Lo-har Senior Living.

(Continued from LIC9099, Page 1) Staff interviews revealed that staff provide medical visits for residents through a mobile doctor who visits the facility on a weekly to biweekly basis. Staff 1 (S1) stated that Resident 1 (R1) is not allowed to sign documents or make financial or medical decisions. S1 noted that R1 sees the mobile doctor on a biweekly basis. S1 told the LPA that they are afraid that R1 could become a victim of financial abuse or worse if they were to sign documents provided by visitors without the POA or responsible party present. Outside Source interviews revealed that R1 has been receiving medical appointments through the facility. Outside Source 1 (OS1) Confirmed they are able to see R1's progress notes and medications through an online charting system. Additionally, OS1 stated they are in communication with the facility twice a week about R1's condition and progress. This corroborates staff interviews. OS1 stated they have no concerns about the facility's ability to provide care for R1 and noted to the LPA that since having moved in, R1's condition has improved greatly. Records review revealed that R1 has been seen by the mobile doctor during the period of the complaint per the progress notes dated, 03/20/2026, 04/01/2026, 04/09/2026. Review of the progress note dated 03/20/2026 stated and confirmed that R1 is "forgetful, unable to concentrate, and unable to make appropriate medical or financial decisions independently." This corroborates outside source and staff interviews. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Yolonda Torres, Clinical Director and Executive director Andy Chin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Correia conducted a Case Management visit to check on the health and safety of the Residents in care. LPA Correia was greeted by Caregiver Bishop, identified herself, was granted entrance, and met with Clinical (CD) Director Torres and disclosed the purpose of the visit.. During today's visit, the LPA Correia toured the facility, briefly spoke to Residents in care, and secured records. There were no immediate health or safety concerns observed during the visit. An exit interview was conducted with CD Torres, to whom a copy of this report, and Licensee Rights (LIC 9058), will be provided at conclusion of the visit.

(Continued from LIC9099 p.1) Both Wellness Coordinators (supervisors) were working the NOC shift during the timeframe of incident. No witnesses or injuries were found in the internal investigation, and Resident 2 (R2) denied touching R1 or getting up in the middle of the night, as accused. Staff noted that the accusation was also inconsistent with R2's typical behaviors. Both residents reside in the facility's Memory Care building. Resident interviews did not corroborate the allegation, as R1 refused to speak about the situation to LPA during interview. R1 did not confirm that they made the allegation about someone hurting them when asked. R2 was aware that R1 accused them of hurting them, but stated that they did not. R2 informed that they try to stay away from R1 and do not engage with them. Outside source interviews did not corroborate the allegation. An outside advocacy agency staff (OS1) familiar with the facility informed that they did not have concerns about the facility's supervision of residents. OS1 advised having visited the facility and speaking with the residents, none of whom have expressed concern about staff supervision. OS1 stated that the staff properly addressed the situation when the allegation was made. OS1 had not seen any resident care needs go unmet related to supervision. A second outside source familiar with the allegation informed that no physical marks or injuries were observed on R1 when the allegation was made, and that no specific date or time was advised regarding when the event occurred. There were no witnesses to the alleged incident. Records review revealed facility progress notes detailing the accusation, the facility's internal investigation, and required reporting. The "Physician's Report for Residential Care Facilities for the Elderly (RCFE)" for both residents showed that both residents suffered from cognitive impairments, and that neither resident had behaviors of aggression. Preplacement Appraisals for both residents indicated that the residents tended to say to themselves. During and unannounced facility visit LPA walked the property twice. LPA observed caregivers, housekeepers, and maintenance staff walking around the facility. LPA observed caregivers engage with residents and ask how they were doing, as well as provide assistance with Activities of Daily Living (ADLs). LPA observed staff in all buildings where residents were residing throughout the visit. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Clinical Director Yolie Torres , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Clinical Director Yolanda Torres. According to the facility’s license, the facility has a maximum capacity of 68 residents of which 41 may be non-ambulatory with a hospice waiver for 10. The facility is comprised of 6 stand-alone buildings, with two memory care areas both approved for secured perimeter. LPA toured the interior and exterior of the facility and inspected multiple rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Water temperature in residents rooms were measured all between 105 degrees F to 119 degrees F. There are no bodies of water present. A few mattresses required replacing and Clinical Director agrees to have them replaced. LPA toured and observed the commercial kitchen and walk-in refrigerator. The kitchen was clean, organized and sanitary. Cooking/dining equipment and utensils were present. There was sufficient perishable food and at least two weeks worth of non-perishable food. LPA observed multiple medication carts and first aids were complete and readily accessible. Medications were labeled, as required, and stored in locked medication carts. Resident records contained the required documentation. Staff records contained the required documentation. LPA reviewed care staff first aid refresher training's within the facility training system. Per Clinical Director, no firearms or ammunition are kept at the facility. Fire extinguishers were readily accessible in each cottage and have been serviced within the last year. No deficiencies were cited on todays visit. An exit interview was conducted with Clinical Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to during the visit.

