Ivy Park at Laguna Creek.

After an additional evaluation, it was revealed that there were no signs of sexual or other abuse. Police report reviewed contained additional interviews and outside agency consultation which revealed no indication or substantiated evidence of sexual abuse. Interviews conducted and other documentation reviewed did not reveal any corroborated statements or evidence to suggest sexual abuse occurred while in care. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator, and a copy of this report was provided. Appeal rights and LIC 811 provided.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. LPA Moleski reviewed an incident report dated 9/23/25. According to the incident report, a resident (R1) was found lying on the floor of their room on 9/21/25 covered in feces after an apparent fall. R1 told responding staff that they had gotten dizzy and fell while on their way to the restroom, according to the incident report. LPA Moleski interviewed R1, who did not remember details relating to the incident. However, R1 said that they do sometimes experience dizziness while standing. R1 also said that staff are responsive when they need assistance. LPA Moleski interviewed the medication technician who found R1 after their fall (S1) and the caregiver who assisted afterward (S2). S1 said they had gone to R1's room for a routine medication pass. S1 said that R1 told them they had been on the ground for about 10 minutes. S2 said they were alerted to R1's condition shortly after starting their shift around 7 a.m. Both S1 and S2 said they were not sure how long R1 had been on the floor, but both said the feces on R1 was not dry. S1, S2, and S3, the facility's health services director, said that R1 does not use their call button when assistance is needed. S1-S3 said that R1 did not use their call button after their fall on 9/21/25. LPA Moleski reviewed R1's file. R1's LIC 602 dated 5/5/25 indicates a diagnosis of dementia. R1's needs and services plan, dated 3/22/25, does not indicate R1 requires additional status checks beyond routine care tasks. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Dial.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. LPA Moleski received an incident report from this facility on 6/24/25. LPA Moleski previously discussed the incident report with staff on 7/8/25. However, due to time constraints, LPA Moleski was unable to complete a case management visit regarding this incident at that time. The incident report described above states that a resident (R1) was discovered missing around 7:20 p.m. on 6/23/25. R1 lives in a delayed-egress memory care cottage equipped with door alarms. The incident report stated that staff searched the cottage, but could not find R1. Staff continued to search the surrounding areas, and R1 was found in a nearby parking lot off facility property around 7:45 p.m., according to the incident report. LPA Moleski spoke with R1 during his visit on 7/8/25. R1 did not remember the incident. LPA Moleski reviewed R1's LIC 602, dated 5/23/25, and observed that R1 has a diagnosis of mild cognitive impairment and has a history of seizures. R1 is not permitted to leave the facility unassisted, according to their LIC 602. R1 suffers from confusion and has an unsteady gait, according to the LIC 602. R1 is nonambulatory, per the 602. R1's pre-admission appraisal, dated 6/11/25, indicates that R1 needs special observation and/or night supervision due confusion, forgetfulness, and/or wandering. R1's LIC 602 addendum, dated 5/23/25, indicates that R1 suffers from hallucinations. [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 LPA Moleski interviewed the cottage's on-duty caregiver (S1) during his visit on 7/8/25 and also on 9/3/25. S1 said that they were sitting near the front doors of the cottage prior to R1 being discovered missing. However, S1 said they heard no alarms, and did not see R1 leave. 22 CCR Section 87705(e)(5) requires that "facility staff shall ensure the continued safety of residents [with a dementia diagnosis] if they wander away from the facility..." Additionally, HSC Section 1569.312(d) requires that staff remain "aware of the resident's general whereabouts..." at all times. This facility is hereby cited per HSC Section 1569.312(d). As this deficiency involves an absence of supervision, an immediate civil penalty in the amount of $500 is hereby assessed. An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.

