Santianna Oakmont Signature Living.

Interviews with staff confirmed that all residents were provided with meals as scheduled. No evidence supported the claim that food was denied to any residents. Staff and outside source interviews indicated that residents are checked and changed regularly. No specific instances of residents being left in soiled bedding were identified. Interviews with staff confirmed that the residents' floors are cleaned according to the schedule. Random checks during the investigation found the floors to be clean and well-maintained. Inspections of residents' rooms and common areas did not reveal any hazardous items that were accessible to residents in memory care. LPA's observations of disposal practices showed that trash was properly disposed of according to facility protocols. The facility was found to be clean and sanitary during visit. Call light response times were reviewed, and interviews with staff and residents did not reveal significant delays a manual logs were not maintained. Response times were within acceptable limits as per the facility’s standards averaging 5 to 20 minutes depending on staffing and residents' needs. The Department's investigation found that all the complaints against the staff were unsubstantiated. The facility's records, staff interviews, interview outside source, and direct observations support the conclusion that the care and services provided meet the required standards. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. A copy of this report along with Licensee/Appeal Rights (LIC 9058) was mailed via USPS Certified Mail to the former licensee’s mailing address on file.

(Continued from LIC9099 p.1) The Executive Director compensated R1 for their inconvenience by taking off $1000 off of R1's rent for one month. Staff additionally noted that while R1 did suffer a hospitalization, it was not due to the temperature of R1's room, but R1's co-morbidities which included gastrointestinal issues and an infection. Staff stated that some of these issues were diagnosed prior to any thermostat issues existing at the facility. R1 stated during interview that they did not have a problem with how the facility handled the temperature and air conditioning situation and corroborated staff statements that a portable air conditioner was provided that sufficiently cooled down their room. R1 informed that they were pleasantly surprised with the compensation provided by the facility for their inconvenience. Additionally, R1 admitted to turning on the heat instead of the air conditioner at times due to misunderstanding the thermostat display. R1 informed that the hottest temperature reached in their room was 78 degrees which was too hot for their comfort, but the facility corrected the issue timely and to R1's satisfaction. R1 stated that staff came right away to assist with thermostat issues and adjustments when called. R1 confirmed that they were hospitalized due to symptoms of both hot and cold flashes and returned to the facility the next day. Review of facility records showed corroboration of staff statements regarding R1's diagnosis of gastrointestinal issues and an infection, as well as the air conditioning repair arrangements. During an unannounced facility visit LPA directly observed portions of the facility as well as R1's room and its temperature. LPA's observations corroborated staff and R1's statements. Portable air conditioning units were observed in the storage unit across from R1's room. R1's room temperature registered at 77.5 degrees using an independent thermometer, during which time R1 was observed to be lying in their bed with a blanket over their legs and torso. During the interview R1 did not state or make any indication that they were uncomfortable at the current temperature of the room. The evidence does not show that the facility delayed/neglected to repair R1's air conditioner, or did not attempt to ensure R1's comfort regarding the temperature of their room. R1's co-morbidities provided an alternate explanation regarding R1's fluctuating temperature; a direct connection was not found to show that room temperature issues caused R1 to become sick. No connection was made that R1 feeling hot in their room caused them to develop an infection or gastrointestinal issues. Additionally, the reported and recorded temperatures in R1's room were within regulation and not associated with extreme temperatures. (Continued on LIC9099 p.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 (Continued from LIC9099 p.2) On 07/19/2024 it was alleged that Licensee did not ensure an elevator was maintained in good repair, which was a burden for R1. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and records review. Staff interviews confirmed that one of the facility elevators was out of service for approximately 2 weeks due to shaking. Staff stated that the facility did not delay in attempting to fix the elevator and it was repaired as soon as possible. Staff additionally stated that there were two elevators in the building, and that the other elevator remained operational. Staff consistently stated that at no time were both elevators in disrepair concurrently, and residents maintained the ability to travel between floors while the elevator in question was out of service. R1 stated during interview that they had no issues during the time the elevator was out of service because they utilized an electric scooter and used the alternate elevator when needed. Review of facility records showed elevator repair communication, arrangements, invoices, and subsequent repairs. Additional records were reviewed regarding the facility's communication to residents via email and text messages with updates on the elevator repairs. During an unannounced facility visit LPA directly observed and utilized the elevator in question to all floors of the building. The elevator was found to be in good working condition with no issues, confirming staff statements that repairs were made promptly. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the last known address for the Licensee.

