Oakmont of East Sacramento.

On 02/10/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to the facility to conduct a case management visit in regard to incident reports received. LPA Lee met with Executive Director (ED) Kathleen Gilbey and explained the purpose of the visit. The census is 151. On 08/18/2025, the Sacramento South Adult and Senior Care (ASC) Regional Office (RO) received a self-reported incident from Oakmont of East Sacramento involving Resident 1 (R1), who reportedly engaged in two separate sexual relationships with Resident 2 (R2) and Resident 3 (R3) while residing at the facility. During an interview, R2 denied knowing R1 and stated that the reported incidents never occurred. R2 further indicated that nothing inappropriate happened and denied being forced to participate in any activity against R2’s will. R3 did not respond to interview questions and was unresponsive during the interview. I t was learned that R1 had moved out of the facility on 08/19/2025 . A review of facility records indicates that staff were aware of R1’s inappropriate and sexualized behaviors and were actively addressing the concerns. Documentation shows that R1 was transported to Kaiser Emergency Room on multiple occasions for evaluation related to these behaviors. As a result, staff required R1’s family to arrange one-to-one supervision. Additionally, R1’s medications were adjusted in an effort to manage R1’s behaviors. Facility charting notes indicate that R1 began exhibiting concerning behaviors in June 2025. On 07/01/2025, the facility met with R1’s family and primary care physician to address the behaviors. On 07/29/2025, facility staff met with R1’s neurologist regarding the ongoing concerns. On 08/07/2025, the facility met with R1’s power of attorney and responsible party to further address R1’s behaviors. Charting notes also document multiple occasions when R1 was sent to the emergency room due to these behaviors. CONTINUED 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 Additionally, it was confirmed that the responsible parties for both R2 and R3 were informed of the situation, were aware of their respective interactions with R1, and expressed support and acceptance. The facility informed R1’s responsible party that R1 required continuous one-to-one supervision due to R1’s behaviors. Subsequently, R1’s responsible party elected to remove R1 from the facility. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.

On 2/4/26 at 9:15am Licensing Program Analyst (LPA) Kevin Gould arrived at Oakmont of East Sacramento for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Kathleen Gilbey and together conducted a tour of the facility. The facility is a three story facility consisting of Assisted Living and Memory Care. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA Gould also observed two movie theaters, fitness room, salon, massage room, several activity rooms and ballrooms. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 108 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA reviewed 8 resident files and 8 staff files. All files reviewed were complete and well organized. Report Continued on LIC 9099-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 LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, Current Administrator Certificate and Client Roster. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.

In addition, S1 referred to R1 only as “she” rather than by name. As a result, R1’s identity was not disclosed on social media. Furthermore, records and interviews confirmed that both staff members involved had received appropriate training on resident rights, HIPAA, confidentiality, and the facility’s team member handbook, which includes policies on social media and internet posting. Moreover, in an interview with 5 out of 5 facility staff who stated that both S1 and S2 were appropriately trained and are aware of policies and procedures. In an interview with R1 who stated “I don’t know” when asked if S1 asked R1 for permission to have their photo taken. In addition, it was learned that disciplinary measures will be taken, including the termination of (S1) and (S2). Based on these findings, the investigation determined that the preponderance of evidence standard was not met, therefore, the above allegation that staff posted a resident’s picture on social media without consent is found to be UNSUBSTANTIATED. An unsubstantiated finding means that while the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Assistant Executive Director Mccune and Memory Care Director Hendrix, and a copy of this report was provided to the facility.

An unannounced case management visit was conducted by the Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee on November 25, 2025, at 11:46 AM. LPAs met with Kathleen Gilbey to explain the purpose of the visit. The purpose of the visit is to follow up on an incident report received on October 29, 2025. During today's visit, LPAs conducted interviews and followed up on the egress system. An exit interview was conducted, and a copy of this report was provided to the facility.

