Woodland Gardens Senior Living

Type of visit: Required - 1 Year

On 07/10/2026, Licensing Program Analyst (LPA) Nakagawa conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an updated emergency disaster plan and infection control plan as required. There are currently 74 residents in care. LPA met with newly appointed Administrator Alka Ralh. LPA and Administrator toured the building and grounds. The facility was found to be well-maintained and at a comfortable temperature. LPA observed an ample supply of perishable and non-perishable food. Refrigerated food was found to be stored as per regulation. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms inspected were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured within the range of 105 to 111.2 degrees F. Fire extinguishers were last inspected 08/28/2025. The Fire Alarm System was tested on 03/10/2026 and operational. Facility conducts quarterly fire and disaster drills with the last one being conducted 06/17/2026 and 06/18/2026 for all shifts by an independent company who provided education and support for staff. Medications were found to be centrally stored Medication Administration Record (MAR) is electronically kept. Facility has well-attended activities program including Arts and Crafts, Dance, a 4th of July BBQ, special events for Mother's Day and Father's Day and even celebrating Staff Appreciation.. LPA conducted a review of 4 resident records and 5 staff records. LPA found all staff to have required annual and initial training as well as current first aid. Medication Technicians have current CPR training. (Continued on 809-C) (Continued from 809) No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/01/2026: Program Plan (review, update if any changes due to new definition of Dementia/Behavioral Expression) Discussed: Online record-keeping including MAR, Staff Training Exit interview conducted with Administrator Alka Ralh and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 10, 2026

Type of visit: Case Management - Other

On 7/10/2026, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a case management inspection and met with Administrator Alka Ralh to discuss. LPA is following up regarding the reported death of resident, R1. LPA reviewed documents. On 05/29/2026, Administrator met with family of R1 to discuss hospice enrollment; family and facility were waiting on return of DPOA from trip and was expected within one week. R1 passed on 06/03/2026. Administrator has agreed to provide LPA a copy of the death certificate once it is available. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Jul 10, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a case management visit and gather information/records regarding an incident which occurred on 04/11/2026 and self reported by the facility on 4/13/2026 that involved staff S1 and resident R1. LPA met with Alka Ralh, Administrator-in-Training, took her statement and requested records for Community Care Licensing to review incident. Alka Ralh stated that the incident of S1 improperly blocking/grabbing the arm of R1 from exiting the Memory Care Unit was captured on video. Staff S2 assessed R1 and found visible bruising and notified administration. LPA requested a copy of video evidence regarding the incident, which will be reviewed. Facility suspended staff S1 immediately after the incident and was discharged on 04/15/2026 due to inappropriate behavior towards a resident. The Department will continue the investigation, review video of the incident and conduct interviews. LPA will return at a later date to discuss findings. Exit interview was conducted with Administrator-In-Training. Copy of report left with Alka Ralh.the state’s words, verbatim · CDSS document, Apr 21, 2026

Allegation investigated: Facility mismanaged resident’s medications.

On March 17, 2026, Licensing Program Analyst (LPA) Nakagawa arrived at Woodland Gardens Senior Living to complete a complaint investigation regarding the allegation listed above and deliver findings. LPA met with the administrator-in-training, Alka Ralh. The complaint alleges that Facility mismanaged resident’s medications. The complainant stated that there were 3 boxes of medications, including medications which the facility had failed to refrigerate. The complainant provided photos of boxes of medications. The label states that medications may be refrigerated but not required. Continued on 9099-C.... Unsubstantiated Continued from 9099..... LPA reviewed medication compliance which showed that one of the medications should be refrigerated once the pouch is opened and then used within two weeks. In addition, outside parties stated that none of the medications which the resident (R1) was receiving required constant refrigeration storage. Based on the information provided by outside sources the medication was not improperly stored. The reporting party also alleges that the facility ordered medications unnecessarily when there were ample supplies. The reporting party alleges that the facility mis-managed R1’s medications by storing them improperly, dispensing them incorrectly, and continuing to order medications unnecessarily when there were already ample supplies. Interviews with outside parties stated that the prescriptions were refilled per physicians orders. Title 22 Regulations do not allow for a facility to determine that a prescription should or should not be refilled. It is the responsibility of the prescribing physician. LPA Nakagawa received a medication release form that was signed by the facility representative and the responsible party. There were no discrepancies noted by either party at that time. LPA Nakagawa received pictures from the responsible party showing that they received three file boxes of medications from the facility. The facility also had pictures of medications released to the responsible party, but there was only one file box. In review of records from outside parties, there were many prescriptions ordered on auto-refill set up by the responsible party. Records reviewed by LPA also indicate there were multiple doctors prescribing medications. The facility is required to follow the orders of physicians and receives authorization through the pharmacy. LPA found that although there were many prescriptions ordered they were all under the order and authorization of the doctors and the pharmacy so there is no fault of the facility. The allegation that Staff mismanaged resident's medications is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 21-AS-20251124093021

