Windsong of Sonoma

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Christi Coppo returned unannounced to complete the required Annual inspection and was greeted by concierge. LPA met with Administrator Lauren Cottman. On 6/9/26 LPA arrived at facility to conduct annual inspection. Today, LPA returned to complete inspection. At approximately 10:30am LPA, Admin, 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. LPA, Admin, and MedTech discussed medication documentation management and possibly incorporating an organizational system that houses all the current signed doctors' orders and discontinuation notices in one location for each resident. Admin provided LPA recent pharmacy audit documentation conducted on 2/13/26. All audit criteria shows as met or not applicable. No deficiencies cited. LPA issued citation for deficiencies identified on 6/9/26, except one. LPA did not issue citation for deficiency of Health and Safety Code (HSC)1569.696 as Admin provided LPA documentation showing all subject matters were covered by vendor training. Therefore, facility found to be in compliance with HSC1569.69. No deficiencies identified at today's continuation visit. Continued on 809C... Continued from 809... Additionally, Resident Care Director (RCD) provided LPA with proof of request for medical assessment for R5. So, LPA removed R5 from list of residents for deficiency of regulation 87463(h). Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jun 11, 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) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by concierge. LPA met with Alicia Dixon, Residential Care Director. Administrator Lauren Cottman arrived later. Administrator certificate # 7028976740 expires 9/21/26. Facility currently has 80 residents in care, ten (10) of which are currently on hospice. Facility has an Assisted Living (AL) unit and two separate (2) Memory Care (MC) Units: The Gardens and The Courtyard. At approximately 9:45am LPA and Admin toured the building and grounds. 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 and both ancillary MC kitchens were not stored in a safe manner and open items were not covered or closed. Items found uncovered or unsealed or both include: tuna and egg salad, chicken tenders, frozen hamburger patties, frozen veggie patties, box of frozen peas, mini lemon pies, piece of cake, bread, buns, crisp rice dry cereal, and ice cream containers (deficiency cited, see 809D). Ice cream found with frost bite and containers of strawberries had some berries with fuzzy black and blue substance present on berries. Container of granulated sugar had active flies buzzing inside container as it was not properly sealed shut (deficiency cited, see 809D). LPA and Admin observed steam heat bins in both MC units to be on and very hot to the touch. Admin and Sean Bannister, Generations Program Director immediately removed items in steam bins and will formulate a new method of delivering hot food from the main kitchen to the MC units. LPA and Admin observed bleach and other toxins stored in main kitchen next to food preparation area (deficiency cited, see 809D). LPA and Admin observed unlocked kitchen cabinet under sink in both MC units to contain disinfectants and cleaning supplies (deficiency cited, see 809D). LPA and Continued on 809C... Continued from 809... LPA and Admin observed bottle of Chardonnay, 12 pack of Coors light in glass bottles, two (2) bottles acetone and three pair of scissors unlocked and accessible to residents in MC unit (deficiency cited, see 809D). Additionally, kitchen cabinet housing gas knobs that operate heating element was unlocked and accessible to resident in care (deficiency cited, see 809D). Laundry soaps are located in a locked closet and inaccessible to residents in care. All bedrooms were equipped with lighting and night stand. Chest of drawers not provided by facility; however, all rooms have two (2) closets, one of which has shelving. All bedrooms were clean and in good repair. Rooms #205 and #121 did not have a pull cord or push button alert present. Per Russell Echeverria, Building Services Director, the facility is currently in the process of getting approval from corporate to replace all push button boxes with pull cords. Push button alert boxes are easily removed by residents by simply pushing down on them, so facility is replacing with a more updated system. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 106.7 degrees F in room #228, 106.9 degrees F in room #229, 105.4 degrees F in room #242, 105.8 degrees F in room #205, and 105.3 degrees F in room #121, all of which are within the allowable range of 105 to 120 degrees F. Facility has other bathrooms used by staff only. Fire extinguishers were last inspected 10/8/25. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced by vendor. Last date of service was 4/2/26. All systems showing as Passed. Facility’s last quarterly disaster drill was conducted on 5/28/26. Facility has a backup generator for use during a power outage. LPA observed evacuation chairs present at top of stairwell and at top of main stair case. At approximately 1:30pm LPA conducted a review of eight (8) resident files. Residents (R1, R2, R3, R4, and R5) do not have current physician reports on file (deficiency cited, see 809D). Resident (R5) did not have TB clearance on file (deficiency cited, see 809D). Continued on 809C(2)... Continued form 809C... At approximately 3:30pm LPA conducted a review of eight (8) Med Tech staff files. Med Tech staff (S1, S2, S3, S4, S5, S6, S7, and S8) did not have the required medication training completed required per Health and Safety Code 1569.69 (deficiency cited, see 809D). S2, S3, S4, S5, S6, S7, and S8 have the required hours of training completed as required per Health and Safety Code 1569.625. However they have not completed all of the required subject matters per Health and Safety Code 1569.696 (deficiency cited, see 809D). S5 and S6 did not have current 1st Aid certification on file (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 9, 2026

