Peninsula Reflections

In addition, S1 and S3 indicated that R1 wanted his/her medication, however they had to keep explaining to R1 that the medication he/she was requesting for is prescribed to be given once every 8 hours, however they made sure that R1 was being checked on every 1-2 hours. Regarding the allegation, staff could not communicate with emergency personnel, according to the reporting party, on June 16, 2025, when emergency personnel arrived to the facility, they requested R1's paperwork, however the staff was Spanish speaking only and radioed another staff member. During the investigation, LPA interviewed staff who were on shift on June 16, 2025. According to Staff 1 (S1), when emergency personnel arrived, S1 admitted he/she had to call S3, the med-tech on shift because S1 speaks Spanish and very little English. In addition, according to 3/3 staff interviewed, although they do not speak a lot of English, they are able to communicate and understand basic English. Regarding the allegation, staff did not have access to residents emergency paperwork for emergency personnel, according to the reporting party, on June 16, 2025, when emergency personnel responded to the facility, they requested for R1's file, however after 10 minutes of waiting, a firefighter went to the staff to see where the file was and was told by staff that they were on the phone with someone (unknown) trying to figure out to to get R1's file. During the investigation, LPA interviewed staff on shift and observed the med-tech room where all resident files are located. Based on observations, LPA observed all resident files available and located in the med-tech office room. According to S3, he/she indicated that normally when staff call 911, the updated system papers are printed and ready for emergency personnel, however, the night of June 16, 2025, R1 called 911 without staff knowing and the papers were not ready so S3 had to go to the med-tech room and print R1's paperwork which took some time as the S3 indicated he/she was experiencing printer issues. According to S3, although it took time to print R1's paperwork, it was eventually printed and provided to emergency personnel. Based on interviews conducted and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with the Activities Director and a copy is provided.

On 3/16/25, a nurse from Sutter Care Home came to assess R1 for the appropriate services that's required for R1's needs. Based on the nurse's assessment from Sutter Care, R1 was admitted to hospice on 3/22/25. R1's responsible party revoked hospice services on 4/6/25. Starting 4/1/25, home health started visiting R1 for physical therapy and continued to come 1-2x a week for leg exercises. Based on R1's progress notes reviewed, on 5/9/25, the facility observed an open wound on R1's sacrum. The facility notified R1's physician and the physician ordered home health to evaluate R1's wound. On 5/14/25, R1 was assessed by Sutter Care at Home who indicated that R1 had a pressure ulcer to sacrum. According to staff interviewed, the facility notified R1's physician, responsible party, and updated R1's care plan. Based on R1's care plan, the facility repositioned R1 every two hours, followed the treatment plan that was provided by home health, and monitored R1 for any changes of condition. In addition, home health was coming 2-3x a week for wound care. Based on the repositioning log, R1 was being repositioned every two hours. According to interviews conducted, med-techs were instructed to call hospice when R1's dressing needed to be changed or was soiled if the facility LVN was not present at the facility. In addition, according to the administrator, R1 had a one-on-one caregiver 24/7 who was also trained to change R1's dressing. Regarding the allegation, staff retained a resident with a prohibited health condition, according to the reporting party, on 5/14/25, R1 was found to have an open stage IV sacral pressure wound. During the investigation, LPA interviewed the administrator and reviewed R1’s file. According to documents reviewed, on 5/23/25, a wound nurse came to visit R1 and determined R1's sacral wound was unstageable. According to the Department's and facility's records reviewed, after the administrator was notified that the sacrum pressure injury was unstageable on 5/23/25, an exception request was submitted to Community Care Licensing the same day to request for the facility to continue providing care to R1 who had a prohibited health condition. Regarding the allegation, staff did not notify authorized representative of change in condition, on May 14, 2025, it was found that R1 had pressure wounds on his/her feet and an open stage IV sacral pressure wound, however R1’s authorized representative was not notified about the wound until May 21, 2025. (Continue to 9099C) 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 During the investigation, LPA interviewed the administrator, reviewed home health notes, R1's charting notes, progress notes, and service plan. Based on home health document dated 5/14/25, R1 was observed to have a pressure ulcer to the sacrum. According to the administrator and service plan reviewed dated 5/14/25, the LVN updated the service plan due to change of condition, in specific to active pressure ulcer on heel and sacrum. Based on the progress reports and charting notes reviewed, R1's responsible party was contacted on 5/16/25 regarding the presence of the sacral wound. Based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with the administrator and a copy is provided.