R1’s Physician Report established that R1 does not require continuous monitoring or continuous bed care According to the second allegation, neglect to R1 resulted in multiple stage 1 and stage 2 pressure injuries to genital area and ankle. Facility records revealed R1 was admitted with a quarter size scab to the ankle. Records also revealed that R1 has a history of skin breakdown prior to admission. Staff interviews did not reveal any information to corroborate that R1 was neglected resulting in pressure injuries. The third allegation states facility retained R1 who required a higher level of care. Records collected revealed facility conducted a pre-admission appraisal and found R1 to be at facility’s level of care available. Physician report dated January 16, 2023, did not show any restricted or prohibited diagnosis. Interview with staff revealed there were no issues with the level of care required by R1. According to the fourth allegation, the facility did not address R1’s ten-pound weight loss while in care. Records were unable to confirm R1 lost the weight during the eight day stay at the facility. Interview with staff could not corroborate that R1 was not monitored or R1’s changes were not identified during R1’s stay. According to the fifth allegation, R1 was not given enough fluids resulting in dehydration. Interview with multiple staff revealed residents are given water or juice throughout the day in addition to the beverage with their meals. Interview with other residents reveal residents are provided with numerous drinks throughout the day. There were no records documenting R1 as dehydrated. The sixth allegation states facility staff were not responding timely to call button. Interview with staff could not establish that facility was not responding timely to call button. Records collected could not establish facility staff were not responding timely to residents in need. Interview with residents revealed that they are assisted within a few minutes of requesting assistance. The seventh allegation states R1 was not provided with any clean clothing. Interview with laundry staff revealed that laundry is done regularly and there is one full time employee conducting laundry service. Interview with residents revealed that they do have full laundry service. LPA Strong observed laundry service and confirmed such information. According to the eighth allegation, R1 was only fully showered one time during R1’s stay. Interview with staff revealed that residents also receive sponge baths as well as showers. Interview with residents established that facility staff provide residents with bi-weekly showers or sponge baths depending on resident. Interview with staff could not establish that facility staff only provided R1 with one shower during stay. Lastly is was alleged that R1 was not assisted with toileting needs. Interview with staff could not establish that R1 was not assisted with toileting. Interview with residents established that they are changed frequently or assisted to the restroom when requested. There were no records available to corroborate allegation. Based on interviews, records available and observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Clinical Director Yolanda Torres and Director Jonathan Wheeler to whom a copy of this report, and the Licensee/Appeal Rights were provided.