Allegation investigated: Facility did not meet with resident or their responsible party when updating reappraisal

At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegation. LPA met with Executive Director Lauren Cottman and Resident Care Director Alicia Dixon and reviewed records. Based on records reviewed and interviews conducted, LPA found evidence that the facility representative did meet with resident, R1, in regards to their appraisal. Based on records reviewed, on 02/24/2026, the Resident Care Coordinator Alicia Dixon met with R1 to conduct a medication Self-Administration assessment. The updated appraisal was created from that meeting. LPA reviewed resident records and observed R1 was their own responsible party. Based on these findings, the facility followed regulation 87467, Resident Participation in Decision making and 87463, Reappraisals, by conducting a meeting with R1. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 17, 2026 · control 21-AS-20260410125527

Allegation investigated: Staff did not provide resident with reappraisal

At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Resident Care Director Alicia Dixon, reviewed records and interviewed staff. Based on a review of documents and interviews conducted, LPA found the faciltiy did not provide resident with a reappraisal or provide residents responsible party written notification within two days of increasing residents care costs. Facility implemented a one on one caregiver on 12/05/2025, and conducted a meeting with responsible party on 12/9/2025. There was no documented evidence of this meeting until 01/29/2026. On 01/29/2026, a care conference was conducted with responsible party and an updated appraisal was provided. Documentation for that meeting referenced the meeting on 12/09/2025. Facility increased R1's care services but did not provide responsible party with written notification, to include the itemized cost of care, within two days. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Alicia Dixon and Appeal rights were given. Substantiatedthe state’s words, verbatim · CDSS document, Mar 13, 2026 · control 21-AS-20260220132139

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Mar 27, 2026

(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure reappraisal was conducted and notification to responsible party was made within two days. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, Mar 13, 2026

Plan of correction: Licensee agrees to ensure written notification is provided to responsible parties within two business days. Violation cleared during visit as resident moved.

Allegation investigated: Staff does not provide food alternatives for residents with medical prescribed diets Staff do not provide food alternatives for residents with religious, cultural beliefs Staff does not ensure food is stored at appropriate temperatures prior to being served to residents in care

Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver complaint findings of an investigation conducted regarding the allegations listed above. LPA met with Administrator John Beltz. During the course of the investigation 2 visits (10/2/25 & 10/23/2025) making observations, documents obtained of; admissions agreements, medical/dietary document along with menus of 5-week increments, and 6 resident along with 4 staff interviews were conducted. Staff does not provide food alternatives for residents with medical prescribed diets & Staff do not provide food alternatives for residents with religious, cultural beliefs - Complainant alleges facility never accommodates special dietary needs that were prescribed by physician, and facility does not provide a meal substitute for religious/cultural beliefs e.g..pork. Investigation revealed on 10/2/2025 when LPA went to facility to open complaint at approximately 8 am, observed residents eating many different breakfast options that included; fried egg and hashbrowns, freshly cut strawberries and blueberries, oatmeal, heart healthy cereal, & Belgian waffles. Continue on LIC9099C Unsubstantiated Continued from LIC9099: Of the 5 residents interviewed, 3 had dietary physician orders, none of the 3 residents indicated there was any problem with the food they received from the facility regarding their special diets or getting alternatives for the meals. Resident (R5) indicated the facility keeps low sodium food due to the residents’ age, and the facility is following their dietary restrictions regarding salt. R5 likes the soups offered by the facility and indicated they believe most of the residents think the food is OK, just repetitious. R6, with a diabetic diagnosis indicated they have no problem with any of the food or options. Just that sometimes they eat upstairs but they like eating in the dining room where they can see more of the options. Interview with Staff (S2) revealed the facility has a dietitian, which was corroborated by Administrator who indicated the facility is contracted with a dietitian that visits several times a year and provides oversight with any menu changes. LPA’s review of 5-week rotational menu showed each of the 3 main meals per day has a full meal substitute with at least 3 to 4 main substitutes not being of pork and having low salt/low carb/ being diabetic friendly. Admissions agreement does not indicate anywhere facility must store or cook personal food. There was no information obtained that supported a violation had occurred. Based on the interviews, record reviews, and related information obtained during the investigation, the allegations “Staff does not provide food alternatives for residents with medical prescribed diets” & “Staff do not provide food alternatives for residents with religious, cultural beliefs” is Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Staff does not ensure food is stored at appropriate temperatures prior to being served to residents in care- Reporting party also indicated observing staff at the facility serving potato salad to residents and the potato salad would be served in a plastic bowl and it would already be warm. LPA’s interview with S1 revealed for residents who eat in their rooms the kitchen staff will cover the hot foods and put on a tray and will put the cold food in a container on the tray separating them. LPA’s 2 visits (10/2/2025 & 10/23/2025 ) to facility during both breakfast and lunchtime did not observe any food that should be cold left out and warm. Interviews with 3 residents regarding temperature of food revealed regardless of where they eat their meals the temperature of the food is appropriate. There was no information obtained to support a violation occurred. Therefore, the allegation staff does not ensure food is stored at appropriate temperatures prior to being served to residents in care is Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 21-AS-20250924120527

Allegation investigated: Facility has rodents

Licensing Program Analyst (LPA) Hansen arrived unannounced to open a complaint investgation and delivered complaint findings. LPA met with Administrator, John Beltz. During investigation LPA made observations, conducted interviews and obtained documents. Facility has rodents- Reporting party alleges for the last couple of months rat droppings have been under drink machines /cup holders in the kitchen and dining room. Based on documents obtained and interviews with staff it was revealed the first presence of rodents was January 2025. In July, rodent problem escalated to needing a different pest control company, that to date has serviced approximately 6 times so far, not resolving the problem. During today’s (10/23/2025) visit, LPA observed a large rodent bait station next to ice cream freezer ...... Continue on LIC9099C Substantiated Continued from LIC9099 & under filtered water station with rodent glue/sticky traps in a few other places in kitchen (see photos). LPA further observed rodent feces on the floor behind the stove where rodents have pulled insulation out and under/behind lower cup trays in kitchen. LPA also observed rodent droppings on service tray containing clean table linens in kitchen (see pics). Based on LPA's observations, interviews conducted, and records reviewed/obtained, the preponderance of evidence standard has been met, therefore the above allegation facility has rodents is found to be SUBSTANTIATED. 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 providedthe state’s words, verbatim · CDSS document, Oct 23, 2025 · control 21-AS-20251022162850

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(27) · Plan of correction due date: Oct 24, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above in that rodents, rodent feces and rodent traps were observed in the kitchen and dining areas which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: ED/Administrator agrees to submit thourough plan of how to eliminate the rodent infestation by POC due date of 10/24/2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and conduct a Case Management - Incident Visit and met with Administrator, John Beltz. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 10/16/2025. The report stated that on 10/10/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community. Staff conducted resident count at approximately 5:15 PM, not locating R1. At approximately 5:35 PM, RCD had been driving around adjacent housing community looking for R1, observed R1 speaking with 2 police & 2 bystanders who had called police. RCD escorted R1 back to community; PCP and family were notified. R1 was assessed at facility, no injuries sustained. During today's visit, it was revealed to LPA that R1 had been in the bistro participating in activities prior to dinner and when activity ended, groups of residents, staff, and others left the area to go to dining area, back to memory unity, and to leave, and R1 had gotten out of facility by the front door, unbeknownst to anyone. The same situation took place with another resident of the memory care unit on 5/3/2025. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited) *****Civil Penalty for $1,000.00 was issued during today's visit for repeat of citation of 87411(a), previous citation given on 5/3/2025 for Zero tolerance. 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, Oct 23, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 24, 2025

