Gardens at Laguna Springs Memory Care, the .

CDSS

→2025-05-06

Mixed

Type A · 1

→2024-12-06

Annual Compliance Visit

CDSS

→2024-09-16

Unsubstantiated

→2023-06-28

Unsubstantiated

View raw inspection records →

→

The Rulebook

The rules that apply to this facility.

State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.

What dementia-care training must staff complete?22 CCR §87705 / HSC §1569.625

Plain language

Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.

Ask on tour

“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”

How many staff must be on duty overnight?22 CCR §87415

What health conditions can this facility legally accept or refuse?22 CCR §87612–87615

What must this facility report to the state — and how fast?22 CCR §87211 / WIC §15630

How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58

Tour Prep

Questions to ask before you visit.

A short pre-tour checklist tailored to Gardens at Laguna Springs Memory Care, the's record and state requirements.

01 /

The facility has 12 serious citations on file across all inspections — can you provide your corrective-action plan for each cited item, and show families any documentation of remediation steps taken?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

02 /

17 complaints are on file with CDSS — were any substantiated, and what remediation did the facility take in response to substantiated findings?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

03 /

One dementia-care citation under §87705 or §87706 appears in the inspection record — can you provide your corrective-action plan for that specific regulatory deficiency and any documentation of steps taken to achieve compliance?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

Full Inspection Record

Every inspection visit, verbatim.

12 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.

reports on file

total deficiencies

severe (Type A)

2025-12-23

Other Visit

No findings

Plain-language summary

An unannounced annual inspection was conducted in April 2026, and no violations were found. The inspector toured the facility and reviewed bedrooms, bathrooms, common areas, emergency equipment, food supplies, and resident and staff files—all were in order and up to date with required documentation. The facility passed all compliance requirements.

Read raw inspector notes

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection, LPA Valerio met with Director of Care Services Tiffany, and explained the purpose of the visit. LPA Valerio later met with Administrator Guadalupe Ramirez. LPA Valerio and Administrator Guadalupe Ramirez toured the facility to ensure compliance of Title 22 regulations. LPA Valerio observed 3 (three) resident bedrooms. The bedrooms were observed to be free from odors, fully furnished, and organized. Resident bathrooms located in the bedrooms were observed to sanitary. Common area bathrooms were observed to be clean, sanitary, and stocked with hygiene supplies. Common areas of the facility, which include the hallways, dinning area, lobby seating area, and activity room, were observed to free from hazardous items, fully furnished, and free from odors. LPA Valerio observed the facility to have an adequate food supply. The fire extinguishers around the facility were observed to be fully charge. The fire company was conducting their annual inspections during LPA's visit. The last emergency drill training was on November 05, 2025. Annual fee was received 10/01/2025. LPA Valerio reviewed four (4) resident files and four (4) staff files. Resident and staff files were observed to be up to date with required annual documentation. LPA Valerio obtained the following annual documentation. LIC 500, LIC 308, LIC 309 LIC 610, and copy of Liability insurance. Per California Code of Regulations - Title 22, no deficiencies were observed. An exit interview was held, and a copy of the report was provided.

2025-10-21

Complaint Investigation

No findings

Plain-language summary

On October 21, 2025, a licensing analyst conducted a case management visit and requested documents related to a former resident, including meal records, records of urine and bowel output, and medical communications. The facility stated that staff do not keep daily records of meals, urine, or bowel movements unless a doctor orders monitoring or there is a change in the resident's condition, though staff may note unusual findings in a resident's chart. No violations were found during this visit.

