Meadows Senior Living, the.

Training dated 2/20/25 included general policies and procedures, grooming assistance, proper storage of hygiene supplies, hydration, meal times, shower and spa room use, and protected health information. These records showed staff received training related to resident hygiene care. Per review of R1’s Physician’s Report dated 10/3/2025, R1 was assessed to be at risks if allowed direct access to personal grooming and hygiene items. R1 was also diagnosed with Alzheimer's dementia. LPA interviewed Resident (R1). R1 confirmed they receive assistance with activities of daily living, including hygiene care. R1 stated not having any issues with staff meeting their hygiene needs at this time. Three additional residents were interviewed and did not report concerns regarding staff not assisting with hygiene care. Staff on duty, (S1) and (S2), were interviewed and denied the allegation. Both staff stated residents receive assistance with hygiene as needed and as scheduled. During a facility visit on 12/10/2025, LPA observed grooming carts containing residents’ hygiene items labeled with residents’ names. Baskets with resident-specific hygiene supplies and additional facility-provided items were also observed. LPA observed resident bedrooms and noted hand soap available for resident use. Based on record review, interviews, and observations, there was insufficient evidence to support the allegation that staff are not meeting residents’ hygiene needs. Therefore, this allegation is unsubstantiated . --------------------------------------------------------------------------------------------------------------- Allegation 2: Staff do not ensure that residents receive shower services The investigation into this allegation included record review, interviews, and direct observation. The LPA reviewed Resident 1’s (R1) shower schedule and shower tracking sheets for October, November, and December 2025. Records showed R1 was scheduled to receive showers at least twice per week on Sundays and Thursdays. {2 of 3} 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 Staff initials were documented on scheduled days, indicating showers were provided. Records also showed R1 requires assistance with parts of the bathing process, including getting in and out of the shower or tub. Per review of R1’s Physician’s Report dated 10/3/2025, R1 was assessed to be at risks if allowed direct access to personal grooming and hygiene items. R1 was also diagnosed with Alzheimer's dementia. R1 was interviewed and stated staff assist them with showers at least two times per week. R1 did not report any concerns about missing showers. Three additional residents were interviewed and did not report concerns about not receiving showers. Staff on duty, (S1) and (S2), denied the allegation and stated staff ensure residents receive scheduled showers. During a facility visit on 12/10/2025, LPA observed the common shower room in the Memory Care area, which included two shower stalls and a walk-in bathtub for non-ambulatory residents. The LPA noted a resident in the Memory Care area being assisted by staff during a shower. The LPA also observed a room where shower schedules were kept. Based on record reviews, interviews, and observations, there was insufficient evidence to support the allegation that staff do not ensure residents receive shower services. Therefore, this allegation is unsubstantiated . Note that an unsubstantiated finding means that although the allegation may have happened or valid, the preponderance of evidence standard is not met. No deficiencies were cited as a result of this visit. An exit interview was conducted with AD and a copy of this report and appeal rights were provided. {3 of 3}

