Bayshire Carlsbad.

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director (ED) Ozz Daynes. The facility's license shows a maximum capacity of 125 residents ages sixty (60) and above. The facility is approved for delayed egress doors and has a hospice waiver for twenty-seven (27). LPA and ED Daynes toured the interior and exterior of the facility and inspected rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per ED Daynes, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with ED Daynes to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099, Page 1) Interviews with staff confirmed that staff are following the procedures established by licensing guidelines. Staff were able to tell the LPA of the steps they follow when a lost/stolen item comes to the administrative departments. Staff were unable to determine if facility staff were responsible for the theft but are reimbursing the resident within regulatory guidelines of $100.00 per item. LPA notes that the action of reimbursement does not suggest culpability on the facility's part. Additionally, staff demonstrated they had knowledge of procedures and preventions to help residents safeguard their belongings when they are admitted to the facility and beyond. Interviews with Residents confirmed that staff have been helpful with trying to recover missing jewelry and following theft and loss policies. Resident 1 (R1) stated that they do not lock their door when they leave and up until the missing jewelry was noticed, left it unlocked all day. R1 also told the LPA they had concerns because facility staff/people are coming in and out of their apartment all day. LPA notes R1 receives bed turn down and trash services which are at most, once and twice a day, respectively. Records review confirmed that R1 and their POA were provided and signed resident safeguard documents including: Client/Resident Personal Property and Valuables list, Theft and Loss Policy and Documentation, and the Admissions Agreement summarizing these policies. Some of the items listed as missing were not present on the valuables form. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Ozz Danes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099, Page 1) Interviews with staff revealed that due to the nature of the relationship and the behaviors of the residents, staff are to check on the residents every two (2) hours. R1 and R2 at the time of the allegation were in a consensual and committed relationship. S1 stated that the alleged incident required staff to intervene and separate R1 and R2 due to a verbal altercation. LPA notes that the alleged physical altercation in this instance was R2 allegedly hitting R1 on the shoulder in a light manner. S1 stated that both residents are able to leave the facility unassisted and they have returned to the facility in an inebriated state multiple times. S1 states that they try to remind both residents about making good choices and alert staff to check on these residents when they return from outings. Interviews with residents revealed that the facility checks on R1 several times a day. R1 stated that facility staff are nice to them and they have no concerns about the facility's ability to take care of them. This corroborates staff interviews about facility staff checking on residents. R1 insisted to the LPA that they were not hurt by R2 "hitting them on the shoulder" nor that the incident in question was considered a physical altercation. R1 expressed that this was R2's way of getting R1's attention and that there was no malice in the action. Records review of both R1 and R2 state in their needs and services that they will be checked at the beginning of every shift and as needed. Physician's reports for both R1 and R2 demonstrate the ability for both residents to leave the facility independently. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with RSD Pam Talamantes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued From LIC9099) Regarding the allegation that facility staff took money from R1. Interviews with staff and R1 revealed that R1 donated money to staff as a gift, and staff documented the cash gift as required. The Department has investigated the above-mentioned allegations and has found that the complaint was unfounded, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the complaint.

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to investigate a resident death. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Thomas "Ozzy" Daynes. Care Coordinator Ariana Ventura arrived during the visit. On 12/15/2025, the Department received an incident and death report reporting Resident 1's (R1’s) death, which occurred on 12/13/2025. [Care Coordinator was provided with an LIC811 Confidential Names List to identify R1] During today’s visit, LPA conducted a health and safety check, observed residents in care, reviewed and obtained copies of facility records, and interviewed staff. LPA requested that the facility submit R1's death certificate to the Department when it became available. No deficiencies were cited on today’s date. An exit interview was conducted with Care Coordinator Ariana Ventura, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).