(Continued from LIC9099 p.1) Staff informed that R1 initially moved into the Assisted Living section of the facility, and was subsequently moved to Memory Care after progressive confusion and combativeness. Staff noted that R2 visited R1 daily in Memory Care and was present when R1 was being given care by staff. Management noted that throughout the internal investigation, R1 was unable to provide details such as which staff member was being accused, or when the incident occurred. Staff 1 (S1) denied handling R1 roughly and confirmed that two staff were always present while care was being provided to R1. S1 additionally stated that R2 was typically present as well, just outside of the door for privacy. S1 informed that R1 accepted care easily and there were no issues. Attempts were made to interview R1 regarding the allegation, however, R1 was unable to be qualified as a valid historian due to impaired cognition. R2 was interviewed during the investigation and informed that they were in the room during the timeframe of incident. R2 stated that the staff did not handle R1 roughly during the timeframe of concern and had never handled R1 roughly. Review of facility records corroborated staff statements of R1's combativeness and increased confusion. Records additionally showed that the facility took immediate action once made aware of the accusation and initiated an internal investigation. 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 report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the last known mailing address for the Licensee .

LIC9099C 2 of 4 On 10/19/23, it was alleged that the Staff had not had the required fire and earthquake drills. LPA Domingo interviewed staff at the facility, and the staff verified that they have regular fire drills and earthquake drills.  All the staff interviewed had been trained during their orientation on fire drills and earthquake drills. LPA Domingo interviewed residents, and they stated that they have observed regular emergency fire and earthquake drills. According to outside sources, they stated that they recalled emergency service drills that the facility regularly conducted. LPA reviewed the facility's records, and the facility has documentation of regularly conducted fire and natural disaster drills. On 10/19/23, it was alleged that Registry staff were untrained. Interviews with staff revealed no concerns with registry staff and how they perform their responsibilities Interviews with residents revealed no concerns with the registry staff. Interviews with outside sources revealed no concerns with regard to registry staff and their work performance. Records reviewed revealed that all registry staff are trained by the company they work for, and additional training was conducted by the facility before working at the facility. On 10/19/23, it was alleged neglect of personal care.LPA Domingo interviewed staff, and all residents receive assistance with bathing, and they are trained to monitor hygiene and report any concerns. Staff are trained to document any resident refusal of care with bathing, grooming, and hygiene issues. LPA interviewed residents, and they stated that the staff provided grooming and hygiene care as needed. LPA interviewed outside sources, and they stated that the staff do their best to assist their loved ones with bathing, grooming and daily hygiene care. Records reviewed provided documentation of resident refusals of baths, grooming, and hygiene care, and the facility Wellness director will investigate the reasons for refusing care and update the resident's care plan, and the MD will be notified of any changes in the resident's behaviors. 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 LIC9099 3 of 4 On 10/19/23, it was alleged that staff are unaware of the census for safety. The facility maintains a daily census log, updated at the beginning of each shift and during shift changes. The log includes residents who are on-site, temporarily off-site (e.g., hospital, family visits), and newly admitted or discharged. Emergency drill records show that staff accounted for all residents during recent fire and earthquake drills. An interview with S1 described the facility’s census tracking system and confirmed that staff are trained to update and review the census log each shift. S2 demonstrated knowledge of the current census and explained the process for tracking residents during outings and emergencies. S3 accurately identified the number of residents present and those temporarily off-site at the time of the visit. R2 and R3 reported feeling safe and stated that the staff are attentive and aware of who is present in the facility.  No residents expressed concerns about staff awareness or supervision. Outside source 2 confirmed that the facility communicates when the resident leaves or returns and expressed confidence in the staff's attentiveness. LPA Domingo observed staff using a census board and a sign-in and sign-out sheet for residents leaving the facility.  There were no discrepancies noted between the observed resident count and the documented census. On 10/19/23, it was alleged that service plans had not been updated for the resident with changes in conditions. Records reviewed revealed that the appraisal/needs and service plans were updated for three (3) residents who had a change of condition.  