Type of visit: Required - 1 Year

08/07/2025, Licensing Program Analyst (LPA) Nakagawa conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan and an infection control plan as required. There are currently 71 residents in care. Administrator Diana Paz (Adm. Certificate in effect until 11/11/2026) was in attendance. LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available located in the bathrooms storage cabinets. Water temperature in sinks accessible to residents in care were measured within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 08/28/2024. The Fire Alarm System was tested on 03/26/2025 and operational. Facility conducts quarterly fire and disaster drills with the last one being conducted 05/22/25. Medications were found to be centrally stored. LPA found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Facility has well-attended activities program. LPA conducted a review of 5 resident records. All records had the required documentation. LPA conducted review of 5 staff records/training. LPA found all staff to have required annual and initial training as well as current first aid. Medication Technicians have current CPR training. Continued on 809-C No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/28/2025: Program Plan (review, update if any changes due to new definition of Dementia/Behavioral Expression) Discussed: In-person first aid and CPR training, linen supplies Exit interview conducted with Staff Member and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 7, 2025

Allegation investigated: Licensee retained a resident requiring a higher level of care.

On 05/13/2025, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a visit for the purpose of initiating a complaint and delivering complaint findings regarding the above allegation. LPA met with Administrator Diana Paz. LPA made observations, conducted interviews and reviewed documents. The complaint alleges that the Licensee retained a resident requiring a higher level of care. The reporting party stated that resident (R1) is receiving care that the facility is not licensed to provide. Based upon LPA’s observations R1 was not receiving care that is beyond the Licensee’s operating license. LPA also reviewed records and conducted interviews and found the information provided by the reporting party was contradicting with a lack of corroborating evidence to support the allegation. Continued on 9099-C.... Unsubstantiated Continued from 9099.... Therefore the allegation that the Licensee retained a resident requiring a higher level of care is unsubstantiated. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, May 13, 2025 · control 21-AS-20250506161931

Allegation investigated: Staff did not provide resident with appropriate sleeping accommodations. Staff denied resident visitors while in care.

On 05/13/2025, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a visit for the purpose of initiating a complaint and delivering complaint findings regarding the above allegations. LPA met with Administrator Diana Paz. LPA made observations, conducted interviews and reviewed documents. The complaint alleges that Staff did not provide resident with appropriate sleeping accommodations. The reporting party stated that resident (R1) was left to sleep in chair for 2 months. LPA conducted an inspection and found that the room of R1 has a lounge chair and a hospital bed. Staff report that R1 does use the chair but staff assist R1 to bed each night. Therefore the allegation that Staff do not provide resident with appropriate sleeping accommodations is unsubstantiated. Continued on 9099-C.... Unsubstantiated Continued from 9099.... *****This Report has been Amended***** The complaint alleges that Staff denied resident visitors while in care. The reporting party stated that I1 and I2 have been denied visitation. LPA conducted interview with S1 and S2 who stated that no residents have been denied visitors except for individuals (I1) who had a court order against their visitation and there is no evidence to corroborate that I2 was ever denied visitation. Therefore the allegation that Staff denied resident visitors while in care is Unsubstantiated. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, May 13, 2025 · control 21-AS-20250509091140

Allegation investigated: Facility is in disrepair. Facility staff did not adhere to handwashing protocols. Facility has mold.