Based on interviews with staff, R1 wandered from their delayed-egress cottage on at least one occasion, and frequently attempted to elope after that. Charting notes regarding R1 indicate that on 6/3/25, R1 wandered "on to the streets," with staff following to supervise R1. After this and other incidents, Dial said R1's RP was "required" to acquire third-party one-on-one caregivers to supervise R1 during certain hours. This issue will be addressed in a separate case management report. In an interview, Dial said that R1 was not a good fit for the facility due to the open cottage-style layout, and R1 would be better served by a more secure facility. Dial said he did explain this to R1's RP, but he never told R1's RP that R1 needed to leave. In an interview, R1's RP did not describe R1's move-out as an eviction, and R1's RP complimented facility staff. R1's RP said that Dial did explain that R1 was "not a good fit" at this facility. R1's RP said they asked Dial what their options were, and Dial gave a preferred timeline for move-out, however this was described by R1's RP as Dial's preference, and not a requirement. In an interview, R1's RP did raise concerns regarding two of R1's medications, a certain depressant and a certain antipsychotic. LPA Moleski reviewed R1's medication list from their previous skilled nursing placement, dated 6/2/25, and a medication clarification signed by R1's physician dated 5/31/25. LPA Moleski observed on each an order for R1 to take the antipsychotic twice daily and an order for R1 to take the depressant as needed every six hours. No additional orders for either medication were included in these records. LPA Moleski reviewed R1's MARs and observed that these orders were listed as described. LPA Moleski further observed that these medications were administered as ordered during the duration of R1's stay at this facility. The department has determined the following as it relates to the allegations that a resident was illegally evicted and that medications were not provided to resident as needed: 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 Dial.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. LPA Moleski reviewed an internal incident report which was provided by facility staff on 06/20/25 during a complaint investigation visit. The internal incident report described a resident (R1) engaged in "hazardous wandering" on 6/3/25. According to the internal incident report, R1 was supervised, but had left the community. Dial said R1 was walking along the sidewalk with staff, and 911 was called as a result because R1 was not redirectable. R1 has a diagnosis of dementia and suffers from confusion and wandering behaviors, according to R1's LIC 602, which is dated 5/31/25. LPA Moleski reviewed CCLD fax and email records and observed no incident report was received regarding this incident. The facility's resident care coordinator (S1) said an incident report was not submitted to CCLD regarding this incident. Dial agreed that an incident report should have been submitted regarding this incident. Dial said there was a second incident on 6/7/25 wherein R1 left their cottage, but did not leave the facility grounds. LPA Moleski asked Dial to provide the internal incident report from this second incident when possible. Dial agreed to do so. This facility is hereby cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.

LPA Moleski reviewed staffing schedules for assisted living and observed that at least two caregivers were regularly scheduled for each cottage during morning and afternoon shifts, with one medication technician scheduled per shift to cover the two assisted living cottages. One caregiver was always scheduled for each cottage for each night shift. LPA Moleski reviewed staffing schedules for memory care and observed that two caregivers were regularly scheduled to work in each cottage for morning and afternoon shifts. On some days out of the week, one medication technician/caregiver was scheduled to work in Dogwood cottage, who also covered medication technician duties for Elm and Fir cottages. On other days out of the week, there was a dedicated medication technician/caregiver scheduled for Dogwood cottage, and another medication technician who floated between Elm and Fir cottages. Title 22 of the California Code of Regulations does not provide specific staff-to-client ratios which must be maintained at all times. 22 CCR § 87411(a) states that “facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs.” 22 CCR § 87415(a)(2) states that “in facilities caring for sixteen to one hundred residents at least one employee shall be on duty on the premises, and awake,” and that “another employee shall be on call, and capable of responding within ten minutes.” There were 58 residents being cared for at this facility at the time LPA Moleski opened this complaint investigation on 11/21/24. During a tour of this facility on that date which included a survey of Aspen, Birch, Dogwood, Elm, and Fir cottages, LPA Moleski observed a minimum of two staff members present in each cottage, and did not observe any residents with any obvious signs of unmet needs, such as poor hygiene, or unmanaged pain, et cetera. Resident rooms inspected during this visit were clean and free of odor. LPA Moleski reviewed six residents’ files (R8-R13) for potential signs of neglect due to lack of care and/or supervision, such as an unusually large number of documented falls, evidence of open wounds, missed doses of