On 1/21/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct their annual inspection visit. LPA met with Business Manager, Kaushik Sharma (S1), and stated the purpose of the visit. The Executive Director/ Administrator, Alyssa Sellers (AD) was notified and unable to be present during this annual visit. Overview : Facility is a two-story building. Facility is licensed to serve up to 160 elderly residents, up to 154 residents may be non-ambulatory and up to 24 may be bedridden. Bedrooms and non-ambulatory rooms are interchangeable. Facility has a hospice waiver granted for 15 residents. Physical Inspection : Areas inspected include, but not limited to, the kitchen, dining, resident units/bedrooms, resident bathrooms, common areas and outdoor areas. Tour of the facility was conducted with Facility Maintenance, Johnna Weaver. LPA inspected 4 resident units, 2 in the Memory Care (MC) area and 2 in the Assisted Living (AL) area. Hot water temperature ranged from 105 - 117 degrees Fahrenheit. The 4 resident units were observed to be in good repair at this time. Pull cords were tested in the residents’ bathrooms and were found to be in good working condition. Each resident room have its own heating/cooling and can be controlled by residents. Hallway temperature was between 68 – 74 degrees Fahrenheit. Fire extinguishers were observed throughout the hallways. One sample was last inspected on 2/11/2025. Smoke and carbon monoxide detectors were observed throughout. LPA observed centrally stored medications, toxins, sharp objects and other dangerous items were kept locked and inaccessible to residents in care. In the kitchen area, LPA observed at least seven-day non-perishable and two-day perishable food supplies. Pantry was observed to be fully stocked with non-perishable food items. {1 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 Facility has one walk in refrigerator and freezer. LPA observed dried blood on the floor inside the refrigerator. LPA observed meat that had been thawed in the refrigerator without label/date opened. Advisory was provided to kitchen staff to properly label opened food items, including date it was opened. Advisory was provided to kitchen staff to ensure refrigerator floor is cleaned. Kitchen refrigerator and freezer were maintained at regulatory temperature at 40 degrees Fahrenheit and 0 degrees Fahrenheit. Menus and activity calendar were posted. LPA met with the Activity Director in the activity room at the second floor. They were preparing for the next activity scheduled. Facility has a courtyard. LPA observed shaded area and outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. Fence and gate were in good repair. Record Reviews: LPA reviewed 8 staff files, 4 care staff, 2 med techs, and 2 kitchen staff. LPA reviewed 8 resident files, 4 AL residents and 4 MC residents. Review of 8 resident files, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. LPA did not review resident medications during this visit. Records indicate that some residents utilize Omnicare Pharmacy. Medication audit was conducted by Omnicare on 11/21/2025. Review staff files included, but not limited, background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. No issues were noted at this time. Review of fire drill/disaster drill records: facility conducts monthly drills and last drill was conducted on 12/29/25. Fire inspection report dated 5/8/25 was conducted by Consumnes Fire Department. Per inspection report, facility passed. LPA did not conduct interviews during this visit due to time constraint. Documents Requested: LPA requested a copy of current Liability Insurance Certificate, LIC500, LIC308 to be emailed to arvin.villanueva@dss.ca.gov. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited. Advisories were provided. Exit interview was conducted. A copy of the report was provided upon exit. {2 of 2}