Licensing Program Analyst (LPA) Jill Nakagawa arrived at Woodland Gardens on April 17, 2025 for the purpose of initiating a complaint investigation regarding the above allegations and met with the corporation’s maintenance director Dale Garrett and Director of Resident Care, Alka Ralh. FAcility administrator was off site at the time of visit. The complaint alleges that Facility is in disrepair. LPA Nakagawa inspected the facility and found renovations were being made in the Memory Care unit. The cabinetry and sink in the large common room have been removed and replacement is being overseen by Staff (S1) and appears to be conducted in a timely manner with consideration to the health and safety of the residents. The entire area has been sealed off from floor to ceiling to keep residents safe and the area free of dust. Therefore, the allegation that the Facility is in disrepair is unsubstantiated. (Continued on 9099-C) Unsubstantiated (Continued from 9099) The complaint alleges that Facility staff did not adhere to handwashing protocols. The complainant states that staff are using residents’ sinks for required hand hygiene. LPA interviewed Staff (S2,S3, S4) who stated that the staff were provided with two restrooms directly outside the memory care unit for hand washing; as well as being provided with gloves and hand sanitizer. If necessary, there is one vacant room (#57), which is locked, but may be accessed by staff. Therefore, the allegation that Facility staff did not adhere to handwashing protocols is unsubstantiated. Complaint alleges that the Facility has mold. The complainant states that they were told by staff that there was mold. LPA Nakagawa spoke with S1 regarding the possibility of mold. S1 stated that the area had been thoroughly cleaned but there was testing for mold being done, however results of the testing has not been received yet. Therefore, the claim that the Facility has mold is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.the state’s words, verbatim · CDSS document, Apr 17, 2025 · control 21-AS-20250416150428

Allegation investigated: Staff engaged in inappropriate abusive behavior with resident.

Licensing Program Analyst (LPA) Nakagawa conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation and met with Diana Paz, Administrator. During the investigation LPA reviewed records, made observations at the facility, and conducted interviews. It is alleged that Staff (S1) has engaged in inappropriate behaviors by throwing a towel at Resident (R1) and intentionally moving R1’s walker out of reach. Continued on 9099....... Unsubstantiated Continued from 9099.... LPA Nakagawa reviewed medical records of R1 and found that R1 had been refusing medications, exhibiting uncharacteristic behaviors and requiring medical interventions. A review of S1’s personnel file and interview of Administrator revealed that S1 has never been written up or reprimanded in the 7 years employed at the facility, is kind to the residents and of good moral character. This incident was during the same time frame of R1 receiving the medical intervention. Due to the medical information received and statement by R1(after receiving medical treatment) stating that there was no physical abuse-only a towel being handed to R1 curtly by S1; S1’s employment record; and Administrator’s assessment of S1’s character, the allegation that Staff engaged in inappropriate behavior is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 21-AS-20250122110522

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management visit regarding a self-reported incident reported on 12/31/2024. LPA met with Diana Paz, Administrator. It was reported by the Administrator that resident R1 found unknown charges on their bank statement and reported them to the facility staff. Administrator contacted Woodland Police Department and police report (#24-5291) was filed. The bank, CCL, Ombudsman's Office and APS were also contacted. An internal investigation was initiated. It was discovered that unauthorized charges were made by staff S1. Administrator placed S1 on Administrative leave while internal investigation was completed. Awaiting final police report and formal charges. S1 to be discharged and removed from Guardian by Administrator.the state’s words, verbatim · CDSS document, Jan 9, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA)Jill Nakagawa arrived unannounced and met with Diana Paz, Administrator. The purpose of the visit was to conduct an inspection, check on the Plans of Correction on past deficiencies and to amend page 9099-D for complaint investigation 21-AS-20241007152406, originally filed on 11/26/24. LPA toured the facility and found it to be clean and sanitary. There were residents involved in a self-led exercise class. The facility has hired a new Activities Director, currently in training, so regular activities led by staff will be beginning within a few days. Residents in Memory Care were clean and dressed appropriately. Most were in the Activity/Dining Room watching an old movie together, although several were doing individual activities at small tables. LPA went over Plans of Correction with Administrator, staffing, the new Activities Director, and amending past report. In addition, LPA requested recent copies of the call bell system for the last 10 days and shower sheets for Memory Care for 11/10/2024 through 12/10/2024. There were no deficiencies found at the time of inspection. No citations issued. Exit interview conducted with Administrator.the state’s words, verbatim · CDSS document, Dec 12, 2024