On 10/20/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the administrator Anna Allas and explained the purpose of today's visit. There are currently 35 residents in the facility during this inspection and multiple staff through out the facility. This is a multi-level facility, Age range 60 and over. Approved for 57 non-ambulatory of which 20 may be bedridden. Maximum of 6 non-ambulatory and no bedridden allowed on second floor. Hospice waiver for 10 residents. There are 5 residents under hospice care as of today's visit. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. Large dining room is clean and organized for residents. LPA observed dining menu and activities calendar posted. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Per staff, all appliances are in working condition. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 03/29/2025. There are additional food supplies, emergency food supplies, freezers, PPE, and water stored in a storage building at the front of the property on Collins Ave. These are observed as in place. Next to that is another building where the marketing office and employee break room is located. First aid kits are observed as complete with required items as observed. Medications are observed to be locked in the medication rooms and medication cart. Cart is in place near the facility dining room to disperse medication to residents during meal times and is able to be brought through out the community. LPA observed multiple residents in the activity room with 2 staff present. Continued on next page... 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 Page 2 LPA reviewed resident medications at random and observed them as current, stored correctly, and documented via electronic medication administration record system. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 03/29/2025. Smoke detectors, carbon monoxide detectors, and full fire sprinkler system is observed in place through out the facility. Central heating and air conditioning is in place. Laundry room is also observed as fully operational and organized. Lint areas are being cleaned on this day and LPA observed them as clear of lint. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Evacuation chairs are in place in emergency exit stairwells as well. Last emergency/disaster drill was conducted in 07/24/2025. Water temperature was measured in resident rooms 20 and 35. Both were measured at 120F. LPA observed 5 resident rooms at random. All are observed to be free of odors and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place stored in various areas and in the laundry room. LPA reviewed five staff files and 5 resident files during today's inspection and all files are observed as current. Staff are actively conducting training and it is observed as current for the staff reviewed Administrator certificate is current expiring 05/01/2027. No citations issued. Report is reviewed with Anna Allas and a copy is provided on this day.

On December 20, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 12/6/24. LPA met with Activities Director, Nancy Medina and explained the purpose of the visit. The Licensee reported on 12/6/24, Resident 1 (R1) reported that Staff 1 (S1) threw a call light at him/her and his his/her head. According to R1, he/she told S1 that he/she will report S1 to the facility. S1 told R1 that if he/she reported S1 to the facility, he/she will kill R1. 911 was called. The facility assessed R1 for any visible injuries. No injuries were notes. Facility spoke to R1's responsible party who indicated that R1 says things like that even when R1 was at home. In addition, R1's responsible party indicated that whatever R1 said did not happen. During the visit, LPA attempted to interview R1, reviewed R1's file and interviewed the Activities Director. According to the Activities Director, this was an alleged incident and the facility found no evidence to prove that S1 actually did hit R1 with a call light. In addition, according to the Activities Director, R1 has dementia. LPA reviewed R1's file. Based on documentation reviewed, R1 has a diagnosis of dementia, and gets confused, aggressive and has inappropriate behaviors. LPA attempted to interview R1 but due to the language barrier and dementia diagnosis, LPA was not able to get much information from R1. R1 mentioned he likes the staff here and does not have many issues at this facility. No citations are issued during the visit. LPA reviewed report with the Activities Director and a copy is provided.

On September 30, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on an incident that occurred on 9/21/24. LPA met with Activities Director, Nancy Medina and explained the purpose of the visit. On September 24, 2024, Licensee reported that Resident 1 (R1) was found outside along the driveway of the facility. According to the Licensee, a bystander observed R1 climbing the metal gate and was able to get out. Bystander was trying to redirect R1 until staff came out to get R1. Skin abrasions were noted. During the visit today, LPA conducted interviews and reviewed R1's file. According to file reviewed, R1 has a diagnosis of Alzheimer's Dementia and is unable to leave the facility unassisted. LPA did not observe any reappraisal for R1 after R1 eloped on 9/21/24. In addition, during the file review, LPA observed that R1's physician's report is dated from 2/28/23. Facility failed to ensure an updated annual medical assessment/ physician's report is maintained in R1's file. According to the Administrator, R1 used the exit door in the dining room and gained access to the courtyard and climbed up the metal gate. In addition, the administrator was unable to provide information on why the staff didn't hear the auditory alarm when R1 opened the exit door and why staff was unable to respond immediately. Based on staff interviewed, it was indicated that staff were assisting other residents and was unable to respond immediately. During the visit today, LPA opened the exit door in the dining room to ensure alarms were on and functioning. It was observed the alarm was on and in good repair. Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Report is reviewed with Activities Director and a copy is provided with appeal rights.