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of resident in care.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: Previoues POC was Administrator submitted 5/6/2025 in-service training for entire staff re elopement procedures that will continue every month,& Initiated a 1:1 companion for R1’s safety. & indicated any memory care residnet leaves the unit will be handed off from person to person until brought back to memory care.(Admin & Regional Clinical Nurse). Administrator to submit thourough plan of how facility will meet regulation 87411 regarding memory care residents needs/safety, preventing elopement by POC due date 10/24/2025. ****A civil penalty is being assessed for $1,000.00

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Inspection of facility and was welcomed by Business Office Mgr. Elizabeth Alfaro, and met with Administrator, John Beltz. Facility is 2 stories and contains both assisted living and two memory care units. There are 43 Assisted Living Apartments and a total of 32 memory care apartments. Facility has approved fire clearance from Petaluma Fire Department for 80 Non ambulatory & 15 Bedridden residents from 5/16/2023. Hospice Waver approved for 12. Facility currently has 44 Assisted Living residents and 39 residents in memory care. Also, there are 7 residents currently receiving Hospice. Facility tour/inspection began at 8:40 AM: LPA toured the facility on 5/27/2025 with Executive Director John Beltz; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility has a special care plan of operation and programming for residents with dementia. Fire Extinguisher was found to be last charged on 10/20/2024. Facility smoke detectors with combination carbon monoxide detectors are hard wired and sound directly to the fire station. Smoke/carbon monoxide detectors (last inspection 10/20/2024) and fire sprinklers are inspected annually, and inspection records are current with the last inspection being conducted on 4/15/2025. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 108.8 degrees F and 120.9 degrees F falling out of Title 22 acceptable regulation of 105 F to 120 degrees F in 2 of 9 resident’s bathroom faucets, boiler was turned down at visit (LIC9102 TA). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Menus are available and provided during meals. Continue on LIC 809-C Continued from LIC809 LPA observed that provisions are made for individuals with special dietary needs; facility keeps a variety of items on the menu, and facility has a board in the kitchen with a picture of the resident & a list of dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents posted. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with towels and hand soap dispensers when a private room. Resident bathrooms had required slip resistant mats and grab bars. A sample tour of nine resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. File Review began at 11:45 AM: A sample review of nine residents & six staff records as well as four resident’s medications was conducted. LPA learned that 9 out of 9 residents have an updated reappraisal/needs & care plan as well as medical assessments. As per sample review of staff records, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. All direct care staff files reviewed have completed annual required trainings; 2 out of 5 direct care staff (S1 & S2) files reviewed did not obtain required proof of 1st Aid certification (see LIC 809-D). Medication Audit began at 1:30 PM: Medications were centrally stored in (5) locked medication carts and in the facility medication room at the facility. LPA observed medications of 4 out of 4 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 4 out of 4 residents were found to have all medications entered for residents. Facility uses bubble pack and pharmacy CSMR for all residents at the facility. Emergency Disaster Plan reviewed with Administrator. Disaster Drills have been conducted monthly and in different shifts with the last one being conducted on 4/28/2025. In addition, John Beltz, Administrator Certificate # 7017264740 expires 9/30/2026. Continue on LIC809-C2 Continued from LIC809-C1 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 Administrator to update the following documents and to submit to CCL by 6/20/2025: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changed) LIC 9020 Register of Facility Resident’s (already received) Copy of Control of Property-Deed or Lease Copy of Administrator Certificate Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, May 27, 2025

Type of visit: Case Management - Incident

At approximately 1:30 PM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, John Beltz. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 05/07/2025. The report stated that on 05/03/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community at approximately 4:30 PM, when R1 was last seen participating in memory care activity, later finding, exited via front door. At approximately 4:50 PM, Activity Director observed R1 sitting on a bus stop bench down the street from community, where Activity Directory escorted R1 back to community; PCP and family were notified. R1 was assessed at facility, no injuries sustained. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited) Civil Penalty for $500.00 was issued during today's visit for Zero Tolerance, Absence of Supervision. 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, May 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 14, 2025