(Continued from Page 1 LIC9099) Staff interviews revealed that Resident 1 (R1) was alert, oriented, and independent with daily tasks. Staff 1 (S1) stated that as a result of the continued elopements, the facility arranged 1:1 caregiver support, used an Apple AirTag for monitoring, and held care conferences with the responsible party and healthcare providers. Despite these efforts, R1 often refused assistance and continued to leave the facility independently. Staff followed protocol by notifying the responsible party and law enforcement when R1 left and sought guidance from the Community Care Licensing Department regarding how to proceed. Staff also noted that R1 expressed a strong desire to live independently and had a history of returning from elopement safely. Outside source interviews revealed that R1 was described as cognitively intact, capable of making informed decisions, and able to manage personal affairs such as finances and medical care. Outside Source 1 (OS1) confirmed as Power of Attorney that the facility made efforts to supervise R1 and responded appropriately to elopement concerns. Outside Source 2 (OS2), a psychiatric nurse practitioner, stated that R1 retained reasoning, safety awareness, and the ability to plan and carry out their own departure. Both sources agreed that R1 was not at risk to themself when leaving the facility. Records review revealed that the facility documented R1’s behaviors, coordinated with healthcare providers, and implemented interventions in response to elopement concerns. R1's preplacement appraisal supported the assessment that R1 was not a harm to themselves or others and was mentally alert and oriented. Progress and Care notes indicate an almost daily log of ongoing supervision and concern for solutions to R1's eloping and independence. There was no evidence of harm or injury resulting from R1’s departure, and the facility’s actions were consistent with regulatory expectations. Based on relevant interviews and records review, a preponderance of evidence does not support that the alleged violation occurred. Therefore, the allegation is determined to be: UNSUBSTANTIATED. An exit interview was conducted with Pamela Talamentes, Resident Services Director, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Cont. from LIC 9099) Regarding the above-mentioned allegation, four(4) staff members and two(2) residents were interviewed. Staff interviews did not corroborate with the allegation, as staff stated there had been no occurrence of staff misconduct when it comes to stealing. Staff consistently stated that they will initially attempt to help locate the item(s), and if staff are unable to locate them, they will inform management for further investigation. LPA interview with Resident 1 (R1) revealed that R1 stated ongoing beliefs that a staff member ha d tampered with or stole their personal belongings. R1 stated that their computer was being hacked, their phone screen protector was altered, and that they have contacted law enforcement and federal agencies such as the FBI and the IRS, regarding these concerns. R1 stated that the agencies have only assisted with filling out some forms. The investigation did not produce evidence t o support the residents’ claims, and the incidents stated by R1 could not be verified. The residents’ statements appeared inconsistent. Staff noted that R1 suffers from a mental health issue with instances of paranoia. During an unannounced facility visit, LPA observed med techs and housekeeping performing duties throughout the facility. LPA observed R1 and R2 groomed and cleaned with room clean and well maintained. Review of the facility records did not corroborate the allegation. LPA records review revealed several progress notes mentioning R1's paranoia and claims of missing items dating back to the beginning of 2025. Records review revealed that the facility has reported theft and loss to the police multiple times for R1 regarding missing items and requested a Psychological Evaluation for R1 through a medical service provider. R1’s medical provider was made aware by the facility that R1's level of care had increased to level 1 as opposed to an independent level related to increasing psychological needs. (Cont. on LIC 9099-C pg. 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 (Cont. from LIC 9099-C) R1's physicians report dated 11/13/2024 stated no history of behavioral expressions, and no mental/cognitive conditions, communication with R1’s medical provider dated 11/26/2024 revealed that R1 had severe increased confusion, decreased energy level, and slight slurred speech, as well as a request for a urinary analysis. The records review for the employee(S2) that R1 claimed may have stolen or tampered with R1's belongings had no disciplinary actions. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.  An exit interview was conducted with Resident Services Director Pamela Talamantes to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from 9099) Resident #1 (R1) was a resident of the facility’s memory care unit from 3/30/22 to 4/3/22 following discharge from skilled nursing. During R1's stay, they were non-ambulatory and required one to two person assistance with activities of daily living, including transfers, toileting, and mobility due to an unsteady gait when rising from their wheelchair. R1 was incontinent of bowel and bladder and demonstrated cognitive impairment, responding with limited verbal ability. Regarding the allegation, the resident sustained injuries while in care, and staff did not respond to the resident's call light in a timely manner. Records show the facility performed a skin assessment on 4/1/2022, and on 4/2/2022, R1 was assisted to the bathroom by a family member when another fall occurred during transfer. Interviews with staff and the family provided conflicting information regarding the timing and staff response.. Additionally, outside source interviews did not support the claim that staff neglected the residents’ needs. Review of the facility’s call light policy indicates proactive monitoring is encouraged, and there is evidence the team remains alert and responsive. Regarding the allegation, residents are not allowed to go to their rooms during the day. Outside source interviews and staff interviews do not support this allegation. Interviews with staff reveal that residents in the memory care typically leave their personal room door open. Interviews with staff reveal that the facility's policy is to promote resident engagement through group activities designed to encourage socialization and support active participation in the community. These activities generally take place in a large common area within the memory care unit. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Resident Services Director(RSD), Pamela Talamantes . A copy of this report was provided and their signature on this report confirms receipt.

