Commons at Elk Grove, the.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit. LPA Moleski reviewed five resident files (R1-R5) and five staff files (S1-S5). LPA Moleski toured the facility with Cortez and inspected common areas, kitchen areas, resident bedrooms, bathrooms, and outdoor areas. The facility temperature was 76 in memory care and 80 degrees in assisted living, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 116 in memory care and 115 in assisted living, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locking medication room for the storage of medication. LPA Moleski observed locked storage closets for the storage of cleaning solutions. LPA Moleski interviewed four staff members (S1, S6-S8) and four residents (R5-R8). No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Cortez.

R1's preplacement appraisal also noted a diagnosis of dementia, but also indicated R1 was active and did not require personal help with most activities. The preplacement appraisal does not mention any significant concerns regarding R1's cognitive abilities at the time. LPA Moleski reviewed narrative charting for R1 dated from their move-in on 3/19/24 to their departure from the facility on 4/9/24. A note on 3/24/24 indicated that R1 had attempted to elope from the facility around 12:38 p.m. According to the note, R1 was escorted back inside from the rear parking lot, where they had been trying to open car doors. In an interview, S1, who escorted R1 back inside, said they heard the door alarm going off and followed R1 out, eventually redirecting R1 and bringing them back into the building without further incident. Another note from 3/24/25 around 10:26 p.m. indicated that R1 had gone out of the building and "walked off towards the road." R1 said they were going for a walk when they were found by a caregiver, who walked R1 back to their room, according to the note. In an interview, S2, the author of the note, confirmed the incident described in the note, and confirmed that R1 was alone outside of the building. A note dated 3/26/24 stated that R1 eloped out through a back door, and was found walking back in through a different set of doors. In an interview S2, the author of this note, said they did not see R1 outside, and by the time they responded to the door alarm R1 was already walking back inside on their own. A note dated 3/28/24 stated that an alarm went off around 3 p.m. R1's friend was present in their room, and told staff that R1 had gone for a walk around the building, per the note. R1 was found by staff walking behind the facility, according to the note. In an interview, S3, the author of the note, confirmed the events described in the note. R1's LIC 602 did not address whether or not R1 was permitted to be outside the facility unaccompanied by staff. The location on the LIC form used to identify whether or not R1 would be at risk when outside on their own was left blank. However, an assessment for R1, effective as of 3/19/24, indicated that R1 needed total assistance or wheelchair escorts to and from activities and meals, that R1 needed extensive psychosocial supports and behavioral interventions, and that R1 suffered from memory impairment, suggesting that R1 needed continuous supervision to maintain their safety. Based on the above, the facility did not prevent R1's elopements and/or did not accompany or supervise R1 during all elopement incidents, which will be addressed in a separate report. [continued on 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 Moleski reviewed email conversations between facility management staff and R1's RP. On 3/28/24, a manager sent an email to R1's RP requesting a care conference to discuss having a one-on-one caregiver for R1 between 3 p.m. and 9 p.m. due to R1 "leaving the building a number of times" and because R1's use of "the back door has escalated and it is challenging to keep [R1] safe." A manager sent another email to R1's RP on 3/29/24 informing them that the rate for one-on-one caregivers was $35 per hour, and notified them that this would be added to their bill. R1's RP sent an email to Cortez on 4/5/24 while discussing the potential for daytime one-on-one hours. R1's RP said that they "insist the initial 'sundowning' hours from 3pm to 9pm remain until we find an alternative." LPA Moleski reviewed R1's billing statements. Starting from 3/29/24, R1 was charged for a total of 40 hours of one-on-one care, totaling $1400 at a rate of $35 per hour, which is just under seven days of one-on-one care given the hours of 3 p.m. to 9 p.m. R1's last day at this facility was 4/9/24, 11 days after 3/29/24. In an interview, Cortez said R1 was not charged for all of the one-on-one care that was provided as a courtesy. Health and Safety Code Section 1569.657(a) states that rates for care may be increased, provided that written notice of the increase providing an explanation of charges is provided to the resident and the resident's responsible party. The requirements of this section appear to have been met based on the emails reviewed by LPA Moleski, given that management explained to R1's RP the rate of the increase and the need for the increase over several emails with sufficient advance notice pursuant to §1569.657(a). On 4/5/24, Cortez sent an email to R1's RP informing them that