Reutlinger Community, the

On 1/30/2026 at 9:30AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit to deliver an immediate exclusion letter. LPA met with Executive Director, Hanh Ta and explained the purpose of the visit. During visit, LPA hand delivered the immediate exclusion letter for S1 to Executive Director, Hanh Ta. Executive Director states that S1 is not currently employed at the facility and will be immediately removed from the facilities Guardian Roster. No deficiencies are being cited on this date.

On 12/2/2025 at 9:30AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit to deliver an immediate exclusion letter. LPA met with Executive Director, Hanh Ta and explained the purpose of the visit. During visit, LPA hand delivered the immediate exclusion letter for S1 to Executive Director, Hanh Ta. Executive Director states that S1 is currently employed at the facility and will be immediately removed from the schedule and informed not to return. No deficiencies are being cited on this date.

On 6/16/25 at 10:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Julie Mammad and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory with 5 bedridden. LPA toured the facility with Julie Mammad including but not limited to 10 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 110.4, 107.7, 110.1 degrees Fahrenheit. Freezer measured at -15 degrees Fahrenheit and refrigerator measured at 36 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/5/2024. Emergency Disaster Plan was last posted on 1/2/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 5/13/2025 At 2:00 pm, LPA reviewed 6 residents records. At 3:00 pm, LPA reviewed 6 staff records and 5 of 5 required have current first aid training and associated to the facility. At 11:40am, LPA reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 6/16/2025 at 9:30 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving an eviction notification for R1. LPA met with Executive Director, Julie Mammad and explained the purpose of the visit. R1 was admitted to the facility on 3/21/2024. R1 has dementia diagnosis and lives in the assisted living section of the facility. ED states that R1 has been seeing a psychiatrist for aggressive behaviors. ED has been working with R1's responsible party to get medication adjustment, 1:1 care, and possibly moving to memory care. ED states that there has been some pushback on these changes from the RP. R1's behaviors have began to effect other residents personal rights. ED states that they issues the eviction notice because they are not able to meet R1's needs currently unless their RP agrees to adjustments. ED states that currently they are still trying to work with R1 and the RP to find a feasible solution but that if none are agreed upon they will not be able to meet the needs and services of R1. LPA requested that ED send over the correspondences with RP and incident reports for R1's behaviors to support the merit for eviction. No deficiencies cited at this time. Exit interview conducted and a copy of this report provided.

On 04/2/2025 at 12:15 p.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving a self report of suspected abuse (SOC341) of a resident having been verbally abused by staff. LPA met with Executive Director, Julie Mammad and explained the purpose of the visit. R1 was admitted to the facility on 4/23/2017. R1 does not have a dementia diagnosis and lives in the enhanced assisted living section of the facility. The facility conducted their own investigation and spoke with R1. R1 stated that S1 did speak to them inappropriately. However, ED did state that R1 was not able to readily identify S1 and stated that they think that is who spoke to them inappropriately. ED states that R1 has a history of making false claims against caregivers and speaks down to the staff. ED states that they interviewed R2 and R3 who states that S1 never speaks inappropriately. LPA interviewed R1, R4, and R5. R1 states that staff spoke to them inappropriately and told them to drop dead. When LPA asked R1 the name of the staff R1 was unable to provide a name. LPA also asked R1 to describe the staff that was rude to them and they were unable to. LPA also observed that R1 is very hard of hearing. LPA was unable to speak to R1 because they could not hear LPA even when voices were raised significantly so LPA had to type out the questions to converse with R1. S1 works NOC shift and interacts with residents seldom unless care is required throughout the night. Neither the facility or LPA were able to confirm if any staff were rude or verbally abusive to R1 No deficiencies cited at this time. Exit interview conducted and a copy of this report provided.

On 03/12/2025 at 9:00 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving a self report of suspected abuse (SOC341) of a resident having fallen in their room and caregivers not appropriately assessing. LPA met with Executive Director, Julie Mammad and explained the purpose of the visit. R1 was admitted to the facility on 2/22/25. R1 is in memory care . Report indicates that R1 had a fall on 3/3/2025 at approximately 3:23am and S3 was notified at 3:31am. S3 called S1 and S1 went to check on R1. Camera footage confirms that S1 went to check on R1 at 3:32am. S2 was on shift at the same time as S1 and was assigned to R1's room. After S1 checked on R1 they notified S2 that R1 was in bed asleep. S1 checked on R1 again at 3:34am. At 6:04 am S2 checked on R1. No injuries were reported until morning ADL's when it was discovered that R1 had blood on their pillow and R1 was sent out to the emergency room. LPA observed the video footage of R1's fall and them getting back into bed as well as the checks done by staff. S1 and S2 both received additional training as a result of this incident and were put on suspension pending an investigation. It was found that S1 did promptly check on R1 but that S1 should have woken R1 up to have a full assessment done. Both S1 and S2 received verbal warnings and in service training. R1 is currently back at the facility and is in physical therapy. No deficiencies cited at this time. Exit interview conducted and a copy of this report provided.