An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on November 10, 2025, at 11:46 AM. LPA Martinez met with Kelli Hendrix to explain the purpose of the visit. The purpose of the visit is to follow up on an incident report received on October 29, 2025. During today's visit, LPA Martinez conducted interviews and conducted a tour of the exterior of the building. At this time, R1 has a 1:1 caregiver and is being provided hourly status checks by facility staff. The exterior exit gate next to the dog park is non-operable a this time. The following documents were requested: R1's current needs and service plan, an updated facility sketch reflecting all egress exterior doors, an updated plan of operation to reflect the use of a secured perimeter at the Assisted Living building, R1's admission agreement, level of care point assessment fee breakdown, wander guard policy and procedures, and R1's safety plan for unauthorized absences. Staff agrees to email documents to LPA Martinez by November 17, 2025, by 5:00 PM. LPA Martinez will request a fire clearance for the egress exterior door. LPA Martinez will continue to follow up on R1'a safety plan, egress door installation, and fire clearance. There were no deficiencies at this inspection visit. An exit interview was conducted, and a copy of this report was provided to the facility.

LPA observed there are a variety of activities offered including lunch outings that take place about 1-2 times per week to different establishments. A flyer for the outing that took place on October 10 was posted prior to the activity date, it read “Join Oakmont East Sacramento on a lunch trip to Oakmont’s very own Flint Maranan’s new Sushi restaurant! Surki Sushi & Teriyaki Grill is a casual Japanese restaurant that brings bold flavors and fresh ingredients to the heart of West Sacramento. Sign up with Concierge". FDA stated AED's wife is an owner of a new restaurant, Suruki Sushi and it was the first and only time they have hosted an outing to this location; Based on record review and interviews it was learned that additional outings in the month of October include "University of Beer", "temple Coffee", "Fizz and Champaign Bubble Bar", "Jayna Gyro" as well as Apple Hill, Picinc at McKinley Park, Monet Exhibit, and Top Golf. S1 hosts a monthly meeting "Activity meeting" in which all residents and family members are welcome to collaborate and give input into activities offered, this meeting last took place in August and will resume November 2025. Family and residents are able to make activity suggestions to Activities Director at any time. Record review shows that two residents were in attendance to the outing that took place on October 10th, 2025. 9 out of 9 residents and 6 out of staff interviewed were not able to corroborate staff has ever forced or pressured residents to attend an outing. The Department has investigated the complaint alleging Staff forced residents to attend an outing . Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

It was reported that the companion responded by stating, “I am surprised you are not allowing us to have it done here.” S1 explained that the library is regularly used by staff at 9:30 AM on weekdays for operational meetings. According to S1, the companion appeared displeased, but both the companion and R1 left the library to allow the staff to proceed with their meeting. Based on interviews conducted during the investigation, LPA Lee was able to corroborate the allegation. As a result, this allegation is SUBSTANTIATED. The finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with (FDA), Gilbey and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.

On September 5, 2025, LPA Pang Lee conducted an unannounced case management visit to Oakmont of East Sacramento. Upon arrival, LPA met with Executive Director (ED) Kathlee Gilbey and explained the purpose of the visit, which was to gather additional information and facility documentation related to a SOC 341 report dated August 18, 2025, and received by Community Care Licensing Division (CCLD) via fax on August 19, 2025. According to the SOC 341 report, a resident's wife observed Resident 1 (R1) engaging in sexually inappropriate behavior with another resident (R2) while seated on a couch in a common area. Additionally, it was reported that R1 has previously had inappropriate sexual interactions with multiple female residents at the facility. The ED and Memory Care Director Kelli Hendrix (MCD) reported that a safety plan has been implemented upon discovering of R1’s behavior to address the behavior of R1 with R1’s responsible party to ensure the well-being of R1 and other residents. During the visit, it was learned that R1 has moved out of the facility. LPA Lee collected the following documentation for further review and investigation: For Resident 1 (R1): · Admission Agreement CONTINUED 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 · LIC 624 – Incident Reports · Charting Notes · Medication List For Residents 2 (R2) and 3 (R3): · LIC 602 – Physician’s Report · LIC 625 – Needs and Services Plan · Charting Notes · LIC 624 – Incident Reports · Admission Agreement Per California Code of Regulations, Title 22, no deficiencies were cited. Exit interview conducted and a copy of this report was left at the facility.