medication, et cetera. LPA Moleski observed no concerning trends in any of these resident records. LPA Moleski interviewed seven residents (R1-R7). R1, R2, R4, R6, and R7 voiced no concerns with the current level of staffing in the facility. R2 described the facility as “really good,” and said caregivers respond to them quickly. R6 said that the facility has an abundance of staff who are kind and helpful. R3 said that the facility’s caregivers “need more help.” R3 said that staff take too long to respond to their calls for assistance, sometimes up to 30 minutes. R5 said the facility was “understaffed.” R5 said that they sometimes have to wait four or five hours to be repositioned in bed, and they sometimes wait up to 40 minutes for a response to their calls for assistance. [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 30-day call button response logs for R3 and R5. While the average response time for each resident was roughly in line with the facility's expectation of 15 minutes per call at 14:13 and 15:11 respectively, there were a number of unusually high response times. For example, R3 had a recorded response time of more than 128 minutes on 2/23/25 and more than 80 minutes on 2/10/25. R5 had recorded response times of more than 77 minutes on 2/24/25, more than 57 minutes on 2/23/25, More than 65 minutes on 2/16/25, more than 80 minutes on 2/11/25, more than 181 minutes on 2/10/25, and a second call for more than 99 minutes on that same date. The facility’s health services director (S2) said that these entries showing excessive response times were likely errors. S2 said that the facility was in the process of changing call response systems due to these persistent errors. LPA Moleski noticed that a number of R5’s calls were recorded as coming from Birch Cottage, including the excessively lengthy calls from 2/24/25 and 2/10/25. However, R5 lives in Aspen cottage. R3's call log, meanwhile, included an entry from Dogwood cottage — the excessively long call recorded 2/23/25 — and a few calls had no location indicated. R3 also lives in Aspen cottage. To demonstrate the errors occurring in the electronic record-keeping system, S2 provided call button response logs from Fir and Elm cottages, which are not equipped with call buttons. These logs show a number of extremely long and extremely short response times recorded for the month of February 2023, ranging from a few seconds to several hours. LPA Moleski interviewed 15 staff members of this facility. Interviews with staff corroborated the staff schedules previously reviewed by LPA Moleski. The majority of caregivers, medication technicians, and management staff indicated that there are at least two caregivers stationed in every cottage serving residents, and when caregivers are busy providing two-person assistance to any particular resident, then a floating medication technician will cover the cottage floor to supervise residents. The majority of caregivers indicated that the medication technician will also cover them while taking breaks or while they are otherwise indisposed. S7 said that they have had to work alone in their cottage, but also said that they have always been able to meet the residents’ care needs. S8 said that there have been instances where there was just one caregiver in their cottage, and said that even two caregivers are not enough. However, S8 also said that all care tasks are completed, and residents do not have unmet needs. S9 said the current staffing levels were “challenging,” but also said that they are able to take care of all the residents. S9 said that the memory care director has asked staff to stay late to ensure sufficient coverage was maintained. All other staff members interviewed did not voice significant concerns regarding staffing levels at the facility. [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 The department has determined the following as it relates to the allegation that the facility has insufficient staffing to meet resident needs: 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 Dial.

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams met with director James Dial and explained the purpose of the visit. LPA Moleski reviewed an incident report that was sent to the Community Care Licensing Division (CCLD) on 12/4/24. The incident report described a medication error which was discovered on 11/27/24 by a medication technician (S1). S1 had attempted to get a refill for a resident's (R1's) thyroid medication on that date, but was told that the medication was not able to be refilled, as there should be doses remaining, according to the incident report. The incident report stated that there was only one pill of the medication remaining at that time. In an interview, S1 said the medication, given in the correct dosage, should have lasted through 12/26/24. In an interview, the facility's health services director (S2) said that both night shift medication technicians (S3 and S4) had been giving one full pill of the medication, rather than the half pill prescribed. S2 said that they asked both S3 and S4 separately what they had been giving R1, and they both reported that they were giving one full pill. This had occurred on multiple occasions, according to the incident report. Neither S3 nor S4 were present at the facility during this visit. LPA Moleski reached out via telephone to each but did not receive a response during this visit. This facility is hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.