Allegation - Staff did not ensure residents received sufficient beverages, resulting in dehydration. The investigation into this allegation consisted of interviews, record reviews and observations. Through interview, witness (W1) believes the facility did not give resident (R1) enough to drink at meals and medication times. W1 said staff once saw R1 “guzzling” ice water and took that as a sign of dehydration. Interviews with staff revealed that water is offered at each meal, often during activities and whenever residents ask. Staff stated that they do not track or log daily fluid intake unless residents show a change in condition and placed on alert; R1 was not on dehydration alert. Dietary and care staff described hydration stations in common areas, water pitchers on dining tables, drinks in the dining-room fridge/freezer, and a mobile cart that offers water, juice, popsicles, and fruit, especially on hot days. Through interviews with current residents in care, they did not report any problems with food or hydration issues. One resident stated that there are places in the facility to get water. Records review showed R1 was not on dehydration alert. Review of facility’s newsletter for July 2025 that provides residents with information and reminders to hydrate, especially during summertime, and the importance of avoiding dehydration, UTI’s, heat stroke and other heat related conditions. During this LPA’s observations on 7/1/25 and 12/26/25, LPA observed hydration stations with water, coffee, and tea near the lobby. At lunchtime, LPA observed a glass of water at each dining table place setting, and many residents also had juice, coffee, or tea. Menu items were posted and easy to see. Staff did not report signs of dehydration for R1 before the hospital transfer, and R1 was not put on a dehydration alert. While W1’s concerns are noted, there is not enough evidence to show that staff did not provide sufficient beverages to R1. Based on the information gathered, the allegation that staff did not ensure the resident received sufficient beverages, resulting in dehydration, is unsubstantiated . {2 of 5} 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 - Licensee did not adhere to resident's admission agreement: The investigation into this allegation focuses mainly around R1’s situation. The investigation included interviews with staff, review of the admission agreement signed on January 22, 2025, R1’s payer ledger, and related correspondence. Based on interviews, R1 was not denied return to the community following hospitalization. The administrator explained that R1 was sent to the emergency room on March 18, 2025, due to stroke symptoms. After hospitalization, the facility’s Director of Health and Wellness typically assesses residents before readmission to ensure care plans remain accurate and regulatory requirements are met. In R1’s case, there was a change in care needs under review. During this time, R1’s Power of Attorney (POA), decided to seek alternative placement that could accommodate these changes and was more financially feasible. Through interviews and record reviews, the POA provided a written 30-day notice via text message on April 2, 2025, which was confirmed by a screenshot and a written message dated April 30, 2025. Review of the admission agreement shows that residents may terminate the agreement at any time by giving a 30-day written notice, and they are responsible for paying all rent and fees during that notice period, even if they do not occupy the apartment. Review of R1’s payer ledger confirms that R1 was billed through April 30, 2025, consistent with the agreement terms. Staff interviews also confirmed that level-of-care charges stop when a resident physically leaves the facility, but rent obligations continue through the notice period, per admission agreement. R1’s last billing stopped on April 30, 2025. Based on the evidence, the allegation that the licensee did not adhere to R1’s admission agreement is unsubstantiated . The facility followed the signed agreement by requiring payment through the 30-day notice period and did not deny R1’s return. {3 of 5} 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 follow resident's diet order: Investigation included interviews with staff, residents in care, and other individuals involved with the care of R1, review of R1’s care plan, diet order, admission agreement, and facility observations. Interview with witness (W1) stated that R1 was diabetic and was supposed to receive a carb-controlled diet after switching from insulin to oral medication. W1 stated that R1 ate the same meals as other residents and that this caused R1’s blood sugar to rise. W1 also reported that blood sugar checks were not done regularly. During interviews, staff explained that diet orders are reviewed during admission and any changes are communicated to the kitchen. Staff also stated that menus are planned by a dietitian and that special diets are documented in a binder accessible to kitchen staff. Interviews with current residents in care did not report issues with food services and did not report staff not following their diet, food allergies or food preferences. Through record reviews, R1 had a diabetic diet. Review of the diet order form signed by the health practitioner on January 16, 2025, indicated R1 was to have a consistent carbohydrate diet, meaning a consistent amount of carbohydrates at meals and snacks. Foods with high sugar were allowed when planned into the total carbohydrate allowance for the meal. Additionally, review of training records showed staff were trained on diet and texture modifications. During observations, LPA observed menus posted and water provided at tables, and interview with kitchen staff confirmed that alternative meals are available upon request. Based on the information gathered, there is not enough evidence to prove that staff did not follow R1’s diet order. Therefore, the allegation is unsubstantiated . {4 of 5} 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 – Unlawful eviction: The investigation into this allegation focuses mainly around R1’s situation. The investigation included interviews, review of R1’s admission agreement, termination clause, and facility records. According to the complaint, R1 was hospitalized on March 18, 2025, and was later informed that the facility would not allow R1 to return. The facility did not provide an eviction notice and that POA learned of the eviction indirectly through hospital staff. Review of R1’s admission agreement and termination clause shows that the facility may terminate the agreement with a 30-day written notice for reasons such as nonpayment, failure to comply with laws or facility policies, or if the resident’s needs can no longer be met. The agreement also states that a 3-day notice may be given with prior approval from the Department of Social Services if the resident poses a health or safety risk. CCR Title 22, Section 87224, requires proper written notice and DSS approval for certain evictions. Records show that R1’s POA submitted a written 30-day notice, via text, on April 2, 2025, to move R1 out of the facility. Staff interviews confirmed that the facility did not issue an eviction notice and did not deny R1’s return; instead, the POA chose an alternative placement that could meet R1’s changing care needs. Based on the information reviewed, there is insufficient evidence that the facility unlawfully evicted R1. The move-out was initiated by the POA, and the facility followed the admission agreement signed by R1 and/or R1’s POA. Therefore, the allegation is unsubstantiated . An unsubstantiated finding means that although the allegation may have happened or valid, the preponderance of evidence standard is not met. No deficiencies were cited as a result of this visit. An exit interview was conducted with S1 and AD, and a copy of this report and appeal rights were provided. {5 of 5}