the night before, R1 had gone out for a walk in the rain trying to look for a friend's car while accompanied by care staff. A narrative charting note dated 4/4/25 corroborated this incident. Cortez went on to say in this email that R1 "has progressively gotten more agitated with the staff who are working with [R1]" and that "at this point I don't believe [R1] is appropriate for Assisted Living. I feel [R1] would do better in a larger memory care setting ... Of course I would love to retain [R1] in our memory care but we are unfortunately full at this point and I am unsure when we will have an opening ... We of course will continue to have him reside in our Assisted Living until he can find another placement in a memory care facility." On 4/8/24, R1's RP said the following in an email response to Cortez: "Thank you for the suggested alternatives for memory care. We have chosen one of them and will be moving [R1] tomorrow..." In interviews, both Cortez and R1's RP agreed that no eviction notice had been served. [continued on 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 Moleski reviewed meal attendance tracking sheets during R1's period of residency, from 3/19/24 to 4/9/24. LPA Moleski observed seven meals for which R1's attendance in the dining room was not recorded. No staff member interviewed was aware of any instances in which R1 had not been provided meals while at the facility. Staff members interviewed indicated that R1 would be brought room service if they did not want to eat down in the dining room. Narrative charting notes for R1 indicated that R1 often preferred to stay in their room for most of the day. According to R1's RP, R1 has severe memory issues and would not be able to recall any events from their time at this facility. The department has determined the following as it relates to the allegations that the facility illegally evicted a resident in care, that staff overcharged a resident in care, and that staff did not ensure a resident was provided meals: Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Cortez. 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 R1's preplacement appraisal also noted a diagnosis of dementia, but also indicated R1 was active and did not require personal help with most activities. The preplacement appraisal does not mention any significant concerns regarding R1's cognitive abilities at the time. LPA Moleski reviewed narrative charting for R1 dated from their move-in on 3/19/24 to their departure from the facility on 4/9/24. A note on 3/24/24 indicated that R1 had attempted to elope from the facility around 12:38 p.m. According to the note, R1 was escorted back inside from the rear parking lot, where they had been trying to open car doors. In an interview, S1, who escorted R1 back inside, said they heard the door alarm going off and followed R1 out, eventually redirecting R1 and bringing them back into the building without further incident. Another note from 3/24/25 around 10:26 p.m. indicated that R1 had gone out of the building and "walked off towards the road." R1 said they were going for a walk when they were found by a caregiver, who walked R1 back to their room, according to the note. In an interview, S2, the author of the note, confirmed the incident described in the note, and confirmed that R1 was alone outside of the building. A note dated 3/26/24 stated that R1 eloped out through a back door, and was found walking back in through a different set of doors. In an interview S2, the author of this note, said they did not see R1 outside, and by the time they responded to the door alarm R1 was already walking back inside on their own. A note dated 3/28/24 stated that an alarm went off around 3 p.m. R1's friend was present in their room, and told staff that R1 had gone for a walk around the building, per the note. R1 was found by staff walking behind the facility, according to the note. In an interview, S3, the author of the note, confirmed the events described in the note. R1's LIC 602 did not address whether or not R1 was permitted to be outside the facility unaccompanied by staff. The location on the LIC form used to identify whether or not R1 would be at risk when outside on their own was left blank. However, an assessment for R1, effective as of 3/19/24, indicated that R1 needed total assistance or wheelchair escorts to and from activities and meals, that R1 needed extensive psychosocial supports and behavioral interventions, and that R1 suffered from memory impairment, suggesting that R1 needed continuous supervision to maintain their safety. Based on the above, the facility did not prevent R1's elopements and/or did not accompany or supervise R1 during all elopement incidents in order to ensure R1's health and safety while out of the building. LPA Moleski reviewed email conversations between facility management staff and R1's RP. On 3/28/24, a manager sent an email to R1's RP requesting a care con

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit. LPA Moleski reviewed an incident report regarding a resident elopement and interviewed Cortez. LPA Moleski will return to conduct additional staff interviews regarding this incident, as the staff members involved were not present during this visit. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Cortez.