LPA Moleski reviewed shift change notes regarding R1 dated between 3/26/24 and 3/29/24. A note made on the night of 3/29/24 stated that R1 refused to be changed for most of the night, but around 5 a.m., staff observed the bump and bruise on R1. The preceding notes do not make any indication of any observed injuries or falls suffered by R1. LPA Moleski reviewed R1’s file and did not observe any prior incident reports regarding falls suffered by R1 while at the facility. LPA Moleski reviewed R1’s preadmission appraisal, dated 11/20/23, which states that R1 did not need help in transferring in and out of bed. The appraisal was signed by R1’s RP. The appraisal states that R1 was active, but had difficulty climbing or descending stairs. Both R1’s appraisal and R1’s LIC 602, dated 11/20/23, indicated that R1 was fully ambulatory. In an interview, R2, R1’s spouse and a resident of this same facility, said that R1 fell three times while they were still living together, before they moved into the facility. In an interview, R1 said they could not recall what had happened on the night of 3/29/24 or the morning of 3/30/24. R1 was diagnosed with dementia, according to their LIC 602. In an interview, S4, said that R1 did not appear to be in pain on the night of 3/29/24 and the morning of 3/30/24. S4 said that R1 stayed up most of the night, calmly sitting in a chair in their room. S4 said that R1 had refused to be changed by the night shift staff until approximately 4:30 or 5 a.m. on 3/30/24, at which point R1’s injuries were discovered. In an interview, S5 said that from the start of their shift, R1 was in their room sitting in their chair. S5 said that R1 remained in their chair until both himself and S4 changed R1 in the early morning. S5 said R1 did not express pain at any point during the shift. S4 and S5 said that R1 is able to get up from the chair independently. S4 said R1 has fallen previously. LPA Moleski interviewed the two caregivers assigned to R1’s cottage during the afternoon shift on 3/29/24. In an interview, S6 said that R1 was in their chair during the afternoon shift, and did not want to get up, so S6 was not able to change R1, and therefore did not observe any injuries on R1. S6 said that R1 has fallen in the past, but is able to get up on their own. S6 said that, during crossover, the other caregiver on the afternoon shift, S7, said they had changed R1. [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 a phone interview, S7 said that they had changed R1 during the shift with their coworker, but had not observed any injuries on R1. LPA Moleski attempted to acquire additional information from S7, but the call was terminated. LPA Moleski called S7 again on 5/29/24, 5/31/24, and 6/14/24, and left voicemail messages each time. LPA Moleski also sent a text message asking to continue their conversation, to which he received no response. LPA Moleski was informed by Swearingen that S7 was terminated as of 8/12/24, in part due to attendance issues. LPA Moleski reviewed a disciplinary action notice regarding S7, dated 8/10/24. The notice stated that S7 was working a night shift on 8/5/24 and was present while a resident was out of bed and sitting on a bench in the common area of their cottage, but did not assist them back to their room. The department has determined the following as it relates to the allegation that a resident fell due to lack of supervision. 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 Swearingen.

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit. LPAs Moleski and Williams reviewed 10 resident files (R1-R10) and 10 staff files (S1-S10). LPAs Moleski and Williams toured the facility with Swearingen and inspected common areas, the kitchen, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 108 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPAs Moleski and Williams observed fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPAs Moleski and Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPAs Moleski and Williams observed locked carts for the storage of medication. LPAs Moleski and Williams observed locked closets for the storage of cleaning solutions. LPAs Moleski and Williams interviewed four staff members (S11-S12) and four residents (R11-R14). No deficiencies were cited during this visit. Technical assistance was provided relating to LIC 602s for dementia residents and staff training. An exit interview was conducted and a copy of this report was left with Swearingen.