Additionally, LPA Lee interviewed 6 out of 6 family members and friends of residents. None expressed concerns regarding incontinence care, and all reported that their loved ones are regularly changed by care staff. They also stated that they have not observed their loved ones in soiled or unclean incontinence briefs. Interviews were also conducted with 5 out of 5 residents, all of whom stated that their incontinence care needs are being met by the facility staff and expressed no concerns. During a facility observation on 07/30/2025, no signs of incontinence odor were detected. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff do not ensure residents incontinent care are being met. It was alleged that staff do not allow residents to eat their meals in a comfortable manner. The investigation included interviews with staff, residents, responsible parties, and direct observations. LPA Lee interviewed all five facility staff members. Each staff member denied the allegation and reported that lunch is typically served between 11:30 AM and 1:00 PM. LPA Lee also interviewed six out of six family members and friends of residents. None of them expressed concerns about residents being unable to eat their meals comfortably. They reported regularly sitting with their loved ones during mealtimes and stated that meals are not rushed. They felt residents are given sufficient time to eat and shared that facility staff are often seen sitting with and assisting residents who may need more assistance with feeding. Additionally, interviews were conducted with all five out of five residents. All residents reported no concerns regarding mealtimes. On 7/30/2025, at approximately 11:15 AM, LPA Lee conducted a tour of the memory care unit. During this observation, care staff were seen assisting residents in the dining area. Lunch service began at around 11:20 AM and continued until approximately 1:00 PM. Throughout the observation, LPA Lee observed a calm and unhurried dining environment, where residents were given adequate time to eat. Five care staff were observed assisting residents with their meals, while two med-techs distributed medications. Approximately 29 residents were present in the dining room during this time. Resident 1 (R1) was observed receiving assistance with their meal but later declined further help from staff. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff do not allow residents to eat their meals in a comfortable manner. It was alleged that staff do not ensure residents are treated with dignity and respect regarding their health conditions. CONTINUED LIC 9099-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 The investigation included interviews with facility staff, residents, responsible parties, and direct observations. LPA Lee interviewed all five facility staff members. Each staff member denied the allegation, stating that residents are treated with dignity and respect. LPA Lee also interviewed six out of six family members and friends of residents. None expressed concerns about how staff treat residents. One friend of a resident stated, “They are loved here.” Another shared that they have no concerns about the care their loved one receives. A third individual noted they have visited their loved ones’ room and observed staff providing care in a kind and respectful manner. All family members and friends of residents stated that they have not witnessed any incidents of staff treating residents without dignity or respect, especially regarding residents’ health conditions. Additionally, five out of five residents interviewed reported no concerns about how they are treated by staff in relation to their health conditions. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff do not allow residents to eat their meals in a comfortable manner. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are 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 violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided at the end of the visit.

On 04/22/2025 at 8:30am, Licensing Program Analyst (LPA) Pang Lee and Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Lee and Hughes met with Kathleen Gilbey explained the purpose of the visit. The facility designated administrator was present in the facility. The current census is 146 and facility staff is 112 LPA's inspected the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA's also toured both the assistant living and memory care. LPA's observed activity rooms, wellness cove, private dining, massage room, and media ballroom. LPA's observed sufficient lighting throughout the facility. LPA's observed the facility to be clean and in good repair. LPA observed residents’ rooms and they are equipped with the required furniture. LPA's observed resident room 109 had a very strong urine odor. It was learned R1 moved to the facility of 2/1/2025 and it was learned that resident has a change in condition. Based on record review, resident has proper documentation in place. During today's visit maintenance shampooed resident's carpet. Resident will relocate to another room temporarily. There are no bodies of water present. LPA's toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 109.1 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. Continuation 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 The fire extinguisher is located in the hallways of each floor and was last serviced on 04/16/2025. LPA's observed the facility has a has a public telephone in the staff offices and the facility has the required posters posted. Facility thermostat was 73 degrees Fahrenheit. LPA's observed toxins located in the kitchen area and kept locked and inaccessible to residents. LPA's observed sharp knives in the kitchen and inaccessible to residents. LPA's checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 5 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA's requested resident and staff files for review. LPA's reviewed 10 out of 10 resident files and it was complete.LPA's reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report (6) LIC 309 Administrator Organization As a result of this annual visit, the facility is in compliance with Title 22 Regulation, An exit interview was conducted with Kathleen Gilbey and a copy of these LIC 809, LIC 809-C, LIC 9102 reports, and Appeals rights were provided to the facility.