In an interview, Cortez said that, since R1 had hit their head when falling, staff were required to call 911. Cortez said that after the initial visit from paramedics, R1’s responsible party (F1) was called to request that F1 take R1 to the hospital. Cortez explained that she was concerned that R1 could have suffered externally unidentifiable brain trauma, and wanted R1 to be seen by a doctor. Cortez said that R1 continued to seem off baseline, which necessitated a second call to first responders. According to Cortez, F1, who is an attorney-in-fact for R1, said staff could call first responders a second time and take R1 to the hospital. Paramedics responding to this second call said that R1 was able to refuse to be taken to the hospital, and so did not take R1, according to Cortez. Cortez said F1 was contacted again, and after further discussing the situation, F1 agreed to have F2 take R1 to the hospital. Cortez said that she was clear while speaking with R1’s responsible party that R1 was not being forced to go to the hospital. In an interview, F1 said that she was told by Cortez over the phone that part of the facility’s admission agreement indicated that R1 had to be sent out to the hospital because R1 hit their head when they fell. F1 said they did eventually agree to have R1 taken by emergency services to the hospital, and after the paramedics declined to take R1, they further agreed to have F2 take R1 to the hospital. F1 said that, before R1 was even seen at the hospital, Cortez called F1 back and said R1 did not need to be seen at the hospital per facility policy. F1 said R1 was not admitted to the hospital. LPA Moleski reviewed this facility’s admission policies regarding emergency medical services and observed no such provisions requiring residents to be seen at a hospital following a fall in which they suffer a blow to the head. LPA Moleski reviewed Commons policy regarding falls which states that caregivers or other staff will call emergency medical services when a resident “exhibits any change in level of consciousness, or received obvious head … trauma.” LPA Moleski did not review any additional policy documents which describe the frequency with which 911 shall be called in the event of a resident fall. 22 CCR Section 87465(g) states that licensees “shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health….” Additionally, 22 CCR Section 87466 states that licensees shall “ensure residents are regularly observed for changes in physical … functioning and that appropriate assistance is provided when such observation reveals unmet needs … When such changes … are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident’s physician and the resident’s responsible party….” [continued on 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 In an interview, R1 said they did not feel forced to go to the hospital, but said staff provided a “strong suggestion” that they should be seen by a doctor. R1 said the outcome of the discussion with staff and paramedics was that R1 could refuse to be sent out if they did not want to be sent out. In interviews, two staff present during the incident as described above on 9/6/2024 (S2-S3) said they did not observe other staff members forcing or pressuring R1 to be seen at the hospital. The department has determined the following as it relates to the allegation that staff pressured a resident to accept emergency transport to the hospital: Based on interviews and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Cortez.

LPA Moleski reviewed notifications which were sent to residents and their responsible parties by text, phone, and/or email. On July 14, residents and their responsible parties were informed that the water heaters were down. On the morning of July 16, another notification was sent stating that one water heater was completely nonfunctional, while the other was having intermittent issues. Residents were asked to notify maintenance staff if the water was too cold. A notification sent on July 17 stated that the water heaters were still having issues, and maintenance staff were waiting on parts to arrive. A notification on July 18 stated that water would have to be shut off for one hour in order to make repairs. A second notification that same day stated that the water was back on and the water heaters were fully repaired. LPA Moleski interviewed the facility maintenance director (S1). S1 said that they were first notified that there was an issue with the water heater when residents began complaining of cold showers on July 14. S1 said they were able to get one of the two residential water heaters up and running that day, but with limited hot water capacity. S1 reached out to a plumbing company, which sent out a technician, who began to diagnose the water heaters. LPA Moleski reviewed a work order for this company which showed they had visited on July 14. S1 and S1's assistant, S2, said that the technician was supposed to return the next morning, but did not do so. Instead, facility staff reached out to a second third-party maintenance company, according to S1 and S2. A technician from this second company arrived on July 15, according to S2. S1 was off on July 15. S2 said this technician performed various diagnostic tests, replacing various parts and testing for functionality. S2 said a technician would need to return for troubleshooting the next day. S1 returned on July 16, and was once again able to make one hot water heater functional. S1 said that a technician returned on July 16 and identified the part which was needed to repair the water heaters, but since it