A staff member (S4) claimed to have conducted a second reassessment on January 1, 2024 with R1’s RP present. LPA Moleski asked Swearingen for a copy of this second reassessment and written notifications sent regarding any increased care costs. Swearingen was unable to provide any such documentation in response to this request. Swearingen reached out multiple times requesting documentation from the prior management company in order to respond to LPA Moleski’s requests, but did not receive documentation to provide to LPA Moleski as described above. The department has determined the following as it relates to the allegation that staff did not provide sufficient notice of rate increase: Based on interviews and record review, sufficient written notice was not provided to R1’s RP after care costs were increased. Therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per HSC Section 1569.657(a). An exit interview was held with Swearingen. A copy of this report and appeal rights were left with Swearingen. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The refunds were processed effective 2/12/24. LPA Moleski reviewed a statement from February 2024 indicating that credits were provided for resident care and for room and board costs for the month of January. In an interview, R1’s RP said that they had received the refunds. LPA Moleski reviewed an incident report regarding R1’s hospital visit on 12/7/23. The report stated that R1’s RP called a staff member to check on R1. The staff member said that R1 was pocketing food and refusing meals. R1’s RP said R1 should be taken to the emergency room. R1’s RP picked up R1 around 1 p.m. and took R1 to the hospital. R1 was diagnosed with failure to thrive and was sent back on 12/12/23 with palliative care. In an interview, R1’s RP was aware of R1’s hospitalization and said they had visited R1 while hospitalized. In an interview, R1’s RP said that staff were “force feeding” R1. When asked for clarification, R1’s RP said that staff continued to ask R1 if R1 wanted to eat, although R1 did not want to eat. LPA Moleski reviewed R1’s daily notes and observed in the record a pattern of limited food intake and many refusals of food and drink. Refusals are documented in the notes, and the authors of the notes indicated on several occasions the exact amounts of food which R1 did accept. None of the staff members interviewed had witnessed staff members force feeding R1 or any other residents, although several did remark that R1 often refused meals and/or ate very little food. Among the staff members interviewed, one staff member (S5) said that on one occasion, S5 came in for their shift and observed that R1 had not been changed by the previous shift. None of the other staff members interviewed had witnessed neglect or lack of care for the resident. Three other staff members (S5, S7, S9) who worked directly with R1 said that R1’s continence needs were met and had not witnessed any instances were R1 had been waiting for care or needing to be changed. Of the staff members interviewed, two (S5, S9) said there were temporarily previous issues with phone calls being transferred from the main line to the appropriate cottage. None of the other staff members interviews reported any issues with the phone systems. LPA Moleski has not had issues reaching someone at the facility by phone. [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 The department has determined the following as it relates to the allegations that staff force fed a resident, that staff did not inform a resident’s authorized person of a change in condition, that staff did not meet a resident’s needs, that staff did not refund fees according to the resident’s admission agreement, and that staff did not answer the facility telephone. 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 Swearingen.

The department has determined the following as it relates to the allegation that staff did not notify a resident's responsible party of incident : Based on interviews, 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 Swearingen.

In an interview, R1’s RP described an incident wherein a former staff member (S16) refused to provide PRN medication to R1. R1’s RP said that S15 witnessed the incident. In an interview, S15 said S15 had not witnessed any incident wherein S16 refused to provide medication to R1 without good cause, and had not witnessed any disagreement regarding medication between R1’s RP and S16. S15 said R1’s RP had often asked for R1’s medication during time periods in which the resident was not to receive additional doses, per R1’s prescriptions. Several other staff members (S1, S2, S5, S9, S13) reported experiencing similar incidents with R1’s RP. No other staff members interviewed were aware of an incident wherein S16 refused to provide medication to R1. LPA Moleski attempted to contact S16. Both phone numbers for S16 on file were inactive. Eleven caregivers and medication technicians (S5-S15) were interviewed regarding staffing levels at this facility. Among these 11, four staff members voiced concerns about the current staffing levels. S5 reported no problems meeting all residents’ needs. S6 said the cottage S6 works in is well staffed and reported no issues. S7 said S7 was able to meet all residents’ needs with the current staffing levels, although sometimes it takes a while to complete all tasks. S8 said S8 was able to meet