It was stated that after inspection there was no evidence to show that there were presence of bed bugs in those apartments other than the affected unit. In addition, the facility ensured to bag up any clothing and went through high heat washing and drying as directed by Eco Lab. About 3 weeks later, the facility stated that the apartment across the hall had bed bugs. Facility management decided that it was best to call in another company to inspect the apartment. That company then conducted a heat treatment and inspected the apartments next to the affected apartment and did not have indications of bed bugs present. A review of the facility records of invoice records of both Eco Lab and Premier Pentacle that show that the facility went through bed bug treatment immediately after the notification of bed bugs. In addition, LPAs observed bed bug canine servicing that was conducted during the visit conducted on 10/30/2024. Based on the information gathered, it is unclear if the facility did not keep the facility free from bug infestation. Allegation: Staff did not ensure a resident had sufficient clothing It was alleged that staff did not ensure a resident had sufficient clothing. During the course of this investigation, LPA reviewed facility records and conducted interviews. Based on interviews conducted, it was learned that the facility hired a second bed bug company Premier Pentacle who advised that all belongings were to be left in the apartment unit to ensure that all items were treated with high heat. As a response, the facility moved two residents over to another unit and contacted their responsible parties to inform them that they would not have their belongings for several days. However, due to unforeseen circumstances, the responsible parties were unable to gather clothing or hygiene items for these residents. In response, the facility went out to local department stores and bought items such as pillows, t-shirts, pants and hygiene items. A review of the facility invoices and copies of these receipts were reviewed and confirmed that the facility had bought these items for the residents affected by the bed bugs. In addition, an interview with 2 residents confirmed that they had clothing at the time of transfer. Based on the information gathered, it is unclear if the staff did not ensure a resident had sufficient clothing. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.

On 07/23/2024, Licensing Program Analysts (LPAs) Arielle Pascua and Pang Lee arrived unannounced to conduct a case management visit. LPAs met with Facility Designated Administrator (FDA), Kathleen Gilbey and explained the purpose of the visit. The purpose of this visit was to follow up on an incident report received by the department on 06/29/2024. On 06/23/2024, the department received an LIC 624 incident report that occurred on 06/23/2024 regarding resident 1 (R1). LPA reviewed the incident report, and it was learned that on 06/23/2024, during an internal community medication audit, it was noted that (R1)’s Megestrol Acetate 40 mg with directions of take 2 tablets by mouth 2 times daily for 3 weeks was not given to resident from 06/03/2024 to 06/06/2024, 06/12/2024 to 06/20/2024 for a total of 12 days. Furthermore, the incident report dated on 06/29/2024 states that R1 was diagnosed by a home health nurse that they have an unstageable wound on 06/20/2024 at 5:30pm and sent to UC Davis hospital for further evaluation on 06/21/2024. Based on record review, this incident report was faxed to the department on 06/29/2024, however the incident occurred on 06/20/2024 and 06/21/2024. As a result, the facility did not follow the reporting requirements. LPA obtained facility records. Due to insufficient time to review documentation and conduct interviews the department will come at a later date to follow up on the incident reported on 06/29/2024. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page. An exit was interview conducted, and a copy of the 809 report, 809-D page, and appeal rights were given to the facility.

It was also learned from Vice President of Operation, Terry Ervin that the facility response time is between 15 minutes or less. The documents revealed that 7 out of 8 residents SMART care log were not responded within 15 minutes or less minutes per Vice President of Operation, Terry. In addition multiple SMART care logs indicated that staff did not respond to residents until 30 minutes later. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with administrator and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. 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 It was also learned that (R1) needed assistance with staff helping (R1) carry the oxygen tank to put on (R1)’s new motorized wheelchair. Based on (R1)’s Physician Report (R1) is able to administer his/her own oxygen. Moreover, (R1)’s Resident’s Assessment dated on 04/30/2024, (R1) uses continuous oxygen and requires staff monitoring and assistance of an appropriately skilled professional. (R1)’s Individualized Service Plan (ISP) also states that (R1) needs assistance with (R1)’s portable oxygen tank and placing on (R1)’s electric scooter, every morning. (R1) also needs to have oxygen tank checked each evening in preparedness for the next day. Based on records reviewed, It was learned that on 05/18/2024 (R1)’s oxygen tank was check during the morning, noon and evening. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are 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 violation(s)occurred.