On September 17, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra arrived at the facility at 09:15 AM to conduct the Annual 1-year required inspection. LPAs met with Nancy Medina, Activity Director and explained the purpose of the visit. Anna Allas, Administrator joined shortly after. LPAs toured the physical plant and observed it to be clean and odor-free at a comfortable temperature. This is a two-story building with 21 resident bedrooms, 21 bathrooms, a dining room, a living room, an activity area, a storage/supply room, a kitchen, a laundry room, a medication room, and offices on the first level. The second level has 13 resident bedrooms, 13 bathrooms, storage rooms, and a spa room. Delayed Egress was observed to be working properly at the main entrance door. Auditory devices were observed to be in place to monitor all exits. No accessible bodies of water or hazards were observed. Video surveillance was observed only in the hallways and common areas of the facility. The fire extinguishers were fully charged and last serviced on April 2024. The smoke detector and carbon monoxide detector were fully operational. LPAs inspected resident’s rooms and bathrooms at random. Rooms were observed to be clean with the required furniture and sufficient lighting. The bathrooms were observed to be mold-free and equipped with grab bars, liquid soap, and paper towels. The hot water temperature in the resident's bathroom was measured on the first floor in room 10 at 108.6°F . Hot water temperature was also measured on the second floor in room 23 at 118.4°F. Sharp objects, detergents, poisons, and soap were observed to be locked and inaccessible to persons in care. No expired food items were observed. The facility had the required 7 days of non-perishables and 2 days of perishables. 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 five resident records and five staff records. All were observed to be complete. Emergency drills are conducted monthly with the last drill documented on September 2024. The resident’s medications are securely stored in a locked cart/cabinet/refrigerator. Medication administration records (MARs) were reviewed, and no expired medications were observed. The First Aid kit was checked and observed to be complete. The following updated forms are requested to be submitted to CCLD by 09/24/2024: · LIC500: Personnel Report · LIC308: Designation of Facility Responsibility · LIC400: Resident Cash Resources · Administrator Certificate · Current Liability Insurance No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Anna Allas, Administrator, and a copy of this report was left at the facility.

On 02/15/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit regarding a police visit to the facility made on this day in the morning hours. LPA met with administrator Anna Allas and explained the purpose of today's visit. During complaint visit made on this day regarding complaint #14-AS-20240214151800. LPA was informed by Anna that the police department came to the facility in the morning hours today regarding medications that R1 supposedly had and where it came from and also the room door of R1 being locked. Staff demonstrated to the officer how the room is unlockable from the outside and how they unlock it. Responding officer provided the facility with a police report number regarding the visit. Police took no further actions during the visit. Facility will provide an incident regarding the police visit. F No citations issued. Report reviewed with Anna.

Page 2 - LIC9099 Staff in the facility are able to communicate to residents as necessary. Some staff do have difficulty but not to the point of not understanding. Those staff with a language barrier, do have resources such as other staff to assist in translation, and have the ability to communicate using translation devices. R1's room mate was diagnosed with dementia and would wake up at random hours during the night due to diagnosis such as sundowning. As a result, the facility moved the room mate and provided R1 with a private room despite only paying for a single bed, not a double, and was able to stay in the room for the duration of their time of the facility. The room mate was deemed compatible at the time of assessmentsm but when the room mates behavior changed, the facility moved the room mate to a better compatible room which provided R1 with their own room. The facility attempted to meet the needs of R1 at all times and made adjustments where needed. The facility communicated with R1 and the social worker of R1 to collaborate and continue to meet the needs and requests made by R1. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Nancy.