Licensing Program Analyst (LPA) Becky Kennedy conducted a visit to the facility. LPA identified herself and met with Ariana Ventura, Care Coordinator, and explained the reason for the visit was to sign an amended report. The only business conducted during this visit was signing the amended report. No violations were observed during the visit. An exit interview was conducted and a copy of this report and and Licensee's Rights (LIC9058) were left at the facility

Per record review and staff interviews, on April 27, 2025, R1 was receiving assistance from S1 and Staff #2 (S2) during a transfer to their wheelchair. R1 was in the restroom prepping to be transferred to their wheelchair. During this incident S1, while assisting R1, attempted to use their transfer board. R1 began to get frustrated with S1 and expressed this frustration verbally. Interviews did not reveal that S1 handled R1 in a rough manner nor did it reveal that S1 spoke to R1 inappropriately during this incident. Review of R1’s physician’s report dated March 21, 2025, revealed that R1 could feed themselves but required assistance with all other activities of daily living. Review of R1’s resident assessment dated March 27, 2025, revealed R1 needs a two-person total assist for transfers. Interviews verified this need for R1 and thus explained the presence of S2 to witness the incident with R1 and S1. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff handled resident in a rough manner and did not treat resident with dignity. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Resident Services Director Talamantes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Becky Kennedy conducted a visit to the facility. LPA identified herself and met with Ozz Daynes, Executive Director, and explained the reason for the visit was to sign an amended report. The only business conducted during this visit was signing the amended report. No violations were observed during the visit. An exit interview was conducted and a copy of this report and and Licensee's Rights (LIC9058) were left at the facility

Interviews revealed that the regular practice is for hospice to confirm a death prior to contacting the family. In this instance, the hospice agency staff contacted the family prior to confirming that R1 had passed away. Although this is an unfortunate incident, the facility staff operated within their roll and responsibility by alerting the hospice agency regarding their observations. This allegation is unsubstantiated. It was also alleged that facility staff did not safeguard resident(s) confidential information, by having the door to the medication room at the facility unlocked and unattended. Through interviews it was determined that this allegation was made second-hand. The investigation could not locate anyone with direct knowledge of the allegation, or under what the circumstances the door may have been unlocked. No evidence was revealed that any confidential information was compromised, nor was that alleged. This allegation is unsubstantiated. Based on the evidence obtained during the complaint investigation, both allegations above are UNSUBSTANTIATED, meaning there isn’t enough evidence to prove a violation occurred. An exit interview was conducted with Ozz Daynes, Executive Director; a copy of this report and Licensee's Rights (LIC9058) were provided to the facility.