It was also alleged that R1 was not assisted with incontinence care during the night. Records collected revealed that as of January 11, 2022, R1 returned from a brief hospital stay with a noted higher level of care. Records show R1’s care plan was updated, and staff were reminded that R1 needed more assistance. Interview with residents revealed that they had no issues with the care being provided by staff. Interview with outside source could not corroborate R1 was not receiving incontinence assistance at night. Lastly it was alleged that R1 was not being provided with prescribed dietary shake. Records collected revealed R1 was prescribed dietary shake as of January 24, 2022, and records show R1 began receiving such shake daily as of January 25, 2022. Interview with staff present during this time revealed R1 was regularly receiving shakes and there was one incident of the prescription not arriving on time due to delivery error. Interview with outside source could not confirm R1 did not receive shakes. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Clinical Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) emailed to.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on two incidents reported to Community Care Licensing. LPA met with Clinical Director Yolanda Torres and discussed the purpose of the visit. Community Care Licensing received a SOC341 on 5/25/25 in which it was reported that Resident #1s (R1) was being treated roughly by Staff 1 (S1). According to interview with Clinical Director, an internal investigation was conducted and S1 was placed on a corrective action plan but no abuse to R1 was found. Additionally, on 7/1/2025, the Department received an incident report stating Resident 2 (R2) did not receive their prescribed medication and suffered no adverse results. According to Clinical Director, all staff have been retrained on medication management and managerial staff will be conducting random medication audits and shadowing of staff. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. No deficiencies were cited during today’s visit. An exit interview was conducted with Clinical Director. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights.

(Continued from 9099) Resident #1 (R1) 's physician report dated July 22, 2023, indicates that R1 uses a wheelchair for mobility and exhibits wandering behavior. However, a review of records and department observations confirmed that R1 can self-propel their wheelchair and navigate the facility grounds independently. Records review of an outside medical provider revealed that the licensee staff appropriately notified R1's medical provider of a change of condition. The medical provider responded for evaluation and determined that a hospital visit was unnecessary. Interviews with staff indicated that staffing was based on residents' acuity levels. Medication Technicians (Med Techs) on each shift were an extra person to assist when needed. Additionally, the facility used an Agency/Registry staff to help assist in the recommended staffing numbers. Regarding the allegation, the facility had no food service director. More specifically, there is no dietary person at the facility, and they do not know if there is emergency food and water as per the regulations. Annual inspections conducted by the department reveal that there are emergency food and water supplies at the facility. Interviews and records review confirm that the Licensee employs one designated person responsible for food planning, preparation, and service. Regarding the allegation, the staff did not meet the residents' laundry needs. More specifically, clothes were not cleaned on time. Interviews with staff reveal that staff usually wash and fold laundry on the NOC shift. Interviews with staff also reveal that they are aware of the laundry service needs and are hiring additional staff. However, the department did not observe residents wearing soiled clothing. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Jonathan Wheeler , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A reply E-mail or read receipt confirmation was requested from Executive Director Wheeler upon receipt of documents

R1 stated that they reported the incident to Wellness Coordinator and the said staff was terminated. Interview with Wellness Coordinator revealed that such incident was not reported to them. Interview with Clinical Director revealed that there have been no known incidents between staff and residents and no staff have been terminated recently due to interactions with residents. Interview with other residents could not confirm the incident. Interview with outside source could not establish the incident occurred. Based on interviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Clinical Director to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Records also show that as of March 31, 2025, R1 was prescribed medication and warm liquids to assist with gastrointestinal issues. Based on this information, facility had active communication with R1’s medical provider. The second allegations states that on a undisclosed date, R1 had not eaten for two days. Records collected revealed that R1 refused meals on March 13, 2025. Interview with multiple staff revealed that R1 did not like to eat and would often skips meals. Interview with an outside source established that R1 did have access to protein shakes as needed. The third allegation states that Resident 2 (R2) had not been given water for two days. Interview with an outside source revealed that R2 was having regular bowel and bladder movements which did not make outside source believe water was being withheld. Interview with staff established that R2 enjoyed eating and drinking and would communicate needs often. LPA Strong also observed multiple water coolers throughout the facility available for resident use. Lastly, it was alleged that facility bedding was not washed correctly, resulting in urine odors. During today’s date, LPA Strong did not notice any malodors in resident rooms or bedding. Interview with staff established that staff were unaware of clean bedding having any remaining malodors. Interview with outside sources could not corroborate that facility bedding had malodors. Based on interviews, and record reviews the preponderance of evidence was not met to prove alleged violations, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

