Palm Villas, Campbell.

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit regarding the elopement of a resident from the facility on 11/30/2025. LPA met with Community Director (CD) Michelle White. LPA stated the purpose of the visit. On 12/3/2025 the Department received an incident report regarding the elopement of Resident R1 on 11/30/2025. The incident report states on 11/30/2025, at approximately 8:30PM staff were unable to locate R1 at the facility. Staff immediately began a search of the surrounding neighborhood, both on foot and by vehicle. At approximately 8:55PM police contacted the facility regarding R1 being located at the Wing Stop (on the corner of Bascom Ave and Camden Ave). R1 was returned to the facility on the same evening and was not injured during the elopement. During today's visit, LPA interviewed staff and 1 resident. LPA requested pertinent documentation to include but not limited to physicians reports, service plans, preplacement appraisals, and staff schedules. LPA determined this case management requires further investigation. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with CD and a copy of this report was provided.

out of 3 staff state R1 is receiving palliative care and receives palliative care five 5 days a week. LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states the staff are taking great care of him/her and has no issues with the care he/she is receiving. LPA reviewed R1’s physician’s report dated 6/1/2025, which states R1 has neurocognitive disorder and is receiving palliative care. LPA reviewed R1's care plan dated 8/7/2025, which states R1 is Max assist with bathing, dressing, grooming, dental, transfer and mobility, and cognitive. LPA reviewed R1's comprehensive palliative care plan dated 10/9/2025, which states R1 is receiving treatment from skilled nurses, palliative aides, and palliative volunteers since 10/11/2025. Facility staff did not provide resident with activities. On 10/20/2025 LPA Tarin interviewed 3 Staff (S1 to S3) and 5 Residents (R1 to R5). 3 Out of 3 staff R1 is being provided activities in his/her room due to ambulatory status. S3 states palliative care volunteers visit with R1 twice a month and provide R1 with activities such as music therapy and pet therapy. LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states he/she participates in the facility activities, but did not recall the specific activities. LPA reviewed the facility's October 2025 activities calendar to included art activities such as art appreciation and physical movement activities. Facility staff did not safeguard residents personal belongings. On 10/20/2025 LPA Tarin interviewed 3 Staff (S1 to S3) and 5 Residents (R1 to R5). 3 Out of 3 staff R1 has not had of his/her personal belongings go missing. Page 2 of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states he/she has not had any of his/her personal belongings go missing. LPA reviewed R1's safeguard for personal property and valuables, which was declined (no items listed) by R1 upon move-in on 9/8/2020. LPA reviewed incident reports for R1 and did not observe reports for missing personal belongings. Facility staff are not meeting residents dietary needs. On 10/20/2025 LPA Tarin interviewed 3 Staff (S1 to S3) and 5 Residents (R1 to R5). 3 Out of 3 staff R1 has a thin/liquids diet, which is provided to R1 by facility staff. S3 states R1 is on a thin/liquids diet as part of R1's care plan. LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states he/she is provided 'healthy' meals by the facility and enjoys the food. LPA reviewed R1’s physician’s report dated 6/1/2025, which states R1 has a modified diet consisting of thin liquids, which is being provided by facility staff. LPA reviewed R1's service plan dated 8/7/2025, which states for 'Meals and Nutrition' R1 needs 'Max assistance' with a soft/thin liquids diet provided by facility staff daily. This agency has investigated the complaint alleging the facility neglected resident in care, facility staff did not provide resident with activities, facility staff did not safeguard residents personal belongings, facility staff are not meeting residents dietary needs. We have found that the complaint was UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report was provided. Page 3 of 3 END OF REPORT.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Designated Administrator (DA) Michelle White. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with DA to include but not limited to the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA observed video surveillance of the courtyard/entrance to the facility. LPA observed cameras in the hallways of the facility. DA states the cameras are non-operational. DA states the courtyard/entrance is the only area with video surveillance in the facility. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed refrigerator temperature at 36F and Freezer at -5F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. The smoke detectors were last inspected by a third party vendor on 3/14/2025 and passed inspection. Fire extinguishers were last serviced on 3/10/2025. Page 1 of 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed and drills are being conducted monthly. The facility's last drill was on 5/21/2025. LPA toured 10 random resident bedrooms. 10 Out of 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA measured water temperature in 7 resident bathrooms with a range of 113.3 F to 119.6 F. LPA reviewed 4 resident records. Resident records included emergency contact information, physician’s report, needs and service plans, and personal rights. LPA reviewed 4 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 4 staff records. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record, and staff training. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Designated Administrator Michelle White and a signed copy of this report was provided.