Through interviews the investigation revealed that in the time frame covered by this complaint, facility staffing was of concern. Information was obtained that there was not any time when only one direct care staff had responsibility for the entire facility. Interviews revealed that the facility had strategies for when staffing is less than standard. The first is having all staff trained and required to supplement direct care staff as needed. An example is that medication staff will provide direct care. The other is to use a staffing agency to supplement regular employees. It was acknowledged that providing care for some residents may have taken longer than when they were fully staffed, but no evidence was revealed to determine that resident care needs went unmet or went unmet for an excessive period of time. Through interviews and a review of records, the investigation revealed that several of the specifics of the above allegations were regarding second-hand information. The extemporaneous notes from the individual who reportedly would have had the firsthand information did not mention any neglect or lack of care. Interviews did not reveal information that would support those allegations. This allegation is unsubstantiated. It was further alleged that the facility was not kept clean. Through interviews and observation it was revealed that the facility had stains on the on carpet and on a ceiling tile. Documents revealed that the facility had been licensed for one month when the allegation was made. The licensee had the carpets professionally cleaned two times in that month. The carpets were in place at the time the facility was licensed. The stained carpet, and the ceiling tile were replaced as verified by subsequent observation. Interviews revealed that housekeeping staff clean each room once a week. Minor cleaning, such as for spilled items, is conducted on an as needed basis by floor staff and larger cleanliness needs are reported to maintenance staff for a resolution. Although there were stains on the carpet, the investigation revealed that facility made appropriate efforts to eliminate the stains and replaced the carpet when those efforts were unsuccessful. This allegation is unsubstantiated. Based on the evidence obtained during the complaint investigation, both allegations above are UNSUBSTANTIATED, meaning there isn’t enough evidence to prove a violation occurred. An exit interview was conducted with Pamela Talmantes, Resident Services Director; a copy of this report and Licensee's Rights (LIC9058) were provided.

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced case management visit to deliver an amended report. LPA was greeted by, identified themselves to, and explained the purpose of the visit with Executive Director Ozz Daynes. During today’s visit, LPA obtained Executive Director Ozz Daynes' signature on the amended report dated April 15, 2025. An exit interview was conducted with Executive Director Ozz Daynes, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified themselves to and discussed the purpose of the visit with Resident Services Director Pamela Talamantes and Executive Director Ozz Daynes. The facility's license shows a maximum capacity of one hundred twenty-five (125) non-ambulatory residents, of whom fifteen (15) may be bedridden. Hospice waiver for twenty-seven (27) and the facility is approved for delayed egress. During today’s inspection there were one hundred nine (109) residents in care. LPA with Resident Services Director Talamantes toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Resident Services Director Talamantes , no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC809-D] 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 [CONTINUED FROM LIC809] LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Resident Services Director Pamela Talamantes and Executive Director Ozz Daynes to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing program Analyst (LPA) Kennedy conducted an unannounced visit to the facility. LPA identified herself upon entry. LPA met with Pamela Talmantes, Resident Services Director. . The purpose of today's visit was to sign an amended a prior report that was found to contain some erroneous information. The only business conducted today was the was the signing of the amended report. An exit interview was conducted with Pamela Talmantes, Resident Services Director. , of a copy of the amended report, this report and the Licensee Appeal Rights (LIC9058 3/22) were left at the facility.

Based on interviews, a review of medication records and observations of the medication on hand, the investigation revealed that there was no apparent discrepancy in the documentation, and that the medication on hand at the facility reflected that medication was given to R1 appropriately. Based on the evidence obtained during the complaint investigation, the allegations above are UNSUBSTANTIATED, meaning the preponderance of evidence standard was not met to prove a violation occurred. An exit interview was conducted with Pamela Talmantes, Resident Services Director ; a copy of this report and Licensee's Rights (LIC9058) were provided.