While interviewing S1, S2, and S3 LPA observed that there were chats on WhatsApp between all the caregivers including S5. However LPA was unable to obtain proof of the claims made by S1, S2, and S3 and their accounts appeared rehersed, leading LPA to question their credibility. LPA also interviewed the ED. ED acknowledged prior issues between S5 and S1, S2, and S3. ED described S5 as assertive but stated that they were always respectful and attentive to residents. ED noted that S5's assertiveness would sometimes rub other staff the wrong way. LPA also attempted to interview S4 but S4 stated that they had never worked with S5. S4 stated that they had no relevant knowledge to contribute regarding S5. LPA was unable to interview any residents as they all reside in memory care and have dementia. LPA also discussed with the ED if there were any incidents or reports regarding R1, R2, and R3 and found that any allegations made regarding these residents were internally investigated and that none of the investigations were substantiated and no injuries were ever found on any of the residents in care. LPA was unable to find any time that residents were not allowed to access their food besides through the interviews with S1, S2, and S3 whom LPA questioned their credibility. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 7/18/2024 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to continue 1-Year Annual Required inspection. LPA met with Skilled Nursing Administrator, Brian Kallio and explained the purpose of the visit. Executive Director was off at the time of visit. The facility’s fire clearance was approved for all may be non-ambulatory with 5 bedridden. LPA toured the facility with Skilled Nursing Administrator including but not limited to 6 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 117.4, 106.2, 114 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Freezer temperature measured at 0 and refrigerator temperature measured at 36 degrees F. Fire extinguishers were last serviced 12/4/2023 No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 7/11/2024 at 12:30 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Skilled Nursing Administrator, Brian Kallio and explained the purpose of the visit. Executive Director was off at the time of visit. The facility’s fire clearance was approved for all may be non-ambulatory with 5 bedridden. Smoke detectors are interconnected with sprinklers and observed throughout the facility. Fire and Disaster Drill was last conducted on 6/13/2024. Emergency Disaster Plan was last posted on 2/21/2024 LPA reviewed 7 residents records. LPA reviewed 5 staff records and 5 of 5 are associated to the facility.Training for staff providing ADLs is current and up to date. LPA reviewed a sample of resident’s medications. The annual inspection is not complete. LPA will return to complete the inspection and tour the facility at a later date. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided

On 01/17/2024 at 9:40AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit in regards to an incident report received on 11/17/2023 and SOC341's received 11/29/2023 and 12/11/2023 . LPA met with Resident Care Coordinator (RCC), Jetrey Inarda and explained the purpose of the visit. Director of Social Services, Olga Leynov and Quality and Compliance Nurse, Janelle Jones also attended visit. Based on the incident report received on 11/17/2023, resident (R1) was given the incorrect medications. Facility notified medical doctor (MD) and R1’s responsible party (RP). R1 was monitored for ill effects but none were noted. Med tech received additional training to avoid medication errors. During visit, LPA reviewed R1's file including physicians report, care notes, and incident report . LPA spoke with RCC and was informed that the medication mix up was a result of S1 picking up a bowl of soup that contained R3s medication. S1 then gave the soup to R1. It is confirmed that the medication in the soup was R3's bowel regiment medication. LPA was informed that S1 received 8hr medication training, a write up, and shadowing. The facility also implemented a labeling system for residents food, facility wide competency training's for med-techs, and that quality compliance nurse now comes to do training's and audits four times a month. LPA also toured the facility kitchen areas to ensure proper labeling of food. As a result of this incident LPA administered a Technical Violation. Report continues 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 Based on the SOC341 received on 11/29/2023 on 11/28/2023 S2 was heard yelling at R2. S3 reported hearing S2 yell something along the lines of "You are always yelling and wanting to be prioritized but I am busy too and have to feed other people." to R2. It was reported that R2 requested that S2 change her pants because R2 had dropped tooth paste on them. S2 inittially did not change R2 and scrubbed her pants with water to get out the stain. R2 stated that, "(S2) wanted their way and I wanted my way, but eventually S2 did change my pants" During visit LPA intervied R2 and found that they are happy and satisfied with the facility . LPA also reviewed Facility 5 day investigation conclusion and it states that S2 no longer works with and monitors R2 and has been reassigned. S2 also received the following training's: "Respect & Dignity; Resident's Rights; Elder Abuse; Communications with patients, residents and clients. R2 has had no ill effects of this incident and no psychosocial disturbances. LPA went over the importance of residents rights and effective communication. Based on SOC341 received 12/11/2023 R4 choked a visitor. Care staff then redirected R4. R4 attempted to enter another residents room when their visitor tried to stop R4, R4 proceeded to choke them. During visit LPA reviewed R4's care plan and found that R4 did not require a one on one and has since passed away. R4 was on hospice and was diagnosed with Dementia among other diagnoses. Visitor was also informed that for any future interactions to notify staff instead of interacting with residents directly. Exit interview conducted. A copy of this report provided.