Read raw inspector notes

On 10/21/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility to conduct a case management visit. LPA initially met with Jordan Reymundi and stated the purpose of the visit. The Executive Director/Administrator, Guadalupe Ramirez, was notified of the visit and arrived shortly after. During the visit, the LPA requested copies of documents related to a former resident (R1). This request included, but was not limited to, meal logs, records of urine and bowel output, and all communications with R1’s doctors and/or other medical professionals. The LPA requested that any available documents be sent by email no later than the end of the business day on 10/21/25. LPA requested any additional documents that are found later be submitted via email. Per interview with Reymundi and Ramirez, staff usually do not keep daily records of what residents eat unless a doctor gives an order or there is a change in the resident’s condition. Sometimes, staff might write in a resident’s chart if the person didn’t eat, but they don’t track meals in detail every day. When it comes to urine and bowel movements, staff also don’t record this information daily unless a doctor orders for it because of a health concern. If something seems unusual in their urine or bowel output, staff might make a note in the resident’s chart, but they don’t regularly monitor these outputs. For communication with R1's doctor, they would need to look through their records and will send any information they find. No deficiencies were cited on today's visit. Exit interview was conducted and a copy of this report was provided.

2025-05-06

Complaint Investigation

Mixed

Type A · 1 finding

Inspector · Arvin Villanueva

Plain-language summary

A complaint investigation found that a resident developed multiple pressure injuries (bedsores) while at the facility, with evidence indicating they developed over several days during the resident's stay despite staff reports of regular brief changes and checks. The investigation also found no evidence that staff neglect caused the resident's hospitalization for low blood sugar and respiratory failure, or that staff failed to meet the resident's bathing needs, as records showed the resident was offered showers twice weekly and received sponge baths when refusing showers.

Type A22 CCR §87466

Verbatim citation text · 22 CCR §87466

“Based on interviews and record reviews, R1 developed multiple pressure sores while in care. This poses an immediate heath, safety and personal risks to resident in care.”