LPA reviewed R1’s records and interviewed staff and the administrator. R1 moved into the facility on February 10, 2025. At first, R1 did not have behavioral problems. Over time, R1’s condition changed. Starting in March 2025, R1 began showing signs of aggression. By June and July 2025, R1 had several incidents where R1 yelled at or pushed other residents and staff. The facility held care meetings with R1’s responsible party on July 2 and August 6 2025 to talk about R1’s behavior and possible next steps. Hospice was added to help manage R1’s care. On August 12, 2025, R1 had a serious incident where R1 refused medication and attacked staff. Police and EMS were called, and R1 was taken to the hospital. The next day, August 13, R1’s responsible party removed all R1’s belongings from R1’s apartment. The administrator said the facility had not officially refused R1’s return yet, but during the August 6 meeting, they agreed R1 could not come back if R1’s behavior continued. After R1 moved out of the facility, the facility sent a letter titled “3-Day Eviction.” The administrator admitted this was a mistake because the resident had already moved out. The letter was sent only for documentation purposes and not to force R1 to leave. The admission agreement says the facility must give 30 days’ notice for termination unless DSS approves a 3-day eviction for emergencies. In this case, DSS approval was not requested because the resident had already left. The administrator said they will fix their process and use the correct type of letter in the future. Based on the information gathered, the allegation that the facility illegally evicted R1 is unsubstantiated . The evidence shows the R1’s responsible party decided to move R1 after care meetings and hospital transport. The “3-Day Eviction’’ letter was sent after the move and did not cause the eviction. Administrator admitted that the title was incorrect. An unsubstantiated finding means that although the allegation may have happened or valid, the preponderance of evidence standard is not met. No deficiencies were cited as a result of this visit. An exit interview was conducted with S1 and AD and a copy of this report and appeal rights were provided.

LPA Hayes returned to the facility to correct the facility visit type from a complaint visit on 11/20/25 (27-AS-202511131209410) from 1:15pm-05:15pm. The report was amended in the Sacramento South Regional Office on 11/24/25 to reflect the original visit was at this facility and not in the Regional Office. LPA Hayes retrieved the original report and replaced it with an updated 9099 and given to Sharma. Report was signed by Sharma with permission from Alyssa Sellers, Administrator.

The assessment tool helps determine whether a resident’s needs can be met by the facility or if a higher level of care, such as a Skilled Nursing Facility (SNF), is required. Interviews also revealed that S1 evaluates residents' ability to perform activities of daily living (ADLs) and provides recommendations to the Administrator, who then sends the final decision to the corporate team for review and approval. Other staff involved in assessments include the Residential Care Director and the Sales Director. A review of R1's records shows that assessments were conducted and documented. R1’s initial care assessment, completed on 8/16/22, showed that R1 required staff assistance with grooming, mobility (wheelchair use), showering, queueing with toileting, and medication management due to medical condition (M1). R1 was noted as alert and oriented, able to communicate needs, and independent in many areas of care. The medical assessment from 8/14/22 confirmed that R1 had no mental health conditions and required only minimal assistance with self-care. A later medical assessment, dated 1/16/25, continued to show that R1 did not have a cognitive impairment, remained alert, and required minimal assistance with daily activities. Though R1 was non-ambulatory, they were able to transfer independently and feed themselves. R1 also remained able to manage personal finances and medications. Progress notes showed that the facility coordinated with outside professionals, including hospital social workers, APS, and the Ombudsman, when R1’s condition changed. In January 2025, the hospital Social Worker informed the facility that R1 would be moved to a Skilled Nursing Facility. The facility, in turn, determined that R1’s condition had changed and that they could no longer meet R1's care needs, thus denying readmission. The facility also took steps by contacting APS and the Ombudsman in assisting R1 find proper placement. Based on the interviews and reviewed documentation, the preponderance of evidence is not met, therefore, the allegation is UNSUBSTANTIATED. An unsubstantiated finding means that although the allegation may have happened the preponderance of evidence does not prove it. No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report and appeal rights were provided. {9099-2}