The MD was updated,  the responsible party was updated, and a care conference was scheduled to review the increased care needed. LPA Domingo interviewed S1 and confirmed that the resident's condition change was documented and the service plan was updated. S2 demonstrated knowledge of the resident's updated care needs and described the changes implemented in daily care routines. S3 confirmed that medication administration protocols were adjusted in accordance with the updated plan. 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 LIC9099C 4 of 4 R2 stated they received additional assistance after returning from the hospital and felt their needs were being met. OS2 confirmed they were notified of any change in condition and received a copy of the updated service plan during the care conference. The Department has investigated a complaint with the above allegations. The Department has found that although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations are unsubstantiated . An exit interview was conducted with Executive Director,  to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Nacole Patterson 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 Memory Care Director Justine Hernandez. The facility's license shows a maximum capacity of 226 non-ambulatory residents, ages 60 and over, 8 of which may be bedridden in the memory care building on first and second floors. Delayed egress approved in memory care building. Hospice waiver for 25. During today’s inspection there were 141 residents in care. LPA and Memory Care Director Justine Hernandez 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. Client 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. 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 clients. Medications were labeled, as required, and stored in locked areas. The facility has an outdoor pool which was inaccessible to residents. Per Memory Care Director Justine Hernandez, 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 clients, 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 Memory Care Director Justine Hernandez to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Operations Specialist Sahar Mosalla, to discuss the purpose of the visit. Today's visit is in response to recent self-reported incidents regarding resident falls, elopements, and medications (see LIC811 Confidential Names List). LPA interviewed staff and residents and collected records. A wellness check was completed; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Operations Specialist Sahar Mosalla, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22).  Their signature confirms receipt of these documents.

During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to the allegation, R1 left the facility on October 14, 2024, and emergency personnel were not contacted until R1 was roughly one mile away from the building. Records collected revealed that on October 14, 2024, R1 attempted to leave the facility unassisted and was followed by staff. Records revealed that R1 was followed for roughly two and a half miles and attempts for redirection were made but not successful. Interviews with staff present revealed that R1 was agitated and aggressive on the date of the incident. Interviews also revealed that R1 was not left unsupervised as S1 and S2 stayed with R1. Records also revealed that R1 was provided emergency medical care on October 14, 2024. Interview with outside source confirmed R1 was not left unattended during exit seeking incidents. It was also alleged that R1 was not provided with psychiatric care prior to above mentioned incident. Records collected revealed R1 agreement was signed on September 30, 2024, two weeks prior to incident mentioned above, and there was no known history of exist seeking or aggressive behaviors. Interview with Executive Director revealed R1 physically moved into the facility on October 4, 2024. Interviews revealed that R1’s behaviors began after date of move in and communication to responsible party and primary care provider had been made. Records showed that R1 was reassessed as of October 9, 2024, for extensive new behaviors. Additionally, interview with outside source confirmed there had been no history of exit seeking behaviors or aggressiveness requiring psychiatric care. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Sam El-Rabaa, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Sam El Rabaa, to discuss the purpose of the visit. Today's visit is in response to the self reported incidents of Resident 1 (R1) and Resident 2 (R2) who suffered falls with injury (See LIC811 Confidential Names List). LPA interviewed staff and residents and collected records. A wellness check was completed; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director Sam El Rabaa, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22).  Their signature confirms receipt of these documents.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Sam El Rabaa, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) who suffered a fall with injuries. LPA interviewed staff and residents and collected records. A wellness check was completed; no health or safety issues were identified.  No deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Sam El Rabaa, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22).  Their signature confirms receipt of these documents.