During the investigation, the Department collected pertinent resident records, outside source records and conducted various interviews. According to details of the allegation, R1 reported that on December 11, 2023, Staff 1(S1) lifted and threw R1 during an emergency evacuation at the facility causing fractures to multiple ribs. Medical records confirmed that on December 12, 2023, R1 was diagnosed with fractured ribs. Interview with S1 revealed that S1 did not assist R1 in the evacuation on December 11, 2023, and S1 was focused in extinguishing the fire in a residents’ room. Interview with Staff 2, who was also present on the date of the incident, revealed R1 was not assisted out of the facility as R1 is ambulatory. Records collected revealed that R1 was later found with a fire lighter and cardboard on the date of the fire and was considered a suspect of arson to the facility. During further interviews it was found that on December 9, 2023, R1 had an outburst where R1 urinated on the floor of the facility, destroyed holiday decoration and hit Staff 3 (S3) and Staff 4 (S4). Interview with S3 and S4 revealed R1 slapped S3 and punched S4; attempts of S4 to intervene in further violence on S3 and residents, resulted in S4 and R1 slipping on the urine-soaked floor, causing S4 to fall on top R1. S4 believes the fall may have caused R1’s fractured ribs. After the incident, S3 and S4 assessed R1 for injuries and R1 reported to be fine. Records collected confirmed R1 has assaulted multiple staff and destroyed facility property. Interview with an outside medical source established that facility attempted to protect R1 from self and others and injuries may have not been an act of abuse. Further interviews revealed that R1 has a history of chest pain, and according to Staff 5 (S5), R1 reported having chest pain as of December 6, 2023. Interview with R1 established that R1 believed their ribs were injured as of the first incident on December 9, 2023. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove p hysical abuse to resident by facility staff resulted in serious bodily injuries. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22 ) were provided .

During the investigation, through record reviews, and interviews, the Department established the following sequence of events. Based on staff statements, on December 23, 2024, at or around 4pm, R1 was heard calling R2 derogatory names then R2 hit R1 in the face, which resulted in a cut and bruising to R1’s face. According to multiple staff, R1 and R2 were separated and R1 was provided first aid while emergency personnel arrived. At this time, R1 was taken to receive medical care and R2 was sent to a psychiatric hold for a safety evaluation. While both residents were away, Wellness Coordinator requested R1 and R2’s Primary Care Provider to re-evaluate both resident’s medications but such changes were denied. On the same night of the incident, both R1 and R2 were discharged back to the facility. On this date, there were three staff present to intervene in the incident, provide first aid and contact emergency personnel. According to outside source records, on this date R1 was diagnosed with an abrasion to the forehead and contusion of the forehead. The investigation also found that on December 24, 2024, at or around 4pm, R1 was heard calling R2 the same derogatory names and R2 hit R1 in the face multiple times. Staff present established that the altercation was heard, and multiple staff assisted in separating the two residents. On this date, emergency personnel were contacted but only medical assistance arrived. R1 was then taken to receive medical care. Outside source records collected revealed that this incident resulted in R1 having a cut to the scalp as well as a hematoma, but no fractures were found. According to interview with the Wellness Coordinator R1 and R2’s rooms are now in different parts of the same building; their meals are served in different locations and there is additional supervision to both residents. R2 has since received medication to assist with agitation. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove staff neglect and/or lack of supervision resulted in resident-on-resident altercation with injury. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Wellness Coordinator Jenna Purnell, and Executive Director Jonathan Wheeler and discussed the purpose of the visit. Community Care Licensing received an incident report on 12/18/24 in which it was reported that Resident #1s (R1) prescribed as-needed medication went missing from the facility. According to records and interviews on 12/9/24 Staff 1 (S1) accepted a delivery of Medication 1 (M1) from a courier. On 12/16/24, Wellness Coordinator was informed that M1 was missing from medication room. Interviews established that R1's medication on-hand was sufficient to provide R1 with medication without missing a dose. It was also revealed that incident was reported to medical provider, pharmacy and another government agency. Interview with R1 corroborated that R1 has not missed medication. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director Jonathan Wheeler. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Wellness Coordinator Jenna Purnell, and Clinical Director Yolanda Torres we discussed the purpose of the visit. Community Care Licensing received an incident report on 10/29/24 in which it was reported that Resident #1 (R1) eloped from the facility on 10/29/24. R1 was found by responsible party. Per interviews the licensee followed absentee notification plan as necessary. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. No deficiencies were cited during today’s visit. An exit interview was conducted with Wellness Coordinator Jenna Purnell, and Clinical Director Yolanda Torres. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights.