was after hours by that point, the part could not be ordered until the following day, July 17. LPA Moleski reviewed an email thread which showed S1 had reached out to a supplier in order to source necessary parts for the water heaters on July 17. S1 said that a technician returned on July 18 and was able to install the necessary part, thus resolving the issue. S1 said the water heater had sprung a small leak, so water had to be shut off for about an hour while repairs were made. S1 and S2 said the water heaters have been functional since then. S1 said that hot water from the kitchen was available to residents during the time period that the residential hot water heaters were down. [continued on 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 Moleski reviewed an invoice from the second third-party maintenance company. Notes provided by the company corroborate the timeline provided by S1 and S2. The notes state that various diagnostic tests were performed on July 15 and 16, and that repairs were made to the water heaters and the water leak on July 18. LPA Moleski reviewed a list of six water tests performed by maintenance staff on July 18. All tests resulted in a reading of 118 degrees. LPA Moleski interviewed three floor staff (S3-S5) and three residents (R1-R3), including the resident council president. All staff interviewed said that residents were informed of the issues with the water heaters and that they were given the option to either shower normally with lukewarm water, or to have hot water delivered from the kitchen for their hygiene and grooming. R1 said staff had informed them of the situation as it developed and said staff "did everything they could" to bring hot water to residents who wanted it. R2 said staff were very accommodating, and offered various options while the water heaters were being repaired, including offering to give sponge baths. R3 said that they were notified that there was hot water in the kitchen while the hot water heaters were being repaired. LPA Moleski tested water at two sites in opposite wings of the facility, which draw water from separate hot water heaters, according to Cortez. LPA Moleski observed a reading of 111 degrees Fahrenheit at both locations, which is within the range of 105 and 120 degrees. The department has determined the following as it relates to the allegation that the facility is not delivering hot water for residents in care. Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Cortez.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit. LPA Moleski reviewed 10 resident files (R1-R10) and 10 staff files (S1-S10). LPA Moleski toured the facility with Cortez and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 106 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked rooms for the storage of medication. LPA Moleski observed locked closets for the storage of cleaning solutions. LPA Moleski interviewed five staff members (S11-S15) and six residents (R11-R16). No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Cortez.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit. LPA Moleski reviewed a death report describing a resident's (R1's) death on 3/12/24. The cause of death was unknown, according to the death report. LPA Moleski interviewed Cortez and four staff members (S1-S4) and reviewed resident records. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Cortez.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit to follow up on two incident reports describing resident falls. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit. The incident reports described an unwitnessed fall suffered by a resident (R1) on 12/4/23 and an unrelated fall suffered by another resident (R2) on 12/8/23. LPA Moleski interviewed Cortez and a staff member (S1) who was present when R2 fell. LPA Moleski reviewed resident records and facility records. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Cortez.

LPA Moleski observed staff count out all centrally stored narcotics stored on two medication carts on October 2, 2023. LPA Moleski observed an accurate count of the narcotics, and reviewed narcotic administration records which reflected the count of narcotics accurately. LPA Moleski interviewed eight residents (R2, R11-R17) and 11 staff members (S1-S11). None of the residents or staff members interviewed expressed any issues with running out of medications, or being unable to order new medications. None of the staff members interviewed were aware of any irregularities with regard to the facility’s narcotic count. The department has determined the following as it relates to the allegations that staff do not ensure medications are properly managed for residents in care and that staff do not ensure medication records are maintained for residents in care: Based on observation, record review, and interviews, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Cortez.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit to follow up on an incident report. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit. The incident report described an unwitnessed resident (R1) fall on August 31, 2023. LPA Moleski interviewed Cortez, a staff member, and reviewed R1's file. R1 was not available to be interviewed. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Cortez.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on an incident report. The report described a physical altercation between two residents (R1-R2). LPA Moleski interviewed Cortez and a staff member (S1). LPA Moleski reviewed R1's and R2's file. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Cortez.