Read raw inspector notes

Hospital Physician corroborated this information by explaining that the pressure injuries could have developed over the course of a few days, but not in a single day. This suggests that the injuries likely developed during R1’s residency at Gardens at Laguna Springs. The Executive Director of the facility, Guadalupe Ramirez (S1), reported that R1 wore briefs that were changed after every meal or accident, and staff reportedly checked briefs every two hours. However, there was no documentation or staff reporting of any pressure injuries. Staff member (S3) stated that R1 wore pull-ups as a preventive measure, that R1 was sometimes incontinent, and that pull-ups were changed approximately three times per day. A review of R1’s medical records obtained from the hospital confirmed the presence of multiple pressure injuries which were described as "community acquired," with moisture components noted on the sacrum, bilateral buttocks, scrotum, penis, and coccyx. Based on the information gathered, the allegation that resident R1 sustained multiple pressure injuries while under the care of Gardens at Laguna Springs Memory Care is SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit. Exit interview was conducted with Guadalupe Ramirez and a copy of this report and appeal rights were provided. {2 of 2} 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 Interview with S1 stated that R1 had been eating less in the days leading up to the incident and this was discussed with W1, who agreed that R1 typically ate small portions. Staff were instructed to assist and hand-feed R1 when needed. Interview with S2 reported that R1 was offered meals three times daily along with snacks. S2 stated that R1 sometimes required encouragement or hand feeding, especially when tired. However, R1 never completely refused meals and always had access to food and snacks. On 07/15/2024, staff reported that R1 was lethargic and did not eat throughout the day because R1remained asleep. Upon finding R1 being nonresponsive, staff checked R1’s blood sugar and found it to be low. 911 was called immediately, and R1 was transported to the hospital. Review of medical documentation from Emergency Medical Services (EMS) confirmed that R1 was hypoglycemic prior to hospital transport. Medical records from hospital listed acute respiratory failure as the primary diagnosis upon admission. Physician stated that low blood sugar could have contributed to R1's altered mental status and may have predisposed R1 to respiratory complications such as pneumonia. Additionally, per record reviews and interviews, there was no physician order in place at the facility for routine blood sugar monitoring for R1, despite a history of diabetes. Based on the gathered information, there is insufficient evidence to support the allegation that staff neglect resulted in R1’s hospitalization. Staff documentation and interviews consistently indicate that R1 was being monitored regularly, provided food, and offered assistance with eating. While R1 did experience a medical emergency due to low blood sugar, there is no clear indication that facility staff failed to meet R1’s basic care. Therefore, the above allegation was UNSUBSTANTIATED. {2 of 6} 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation - Staff did not meet the residents bathing needs The investigation into this allegation consisted of review of facility records, interviews with staff and review of documentation related to R1’s bathing schedule and care. Review of the Resident Assessment dated 07/16/2024 , R1 requires assistance with bathing twice a week. The assessment specifies that R1 needs hands-on help with bathing, utilizing a shower chair, and staff assistance for scrubbing hard-to-reach areas. Review of the shower body audits for 07/10/2024 , 07/14/2024 AM , and 07/14/2024 PM reveal that on the dates R1 was scheduled for a shower, R1 refused to take a shower but accepted sponge baths instead. The audits also indicate that staff observed R1’s body during the sponge baths and did not note any wounds, bruises, burns, excoriations, or rashes. Review of staff statement, S1 documented a statement about R1's bathing needs, mentioning that R1's responsible party (RP) had accused the facility of failing to provide a shower on a specific date. However, Guadalupe clarified that the facility had provided sponge baths during the AM and PM shifts on that day, as R1 had refused the shower. Review of another staff statement, S2 confirmed that R1's shower schedule was set for two days a week (Tuesday and Saturday). On days when R1 did not have the energy for a shower, R1's responsible party agreed that staff could provide a bed bath. S2 also stated that when residents refused showers, staff attempted different techniques to encourage bathing, but residents could not be forced to bathe. When a shower or bed bath was provided, staff performed a skin assessment and documented any findings. Staff interviews confirmed that R1 had refused showers on occasion, it was explained that R1's physician’s report did not provide specific instructions for bathing or shower needs. Additionally, staff interviews confirmed that R1 was offered showers twice a week and provided with sponge baths as an alternative. Based on the gathered information, there is insufficient evidence to support the allegation that staff did not meet R1’s bathing needs. Therefore, this allegation was UNSUBSTANTIATED. {3 of 6} 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation - Staff did not ensure a resident was properly fed The investigation into this allegation consisted of review of facility records, interviews with staff and review of documentation related to R1’s bathing schedule and care. Review of the Resident Assessment dated 07/16/2024 indicates that R1’s care plan for meals was labeled as "minimal," with the requirement for assistance with cutting food, encouragement for hydration, and supervision due to R1’s special dietary needs. These included a mechanical soft meal, avoidance of sugary desserts, and the need for thin liquids due to R1’s diabetes and lactose intolerance. R1’s care plan specifically outlined these requirements, and it was the responsibility of the facility staff to ensure the care plan is followed. Interview with W1 claimed that on 07/14/2024, staff reported that R1 had not eaten breakfast or lunch, and that staff had forgotten R1 was diabetic, leaving R1 without food until the W1 intervened. However, interviews with facility staff, including staff members S2 and S3, provided additional information. Statement from S2 revealed that R1 was offered food three times a day, with snacks, and that when R1 was tired or uninterested in eating, staff would either try to hand-feed R1 or leave food nearby for R1 to eat independently. S2 confirmed that R1 always had access to food, and there was never a failure to offer meals. S3’s statement further supported this, detailing how R1 had been sleeping throughout the day on 07/15/2024, and that R1’s family had requested staff not to disturb R1 during these periods of deep sleep. S3 confirmed that snacks and ice water were provided, in case R1 woke up hungry. Review of the facility’s documentation and progress notes indicated that R1 had been monitored for vital signs, though there was a noted discrepancy regarding blood sugar monitoring. However, no direct evidence was found in the records to suggest that R1 was not offered food or hydration. Based on these findings, there is no sufficient evidence that staff did not provide adequate meals or assistance with feeding to R1. While there may have been lapses in documentation and monitoring, these do not directly support the allegation of neglecting R1’s basic nutritional needs. Therefore, the allegation is UNSUBSTANTIATED. {4 of 6} 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation - Staff left a resident unattended The investigation into this allegation consisted of interviews with facility staff and other relevant parties. Interview with W1 revealed that R1 reported being left alone for five hours without staff checking in and that R1 felt thirsty but was unable to get up. Interviews with multiple facility staff consistently indicated that staff were attentive and followed regular check-in procedures. Staff reported that they generally checked on residents every hour, and more frequently if necessary, depending on the resident’s individual needs and mobility. Interview with staff member S1 confirmed that most residents, including R1, spent much of the day in the common area under staff supervision. Residents who chose to stay in their rooms were checked on after every meal and monitored by motion detectors that alerted staff if residents moved. S1 further stated that staff would often check on residents anytime they passed by their rooms, in addition to the standard hourly checks. Interview with S2 similarly indicated that staff were in frequent contact with residents, aiming to check on them hourly and monitoring for signs of medical concerns, such as pressure injuries. S2 also explained that residents like R1 wore briefs, which staff checked and changed every two hours or sooner if needed. S3 added that residents were generally checked on every 30 to 45 minutes when in their rooms, with the assistance of motion detectors to alert staff of movement. Additional interviews with staff members (S4, S5, S6) consistently confirmed that hourly rounds were c