According to interview with R2, R1 hit R2 while sitting in the common area. Interview with R2 corroborated that R2 hit R1 after R1 called R2 derogatory names. Interview with staff present revealed R1 and R2 have not had previous instance of disagreements or violent behaviors with each other. Interview with staff present on the date of the incident revealed that staff were feet away from residents when the incident occurred. Interview with outside source revealed that this was an isolated incident. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Business Office Manager Amanda Pepin and Clinical Director Yolanda Torres, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Iby Strong conducted a plan of correction visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Business Office Manager Amanda Pepin-Laphen. The purpose of the visit was to issue LIC421FC for ongoing civil penalties. On 5/17/24, the licensee was issued a duplicate deficiency for a violation in California Code of Regulations Section 87411(c)(1) originally issued on 11/3/23 . As of yesterday, 5/21/24, Executive Director provided LPA with proof of correction. Based on such information, a civil penalty of $100 per day from 5/18/24 until 5/21/24 was assessed. An exit interview was conducted with Business Manager Amanda Pepin-Laphen, whose signature below confirms receipt of a copy of this report, the LIC421FC, and the Licensee Appeal Rights (LIC9058 3/22).

Outside source also revealed facility does not have any history in limiting resident from contacting emergency personnel. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation are unsubstantiated. An exit interview was conducted with Executive Director Jared Green, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Rebecca Ruiz conducted a plan of correction visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Interim Wellness Director Jenna Purnell. LPA met with Administrator Jared Green. The purpose of the visit was to verify if the deficiencies issued on 3/29/2024 had been corrected. On 3/29/2024, the licensee was issued multiple deficiencies with a correction due date of 4/29/2024. As of today’s date, 5/6/2024, the licensee has not submitted proof of correction to the Department. During today’s visit, LPA Ruiz observed residents in care and spoke with Administrator and Interim Wellness Director. Per Administrator and Interim Wellness Director, the report that LPA Ruiz provided the previous Wellness Director on 3/29/2024 was not provided to the Administrator, and both individuals were not aware of the POC due date. Additionally, the previous Wellness Director's last day working at the facility was 4/15/2024. LPA Ruiz provided Administrator with an LIC178 and granted a POC due date extension for the deficiencies cited on 3/29/2024. The new POC due date is 5/31/2024. An exit interview was conducted with Interim Wellness Director Jenna Purnell and Administrator Jared Green, whose signature below confirms receipt of a copy of this report, the LIC178, and the Licensee Appeal Rights (LIC9058 3/22).

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Executive Director Jared Green, and we discussed the purpose of the visit. Community Care Licensing received an incident report on 4/15/24 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 4/13/24. R1 was found by emergency responders and returned to facility. Per records reviewed licensee followed absentee notification plan as necessary. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. LPA Strong observed auditory alarm installed in the memory care cottage. No deficiencies were cited during today’s visit. An exit interview was conducted with Medication Technician Anastasia Hanna who was also provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights.

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to deliver an amended LIC9099 report. LPA was greeted by, identified herself to, and explained the purpose of the visit with Wellness Director Rosa Barajas. During today’s visit, LPA obtained Baraja’s signature on the amended complaint report dated 1/27/2023. An exit interview was conducted with Wellness Director Rosa Barajas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

Interview with an outside source confirmed R1 does not have a history of declining medication. Records collected did not corroborate that resident did not take medication. It was also alleged that staff entered R1’s medication into the medication administration records as administered when R1 was not at the facility. Interview with staff revealed that computer has a special code that identifies when medication is issued with a number 0 and not issued with a number 8. Records reviewed verified R1 was not at the facility starting February 29, 2024, and a number 8 was entered into those records. LPA Strong also observed two medication administrations had been edited by staff. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Business Office Manager to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Executive Director Jared Green, and we discussed the purpose of the visit. Community Care Licensing received a phone call and voicemail on 3/10/24 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 3/10/24. R1 was found by emergency responders and taken to local emergency room. Per records reviewed licensee followed absentee notification plan as necessary. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director Jared Green. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Jared Green, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided

Two caregivers were in the dining room at the time of R1’s fall, and two additional staff members responded to assess R1. Facility staff called 911 as R1 reported being in pain. R1 was taken by ambulance to the hospital where R1 was diagnosed with a hip fracture. Interviews with R1, staff and outside sources revealed that R1 is prone to falls due to both a medical condition and a temperament such that R1 is resistant to efforts intended to discourage R1 from attempting to walk and other fall mitigation efforts. The facility provided R1 with a pendant to alert staff when they need assistance and fall alert mats were placed near R1’s bed and chair. R1 lost the pendant and disabled the fall alert mats. Due to R1’s vulnerability to falling, staff member check on R1 every 30 minutes. Staffing the facility has been a concern since the COVID-19 pandemic. The facility had ongoing hiring efforts to replace staff that resigned. Although at the time of the incident staffing was not at pre-pandemic levels, interviews with staff and outside sources revealed that staff worked hard to meet all resident’s needs. R1’s fall was not due to either inadequate staffing or a lack of care and supervision. Based on observation and statements from internal and external sources including R1, the investigative findings are unsubstantiated. An exit interview was conducted and a copy of this report, and appeal rights were given to Karriem Jones.

Interview with Staff 1 (S1) revealed R1 has requested assistance with eating from S1, S1 has assisted R1, R1 will eat a small portion then R1 will state that was enough assistance and continue eating on their own. Interview with R1 revealed R1’s increased frustration with disease progression but no information to corroborate allegation. Interview with outside source did not reveal any corroborating evidence to prove staff have denied R1 with assistance. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Jared Green, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Iby Strong conducted a Case Management Visit on today’s date. LPA met with Wellness Director Jenna Purnell and discussed the purpose of the visit. On 12/11/2023 the RO received notification from the Licensee that the facility had a fire. There are six (6) buildings on the property. The fire was reported to occur in Building B, room 8. According to staff present, at approximately 8:45am, the facility fire alarms went off. Staff immediately evacuated 20 of the residents residing in this building. All 20 residents of this building were accounted for and were brought to the adjacent buildings on the property. Local fire and police arrived. Local fire department provided all clear of fire at approximately 1:00 PM. During today's visit, LPA conducted a health and safety check on the residents in care and observed the room where the fire took place. The room was clean and damaged furnishings have been replaced. No deficiencies were cited or observed on this date. An exit interview was conducted. The Licensee will be provided a copy of the Licensee/Appeal Rights (LIC9058 03/22).