Allegation investigated: Staff did not reposition resident causing resident's pressure injuries to worsen Staff did not seek medical attention for resident in a timely manner

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 11/26/24 to conclude an investigation and deliver findings regarding the above allegations and met with Administrator Diana Paz. The complaint alleges that staff did not reposition resident causing resident’s pressure injuries to worsen. LPA reviewed records and conducted interviews which report that resident was repositioned as ordered. A review of R1's hospice care notes showed no documentation to indicate R1's condition worsened as a result of not being repositioned as ordered, therefore the allegation that staff did not reposition resident causing resident's pressure (Continued on 9099-C) Unsubstantiated (Continued from 9099...) injuries to worsen is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. The complaint alleges that Staff did not seek medical attention for resident R2 in a timely manner. LPA Nakagawa reviewed records which show that staff at the facility did follow protocol: notifying the responsible party and primary care physician when R2 fainted, which was witnessed by carestaff. The following day records indicate PCP requested that R2 be sent to the hospital. Tthe staff at the facility followed the directive given by the physician and had R2 sent to ER, therefore the allegation that staff did not seek medical attention for resident in a timely manner is unsubstantiated. 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.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 21-AS-20240906151123

Allegation investigated: Staff do not ensure residents are changed out of soiled clothing in a timely manner Staff do not ensure transportation arrangements are provided to residents in care

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an investigation and deliver findings regarding the above allegations. LPA reviewed documents, conducted interviews and made observations. The complaint alleges that staff do not ensure transportation arrangements are provided to residents in care. LPA interviewed resident R1 who had an appointment on 9/10/24 but due to transportation errors the resident was transported to wrong address and missed their appointment. R1 reported to LPA that a new appointment was made for 9/18/24 but due to staff not following up with R1 ensuring new appointment and transportation were scheduled that appointment was missed as well. Missed appointments resulted in R1 being sent to Emergency Department via ambulance for emergency wound care (see photo). Therefore the allegation that staff do not ensure transportation arrangements are provided to residents in care is substantiated. Substantiated Continued from 9099.... .A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency was cited on 9099-D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator. It is alleged that Staff do not ensure residents are changed out of soiled clothing in a timely manner. LPA toured the facility and residents in Assisted Living to be clean and dressed appropriately. Observations of residents in memory care found them to be clean; and resident preferences for attire respected. Call bell records for Assisted Living for 09/7/2024 through 09/10/2024 showed approximately 387 call bells pressed in Assisted Living with approximately 83 call bells that took over 15 minutes to clear; 1 response took over an hour, another over 2 hours and one over 3 hours before call bell was cleared. Although 66% of the call bells were answered in 10 minutes or less on the 3 days studied, 21% were not therefore the allegation that staff do not ensure residents are changed out of soiled clothing in a timely manner is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is being cited on 9099-D. **Civil penalty in the amount of $250.00 has been assessed on this date for a repeat violation in the past 12 months for regulation 87411(a) on 03/21/2024. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 21-AS-20240911105628

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Nov 26, 2024

87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(2)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement was not met as evidenced by: Based on LPA’s interview with R1 the Administrator did not make arrangements or provideadequate transportation assistance for R1, which led to emergency treatment via ambulance.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administrator to provide plan that will ensure resident transportation needs are met to CCL by 11/27/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Nov 26, 2024

87411Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs***Based upon records reviewed and interviews conducted, this requirement has not been met as evidenced by: A review of call bell records show that response times were delayed up to 1 hour. This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administration to provide a written plan that outlines protocols going forward that will guarantee that sufficient staff are on duty to ensure that all residents' needs are met timely. Plan to be submitted to CCL by POC date of 11/27/2024 to clear the deficiency.