2024-12-06

Annual Compliance Visit

No findings

Inspector · Christina Valerio

Plain-language summary

A state inspector made an unannounced visit to conduct the facility's annual inspection, checking common areas, bedrooms, bathrooms, emergency equipment, food supplies, and resident and staff files. All areas were clean and well-maintained, hot water was at the proper temperature, medications and hazardous items were locked up safely, fire equipment was in working order, and required documentation was current. No violations were found.

Read raw inspector notes

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA Valerio met with front desk staff, and explained the purpose of the visit. LPA was shortly met by Administrator Guadalupe Ramirez. LPA Valerio and Administrator toured the facility to ensure compliance of Title 22 regulations. LPA Valerio observed common areas, which included the lobby area, two lounge areas, an activity room, dinning hall, and hallways. All areas were observed to be clean, fully furnished, free from debris, and free from odors. Residents were observed walking in the hallways, sitting in common areas, or engaging with staff members. LPA Valerio checked one restroom located in the common area. The bathroom was observed to be sanitary, have hygiene supplies, and stocked with toilet paper and paper towels. Hot water in the bathrooms were measured and determined to provide hot water within the regulatory range of 105.0 - 120.0 degrees F. LPA Valerio toured multiple resident bedrooms. Bedrooms, which include a bathroom, were observed to be fully furnished, free from odors of incontinence, and clean. Toxins, sharps, and medications were observed to be locked and inaccessible to residents in care. Fire extinguishers were observed to be within compliance and fully charged. All emergency exits were free from obstructions. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises LPA Valerio reviewed four (4) resident files. Resident files were observed to be up to date with required annual documentation. LPA Valerio reviewed four (4) staff files. Staff files were observed to have required annual training. Continues on LIC 809 - C... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC 809 LPA Valerio followed up on an incident report submitted to the Regional Office on 11/28/24. After discussion with Administrator Guadalupe Ramirez, there are no health or safety concerns regarding the incident. LPA Valerio obtained the following for the Regional Office Facility File: LIC 500 - Personnel Report, LIC 308, LIC 309 - Administrative Organization, LIC 610D, and copy of current Liability Insurance. Per California Code of Regulations (CCR) - Title 222, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.

2024-09-16

Complaint Investigation

Unsubstantiated

No findings

Inspector · Christina Valerio

Plain-language summary

A complaint alleged that a resident's pillow had ants on it; a video submitted showed black ants on bedding. During an inspection on August 26, 2024, inspectors found no pests in the resident's room, common areas, or bathrooms, and staff showed documentation of monthly pest control services with increased treatments in recent months. The complaint was unsubstantiated due to insufficient evidence that a violation occurred.