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Care Coordinator Ariana Ventura. Executive Director Thomas Ozz Daynes arrived shortly after. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/02/2024). According to the LIC624: on 09/26/2024, Resident #1 (R1) fell and suffered a fracture. [See LIC 811 Confidential Names List for a description of R1.] R1 was sent to the Emergency Room on 09/27/24, then transferred back to Bayshire Carlsbad Skilled Nursing Facility. During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed R1 and the Care Coordinator. LPA did not observe and health and safety concerns. No deficiencies were cited during today's visit. An exit interview was conducted with Ariana, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Resident Services Director Pamela Talamantes . The facility's license shows a maximum capacity of one hundred and twenty-five (125) residents. During today’s inspection there were one hundred and eighteen (118) Residents in care. LPA and Pamela Talamantes toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all of which are safely stored. Cooking/dining equipment and utensils were present. Toxic chemicals/poisons were locked and inaccessible to residents. Medications were labeled, as required, and stored in locked areas. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to residents were all compliant: Kitchen sink was N/A F; bathroom #1 sink was 113.6 F bathroom #2 sink was 108.2 F Bathroom #3 was 113.0 F and bathroom #4 was 110.9 F . No pools or bodies of water exist on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide/Smoke detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. No deficiencies were cited during the inspection. An exit interview was conducted with Pamela Talamantes to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Records review of R1's progress notes dated October 2023 through March 2024 revealed facility staff documented R1's daily status, including; complaints of pain or discomfort, safety checks, shower refusals, unwitnessed falls, etc. LPA interviewed R1 at the facility. R1 stated that at first facility staff would ask R1 over and over if R1 wanted to shower whenever R1 refused to shower. R1 stated that now they only ask a few times whenever R1 refuses to shower. R1 further stated that staff have never forcefully made R1 shower or grabbed R1 by force to shower. Interview with facility staff (FS) revealed all of the residents have a shower schedule. FS stated that if a resident refuses to shower they come back later and encourage the resident to take a shower. FS stated that R1 usually refuses to shower and also refuses to go to their doctors appointments. FS stated that R1 immediately says no to shower on R1's shower day and throughout the day various staff will try to encourage R1 to shower. LPA interviewed facility staff II (FSII) who stated that if a resident refuses to shower they notify the doctor and discuss the importance of showering with the resident. FSII stated that staff will encourage the resident throughout the day to take a shower or a sponge bath if requested. FSII stated that R1 does not like to shower. FSII further stated that they have never heard of staff forcing R1 or any other resident to shower. LPA interviewed outside agency (OA) who stated that they believe the staff at the facility are doing the best they can. OA stated that the facility offers to help R1 but R1 thinks they are "forcing" R1. OA stated that R1 also refuses to go to their outside agency appointments to see a specialist. OA stated that they do not believe that the facility staff are actually forcing R1 to shower but that is how R1 "feels". The facility Resident Services Director (RSD) stated that community has attempted to care for R1 as best as they can and as much as R1 will allow them to. RSD stated that they do understand that a resident has a right to refuse ADLs, to include showers, however, they do have certain protocols that they implement when a resident refuses assistance with ADL’s. The facility will implement a change of face and a second or third attempt to assist the residents. As a result, a resident may see that protocol as the community being forceful. At no given time is a resident ever forced to take a shower or do something against their will. 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 Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Pamela Talamantes. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Pamela Talamantes whose signature below verifies receipt of these rights.