(Continued from LIC9099 p.1) The internal investigation included random, unannounced visits during the NOC shift, interviews with NOC shift staff, and review of electronic clock in/out times. Staff interview revealed that staff were permitted to sleep during their scheduled breaks due to it being personal time. Staff interview further revealed observations of resident needs being met during each shift, regardless of the time of day. Resident interviews did not corroborate the allegation, as residents confirmed that staff met their needs with no exception for the time of day. Outside source interviews did not corroborate the allegation, informing of regular facility visits during the NOC shift, with no staff observed to be sleeping. Records review did not corroborate the allegation, revealing daily End of Shift reports for NOC shift during the month of concern with detailed reporting regarding resident care and incidents for follow-up. Regarding the allegation, "Licensee did not follow resident's care plan", it was alleged that staff did not conduct 1-hour status checks on resident 1 (R1) per their care plan. Review of R1's records did not corroborate the allegation, as no records were found to prove that R1's care plan stated hourly checks. Review of facility records revealed that R1 was monitored at regular intervals and assisted with their needs. Records review further revealed that R1 suffered from sleeping issues and was frequently combative during the early morning. Outside source interview did not corroborate the allegation, informing that a visit was conducted with R1 during the timeframe of complaint and R1 was observed to be clean with no issues. During an unannounced facility visit, LPA directly observed R1 participating in group activities and eating dinner with other residents; LPA did not observe R1 in their room unassisted at any time during the visit. Additional observations revealed that residents were together in the common areas most of the day due to the structure of programming, and LPA did not observe an opportunity for R1 to be by themselves without a staff member nearby. Due to their baseline memory loss, R1 was not able to participate as a valid historian for interview. Regarding the allegation, "Licensee did not ensure resident rooms were kept clean", staff interview revealed that housekeepers and caregivers were responsible for maintaining resident rooms. Caregivers removed trash in resident rooms 2-3 times per shift due to soiled incontinence supplies, and also organized the rooms. Housekeeping made the beds and cleaned the rooms. (Continued on LIC9099-C p.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 (Continued from LIC9099-C p. 2) Staff interview further revealed that due to the nature of the memory care population served, it was not uncommon to see random items out of place in resident rooms. Outside source interviews did not express concern regarding cleanliness or sanitation of resident rooms. Residents interviewed informed that staff cleaned their rooms daily and that the rooms were "immaculate". During an unannounced facility visit LPA directly observed 6 resident rooms; LPA did not observe any room to be cluttered, in disarray, or unsanitary. LPA observed 1 unmade bed and one small pile of clothing outside of a laundry basket. LPA did not observe any room that looked as if it had not recently been cleaned. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Sam El Rabaa, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099 p.1) Staff informed that proposals had been made to further correct the doors, and the information was communicated to residents during the monthly Town Hall meeting with the Executive Director. These statements by staff were corroborated by records from 2 (two) independent contractors, and the resident Town Hall meeting notes. Residents interviewed confirmed that the doors were heavy and closed too quickly, resulting in a prior fall with minor injury. While residents expressed concern with possible future injuries regarding the doors, they also acknowledged that the Licensee had been working on the issue, but were dissatisfied with how long it has taken. Outside source interview revealed knowledge of the residents' concerns about the doors, with no knowledge of what the Licensee had done to address the issue. Records review revealed email communication, outside contractor proposals, invoices from work completed, and Town Hall meeting notes. These records gave evidence to the fact that the Licensee had been addressing the issue of the doors since November 2023 and communicating the progress to residents. During an unannounced facility visit, LPA directly observed the doors in question, as well as their operation. LPA observed that the doors were slightly heavier than a regular door, and the bathroom doors closed quickly after being opened, with little resistance or delay. The doors and door frames contained permanent metal tags with serial numbers on them. The tags contained the following statements: "Meets UL 10C/NFPA 252 requirements positive pressure. Do not remove or cover this label". This gave evidence to the doors meeting code regulations. Although the issue of the doors was proven to exist, evidence was not found to prove that the Licensee did not make efforts to correct it. 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. An exit interview was conducted with Executive Director Sam El Rabaa, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099 p.1) Outside sources interviewed did not express concern regarding the Licensee's physical care of residents. Outside sources further revealed that external investigations were conducted with no findings of physical abuse or neglect by staff. Records review revealed that the the licensee reported the incident to the Department within the required timeframe, which included proof of an internal investigation regarding the event. Records review showed no corroboration and did n ot produce evidence that the event occurred. Outside source investigation documents did not indicate that the event occurred or that there was evidence to support the allegation. Due to their baseline memory loss, R1 was unable to participate as a reliable historian/interviewee about the incident. 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.  