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...Continued from LIC 9099 On 08/23/2024, the Local Ombudsman conducted an announced visit to the facility. It was reported that when they visited, the room was spotless and free from pest. On 08/26/2024, LPA Valerio observed the facility and R1's bedroom. LPA inspected common areas, hallways, dining tables, and activity area. LPA inspected R1's bed, pillow, corners of the bedroom, around the cat food, and in the bathroom area. Pests were not observed during the visit. LPA took pictures for future reference. On 08/26/2024, LPA Valerio reviewed the video submitted to the Regional Office. The video captures a pillow on a Resident 1 (R1) bed. The pillow is covered with black ants, small to medium sized ants. There are some that are dead on the pillow and some that are crawling on the pillow along with a few on the bed sheets. LPA Valerio attempted to interview the resident in care. However, due to communication barriers, the interview was unsuccessful. Residents did not appear to be in distress and were being supervised by staff members. LPA Valerio interview Staff 1 (S1). S1 reported that "they do have ants; however, staff do a good job about cleaning up after the residents. This place is in the middle of a field, so I assume this was the ant's home before we got here… There is not a time where we do not try to address the issue." According to an interview with Staff 2 (S2), S2 stated that they have had pest control services come every month, but they have also increased their services within the last month. S2 provided invoices from June, July, August, and September. S2 stated that they comes and check all the rooms and outside of the facility. They put the sprays and everything. Staff do constant check of the rooms and when it is known there are pest, they say it on their walkie talkie. They assess to see if the resident has any on them, if they are in the room. They shower them, check for any food, and clean the room. According to Pest Control Invoices, the facility has a monthly pest service. On 05/29/24, 06/18/24, 08/09/24, pest control services provided normal service in addition to treats for the ant issue. 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(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.

2023-12-14

Other Visit

No findings

Inspector · Ruth Wallace

Plain-language summary

During a routine annual inspection in December 2023, inspectors toured the facility's living areas, kitchen, medication room, and common spaces, and reviewed resident and staff records. No violations were found; the facility maintained proper food supplies, secure medication storage, working safety equipment, and appropriate water and indoor temperatures. The facility was in compliance with state regulations.

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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Annual Inspection Visit. LPA met with Administrator and explained the purpose of the visit. Administrator assisted with today’s visit. The facility had a mitigation plan completed and approved on 6/17/2021. LPA toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. A review was conducted of the apartment sizes and different layouts. Each unit has mini-split air and heating unit. The medication room was toured. Kitchen pantry and walk-in freezer was toured for adequate food supplies and storage. LPA observed required furniture and lighting throughout the facility. The hot water temperature was measured at 113.4*F in resident apartment during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility measured at 73*F which was within the required range of 68-85*F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s) were last inspected on December 7, 2023. First aid kits were up to date. Smoke and carbon monoxide detector(s) in the facility were in good repair. Continued on 809-C Page 2 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 809 - Page 2 LPA reviewed seven resident files and seven staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. LPA requested the following documents for facility file to be sent via email by December 20, 2023: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 610-E Emergency Disaster Plan, and Liability Insurance. ruth.wallace@dss.ca.gov Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held with administrator. A copy of report and LIC 811 (Confidential Names) left at facility.

2023-10-30

Complaint Investigation

Unsubstantiated

No findings

Inspector · Tung Truong

Plain-language summary

A complaint investigation found no evidence to support allegations that staff failed to safeguard residents' belongings, mismanaged medication, improperly supervised fall-risk residents, or spoke inappropriately to residents in care. The facility was found to have monthly pest control services with additional treatments for ants that residents reported seeing, and residents have access to snacks and food throughout the day, though not unsupervised kitchen access. Staff training records were reviewed and verified, and the facility encourages families to lock up valuables when residents move in.