LPA interviewed Staff S1. S1 states R1 was taken to the hospital on 6/3/2025 and is still at a SNF. Based on interview and documentation review, R1's injuries did not occur at the facility as R1 was taken to the hospital on 6/3/2025 and was then transferred to a SNF. As of 6/19/2025, R1 has not returned to the facility. This agency has investigated the complaint alleging that facility neglected resident in care causing resident to sustain injuries . We have found that the complaint was UNFOUNDED , meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Staff Jimena Pulido, and a copy of this report was provided.

S1 states he/she and a Private Caregiver (referred to as PC) were in the dining area. S1 was serving lunch to a resident. S1 states he/she observed R1 touch R2 on the arm and stomach. S1 states he/she then heard R2 tell R1 to not touch him/her. S1 stated when he/she saw/heard this, he/she walked towards both residents. S1 stated while he/she was walking towards R1 and R2, that is when R1 touched R2 again, and R2 pushed R1 causing R1 to fall to the ground. S1 stated this all happened in less than 10 seconds. During interviews both individuals were busy with clients when then heard R1 and R2 arguing. Staff S11 stated he/she had just clocked in the day of the incident. S11 stated he/she was in the staff lounge area walking towards the dining room. S11 stated as he/she entered the dining room, S11 stated he/she saw R2 make contact with his/her arm toward R1, and saw R1 fall. S11 described the hand motion as a swiping motion, in R1's direction. S11 stated he/she saw S1 walking in the direction of both R1 and R2. S11 stated S1 was in the middle of the dining area, when the incident occurred. Residents were in the dining area at approximately 2PM, S1 heard R1 and R2 talking and heard R2 state “Don’t touch me” to R1. According to staff, they heard R1 and R2 briefly exchange conversation. LPAs interviewed PC on 4/1/2025 and states he/she was in the middle of the dining room on 11/15/2024. PC states that he/she was taking care of his/her resident when he/she observed R1 push R2. PC states that S1 went over to assist R1 when R2 pushed R1 down to the ground. LPAs interviewed 6 residents, R1-R5. 3 Out of 6 residents stated they did not observe the incident between R1 and R2. 3 Out 6 residents did not respond to questions due to neurocognitive disorder. LPAs reviewed physician’s reports for R1 and R2. R1’s physician’s report dated 12/3/2024 with a primary diagnosis of neurocognitive disorder , associated with “confusion, and sundowning behavior.” On the other hand, R2’s physician’s report dated 3/15/2023 with a primary diagnosis of neurocognitive disorder, associated with a mental condition of ‘confusion, inappropriate behavior and aggressive behavior.’ Page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ’LPAs reviewed R1 and R2’s appraisal needs and care plans dated 12/11/2023 and 12/27/2023. R1 and R2 have similar behaviors of aggression due to his/her neurocognitive disorder wherein both residents require supervision by staff. LPAs obtained and reviewed staff daily notes for R1 from 11/19/2024-12/11/2024. R2 had a previous incident documented on 8/16/2024, where R2 had aggressive behavior involving foul language and being physically too close to another resident. The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the Department has found that the above allegation is UNSUBSTANTIATED. Although the allegation that resident R1 pushed R2 is true, there is not a preponderance of evidence to prove that the allegations did or did not occur. An exit interview was conducted with Activities Director Michelle White and a copy of the report was provided.