Page 2 - LIC9099C In regards to staffing numbers and staff competency, again the facility indicated that the resident was fairly independent and they assisted and provided the level of care that they were able to meet her everyday needs. There was not an observable lack of competency or staff not being able to meet the resident's needs. LPA could not observe or determine if this allegation is true. In regards to the facility not reporting changes in the residents physical condition to the responsible party or physician, According to staff they reported any changes to them the best of their ability. In regards to a resident's condition change in physical nature, facility acknowledged that the resident did enter the facility with a specific condition and were aware of what signs to observe. They indicated that if there was any change that needed to be reported that they would report as soon as possible. In the case of the resident being swollen, this was reported to the responsible party as acknowledged by the reporting party. LPA could not determine if this allegation is true. In regards to not meeting the resident's hygiene needs, LPA discussed and reviewed documents relating to the needs and services of the resident. LPA could not determine of the hygiene needs were not able to be meet. Facility confirms that there was teeth brushing instructions provided and says they were able to assist when needed. In regards to other hygiene needs not being met, such as hand washing, the facility could not determine if soap was not provided. LPA observed soap dispensers at random through out the facility and soap appeared to be in place. LPA could not determine if this allegation is true. In regards to communications being answered promptly or appropriately by staff, LPA discussed the procedures regarding this and identified that there is a facility phone that families can send text messages to and make calls to that is maintained by staff. Reporting party confirms there had been communications made to her from this number and acknowledged being responded to from this phone. Staff interviewed confirmed that they do respond and message from this phone. Staff are aware that they can report and respond at any time on this phone and do so in a timely manner to the best of their abilities. LPA could not determine if this allegation is true. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. No citations issued. Report is reviewed with Kathy Nguyen.

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with administrator Anna Allas and explained purpose of today's visit. LPA conducted a tour of the facility's physical plant and grounds. There are no accessible bodies of water or fire safety hazards are observed. Infection control practices are reviewed: Entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are posted prominently. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained measured at 70F, and lighting is sufficient for comfort and safety. First-aid kit is inspected and complete. There are three first aid kits available through out the facility. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed; first-aid training for staff is current. Staff training is current according to administrator. Anna is a certified RCFE administrator (x 5/2021) that oversees facility operations. According to her she submitted her renewal certificate. She says she provided all documents and training verification to the Administrator Certification Section (ACS) but has not received an update. LPA observed the documents she submitted to ACS including the payment checks and training hours. She says she will follow up again regarding this. Water temperature is tested at 105F on ground level bathroom. Bathrooms and shower rooms have grab bars and non-skid mats in showers. PPE is observed as in place in exterior storage building. Fire extinguishers are charged and ready for use last being inspected on 3/8/2022. Smoke alarms and carbon monoxide detectors are in place. The following updated forms were received during today's inspection: • LIC610E Emergency Disaster Plan • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report There are no citations issued during today's inspection. Report is reviewed with administrator Anna Allas.

On October 26, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA was screened at the front entrance but did not see COVID-19 signage at the front door. LPA was greeted by LVN, Kathy Nguyen. LPA explained the purpose of the visit. LVN was able to provide LPA with a daily resident and staff temperature log as well as a visitor log. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, containment strategies, PPE supply and the environmental cleaning supply are adequate. COVID-19 signs were observed throughout the facility but LPA recommends more reminder signage to be posted in the hallways on first and second floor, and the front door. The beds in the semi-private rooms are observed to be 6 feet apart. All bathrooms are equipped with non-skid mats, liquid soap and paper towels. LPA advises to cover all trash bins with lids and add hand-washing signs in all bathrooms including residents. LPA observed the residents in the activities room to be social distancing. Dining room was observed to have tables and chairs distanced enough to maintain COVID-19 social distancing protocols. Medications, toxins and sharps are stored appropriately and inaccessible to resident, and a comfortable temperature is maintained, lighting is sufficient for comfort. According to the LVN all staff and residents are vaccinated. LPA requested for the following documents to be submitted to CCLD by 11/2/2021. -LIC 308 -LIC500 -Administrator Certificate -LIC610E -LIC402 -Surety Bond This report is reviewed with LVN, Kathy Nguyen and a copy is provided.