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Regarding the allegation that staff are not safeguarding residents’ belongings, it was determined that there is not a preponderance of evidence to substantiate the allegation. Based on statement obtained, it was learned that facility has encouraged families to lock resident’s valuable upon move-in. Based on staff interviews, staff stated that they will help locate misplaced items and redirect residents if they try to enter a room that is not theirs. As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated 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. Exit interview was conducted and a copy of the report was provided upon exit. 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 Regarding the allegation that staff are not properly addressing pest infestation in facility, it was learned that pest control services were being done monthly and additional days were added to address the pest infestation that was happening in Elk Grove. According to resident interviews, residents stated that they observed some ants in their rooms, but it was treated. LPA conducted a review of the resident rooms and did not observe any pests. Regarding the allegation that staff prevent residents from accessing food, it was learned that all staff and residents have access to snacks and a variety of food on a daily basis. It was learned that residents do not have access to the kitchen for safety reasons. Based on resident interviews, residents stated that staff will provide snacks and food if they ask. Regarding the allegation that staff mismanage residents’ medication, there is not a preponderance of evidence to substantiate the allegation. Based on statements obtained, it was learned that medications were provided to residents according to doctor’s order. LPA conducted a medication review and did not observe any discrepancies. Regarding the allegation that staff are not properly supervising residents who are a fall risk, LPA finds insufficient evidence to substantiate the allegation. Based on statements obtained, it was learned that residents who are at fall risk were closely monitored. Regarding the allegation that staff speak inappropriately to residents in care, LPA finds insufficient evidence to substantiate the allegation. Based on statements obtained, there was no supporting information found. LPA interviewed staff S1, S1 denied making any inappropriate comments about residents. Regarding the allegation that staff are not trained appropriately to provide care to residents, LPA reviewed staff files and verified staff training. LPA interviewed staff S2. S2 denied providing any care to residents. S2 stated that they were only redirecting resident while waiting for available caregivers to come and assist. Continued on 9099-C

2023-10-26

Other Visit

No findings

Inspector · Tung Truong

Plain-language summary

This was a follow-up meeting held in October 2023 to address ongoing compliance problems at the facility, including six new complaints and four violations related to administrator qualifications, resident rights, care supervision, and the facility's operational plan. The state identified concerns about how the facility oversees staff, handles residents with behavioral challenges, and uses outside agency workers. The facility agreed to provide updated policies, revise its plan of operation, and ensure all staff and the administrator receive training on resident care and reporting requirements by early November 2023.

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A Non-Compliance Conference (NCC) was conducted on this day, 10/26/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 9/30/2022. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, LPM Stephen Richardson, Licensing Program Analyst (LPA) Tung Truong, LPA Christina Valerio, facility Regional RCFE Stephen Sarine, VP of Operation Michelle Baker and facility staff Barb Rose and Kayleen August. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process as well. Since the last meeting on 9/30/2022, six new complaints have been filed against the facility and four Type A deficiencies have been cited. The facility was cited for the following issues: Personal Rights of Residents in All Facilities, Administrator Qualifications and Duties, Basic services care and supervision and Plan of Operation. The focus of the concerns at this time were as followed: - Designated Facility Administrator-Qualifications/Duties - Maintaining continued compliance - Oversight of facility staff for proper care and supervision - Facility staff roles, duties, and responsibilities - Plan of Operation regarding outside agency Continued on 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 - Plan of Operation regarding resident with behaviors - Adhering to the Plan of Operation - Outside staff fingerprint clearance and facility association Licensee agreed to do the following in order to bring the facility into compliance: Please provide the following to LPA by 11/3/23. - Provide updated Plan of Operation regarding admitting resident with behaviors - Provide updated policies and procedures regarding using outside agency staff - All staff including administrator shall receive training on Resident Intervention and Redirecting - All staff and administrator shall receive in-service training on Reporting Requirements Exit Interview Licensee/Administrator signature on file.

2023-10-20

Complaint Investigation

Unsubstantiated

No findings

Inspector · Tung Truong

Plain-language summary

A complaint investigation was conducted at the facility. The allegations in the complaint could not be substantiated based on the available evidence. An exit interview was held with facility staff and a copy of the report was provided.

Read raw inspector notes

As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated 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. Exit interview was conducted and a copy of the report was provided upon exit.

2023-09-07

Other Visit

Type A · 4 findings

Inspector · Tung Truong

Plain-language summary

During a follow-up visit on September 7, 2023, inspectors found that the facility had not corrected deficiencies identified in a previous complaint investigation from September 2022. The earlier investigation had found that staff blocked a resident's doorway with a couch to prevent them from leaving, the facility did not provide adequate supervision resulting in multiple fall injuries, the designated administrator was not properly fulfilling their role, and the facility was housing a resident whose aggressive behavior made them unsuitable for the facility according to the facility's own admission criteria.