Interview with outside source verified that R1 is receiving such care. Interview with outside source also revealed that they did not believe that R1 was neglected, rather that the facility established wound care with medical provider in a timely manner. Records and interviewed also revealed that R1 Stage II pressure ulcer has healed due to proper care of wound. It was also alleged that R2 was forced to sleep on the living room couch and their bed was given to another resident. Interview with staff revealed that R2 preferred to sleep on living room couch and multiple staff attempts to redirect resident but resulted in resident returning to couch. Interviews also revealed R2’s bed was not given to another resident, rather, another resident slept in R2’s bed when it was not in use. Interview with outside source revealed that R2 was given the right to a safe and comfortable accommodation. Additionally, it was alleged that staff did not prevent R3 from harming R4. According to interviews with Staff 1 (S1) and Staff 2 (S2) on November 2, 2023, staff observed R3 having an emotional outburst that resulted in R4 being pushed by R3 and R4 sustaining a skin tear on the back of the hand. Interviews also revealed R4 was given first aid. Interview with outside source established that there were no concerns regarding the supervision and care of R3 as well as R4 are receiving. Lastly, it was alleged that R4’s responsible party was not notified of R4’s injury after altercation with R3. According to S2, S2 contacted the responsible party by telephone on the date of the incident. LPA Strong also observed a signed incident report created by S2 that documented S2 contacting the reporting party. Interview with outside source established that responsible party did not receive a phone call regarding such incident. Based on LPA's interviews, observations, record reviews and conflicting statements there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Wellness Director Jenna Purnell to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Interview with an outside source revealed that R1 was not withheld from conducting telephone calls. Lastly, LPA Strong observed two functioning telephone’s in R1’s cottage. Based on LPA's interviews, observations and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Wellness Director Jenna Purnell, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to observe the physical plant. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Jared Green. On 07/06/2023, Licensee submitted a written request to the CCLD San Diego Regional Office (RO) applying for approval to lock perimeter fence doors and gates associated with the facility's two (2) memory care buildings, thereby creating a secured perimeter around those areas. The request did not involve locking other perimeter doors of the facility, and did not involve amending the facility's total capacity, bedridden capacity, or floor plan layout. On 09/08/2023, the local fire authority granted an updated fire clearance to the facility. The secured perimeter associated with the facility's memory care buildings was already present on the date of the fire inspection. The fire clearance gave approval for the secured perimeter. During today’s visit, LPA briefly toured facility, interviewed staff, and reviewed pertinent records. LPA verified that the current sketch/floor plan is consistent with the current layout of the facility, and that the facility’s posted evacuation routes have been updated to reflect the locked courtyard fence gate. Per review of the LIC624 Physician's Reports for the residents who live in the facility's memory care section: a) all were diagnosed with dementia or a similar neuro-cognitive disorder, and b) none had as their primary diagnosis a mental disorder unrelated to dementia. Licensee has also informed each resident's responsible person (where applicable) in writing of the use of secured perimeter in the facility's memory care section. [CONTINUED ON LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] In their interviews, staff confirmed: c) without violating residents' personal rights, they attempt to redirect residents who try to leave the facility, d) residents who still insist on leaving are allowed to leave, with staff accompanying them for safety, and e) staff understand that locked perimeter doors/gates are not a substitute for trained staff in sufficient numbers to meet the care and supervision needs of residents. Licensee has obtained from CCLD an approved waiver to California Code of Regulations, Title 22, Section 87468.1(a)(6). The facility’s disaster drill logs showed at least one drill per quarter was conducted on each of its three work shifts. Licensee’s Plan of Operation describes the facility’s locked perimeter fence gate. LPA observed no immediate health or safety issues. No deficiencies were cited during today's visit. This portion of the application process is complete. Pending CCLD management’s final review and approval, the licensee will be sent an updated license to reflect the new fire clearance. An exit interview was conducted with Green, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

According to allegation, R1’s was left outside of facility and due to such neglect suffered a medical emergency. Interview with Wellness Director revealed that on the date of incident R1 was sitting outside on memory care porch when R1 stated they did not want to come inside. Wellness Director indicated assessing resident multiple times and each time R1 was at baseline. According to the interview, one hour later R1 was slouching down, no longer at baseline and emergency personnel were contacted. Interview with staff present on the date of the incident corroborated that R1 was assessed multiple times prior to incident. Records collected revealed that on September 9, 2022, R1 was taken to emergency room by paramedics and was diagnosed with a urinary tract infection. Records collected did not reveal any information that indicated neglect of resident. Outside source interview revealed that R1 prefers to sit outside on facility porch and will chose to stay outside for long periods of time. Outside source also revealed that they have no issues with care being provided to R1 by facility staff and have seen no indication of resident neglect. It was also alleged that R2’s medical records were not maintained accurately. During investigation, LPA reviewed R2’s records and observed physicians report, resident plan of care and multiple medical records including medication prescriptions. Interview with outside source did not reveal any documentation missing or inaccurate. Interview with Wellness Director did not corroborate R2’s records were not maintained. Lastly, it was alleged that R2 was not afforded a bed to sleep on. According to R2’s Physician Report signed July 13, 2023, R2 can leave facility unassisted and can communicate needs. Additionally, R2 records collected revealed that R2 has had recent increases of agitation towards staff and roommates. During investigation LPA Strong observed R2’s assigned room within assisted living with a bed, television, night stand, lamp, and personal belongings. Interview with R2 revealed that R2 is sleeping on wheelchair in the memory care cottage living room by choice and is refusing to use bed in assigned room. According to interview with R2, bed in assigned room is not comfortable for their personal needs. Interview with outside source revealed that R2 was scheduled to move out of this facility on September 26, 2023, but declined new facility and chose to stay at current facility. Interview with Executive Director revealed R2 chooses to sleep in wheelchair and R2 has declined three other room options. Records also did not reveal any special bed prescribed to R2 by the medical provider. Based on LPA's interviews, observations and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Wellness Director Jenna Purnell, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