(Cont. from LIC9099) Interviews with seven other residents revealed that only one, Resident 2 (R2), claimed to have had any personal items of their own go missing. R2 stated that she had some make-up disappear, but said that she had left her door open and anyone could have taken it. One other resident, Resident 3 (R3), stated a few people have experienced missing clothing, and Resident 4 (R4), who has lived at the facility for 7.5 years, stated a few residents have had "inexpensive" jewelry go missing. A records review revealed that R1 moved into the facility on 06/30/2022. During today's visit, additional records were reviewed by LPA Mark Mandel, which showed that R1 waived her right to list any items, including the items R1 reported as being stolen, on the Client/Resident Personal Property and Valuables Form, which she signed. In addition the Theft and Loss Policy states the facility can provide a lock for the resident's bedside drawer or cabinet upon request and residents are encouraged not to bring valuables to the facility. R1 did not state during a previous interview that the she requested a locked drawer or that it was broken into in relation to the money of hers that she said disappeared. Based on the interviews conducted and records obtained and reviewed, the allegation that facility staff are stealing residents clothes is Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with Resident Services Director, Pamela Talamantes, whose signature below confirms receipt of this report and the Licensee Appeal Rights (LIC9058 01/16).

Licensing Program Analysts (LPAs) Amy Rodgers and Juliana Barfield, made an unannounced visit to conduct a required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPAs Amy Rodgers and Juliana Barfield were granted entry into the facility by Executive Director, Thomas Daynes, after identifying themselves and stating the purpose of the inspection. The facility serves 125 non-ambulatory residents, age 60 and above, of which none may be bedridden, and currently has 113 residents in care. There is an approved Hospice Waiver for 27 residents. This is a three-story complex, comprised of three (3) wings and equipped with delayed egress and secured perimeters. LPAs were accompanied by Executive Director, Thomas Daynes during a tour of the facility. Tour was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. All areas were clean and passageways unobstructed. Signal systems are in place and operational. The last disaster drill was conducted 9/13/2023. A decorative water fixture was present in the inside patio area but patio is not accessible to residents with dementia. According to Executive Director, Thomas Daynes, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident unit and were tested for functionality. Delayed egress and secured perimeter doors were also tested for functionality. Resident's room temperatures were within a comfortable range. Continued on 809-C 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 Continued from 809 Each resident had clean and sufficient bed linens.All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars, and nonskid strips were present in residents’ showers. Hot water temperature in residents’ bathrooms were compliant between 105-120 degrees. Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activity schedule were posted. Chemicals and cleaning supplies were stored in a locked cabinet. All medications were stored in a locked medication cart, emergency supplies, and medications were labeled and kept in compliance with label instructions. Staff records reviewed verified that at least one staff member, per shift, has a First Aide/CPR certificate. All staff records had a Criminal Record Clearance, Personnel Record, TB clearance, and Health Screening Report, and required training. Resident files were reviewed and verified that each resident had a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. Conducted a thorough review of Inservice training procedures. Transportation procedures were reviewed and compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted. This report was discussed with Executive Director, Thomas Daynes, and a copy of the report along with Licensee/Appeal Rights (LIC 9058) was provided to Thomas Daynes.

[Continued from LIC9099] LPA reviewed the staff schedule and interviewed Staff 1 (S1) S1 has worked as a caregiver for the last 3 years. S1 stated that R1 has severe memory deficits.  S1 has not observed any inappropriate sexual touching during care.  Staff 2 (S2) confirmed that R1 has severe memory deficits and there has not been any observation of inappropriately sexually touching resident. Staff 3 (S3) stated that R1 was being tested for a possible infection.  S3 stated R1 has a history of infections that causes delirium or hallucinations.  Outside Source 1 (OS1) was interviewed by LPA Domingo and there has not been any concerns regarding care of residents.  Outside Source 2 (OS2) stated that there has been no concerns of staff providing care to the residents. Outside Source 3 (OS3) was interviewed by LPA Domingo and OS3 stated that there has been no concerns regarding resident's care. OS3 confirmed that R1 has severe dementia and has very poor long and short-term memory. The Department has investigated the allegation listed above.  Based on evidence obtained, including interviews and records reviewed, the above allegation has been determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard. An exit interview was conducted with Pamela Talamantes Resident Services Director and a copy of this report and Licensee/Appeals Rights (LIC 9058 03/22) were provide.