Type A22 CCR §87468.1(a)(3)

Verbatim citation text · 22 CCR §87468.1(a)(3)

“Based on the department's findings, the licensee did not ensure R1 was free from punishment while in the care. Facility staff blocked R1's doorway with a couch to prevent R1 from leaving, which poses an immediate health and safety risk to residents in care.”

Type A22 CCR §87405(b)

Verbatim citation text · 22 CCR §87405(b)

“Based on interviews and records review, facility representative A1 denied the fact that he was the responsible administrator. This poses an immediate health and safety risk to residents in care.”

Type A22 CCR §87464(f)(1)

Verbatim citation text · 22 CCR §87464(f)(1)

“Based on the department's findings, the facility did not provide adequate care and supervision which resulted in R1 sustaining multiple injuries from falls. This posed an immediate health and safety risk to R1.”

Type A22 CCR §87208(a)(3)

Verbatim citation text · 22 CCR §87208(a)(3)

“Based on records review, although the facility has a plan of operation in place the facility failed to follow prohibited conditions outlined in the plan of operation regarding combative, dangerous behavior or the inability to get along in a congregate setting. This poses an immediate health and safety risk to residents in care.”

Read raw inspector notes

On 9/7/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit. LPA met with facility representative Steve Sarine and explained the purpose of the visit. The purpose of the case management visit is to follow up on deficiencies found during a complaint investigation conducted by the Department for complaint dated 9/19/2022, control number: 27-AS-20220919221525 The following deficiencies were identified during the complaint investigation: - Personal Rights - Staff blocked resident (R1’s) doorway with a couch to prevent resident from leaving. This incident was witnessed by facility staff. - Administrator Qualifications - The designated administrator (A1) did not act in their capacity as the Administrator. A1 told the Department that he was hired as a consultant and was working in the facility only until designated administrator (A2) could obtain their Administrator certificate. On 8/4/22, during a non-compliance meeting, A1 was designated as the facility administrator. - Basic Services - Facility did not provide adequate supervision which resulted in R1 sustaining multiple injuries from falls. During the investigation, (A1) stated that the private care agency will provide all the care and supervision to the resident, however per Department guidelines, private agencies are only allowed to provide companion services not care and supervision. Continued on 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 - Plan of Operation - Observation of resident change in condition, bruises, prohibited condition. Per facility’s Plan of Operation which stated that a condition of combative, dangerous behavior or the inability to get along in a congregate setting is prohibited and would make the resident inappropriate for admission/move in. During the investigation, it was learned that R1 has displayed aggression towards staff on multiple occasions. Moreover, R1’s Physician’s Report also stated that R1 has behavioral disturbance and aggressive condition. As a result, deficiencies were cited on LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were provided. Failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.

2023-09-07

Complaint Investigation

Unsubstantiated

No findings

Inspector · Tung Truong

Plain-language summary

A complaint was investigated but could not be confirmed based on the evidence reviewed. While the allegation may have had some basis, there was not enough proof to establish that a violation actually occurred. An exit interview was conducted with the facility.

Read raw inspector notes

This Department has investigated the allegations noted above and have found the complaint to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated 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. Exit interview was conducted and a copy of this report was provided.

2023-06-28

Complaint Investigation

Unsubstantiated

No findings

Inspector · Tung Truong

Plain-language summary

The state investigated a complaint that the facility did not have enough staff to meet residents' needs. Investigators interviewed residents and staff and found no evidence to support the complaint—two of the three residents interviewed said their needs were being met, and staff confirmed adequate staffing levels.

Read raw inspector notes

Regarding the allegation of facility does not have enough staff to meet the needs of residents in care, LPA did not find sufficient evidence to support the allegation. Based on interviews conducted with residents, 2 out of 3 residents stated that their needs were met and do not feel the facility is short staff. Staff who were interviewed stated that the facility has adequate staffing to meet the needs of the residents. This Department has investigated the allegations noted above and have found the complaint to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated 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. Exit interview was conducted and copy of report left at facility.