[Continued from LIC9099] Outside Source 3 (OS3) was interviewed and there has been no observations or reports of staff hitting any residents. R1 was interviewed and R1 reported that the staff have been respectful and has never hit R1, nor has R1 ever observed any other residents being hit or treated poorly.  R1's Physician's Report confirmed that R1 is able to make decisions and does not have any cognitive deficits. R1 was observed to have no cognitive deficits which concurs with the Physician's Report.  Resident 2 (R2) was interviewed and R2 had no concerns or complaints regarding staff.  Resident 3 (R3) was interviewed and R3 stated that there were no complaints with staff. It was alleged that the Facility staff did not safeguard residents belongings. LPA Domingo reviewed records and there is sufficient evidence that R1 had a list of belongings and the list coincided with R1's belongings.  R2 records were reviewed and the resident belongings matched what R2 had in R2's room.  R1 was observed with all of the listed items on the belongings list and R1 stated that there were no missing items. R3 records were reviewed and the belongings matched what R3 has in R3's room.  Staff 1 (S1) was interviewed and was able to explain the policy and procedure of recording resident's belongings. Staff 2 (S2) was interviewed and S2 was able to explain the residents personal belongings list and how the list is updated as needed.  Staff 3 (S3) was able to provide the facility policy of replacement of misplaced items. The Department has investigated the allegations listed above.  Based on evidence obtained, including interviews and records reviewed, the above allegations are determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard. An exit interview was conducted with Wellness Coordinator Jenna Purnell and a copy of this report and Licensee/Appeals Rights (LIC 9058 03/22) were provide.

During the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Wellness Director, Jenna Purnell whose signature below confirms receipt of these rights.

Interview with Maintenance Director revealed that management has been collecting bids for contractors to begin replacing the HVAC and repair the damaged ceiling. Records collected revealed that there are agreements in place with two companies to begin repairs, these documents date back to August 18, 2023. Interview with outside source confirmed these contacts are in place as of today’s inspection. Lastly, it was observed that the area in the living room was closed off with caution tape and there were no health or safety issues present. Based on LPA's inspection, interviews, and record reviewed there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Jared Green to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided .

It was alleged that there was uncleared staff at the facility. Interviews revealed all staff that work at the facility are cleared. Interviews revealed one staff was hired in early 2023 and worked a half of day, at the end of the day the old administrator told the staff they were no longer allowed to work at the facility until they are fully cleared and that they made a mistake. The staff was not around any residents, and did not work directly with the residents while they were there. Interviews revealed at the that time the staff was cleared by DOJ but had not been cleared from FBI. Once the administrator noticed their mistake the let the staff go the same day. That same staff came back once they were completely cleared. Interviews did not reveal that uncleared staff were at the facility. It was alleged that facility toilets are in disrepair. Interviews revealed the maintenance man fixes the toilets around the facility. Once a complaint has been made and a ticket has been put in they work on the issue as soon as possible. There were maintenance reports that show a plumber coming out to the facility to fix what the maintenance man could not correct. Upon LPA observations while touring the facility, random toilets were flushed in the different buildings with no issues Interviews did not reveal that facility toilets are in disrepair. It was alleged that facility is not conducting emergency drills as required. Interviews and documents revealed there are monthly emergency drills being done. Facility provided documentation of drills. Interviews did not reveal that facility is not conducting emergency drills as required. The allegations of illegal Eviction, uncleared staff at the facility, facility toilets are in disrepair and facility is not conducting emergency drills as required are unsubstantiated. An exit interview was conducted with Jenna Purnell, Wellness Coordinator . A copy of this report and Licensee Appeal provided at the conclusion of the visit.