During record review, AGPA observed a text message on 1/21/22 between S3 and the scheduler from registry agency confirming two registry staff are being sent to work at the facility in the AM shift and five staff in the PM shift for 1/22/22. Registry agency responded and confirmed it was correct the following day. AGPA observed a text a couple minutes after confirming that the five registry staff for PM shift are actually scheduled on Sunday, 1/23/22, but the two registry staff in the AM were are willing to work double shift. However, interview with S1 revealed that the facility made multiple efforts to obtain staffing by contacting facility staff and registry agencies to obtain additional staffing for coverage. S1 stated staff from assisted living covered during the transition until another staff and S1 arrived to the facility. Allegation: Facility is making false claims about caregiver to resident ratios. However, LPA reviewed a sample of 5 residents records during January of 2022 and 5 of 5 residents did not require 1 on 1 care. Interview with S1 and S2 revealed that if there were issues with coverage, the facility will go through registry staffing to provide the coverage needed., Allegation: Administrator is not adequately performing required duties. However, based on interview and record review, during the COVID-19 outbreak, staff and Executive Director were in communication with each other to address any staffing issues. Allegation: Facility is not carrying out planned activities. Based on interview with staff and residents, when there was a COVID outbreak, activities were being delivered to residents rooms during isolation. Although the 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 allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Executive Director.

Allegation: Facility is unkempt AGPA interviewed 5 residents, 5 of 5 residents are satisfied with housekeeping. During the tour on 4/4/23, AGPA observed facility appeared to be sanitary and well kept. Allegation: Residents are not provided adequate meals AGPA interviewed 5 residents and 5 of 5 residents stated they are provided adequate meals. Although 2 of 5 expressed food did not have enough salt, there were no issues on the amount of food that are being provided. S2 stated salt are provided to each table if residents want to add salt to their meals. Although the 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 allegations are UNSUBSTANTIATED . Exit interview conducted with Executive Director and a copy of this report provided. 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 AGPA Francisco reviewed medication orders from 12/15/2021 and compared to hospice care notes. AGPA Francisco did not find any discrepancies between the two records reviewed. The Department obtained a copy of R1’s death certificate and it was determined cause of death was from a condition that was onset for years. This agency has investigated the complaint alleging questionable death. We have found that the complaint was UNFOUNDED , meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted with Executive Director and a copy of this report provided.

Allegation: Staff failed to seek medical attention for resident in a timely manner Based on record review, first aid was performed on R1's lower leg by facility staff. R1 was admitted to the hospital and was treated wound care for extremity laceration. When R1 returned to the facility late in the evening, R1 was under observation by staff and wound would not stop bleeding post sutures completed at the hospital. Resident was admitted to emergency on 9/3/21 and 9/4/21. Facility conducted a meeting with R1's responsible parties once it was determined facility is unable to care for the wound. Resident was transferred to skilled nursing facility on 9/4/21. Allegation: Insufficient staffing to meet residents' needs Based on interview with 6 residents, 5 of 6 residents had no issue with staffing. 5 of 6 residents stated staff checks on them and meets their needs. Allegation: Facility is going through a possible financial crisis The Department investigated facility is going through a possible financial crisis. Based on information obtained, the Department discovered the occupancy trend from Key Indicator Report (KIR) reveals that the decline occurred in FYE 12/31/20 and afterward because of restrictions placed during COVID-19. This community has a 60-bed skilled nursing facility and 40 beds were occupied as of June 2022. The meeting with the Eskaton, the management company and affiliate, confirms that they have a plan in place and working to improve operating performance and occupancy. REPORT CONTINUES ON 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 Allegation: Facility failed to provide adequate food service Based on interview with 6 residents, 5 of 6 stated they receive adequate food service. Allegation: Facility did not respond to family council's concern in a timely manner Based on interview with S4, family council is held once a month and when COVID started, meeting was conducted via zoom. Family council member will email S4 the schedule and an email blast will be sent to all the family members. Executive Director at the time would respond to any concerns via email. AGPA was unable to prove or disprove allegation. Although the 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 allegations are UNSUBSTANTIATED . Exit interview conducted with Executive Director and a copy of this report provided.

