.00 for not having DOJ clearance of Individual/Caregiver Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, Dec 14, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1(D) · Plan of correction due date: Dec 15, 2023

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:LPA learned that the facility was made aware about the incident in late November 2023 and failed to report to the Department of Social Services-Community Care Licensing Division which presents an immediate health, safety and personal rights risk to the residents in care. As well, CCL has not received any reports from facility since 11/21/2023 (4 weeks), when they use to submit SIR’s Hospice Initiations, Death Reports, & SOC’s weekly.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Licensee shall submit an LIC 9098 understanding the regulation. Licensee shall submit a Plan for Future Compliance and how this plan will be implemented. Licensee shall retrain ALL staff that provide Care and Supervision regarding Reporting Requirements and submit signed, dated doc to CCL by POC 12/20/23 Plan of Correction for 2nd document due on December 20, 2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(1) · Plan of correction due date: Dec 15, 2023

87355 Criminal Record Clearance- (e) All individuals subject to a criminal record review pursuant to H&S Health and Safety Code Section 1569.17(e) shall prior to...residing...in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidenced by: Based on LPAs record review and interview with Administrator, facility did not ensure private agency caregiver (I1) was fingerprint cleared and had been working at the facility for approximately three months when incident happened and has been let go. This presents an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Administrator to ensure all individuals subject to a criminal record review are fingerprint cleared and associated to facility if volunteering or working at facility. Facility to submit a written statement they understand regulation 87355(e)(1) and will be in future compliance. Facility to submit statement to CCL by POC due date 12/15/2023. Civil Penalties in the amount of $500.00