Allegation investigated: Staff do not ensure residents receive bathing services

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conclude the complaint investigation regarding the above allegation and to deliver findings. LPA met with the Administrator Diana Paz. The complaint alleges that Staff do not ensure residents receive bathing services. During the course of this investigation LPA made observations and documents were reviewed. Based on R1’s care plan and shower sheets for the months of August, September, and October: records indicate that R1 did not receive showers in accordance with their care plan. In August, R1 received 2 showers, 8/9/24 and 8/25/24. In September R1 received 2 showers, 9/18/24 and 9/28/24; Substantiated Continued from 9099A... Snacks and beverages for residents in AL are available at the coffee bar at the front of the building. Meals are provided for residents three (3) times per day and snack times are served in Memory Care at approximately 10 AM, 3PM and in the evening. According to the Administrator, the kitchen is staffed from at least 7 AM to 6 PM and staff can request food from the kitchen during that time, or requests can be made to med techs who can access kitchen outside of dining room hours. LPA was unable to substantiate the allegation that Staff do not ensure residents are provided meals. Food was found to be readily available and served at regular times with snacks and extra food available as needed therefore the allegation that Staff do not ensure residents are provided meals is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. The complaint alleges that Staff do not ensure medications are dispensed as prescribed. LPA Nakagawa conducted a random inspection of the Centrally Stored Medication Records from August 2024 to October 2024 and found no irregularities in the records at the time of inspection; indicating Staff are dispensing medications as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continued from 9099..... and from October 1-10 R1 received 1 shower on 10/09/24. Based on LPA’s record review the preponderance of evidence standard has been met, therefore the allegation Staff do not ensure residents receive bathing services was found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 is being cited on the attached LIC 9099D.”)the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 21-AS-20241009090125

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Nov 26, 2024

87464 (f)(4)Basic Services. Basic services shall at a minimum include:...Personal assistance and care...such as dressing, eating, bathing.. .***Based on documents, this requirement not met as evidenced by: Shower Sheets indicate R1 was not showered as per Care Plan from 8/01/2024 through 10/10/2024.This poses an immediate risk to the health and personal rights of R1.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administration to provide plan to provide training on the importance of showers by 11/27/24 and proof of refresher training to staff about the importance of showers by 12/05/2024.

Allegation investigated: Staff do not prevent resident from wandering into residents rooms. Staff does not assist resident in a timely manner.

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conclude a complaint investigation and deliver findings regarding the above allegations. LPA met with Administrator Diana Paz. The complaint alleges that staff do not prevent resident (R1) from wandering into residents’ rooms. LPA conducted a review of records, interviews, and made observations. Through interviews, LPA discovered that a new resident had been placed in Assisted Living for a respite stay, and it was discovered that resident R1 had unknown behaviors which led to wandering and entering other residents’ rooms. R1 was not re-assessed nor was additional staff dedicated to R1’s supervision for at least two (2) days, therefore the allegation that Staff do not prevent resident from wandering into residents’ rooms is SUBSTANTIATED. Based on LPA’s interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, are being cited on the attached LIC 9099D.”) Continued on 9099-C.... Substantiated Continued from 9099.... The complaint alleges that Staff does not assist resident in a timely manner. LPA reviewed call bell records and interviewed residents and staff. LPA looked at call bell records for 10/05/2024 through 10/07/2024 and found that R2 and R3 had used the call bell system a total of 11 times. The response times were: 2 calls were under 5 minutes, 2 were 5-6 minutes, 2 were within 10-13 minutes, 3 were within 15–17 minutes, 1 was 28.37 minutes, and 1 was 42.38 minutes. Response times over 15 minutes indicate staff did not respond to the care needs of R2 and R3 in a timely manner, therefore the allegation that Staff does not assist resident in a timely manner is substantiated. Based on LPA observations, interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. A civil penalty was issued today for $250.00 for repeated citation within 12 months. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted & appeal of rights given.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 21-AS-20241007152406

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Nov 26, 2024

87468.2Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents... shall have all of the following personal rights: (1)To have a reasonable level of personal privacy in accommodations... conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by: Based on interview of R2 LPA found resident R2 and R3 were not allowed personal privacy due to resident R1 wandering about the facility and accessing their room on more than one occasion due to lack of supervision of the resident R1.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administrator will submit a plan on how they will ensure that thorough assessments are completed prior to residents moving in, either permanently or as a respite, by completing all pre-assessments and interviews prior to new residents moving in. Administrator to submit plan to LPA by 11/27/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 26, 2024