Licensing Program Analyst (LPA) K. Nguyen and Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to conduct a 1-Year Annual Required visit on this date starting at 10:15am. LPA and AGPA met with Executive Director (ED), Julie Mammad, and Social Services Director (SSD), Caroline Allen. LPA toured facility with SSD including but not limited to random resident's bedrooms, bathrooms, kitchen, common area, and outdoor area. There are no bodies of water observed. Indoor and outdoor passageways are kept free of obstruction. Room temperature in the hallway is maintained at 74 degrees F. Hot water temperature in random residents’ bathroom is maintained at 110, 111, 115, and 106 degrees F. Random resident's bathrooms were equipped with grab bars and non-skid mats. Hygiene supplies were available for residents. Centrally stored medications are inaccessible to residents. There is a minimum of one week supply of non-perishable and 2-day perishable foods. Refrigerator temperature was maintained at 38 degrees F and freezer temperature was maintained below 4 degrees F. Smoke detectors are interconnected with sprinklers and observed throughout the facility. Fire extinguisher was last serviced on 12/02/2022. Fire and Earthquake Drill was last conducted on 6/25/2023. Emergency Disaster Plan was last posted on 11/20/2022. LPA reviewed 5 staff records. 5 of 5 staff are associated and have current first-aid training. Training for staff providing ADLs is current and up to date. LPA reviewed 5 resident records and 5 of 5 residents have current Medical Assessment on file. LPA reviewed a sample of resident's medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 8/29/2023 at 9:40 AM, Associate Governmental Program Analyst (AGPA) and Licensing Program Analyst (LPA) L. Francisco and A. Gomez arrived unannounced to conduct a Case Management to following multiple incident reports submitted to CCLD. AGPA and LPA met with Executive Director, Julie Mammad, Director of Social Services, Caroline Allen, and Resident Care Coordinator, Jetrey Inarda, and explained the purpose of the visit. On 7/14/23, CCLD received an incident report indicating R1 was exhibiting low oxygen level and other symptoms. According to S2, PCP and R1's responsible party was notified and R1 was taken to the hospital by R1's responsible party because R1's oxygen was not at a critical level. AGPA and LPA discussed the facility's procedure of when to call emergency. On 8/1/2023, CCLD received an incident report where R2 alleged S3 was being rough with R2 after a shower. According to the incident on 7/27/23, S3 was drying R2 with a towel "so hard that it hurt". Interview with S1 and S2 revealed that an internal investigation was conducted and S3 was suspended. It was determined after a 4 day of investigation that there were no other complaints from other residents. S1 and S2 stated that R3 is sensitive and on a lot of pain management. Staff were retrained to pat dry the resident with a towel after a shower and is now placed on a 2-person assist. In addition, S3 was reassigned to care for other residents. CCLD received multiple incident reports regarding S4 that occurred on 3/19/2020, June of 2020, and 8/15/2020. Based on record review of incident reports, it was alleged S4 caused bruising on R3's left lower arm and sustained a large skin tear on top of right hand and nose was sore. On June of 2020, S5 overheard S4 telling S5 that when R4 does not sit still or listen, S4 "motioned flicking S4's own arm" to make R4 sit still. On 6/28/2020, R4 was interviewed by S6 and R4 identified S4. REPORT CONTINUES ON 809C 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 According to S1, an internal investigation by the union and S4 was terminated on 8/20/2020. However, according to S1, it was not determined whether the internal investigation resulted in substantiated or unsubstantiated. AGPA and LPA requested a copy of internal investigation to be submitted to CCLD via email by 9/8/23. No deficiencies cited during visit. Exit interview conducted with Executive Director and a copy of this report provided.

LPA interviewed 2 residents, but LPA was unable to obtain additional information. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Executive Director.

On 11/9/22 at 1:50PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Executive Director and explained the purpose of the visit. During visit, LPA obtained Reutlinger (REUT) assisting living staff schedules. A total of 3 residents from GLG are currently living in REUT. LPA attempted to visit 1 resident who moved in to assisting living last week but resident was sleeping. Adequate food, paper, PPE supplies were observed, staffing is stable. There was no imminent health/safety concerns on today's date. Exit interview conducted with Executive Director and copy of this report provided.

On 11/9/22 at 9:00AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Executive Director and explained the purpose of the visit. During visit, LPA obtained Reutlinger ( REUT ) staff schedules. Total of 2 residents from GLG are currently living in REUT. LPA met with 2 residents, and both of them stated that they were feeling safe and comfortable, fed well, and their needs were met. Adequate food, paper, PPE supplies were observed, staffing is stable. There was no imminent health/safety concerns on today's date. Exit interview conducted with Executive Director and copy of this report provided.

On 8/31/2021 starting at 9:00am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. LPA met with Executive Director, Clara Allen and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility Executive Director and Care Coordinator including but not limited to front entrance, screening station, hand washing stations, apartments, common areas, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front lobby. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.