An exit interview was conducted with Executive Director Sam El Rabaa, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099) Staff interview revealed that the wound care instructed by the physician was not care that facility staff could provide, due to not being a medical facility. Staff interview further revealed that the Licensee assisted the resident with obtaining Home Health agency services to provide the care required. Records review revealed that the Home Health agency came to the facility and administered wound care to the resident. Regarding the allegation, "Licensee obtained a Home Health service provider without consent", it was alleged that the Licensee did not allow the resident and/or responsible party to be involved in the resident's healthcare decision making. Staff interview revealed that the Licensee assisted the resident in finding a Home Health agency, and the resident in question signed consent for care from the agency. Records review corroborated the staff statements, revealing signed consent forms by the resident for the Home Health agency to provide the required care. Outside source interview also corroborated staff statements, informing that the resident directly consented for care, in writing. Regarding the allegation, "Licensee did not allow Home Health agency to visit resident", it was alleged that the Licensee turned away a Home Health agency who came to provide care to a resident. Staff interview did not corroborate the allegation, staff stating that no Home Health agencies have been denied access to provide care to any resident. Records review revealed that the resident in question refused care from the Home Health agency directly on the day in question; the Home Health agency returned to the facility the next day, and was granted access by the facility and resident to provide care. Outside source interview did not corroborate the allegation, revealing that the Home Health agency was granted access to the resident and care was provided. Based on interviews, and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Sam El Rabaa, Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099) Records review revealed that the door company completed an inspection of all Memory Care doors and they were found to be without mechanical issue. 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. An exit interview was conducted with Executive Director Sam El Rabaa, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Sam El-Rabaa. Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 09/07/2023), involving Resident #1 (R1) and Staff #1 (S1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a facility tour and welfare check on R1, verifying they were safe. LPA collected copies of pertinent care, medical, and personnel records. LPA reviewed handwritten witness statements and time-stamped documents from Licensee’s internal investigation. LPA also interviewed pertinent staff and outside sources. According to R1’s latest LIC602 Physician’s Report (dated 01/09/2023), they were diagnosed with Alzheimer’s type Dementia, but their doctor determined that R1 was continent of bowel and bladder. Licensee’s own Service Plan and internal care assessment (both dated 08/08/2023) corroborated that R1 had dementia but was independent with toileting tasks. Due to their baseline memory loss, R1 was unable to participate as a reliable historian/interviewee about the incident. However, records and staff interviews showed: During the morning of 09/06/2023, S1 sat beside R1 on a couch and used their hand to touch R1’s upper thigh in a sexualized manner. S1 also touched the side of R1’s breast on a separate occasion. R1 did not suffer physical injuries as a result. [CONTINUED ON LIC 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 LIC 809] Personnel records and staff interviews further showed: Facility management first became aware of allegations on 09/06/2023, and suspended S1 pending further investigation. On 09/09/2023, Licensee terminated S1’s employment, after concluding that S1 had engaged in “inappropriate touching.” Although Licensee timely investigated the incident, Licensee’s staff did not report the incident to local law enforcement (which is required upon receipt of an allegation of physical abuse). [CCLD subsequently cross-reported the incident to local law enforcement.] According to Resident #1’s (R1’s) Face Sheet: R1 had a responsible person (RP) other than themselves. Via phone call, Licensee timely notified the RP of the incident, then on 09/11/2023 sent CCLD a written LIC624 Incident Report. However, per manager and outside source interviews, Licensee did not send a copy of the written incident report to R1’s responsible person, as was required to be done within seven (7) days of incident occurrence. A preponderance of evidence exists to show that during the incident in question, licensee’s staff (S1) did not ensure R1 was free from abuse. A preponderance of evidence also exists to show that Licensee did not fully meet reporting requirements. Three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction was jointly developed with the licensee. An exit interview was conducted with El-Rabaa, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

(Continued from LIC9099) Interview with R1 revealed that they enjoy walking around the front and back of the facility and spend much of their time exercising. During a facility visit LPA directly observed R1 ambulating using their walker in the courtyard without issue. Records review revealed that R1 was independent and able to ambulate on their own without supervision around the facility. No evidence was found to prove that the Licensee was not meeting R1's supervision needs. Regarding the second allegation, "Facility gate was in disrepair", it was alleged that an outside facility gate did not have a lock or handle, which resulted in a safety issue by allowing anyone to come and go from the facility. LPA direct observations of the gate in question revealed that the gate was located on the East side of the facility by the Assisted Living wing. LPA directly observed that a handle existed on the gate and was in good repair by physically testing it, and the gate could be opened without issue. Staff interview revealed that the Licensee was in the process of upgrading the gate to include a spring that allowed the gate to self-close, and a new handle that included an outward-facing lock for additional safety. Records review corroborated the staff statements regarding the repairs and showed the timeline of events for the upgrade. No evidence was found to prove that the Licensee allowed the facility gate to be in disrepair without taking action. Residents interviewed stated that the Maintenance Director is very timely with repairs, and addresses physical plant issues right away. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Sam El Rabaa, Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.