Licensing Program Analysts (LPAs) Marcella Tarin and David Marrufo conducted an unannounced required 1 year visit and met with Administrator Garry Sneper. During visit LPAs toured the facility inside and out. LPAs toured the facility kitchen area. LPAs observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. LPAs observed storage area with cleaning supplies and tools. The storage area was locked and inaccessible to residents. LPAs toured 1 hallway bathroom and measured the water temperature to be 114 degrees Fahrenheit. The bathroom had functioning lights and available soap and paper towels. LPAs toured 7 resident rooms. Each room had working lights, and available bedding and clothing storage areas. LPAs toured the bathrooms in each bedroom and found them to have working lights, available soap and paper towels. Water temperatures in the toured resident bathrooms ranged from 114 degrees Fahrenheit to 119 degrees Fahrenheit. LPAs tested the smoke detectors in each room, and observed the smoke detectors to be functioning properly. The smoke detectors also function as carbon monoxide detectors. LPAs tested 1 hallway carbon monoxide detector and it functioned properly. LPAs observed 2 resident exits to be clear of obstruction, and 1 out 1 tested alarmed exit tested properly when tested. LPAs reviewed 7 resident Centrally Stored Medication and Destruction Record (CSMDR). Each reviewed CSMDR was complete during visit. LPA's reviewed 7 resident records, R1-R7. Resident R2 and Resident R4 did not have Appraisal Needs and Service Plan. Resident R5 is missing the first page of the Safeguard for Property and Valuables form. LPAs reviewed 7 out of 7 staff records to be complete. The last conducted Fire Drill is recorded at 5/20/2024. Advisory notes were issued. See LIC 9102 pages for more information. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Garry Sneper. A copy of this report was provided.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Collateral visit and Met with the facility Medication Manger Jimena Pulido (MM). The purpose of the visit was to interview resident R1 and to collect R1's medical records as part of a complaint investigation of another licensed facility.. During the visit, LPA interviewed MM, resident R1, and 3 staff (S1 - S3). LPA toured the bedroom of R1 with MM. LPA requested R1's medical records and medical notes. No deficiencies cited today. The report was provided to MM for signature. A copy of the report was provided to MM.

On 2/8/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Administrator Garry Sneper & Office Manager Myra Belza. LPA explained the purpose of the visit. LPA is delivering 2 amended reports for the following complaints: 26-AS-20220225121016 26-AS-20220412110249 No deficiencies cited today. Report is reviewed and copy is provided.

Based on interviews by LPA Heberle, two staff members mentioned that there never was an issue of residents having mismanagement of medications. On staff member (S1) stated that the facility does not have any involvement in which medications residents are taking. The family can make request that the facility administer certain medications, but staff always makes sure the doctor okays and prescribes it first. The facility communicates with doctors if they believe the medication needs to be changed. LPA Heberle & LPA Donato was also able to interview residents and two out of five mentioned that they don’t have any issues with medications, and they are able to get it on time. Three residents were not able to respond to questions due to cognitive diagnosis.. LPA Donato was able to review records for R1, and according to the centrally stored medication, facility gave the medication according to doctors’ orders. Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations mentioned are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The report was reviewed, and a copy is provided.

Regarding the allegation of facility restricting visitation, RP stated that visits were only 30 mins. Based on interviews, S1 stated that RP is allowed to visit every day. No visitor has been denied visitation in the facility. They have scheduled visitation during this time. Even if visitors don’t have a schedule around this time, the facility still lets them in. Family visits are always accommodated. Depending also on the residents, the facility requests that they delay visitation for up to a week to allow for assimilation. It is never mandatory; it is only a recommendation. LPA reviewed visitation logs and it showed that RP was able to sign in and temperature was checked upon entering the facility as well as other visitors visiting other residents. Based on records review, the facility was also following some COVID-19 protocols during this time. Visitation is allowed but Screening protocol is followed, scheduled visitation, well-fitting face mask are always required upon entry and within the facility. Limit the number of visitors on the facility premises at any one time to avoid having large groups congregate. Facility encourages short indoor visits and longer outdoor visits. Regarding the allegations resident’s sustained unexplained injuries and staff not reporting an incident to resident's representative. RP said the staff never reported a skin laceration to RP, RP stated that On 10/1/2021 staff reported to RP that R1 had a lemon size bruise on the outer arm. Based on record reviews, this incident happened around 9/27/21 where staff found a skin discoloration on R1’s right arm. This skin discoloration was observed by staff during routine checks done in the facility. There were no prior incidents that happened before this, so it is hard to determine how R1 sustained this skin discoloration. On the progress reports for R1, its was stated there that incidents were all reported to physician and responsible parties. These incidents were also reported to Licensing. Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations mentioned are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Report is reviewed and a copy is provided.