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of resident in care.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: Administrator submitted 5/6/2025 in-service training for entire staff about elopement procedures that will continue every month,& Initiated a 1:1 companion for R1’s safety. POC cleared at time of visit ****A civil penalty is being assessed for $500.00

Allegation investigated: Staff are not meeting residents’ dietary needs Staff are not providing adequate food service to residents

Licensing Program Analyst (LPA) Hansen arrived unannounced for the purposes of delivering complaint findings to the allegations listed above. LPA met with Administrator John Beltz. Staff are not meeting residents’ dietary needs – Complainant alleges residents (R1) who have doctor’s order for low sodium diet & is diabetic, alleges everything the facility serves is full of a lot of salt and doesn’t eat sugar or dairy. During the investigation LPA obtained physicians report indicating resident (R1) has an order for specialized diet dated 9/26/2024. Plant based/low sodium/diabetic carb control. Interviews with kitchen personal (S1 & S2) informed they manage a 5-week menu rotation through a dietician service that approves all menus, which are changed regularly but remain balanced and approved by the dietician. Fish is on the menu approximately 3 times per week and rotate the types of fish (ie..,cod, shrimp, salmon). During visit on 1/27/2025 & 4/18/2025 LPA toured the kitchen area and observed plenty of perishable and nonperishable fresh fruits and vegetables for residents in care as well obtained current week (1/20/2025 -1/27/2025) facility menu.. Continue on LIC9099-C Unsubstantiated Continue from LIC9099 ..that offers fresh cut seasonal fruit at every breakfast, diabetic friendly, low sodium, low calorie, low to no sugar lunch including House Salads. Dinners also offer Diabetic-Friendly, low sodium, low calorie, low to no sugar, House Garden Salads with other options. Based on interviews conducted with residents R1 disclosed they provide outside food items of their preference to facility kitchen staff to prepare for them. According to LPA’s observations, records review, and interviews conducted with staff and residents in care, LPA is unable to determine allegation staff was not meeting residents’ dietary needs at a prior date, finding UNSUBSTANTIATED. Staff are not providing adequate food service to residents- Complainant alleges the food served at the facility is all prepackaged and full of preservatives, and chemicals. As well, is served semi warm or burnt as with broccoli, boxed mashed potatoes, and dry turkey. LPA's interview with S3 informed Food for Thought meetings conducted monthly with Culinary Services Director provide opportunity for residents to provide feedback regarding the food services at the facility. The Culinary Services Director provides responses to some requests/suggestions immediately but others may take time for research and responds to those by or at the following months food for thought meeting. Based on records reviewed LPA obtained monthly food for thought meetings that confirms the involvement of residents food choices to modify the menu (ie.. romaine lettuce to butter lettuce). LPA conducted walk through of kitchen on 1/27/2025 and 4/18/2025 that appear to be per regulation enough perishable and non-perishable foods (see LIC 812-pics). LPA observed Culinary Services Director preparing each order request that had just been taken, individually, and then taken out to the dining room immediately when meal was just prepared. Therefore, allegation staff are not providing adequate food service to residents is found to be UNSUBSTANTIATED. Although the allegations may be true, based upon the review of documents, observations made and statements provided, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the complaint is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 18, 2025 · control 21-AS-20250123150458

Allegation investigated: Staff did not issue a refund to resident's authorized representative

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced at facility to open complaint investgation and delivered complaint findings. LPA met with Business Office Manager (BOM) Liz Alfaro as Administrator was out of the building. LPA investigated the above allegation. During the investigation LPA requested and obtained copies of documents and conducted interviews. The following was reported to The State of California Department of Social Services (DSS), Community Care Licensing Division (CCLD), Santa Rosa Regional Office: Continue on LIC9099-C Substantiated Continued from LIC9099 Responsible parties (who paid in advance) of deceased resident has not received a refund check as required. Resident (R1) passed away at the beginning of January, 2025, it has been over a month and they did not receive their refund check. Allegation - Licensee did not issue a refund to resident's authorized representative : Interviews conducted with Business Office Manager and other parties revealed. There was a laps of approximately a month and a half in processing of refund due to it falling through the cracks on my end and somewhere on accounting's end. Review of records revealed Move out was 1/14/2025, request for refund was sent to accounting 1/30/2025. On 2/21/2025 records show facility sent refund check, although BOM is waiting for response from accounting of confirmation. Staff stated they did not know regulation requires refunds to be paid within 15 days of when the resident's belongings are removed from the facility after move out or death. This agency has investigated the complaint alleging "Licensee did not issue a refund to resident's authorized representative Based on record review and interviews conducted, licensee did not pay the refund to the resident's Responsible Party within the required 15 days after the removal of resident's belongings, therefore the preponderance of evidence standard has been met, the above allegation is found to be SUBSTANTIATED. 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, Feb 21, 2025 · control 21-AS-20250219092309