On 04/24/2024 at 8:28 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Kathleen Gilbey and explained the purpose of the visit. Administrator Certificate # 6059719740 expires on 05/19/2025. The current census is 138. LPA Lee and Marketing Director Janae Fernandez inspected the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA Lee and Marketing Director also toured both the assistant living and memory care. LPA Lee observed two movie theaters, activity room, wellness cove, bar and lounge, private dining, fitness room, salon, massage room, activity rooms, wine cellar and media ballroom. LPA Lee observed sufficient lighting throughout the facility. LPA observed the facility to be clean and in good repair. LPA observed 10 residents’ rooms and they are equipped with the required furniture. LPA Lee and Marketing Director observed resident room 333 had a very strong urine odor. There are no bodies of water present. LPA measured the water temperature, temperature measured at 113.1 degrees F which meets the 105–120-degree Fahrenheit regulation. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Grab bars awere observed to be stable and in good repair at this time. Continued 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 Smoke and carbon monoxide detectors are in compliance with fire safety. Multiple fire extinguisher is located throughout the building in both assistant living and memory care building and was last serviced on 04/12/2024. Facility thermostat observed at 72 degrees Fahrenheit. LPA Lee observed toxins kept locked and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed and compared 3 medication administration record (MAR) along with residents’ medications and it was complete. The first aid kit was checked and contained all the required components. LPA Lee checked and tested 5 residents pendant and it was observed that facility staff came to check on those 5 residents under 5 minutes. LPA Lee inspected the two elevator in the building and it is in good repair and is current and will expire on 08/23/2024. LPA Lee also inspected the exhaust hood and is in good repair. Last service date was on 02/15/2024 and an upcoming service date is scheduled for 06/2024. LPA Lee requested residents and staff files for review. LPA Lee reviewed 6 resident files and 5 staff files, and they were complete and organized. The following documents were given to LPA during today's visit. (1) LIC 308 Designation of Administrative Responsibility (2) LIC 610 Emergency Disaster Plan (3) Proof of Current Liability Insurance (4) Current LIC 500 Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.

on 3/20/24 at 11:00am Licensing Program Analysts (LPA) conducted an unannounced case management inspection to address concerns discovered during an unrelated complaint investigation. LPA conducted and interview with S1 and R1. LPA conducted file review for R1. Due to time constraints the case management will be continued on a later date. There are no deficiencies cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff and a copy of this report was left at the facility.

Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 11/16/2023 at 12:30 PM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee met with administrator, Luis Olivas and explained the purpose of the visit. The purpose of this visit is to follow-up on prior deficiency and plans of correction that were due on 11/07/2023 from a complaint investigation which was conducted on 10/24/2023. The census is 147. As of the dated of this visit, 11/16/2023 at 12:30 PM, the department has not received any forms and documents from the administrator to support the plan of correction has been completed by the facility. Civil Penalties were assessed on today’s date for failure to correct 87303(i)(1)(B). The Facility was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected. However, during today's visit at 2:30 PM, administrator, Luis Olivas provided LPA Lee POC documents of training materials and staff sign in sheet for the Personal Health Button Report (PHBR) training. Administrator also provided statement of acknowledgement that administrator is aware of the regulation that was cited on 10/24/2023 and two audit (PHBR) logs. Based upon this inspection and interview, the LPA observed the following: I. The deficiency cited under Title 22 Regulation 87303(i)(1)(B) has been cleared. The licensee did not complied with the terms of the POC by POC due date 11/07/2023; however, during today's POC visit, administrator, Luis Olivas provided POC documents to LPA Lee. A POC letter was generated and provided to the facility. An exit interview was conducted and a copy of this LIC 809 report, and civil penalties was provided to administrator, Luis at the end of this visit.

As a result, the facility addressed the elevator issue in a timely manner. Due to the above noted 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, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.

Per the report received and statements obtained by the LPA from RP, resident had a seizure like episode when staff were present in the room. Staff immediately contacted alpha one for medical transport as resident stabilized and was responding to questions when ambulance was called for transportation. Resident had another unidentified episode and expired at the facility. resident had a due not resuscitate order. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegation of questionable death is unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies noted or cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility. 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 Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of personal rights are unfounded but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies noted or cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.