Personnel Requirements -General. (a) Facility personnel shall at all times be sufficient... provide the services necessary to meet resident needs***Based upon records reviewed and interviews conducted, this requirement has not been met as evidenced by: R2 states that on numerous occasions in the recent past, staff shortages resulted in call buttons not being answered timely; up to nearly an hour delay. This posed an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: **Amended*** Administration to provide a written plan that outlines protocols going forward that will guarantee that sufficient staff are on duty to ensure that all residents' needs are met timely. In addition, Administrator will provide proof that staff are trained adequately to ensure resident care needs are met timely. Plan to be submitted to CCL by POC date of 11/27/2024, and proof of training submitted by 12/04/2024 in order to clear the deficiency. This is an amendment of the original report to indicate civil penalty language** Civil penalty of $250 issued for repeat violation within a 12 month period for regulation87411(a).

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management visit for the purpose of inspecting facility for adequate staffing. At the time of inspection, LPA found 2 care staff and 1 med tech caring for 20 residents in the Memory Care (MC) unit and 3 care staff and 1 med tech in Assisted Living (AL), caring for 45 residents. The facility was clean and orderly. Staff were engaged in providing care. LPA inspected several rooms in AL and found them to be clean with appropriate linens and residents clean and dressed appropriately. During the inspection, an incident was reported to LPA by resident (R1). According to (R1) interview, a medication technician ( S1) attempted to give (R1) the wrong medication. Per R1, on 09/17/2024 S1 failed to review the identity of the resident or physician's orders for medications and placed the wrong medication in front of R1. R1 indicated that the medication was incorrect and after some discussion S1 removed the medication. In addtion, review of Medication Administration Record (MAR) for residents (R2) and (R3) indicate medications were not dispensed as ordered on 9/17/24 for R2 and 9/18/24 and 9/19/24 for R2 and R3. (See LIC 809-D) During the inspection of residents' rooms in memory care, LPA observed on two occasions (9/15/24 and 9/20/24) furniture was being used as a restraint to prevent residents from getting out of their beds. In one instance, R4 had a wheelchair pushed against the bed. (Photos taken) Continued on 809-C Continued from 809..... LPA was told by staff that another resident would try and pull R4 out of the bed and the furniture was placed next to the bed to detour this from happening. LPA observed resident (R5) with a table, wheelchair, and bedside table pushed against their bed while R5 was in bed. (Photos taken). (See LIC809-D) 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 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6)(a) · Plan of correction due date: Sep 20, 2024

1569.269(a)(6) (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet tas evidenced by:heir needs. This requirement is not met Based on 9/15/2024 and 9/20/2024 inspection LPA observed resident R4 and R5 had a wheelchairs and other furnsihings placed in front of their bed to prevent resident from being pulled out of bed by another resident. LPA went over resident personal right and explained staff must be sufficient to observe and meet residents needs. Staff pushed the wheelchair away during the inspections. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 20, 2024

Plan of correction: Facility to send in written plan on how they will meet regulation and meet resident R4's and R5's needs. Facility to send in proof of staff training. Plan of correction (POC) written statement due 9/23/2024 and proof of staff training due 9/27/2024. POC to be sent to CCL attention LPA Nakagawa by close of business

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Sep 20, 2024

87465 Incidental Medical and Dental Care(a) A plan... shall be developed... The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced.by. Based on document review and interview with resident R1 Licensee did not comply with the section cited above. R1 did not receive medication as prescribed due to caregiver not verifying the correct resident or the right medication; and medication administration not being documented in MAR for R2 and R3. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 20, 2024