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.562(c) · Plan of correction due date: Feb 28, 2025

1569.652 Termination of admission agreement upon death of resident; removal of resident's property; refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident's personal property has been removed from the facility shall be issued to the individual...responsible for the fees or..resident's estate, within 15 days after the personal property is removed. This requirement has not been met as evidenced by : Based on record review and statements received, licensee did not ensure the Health & Safety Code as required. This is a potential personal rights risk to residents.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: Licensee to provide a written detailed plan on how the facility will ensure resident's refunds are issued accordingly and timely per H&SC. Facility to submit their plan to Community Care Licensing as plan of correction by POC due date 2/28/2025

Allegation investigated: Resident was unlawfully evicted. Facility overcharged resident.

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPAs Frank and Stevenson arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPAs met with Business Office Director (BOD), Elizabeth Alfaro. Administrator John Beltz was not at the facility during today’s visit. Complainant alleges after resident had been in the hospital for 4 days due to pneumonia, on January 11, 2024 resident's physician cleared to return to facility. Complainant indicated the facility communicated to the resident's physician they would not accept the resident back although did not inform the resident or their spouse. When the family called to ask why the resident was not being permitted to return to the facility, Interim Administrator stated it was because the resident needed a level of care that the facility could not provide. The assessment was made without any evaluation of the resident by the facility. Investigation confirmed facility conducted an assessment while resident was outside of the facility. Outside party confirmed resident was observed to be beyond the level of care the facility could provide. Continued on 9099-C... Unfounded ...Continued from 9099 Interview with responsible party on 2/5/2025 confirmed no eviction notice given or complaints of overcharging. Responsible party also indicated they received all items from resident apartment and are no longer receiving a bill. Per interview with facility there was an outstanding balance for January 2024, which was waived. The investigation did not reveal information to support these allegations. Based on review of documents/records and interviews conducted, this Agency has investigated, the above allegations, resident was unlawfully evicted & facility overcharged resident are UNFOUNDED. A finding that the complaint is UNFOUNDED means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Copy of report discussed and provided to BOD Alfaro. Signature on form confirms receipt of documents. No deficiencies cited.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 21-AS-20240909141913

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hansen arrived unannounced at facility to conduct a case management and met with Elizabeth Alfaro, Business Office Director (BOD) as Administrator, John Beltz was not available. The purpose of this case management inspection is to follow up on a self-reported incident report submitted to Community Care Licensing (CCL). On 6/14/2024 CCL received an incident report form reporting on 6/11/2024 at approximately 4:45pm resident (R1) had eloped from community. Facility staff conducted search at 4:50pm, after not locating R1 in facility staff left in car and at the same time as Law Enforcement located R1 two intersections away laying on the lawn at approximately 5:20pm. Report indicates R1 sustained 2 skin tears on left hand with bruise on palm. 911 contacted after returning to community. EMT’s evaluated & cleared for resident to remain at facility. Staff informed, R1 left through back egress gate of facility memory care unit. LPA obtained records indicating R1 has diagnosis of dementia and is not to leave facility unassisted. Interview with staff informed R1 exit seeks. LPA is issuing a citation today for R1 eloping from facility without staff knowledge on 6/11/2024. *******Total Civil Penalties issued today in the amount of $250.00 A $250.00 civil penalty is being issued for 2nd citation in less then 12 months for the same violation 87705(b)(2). Previous citation 2/1/2024. Appeal Rights Given 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, Aug 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Aug 21, 2024