all residents’ needs. S9 said staff were not overworked and were able to complete all tasks. S10 said sometimes medication technicians must pass medications in three cottages, and during those times they are short-staffed. S11 said S11 needs additional assistance from a medication technician when caring for a bedridden resident, but said all care needs were met. S12 said staffing was not sufficient during mealtimes, which are very busy. S12 said S12 was able to meet all residents’ care needs. S13 said the facility is short staffed during the lunch hour, but said all care needs were being met. S14 said current staffing levels were sufficient. S15 said staffing was sufficient provided that the right staff members were on shift. S15 said all care needs were being met. Among the nine residents interviewed, four voiced concerns regarding current staffing levels. R2 said all R2’s needs were met and felt staffing was sufficient. R3 said there were enough staff to meet R3’s needs. R5 was not sure if the facility was understaffed, but said R5’s needs were being met. R9 said that R9’s needs were being met and said there were enough staff. R10 said R10’s needs were being met and did not voice concerns regarding staffing or regarding care received at the facility. [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, R4 said that the facility was understaffed, and said staff had not offered to shower R4 for four days. LPA Moleski reviewed a shower schedule which showed R4 receives two showers a week. LPA Moleski interviewed three staff members, (S1, S17, and S18). S1 said R4 had been refusing care. S17 said R4 had been weak and unable to transfer. S18, who was present on R4’s scheduled shower day, said R4 was in pain and unable to transfer for the shower. During the same interview, R4 said that staff have made her wait for toileting assistance, but staff typically respond to R4’s call button, and are typically supportive of her needs. In interviews, R6-R8 said that the facility was understaffed due to lack of timely response to calls for assistance. LPA Moleski reviewed response times for a period of 30 days for R4, R6, R7, and R8. LPA Moleski observed average response times of 14 minutes and 41 seconds for R8 and 9 minutes and 32 seconds for R7. R4 and R6 did not press their pendants during the 30-day period reviewed. Previous records were not available. LPA Moleski reviewed staffing schedules and resident rosters. LPA Moleski observed that four of the five operational cottages are typically staffed with two caregivers each. The fifth is typically staffed by one or two caregivers. This fifth cottage was inhabited by seven residents at the onset of this investigation. The remaining four cottages were inhabited by 11 to 15 residents each. Medication technicians are typically assigned to cover two to three cottages each. Based on interviews, medication technicians assist with direct care of residents when needed. LPA Moleski visited this facility to investigate this complaint on 2/14/24, 3/11/24, 4/11/24, and 4/15/24. During these visits, residents observed appeared healthy and clean. LPA Moleski observed residents in common areas being supervised by staff members. The department has determined the following as it relates to the allegations that staff did not administer a resident's medication as prescribed, and that the facility does not have sufficient staff to meet residents' needs: Based on interviews, observation, 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 during this visit. An exit interview was held and a copy of this report was left with Swearingen.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with resident care coordinator Daiya Jorlen and explained the purpose of the visit. LPA Moleski discussed reporting requirements with Jorlen and provided technical assistance on this topic. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Jorlen.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on an incident report. LPA Moleski met with facility administrator Morgan Whinery and explained the purpose of the visit. LPA Moleski reviewed an incident report that described an unwitnessed fall suffered by a resident (R1) on September 13. Whinery said R1 went to the hospital after the fall and returned on hospice. R1 died on September 29, 2023, according to Whinery. The staff member on duty was 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 Whinery.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on a deficiency issued during this facility's annual inspection. LPA Moleski met with facility administrator Morgan Whinery and explained the purpose of the visit. LPA Moleski issued a citation on 7/20/23 for a resident (R3) diagnosed with dementia who had not received a new LIC 602 within a year as required. Whinery said attempts have been made to make an appointment for R3 to get a new LIC 602 but facility staff have not heard back from R3's hospital as of this date. LPA Moleski reviewed two fax transmittals dated 7/27/23 requesting an appointment for a new LIC 602 for R3. LPA Moleski reviewed a functional evaluation for R3 dated 7/31/23 which was faxed to R3's hospital along with another request for an appointment, according to Whinery. Whinery said the person responsible for faxing the functional evaluation did not keep the fax transmittal sheet, and no longer works at the facility. Whinery said she made two calls to the hospital, S1 made at least one call to the hospital, and R3's family member called as well. Whinery said she has made plans to have R3's LIC 602 renewed within the week by a concierge physician, due to the lack of response from R3's hospital. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Whinery.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit to follow up on several incidents. LPA Moleski met with administrator Morgan Whinery and explained the purpose of the visit. Whinery had to leave during this visit to make an appointment and said business office director Susie Sarria could sign this report in her absence. LPA Moleski interviewed Whinery, and a staff member (S1) regarding two incident reports describing an act of aggression between residents (R1, R2), and regarding two incidents involving R3 and R4. R1 was out at the hospital at the time of this visit. LPA Moleski interviewed R4. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Sarria.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit regarding an incident report. LPA Moleski met with administrator Morgan Whinery and explained the purpose of the visit. The incident report described an unwitnessed resident fall. LPA Moleski interviewed Whinery and a staff member (S1). No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Whinery.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on two incident reports. LPA Moleski met with administrator Morgan Whinery and explained the purpose of the visit. LPA Moleski reviewed an incident report that described a resident (R1) tipping over in their wheelchair while on their way back to the facility in a van. The driver did not fasten R1's seat belt, according to the incident report. The driver pulled over afterward and paramedics were called. R1 refused transport to the hospital. Paramedics helped R1 back into a sitting position. Bruises were later found on R1's knees, and R1 said they hit their head, according to the report. LPA Moleski interviewed administrator Morgan Whinery. R1 is able to leave the facility unassisted. The van was publicly operated, according to Whinery. LPA Moleski also reviewed an incident report that described a resident (R2) walking out of a cottage and down into the street. According to Morgan, staff followed along with her until paramedics arrived. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Whinery.

R1’s LIC 602 and R1’s MARs both contained R1’s allergy information. According to the widespread illness trackers, the first resident to fall ill began showing symptoms on February 26, 2023. The letter reviewed by LPA Moleski stated that “active GI” [gastrointestinal] “infection cases” were “impacting our Elk Grove Park Family.” The letter includes several infection control guidelines intended to “end the outbreak much sooner.” According to S1, the letter was posted and sent out to families on March 5, 2023, which is seven days after the first resident onset documented in the widespread illness tracker. The photographed posting of this letter reviewed by LPA Moleski was dated March 5, 2023. S1 told LPA Moleski that staff also made phone calls to families of residents, including those who had not tested positive for Noro Virus, in order to inform them of the outbreak. S1 told LPA Moleski on March 6 that the facility would be testing residents for Noro Virus. As of March 7, three residents were still symptomatic, according to S1. As of March 10, S1 had received lab results indicating that all three of those residents were positive for Noro Virus. By that time, no residents were still symptomatic, according to S1. During interviews, S2-S8 described proper use of PPE and proper glove disposal procedures. None said they had witnessed any other staff members using soiled gloves. During interviews, R2, R3, R4, and R6 said they had never seen staff using soiled gloves. R5 described an incident that allegedly occurred six months previously in which staff did not properly dispose of gloves during meal service. The department has determined the following as it relates to the allegations that staff do not ensure residents responsible parties are informed of epidemic outbreaks, that staff do not ensure resident records are maintained, and that staff do not ensure soiled gloves are properly discarded after use: Based on review of facility records, review of resident records, interviews with S1-S8, and interviews with R2, R3, R4, and R6, 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 Whinery.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit following up on an incident report. LPA Moleski met with administrator Morgan Whinery and explained the purpose of the visit. On 6/6/23, a resident (R1) called 911 during mealtime. A medical technician overheard R1 calling 911. According to the incident report, R1 said that R1 "was not feeling well." LPA Moleski interviewed S1 regarding the incident report. S1 said that R1 had shown and expressed no previous signs or symptoms. LPA Moleski reviewed R1's LIC 602 and daily notes for the month of June 2023. R1's daily notes indicate that R1 was treated for neck pain and discharged with no new orders the same day. S1 said that staff reminded R1 that R1 can ask staff to get help if needed. LPA Moleski interviewed R1. R1 did not express any concerns regarding facility staff members or staffing levels. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Whinery.