Plan of correction: Administrator to conduct Medication Administration Training to medication technicians by 9/22/2024. Proof of training to be submitted to CCL, attention LPA Nakagawa by close of business 9/23/2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection on 07/22/2024. LPA met with Lauren Andersen, Administrator. There are currently 64 residents in the facility. The facility operates as an RCFE providing assisted living and memory care. The facility is one level, with resident rooms, an activities room, living room, dining room, kitchen, medication room, laundry room with storage room, and a memory care unit with dining/activities room and resident bedrooms. There are secure outside areas for residents to enjoy, as well. A locked storage for toxins and cleaning supplies is provided in the kitchen separate from food storage. There are also secured storage areas in hallways, housekeeping closet and in storage building. All exits were unobstructed. There was a First Aid Kit, night lights and flashlights for emergency lighting, an ample supply of linens, paper products and hygiene supplies. Bathrooms were equipped with grab bars and non-slip mats. Fire Extinguishers were fully charged and serviced on 01/24/2023. The last Fire Drill was on 6/25/2024 and staff receive training regarding emergency situations each month at employee/staff meetings. The dining room and kitchen area were clean and sanitary. The facility had an ample supply of perishable and nonperishable food as required by Title 22. There is an active Activities Program with multiple participants taking part in many calendered events including Wii -Bowling, Bingo, crafts, and other favorites chosen by the Resident Council. LPA found no deficiencies during this inspection. No citations issued.the state’s words, verbatim · CDSS document, Jul 22, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Nakagawa and Macias conducted an unannounced case management inspection and met with Alka Ralh, Assisted Living Director. At approximately 12:00pm, LPAs Nakagawa and Macias conducted a tour of the Memory Care Facility and found the Medication stored room to be wide open, unsecured, with no staff present, accessible to residents in care (deficiency cited, see 809D). LPAs also observed Memory Care Residents restroom cabinets to be unsecured with toxins accessible to residents. Facility is being cited per Regulation 87465(h)(2) and 87705(b)(2). 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 4, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jun 4, 2024

87465(h)(2)Medical and Dental Care:(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines... not accessible to persons other than employees responsible for the supervision of the centrally stored medication... This is evidenced by : Based on LPA's observations medication room was unlocked with medications unsecured without staff present while Residents were having lunch which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 4, 2024

Plan of correction: Administrator to ensure medications are not accessible to residents by keeping Medication Room locked at all times. Administrator to submit in-service Training reviewing Regulation for all staff with the following information: A plan for immediate In-service Training date, In-service topic submitted by POC date of 6/5/2024 to LPA and Training Roster with signatures and job role to LPA by POC date of 6/11/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(b)(2) · Plan of correction due date: Jun 4, 2024

87705(b)(2) Care of Persons with Dementia: (b) In addition to the requirements as specified in ....the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This is evidence by: Based on LPAs observation, 4 out of 6 cabinets in Residents bathroom were unsecured with toxins, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 4, 2024

Plan of correction: Administrator to ensure all cabinets are functioning and ensure all employees have keys to the cabinets. Administrator to submit a statement stating corrections are being completed by POC due date of 6/5/2024. Administrator to review Regulation for all staff regarding Care of Persons with Dementia.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Nakagawa conducted an unannounced inspection and met with Lauren Andersen, Director. The purpose of this inspection was to check on staffing. LPA found the facility was fully staffed at the time of inspection. In addition, LPA amended Complaint findings of 3/21/24. Exit interview conducted with Lauren Andersen, Director.the state’s words, verbatim · CDSS document, Apr 25, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jill Nakagawa arrived to conduct an unannounced inspection and check on the program plan. LPA met with Lauren Andersen, Director and Robert Godfrey, Administrator. There were 64 residents at the time of inspection. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The common areas, dining room, and activities room were inspected. Toxins are stored in a locked cabinet inside the laundry room. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The facility was recently painted inside and out and new floors installed. The outdoor courtyard was free of debris, flowers planted and plenty of covered seating for residents and guests provided. Residents were observed in the dining room, socializing and enjoying their meal on cloth-covered tables. There were no deficiencies found at the time of inspection. No citations issued.the state’s words, verbatim · CDSS document, Apr 23, 2024

Allegation investigated: Staff do not respond to resident call bells in a timely manner