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by** Based on a review of facility incident reports and resident records it was found that resident (R1) had eloped from the facility without supervision. R1 is diagnosed with dementia and based upon Physicians Report, requires special supervision for confusion and wander risk. This is an immediate health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: Licensee/Administrator to ensure full staff training on elopements. Also to ensure plan for egress doors/gates along with pagers/phones are in working order. POC to submit training sheet signed & date by staff with self certification egress gates/doors are connecting with staff pagers/phones to CCL by 8/21/2024 to clear POC. ***Civil Penalty for $250. for repeat violation

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Inspection and was welcomed by Business Office Mgr. Elizabeth Alfaro, and met with Administrator, John Beltz. Facility currently has 41 Assisted Living residents and 38 dementia residents in memory care. There are 10 residents currently on Hospice. Facility tour/inspection began at 8:30 AM: LPA toured the facility on 6/10/2024 at approximately 8:35 AM with Business Office Manager (BOM) Lizabeth Alfaro and was joined by Administrator John Beltz shortly after; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility has a special care plan of operation and programming for residents with dementia. Fire Extinguisher was found to be last charged on 10/16/2023. Facility smoke detectors with combination carbon monoxide detectors are hard wired and sound directly to the fire station. Smoke/carbon monoxide detectors and fire sprinklers are inspected annually, and inspection records are current with the last inspection being conducted on 4/15/2024. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 113.7 degrees F and 128.3 degrees F falling out of Title 22 acceptable regulation of 105 F to 120 degrees F in 5 of 11 resident’s bathroom faucets, all 5 in memory care, boiler was turned down at visit (see LIC809-D). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Menus are available and provided during meals. LPA observed that provisions are made for individuals with special dietary needs; facility keeps a variety of items on the menu, and facility has a board in the kitchen with a picture of the resident & a list of dietary needs. Food is available for residents any time of the day. Continue LIC 809-C There is a daily activity schedule for residents posted. Toxins are stored in a locked housekeeping room; although while touring facility at 9:24am LPA, BOM, and Administrator observed cleaning supplies under both sinks of memory care kitchenettes in cabinets without locks (see LIC809-D) Building Service Director Russell Echeverria informed due to upgrades throughout the facility, locks in this area had not been completed yet. Locks were installed by end of visit. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with towels and hand soap dispensers when a private room; although at 8:40am LPA & BOM observed in a memory care bathroom an unlocked cabinet with Lidocaine patches, razors, and other cleaning supplies, see pic (see LIC809-D). Items were removed during inspection and locked in resident bathroom cabinets. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. The facility has obtained new flooring throughout and paint, Garden Neighborhood dining area has completed construction due to water leak a year ago. File Review began at 11:15 AM: A sample review of five residents & five staff records as well as four resident’s medications was conducted. LPA learned that 5 out of 5 residents have an updated reappraisal/needs & care plan as well as medical assessments. As per sample review of staff records, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. 3 out of 3 direct care staff have not completed annual required trainings (see LIC809-D); 1 out of 3 staff (S1) reviewed did not obtain required proof of 1st Aid certification (see LIC 809-D). Medication Audit began at 10:45 AM: Medications were centrally stored in locked medication carts and in the facility medication room at the facility. LPA observed medications of 4 out of 4 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 4 out of 4 residents were found to have all medications entered for residents. Facility uses bubble pack and pharmacy CSMR for all residents at the facility. Continue LIC 809-C LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have been conducted monthly and in different shifts with the last one being conducted on 5/31/2024. In addition, John Beltz, Administrator Certificate # 7017264740 expires 9/30/2024. Civil penalties are being assessed for $250. For repeat of same regulation within a 12 month period. 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 Administrator to update the following documents and to submit to CCL by 6/20/2024: LIC 308 Designated LIC 500 Personnel Summary (already received) LIC 610 Emergency Disaster Plan (if changed) LIC 9020 Register of Facility Resident’s (already received) Copy of Administrator Certificate Copy of Certificate of Liability Insurance (already received)the state’s words, verbatim · CDSS document, Jun 10, 2024