On June 11, 2021 Licensing Program Analyst (LPA) Jaime Vado met with Wellness Director Kathy Nguyen for a Case Management visit to follow up on a complaint regarding physical abuse on a resident. On February 12, 2019, LPA Marie Rodriguez conducted an unannounced Case Management visit in response to information received by the Department through online news articles. On February 11, 2019, the Department was made aware of a news article dated February 6, 2019, written by a local media source. This news article was an update to a previous report from October 25, 2018. It was reported that facility medical technician, Staff 1 (S1), was charged with attempted voluntary manslaughter and elder abuse. The facility medical technician, S1, had pushed a pillow down on a resident’s (R1) face diagnosed with dementia. S1 was arrested and transported to a local County jail on October 23, 2018, pending further investigation. The investigation consisted of administrator and witness interviews and the collection of physical and audio evidence such as the pillows used by S1 and an audio recording of the incident. Officers conducted interviews with Peninsula Reflections Administrator and S2, an employee who was present at the time S1 pushed a pillow down on R1’s face. Administrator’s interview pointed to S2 as the only witness to the event. The interview with S2 revealed another incident that occurred the previous week of October 23, 2018. For the incident of the previous week, S2 described a different resident as potentially combative and difficult, but also added that these were the patients they dealt with because the facility is a dementia facility. S2 said S1 yelled at this resident, saying, “shut your f--king mouth,” while S1 took the resident to the resident’s room. Regarding R1’s incident, R1 was reported to have been blocking R1’s room door with R1’s walker. S2 noted that R1 had never blocked R1’s door before S1 began working at the facility. It seems R1 had felt safer with the walker in front of R1’s door as S2 described the habit. S2 continued detailing how S2 had witnessed S1 get upset with R1 and forced S1 to R1’s room. S1 grabbed R1’s arm along the way then tossed R1 on to R1’s bed. S1 took R1’s shoes off, throwing them on the ground, and then grabbed a pillow and forcefully put it over R1’s face. S2 recorded the incident on video and then intervened to stop S1. The video clip from the evening of October 18, 2018 and October 19, 2018 revealed an exchange of words, a minute long, in Tagalog and Illocano (Filipino dialect). The recording unveils S1’s violent actions and R1’s reactions. S2 noted that S1 acts one way with management staff and another way with the patients and residents. S2 also added that the reason she recorded the incident was because when S2 had reported a prior incident regarding S1, management did not believe S2. Continued on next page... 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 Page 2 - LIC809 Additionally, S2 believes that if S2 did not grab S1 and get S1 off R1, S1 would have suffocated R1 to death. Approximately 10-15 minutes later, S1 told S2, “I don’t think this job is for me.” S2 also notes that while S2 has been a caretaker for R1, S2 has never seen R1 frightened or defensive when another caretaker was nearby, except for S1. S2 believes R1 is afraid of S1. The allegations regarding R1 were confirmed by S1 himself. S1 stated that S1 and R1, who is diagnosed with dementia, had numerous verbal disagreements in the past, and R1 would call S1 bad names and get angry with S1 frequently. S1 told officers S1 was just angry and wanted R1 to go to bed and not argue with S1. S1 stated S1 had pushed the pillow down on the resident’s face for approximately five seconds before stopping. S1 revealed what R1 had said during the incident, “Are you going to kill me?” And S1 replied with, “Yes, I am going to kill you if you don’t go to bed.” After officers confirmed this was fact, S1 told officers that S1 could have killed R1 and that “circumstances forced me to do it because I was stressed out.” S1 added that S1 was just trying to make R1 shut up and go back to bed. Based on all the evidence collected, the police report and interviews, S1 attacked and attempted to suffocated R1, who is diagnosed with dementia, with a pillow to silence R1. Additional evidence points to a previous outburst of anger and violence from S1 towards another resident. With a profession as a facility medical technician, S1 has exhibited violence and anger that place the residents S1 is assigned to take care of, with varying illnesses, and potential coworkers, in danger. S1 attempted to suffocate R1 with a pillow that could have resulted in R1’s death and meets the definition of physical abuse. At the time of the complaint visit on February 12, 2019, the issuance of a civil penalty was still being determined based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for physical abuse. Per Welfare and Institutions Code § 15610.63 defines physical abuse as, “(a) Assault, as defined in Section 240 of the Penal Code.” PC Section 240: “An assault is an unlawful attempt, coupled with a present ability, to commit a violent injury on the person of another.” Today, June 11, 2021, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as physical abuse in the amount of $10,000. A copy of the LIC 421D was given to Kathy Nguyen and originals were signed. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Kathy Nguyen's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.