****This is an AMENDMENT**** Licensing Program Analyst Jill Nakagawa arrived unannounced to conduct an investigation on the above allegation and to deliver findings. LPA met with Director Lauren Andersen. Facility census on this day is 63. This Department has investigated the allegations of “staff do not respond to resident call bells in a timely manner”. LPA conducted interviews, reviewed records and made observations. Continued on 9099C.... Substantiated Continued from 9099..... ****This is an AMENDMENT**** The following determinations have been made: LPA interviewed seven (7) of forty-seven (47) staff and fourteen (14) of (63) sixty- three residents and outside parties. It was discovered through interviews, that response times to call bells were reported to take anywhere from 10 minutes to “hours”. LPA reviewed a sample review of call bell records from 2/6/24, 3/9/24 and 3/16/24 from all three (3) shifts (AM, PM and NOC). Based on LPA’s review LPA found that on 2/6/24 there were over 128 requests for service: one (1) call took over one (1) hour to clear the call bell, six (6) took over thirty (30) minutes and twenty-two (22) calls took fifteen (15) minutes or longer to clear. On 3/9/24 there were 123 requests for service: one (1) call took over one (1) hour to clear, two (2) took over thirty (30) minutes to clear and fifteen (15) calls took over fifteen (15) minutes. Finally, on 3/16/24 there were 134 requests for service: two (2) took over thirty (30) minutes and thirteen (13) took over fifteen (15) minutes to clear. Interviews revealed that due to the long response times some residents were unable to get to the bathroom in a timely manner, left in soiled clothing, unable to get dressed and attend meals in the dining room, or unable to be re-position as needed. In addition, a review of the facility's Resident Handbook, page 2, item 4 Requesting Assistance, it states “If there is an urgent matter or health care emergency please use the emergency call button located in your room." Based on LPA observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. 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 and appeal of rights provided.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 21-AS-20240312153911

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 21, 2024

**Amended** Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs***Based upon records reviewed and interviews conducted, this requirement has not been met as evidenced by: A review of call bell records show that response times were delayed up to 1 hour. This posed an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Administration to provide a written plan that outlines protocols going forward that will guarantee that sufficient staff are on duty to ensure that all residents' needs are met timely. Plan to be submitted to CCL by POC date of 04/26/2024 to clear the deficiency. This deficiency was amended.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management inspection and met with Resident Care Coordinator, Alka Ralh.. Facility recently reported that they had a medication error that resulted in a resident receiving the wrong medication. The error was noticed immediately and the proper reporting and monitoring was carried out. PCP and family were notified immediately. Facility transported resident to Emergency Room for observation. The client did not have any adverse effects. Executive Director has conducted trainings to all staff handling medications, and made changes to the medication process that provides additional oversight when medications are passed. No citations were issued at this time.the state’s words, verbatim · CDSS document, Feb 28, 2024

Allegation investigated: Staff does not prevent resident from physically and verbally abusing other residents in care. Staff does not provide a safe environment to residents in care.

LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 2/1/24 at approximately 1:40 PM to conduct an investigation and deliver findings on the above allegations. LPA met with Executive Director, Lauren Andersen, to review the findings. (Continued on 9099-C) Unsubstantiated ****Report has been amended**** The allegations state that Staff does not prevent resident from physically and verbally abusing other residents in care and Staff does not provide a safe environment to residents in care. The reporting party stated that R1 has been continuously threatening and harassing multiple residents; residents have been asking staff to help them but say until he's violent there is nothing that can be done and R1 is intimidating to many....sabotages games....explodes in anger...barges in rooms without permission...uses foul language. LPA made observations, conducted interviews and reviewed records. LPA's review of records found that there had been no formal complaints made by residents to administrator of the facility regarding R1, although both residents and staff mentioned that there were multiple informal conversations between staff and residents R2 and R3 about R1. Observations made by LPA on several occasions, including 9/20/2023, 1/9/2024 and 2/1/2024 did not find any behaviors that would be considered harassing, intimidating or violent. R1 was observed with pet, which was well cared for and did not exhibit any signs of neglect or mistreatment. Interviews with staff and residents indicate that there are 2 or 3 residents who do not get along and find discomfort in being together, however, it was observed that they do attend activities at the same time, and occasionally use inappropriate language but with redirection by staff, can maintain civility towards one another. It has been reported that R1 and R2 socialize together quite a bit. LPA has observed the same with no signs of threatening behaviors or intimidation. LPA has been told by staff that there are residents who do not get along but staff are aware and able to redirect residents: there have been no episodes of harassment or violence, but rather unkindness and misunderstandings. Although the allegations may be true, based on observations, statements and documents, there is not a preponderance of evidence to prove the allegations true or false therefore the complaint is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 21-AS-20240108111640