Allegation investigated: Facility is retaliating against resident

Licensing Program Analyst Leibert arrives unannounced for the purpose of investigating the above captioned complaint allegation. LPA has taken a statement from the Complainant on 5/31/2024 and from facility staff this date. LPA has reviewed pertinent documents. Facility staff deny retailiating against the Complainant and indicate the Complainant is the subject of an eviction proceedure which has been issued in accordance with current law and Title Twenty-Two regulations. On May 31, 2021 Complainant indicated to CCL staff that Complainant did not want the complaint to be investigated. When asked if Complainant did, or did not, have a complaint with the facility, complainant responded, "No." Based upon the statements made and documents reviwed, we have determined that the allegation that the facility is retaliating against resident is false and without a reasonable basis. Therefore, the complaint is UNFOUNDED. The complaint is DISMISSED. Report left. No citations issued today. Unfoundedthe state’s words, verbatim · CDSS document, Jun 3, 2024 · control 21-AS-20240528162916

Allegation investigated: Staff are not ensuring resident has privacy Staff are discriminating against resident Staff are threatening resident

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Mary McClure. Staff are not ensuring resident has privacy - According to complainant, staff are coming into resident (R1)’s room without permission or any notice. R1 was relocated from a sister facility during an emergency evacuation 4/2023. Facility policy is to clean resident’s rooms weekly/as needed and conduct room checks, which began upon R1’s arrival. Facility and R1 had an agreement regarding room checks and cleaning. Later, R1 expressed they did not want this service and the facility complied. Based on LPAs interviews, record review, and observations, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, staff are not ensuring resident has privacy, did or did not occur, therefore the allegation is Unsubstantiated. Continue on LIC9099-C Unsubstantiated Staff are discriminating against resident -& Staff are threatening resident - According to reporting party , an incident occurred at facility during dining hours between R1 and a staff (S1) member. Based on LPAs interview with witness resident and staff it was revealed that R1 was verbally loud and disruptive in the dining area. LPA was unable to obtain clarification regarding reason for R1’s outburst. Administrator was made aware of incident and had a meeting with R1. After the meeting, Administrator provided a letter to R1 summarizing their conversation and informing of facilities polices. The letter informed if facilities policies are violated moving forward an eviction may be warranted. LPA obtained a copy of the notice provided to R1. Reporting party informed LPA based on the dining room incident and letter received R1 felt threatened and discriminated against. The investigation did not reveal information to support these allegations. Based on LPA’s record review, interviews conducted, and observations, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations staff are discriminating against resident & staff are threatening resident did or did not occur, therefore the allegations are Unsubstantiated.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 21-AS-20231004154753

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and conducted an unannounced case management and met with Administrator, Mary McClure. The purpose of this case management inspection is to follow up on two self-reported incident reports submitted to Community Care Licensing (CCL). CCL received the first self-reported incident report form on 10/25/2023 reporting on 10/20/2023 at approximately 1:35 pm resident (R1) had eloped from community. Facility staff conducted search and located R1 at a local park at approximately 3:10 pm. Report states garden latch was not locked by gardeners who obtained key from staff to conduct work, when elopement occurred. No visible signs of injury noted by resident care director (RCD) and R1 denied any pain. LPA obtained records indicating R1 has diagnosis of dementia and is not to leave unassisted. Interview with RCD informed R1 exit seeks. LPA is issuing a citation today for R1 eloping from facility without staff knowledge on 10/20/2023. LPA also followed up on a second incident submitted to CCL on 12/19/2023 of an attempted suicide on 12/18/2023 where R2 was sent out to emergency room. Resident is being placed in different placement from discharge from hospital. 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, Feb 1, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(2) · Plan of correction due date: Feb 1, 2024

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by** Based on record review it was found that resident (R1) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: Facility provided Elopement in-service training conducted, for regulation 87705 Care of Persons with Dementia with staff. LPA Obtained copy of trainings w signatures and dates. POC cleared at visit.

Type of visit: Case Management - Other

License Program Analyst (LPA) Hansen arrived unannounced to open a complaint at facility and conduct a case management of facility and met with Business Office Director Liz Alfaro and Sammy Howeidy, Memory Care Director regarding unsigned documents. During complaint investigation LPA was informed resident (R1) did not have a signed Admissions Agreement. Which is a violation of regulation 87507(c). Facility will obtain a signed admissions agreement from all residents. LPA is giving facility a technical violation for not following California Code of Regulations Title 22, of Division 6, of California Regulations 87507(c). No citations given during today's visit.the state’s words, verbatim · CDSS document, Oct 5, 2023