Through review of facility records, R2 had been at this facility for five days and had known diagnoses of acute kidney failure and hypertensive heart disease. R2’s POLST documents indicate Do Not Resuscitate (DNR) orders and a focus on comfort care. Further review of facility records from 8/8/2024 to 8/13/2024 shows that staff followed physician orders, appropriately managed medications, and provided care consistently with R2’s comfort-focused instructions. Based on the information gathered, there is no found evidence to indicate that R2’s death was the result of neglect, mismanagement, or any questionable circumstances. Therefore, the allegation is UNFOUNDED. Note that an unfounded finding means that the allegation is false, could not have happened, and/or is without a reasonable basis. Based on this investigation, no citations are issued. Exit interview was conducted and a copy of this report was provided. {LIC9099-2}

The facility collaborates with pharmacies, including Omnicare, which is offered to residents at no additional charge. Omnicare typically delivers medications on time, and if the resident opts not to use this service, staff coordinate with other pharmacies. For residents who use Kaiser as their pharmacy, the AD explained that while there are occasional delays, staff take extra steps to ensure the medication is obtained, even dispatching a driver to pick it up as a last resort. However, this is only done in emergencies, such as an evacuation situation, and is not a regular service offered by the facility. Staff S1 reported that when a resident is down to a seven-day supply of medication, staff make contact to the pharmacy for refills and, if necessary, contact the prescribing physician. Staff S3 and S4 provided similar accounts, confirming that medications are ordered well in advance—often when there are 7 to 10 days remaining in a resident's supply. Staff S4 emphasized that medications are ordered as early as possible to prevent shortages and that any delays are typically due to issues on the pharmacy's end, not from staff failing to place orders on time. In cases where a pharmacy does not have a medication in stock, staff take immediate action to contact the doctor and arrange for an alternative solution. S5 further confirmed that the facility has procedures in place to reorder medications well before supplies run out. She explained that when a medication supply reaches 7 days, staff confirm whether additional medication is available, and if not, an order is promptly placed. Additionally, Staff S5 outlined the steps taken when a medication is out of stock, including notifying the resident’s doctor, the responsible party, and coordinating with pharmacies to expedite the delivery. A review of the facility’s medication ordering forms also supports the finding that the facility follows appropriate procedures. The Omnicare Refill Order Form requires staff to place orders at least five days before medication runs out, or 10 business days for Schedule II Narcotics. The facility’s own Medication Refill/New Order Roster is used less frequently but also includes clear instructions for tracking orders and deliveries. While there have been occasional delays in receiving medications from certain pharmacies, the evidence gathered from interviews and records indicates that staff follow a structured and timely process for ordering medications. Therefore, the complaint alleging that staff are not ordering resident medications in a timely manner is UNSUBSTANTIATED. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies are being cited based on today's visit. Exit interview was conducted with Kaushik Sharma (in person) and Carley Taylor (via phone) to discuss the report. A copy of this report and appeal rights were provided. {2 of 2}

Similarly, S1, as the Health and Wellness Director, holds a significant role in assessing residents' health and wellbeing. With a background in nursing and a current nursing license, S1 supervises personal care staff and coordinates the services provided to residents. S1’s responsibilities include performing thorough health assessments of all new residents, monitoring the health status of current residents, and participating in care conferences to discuss the ongoing needs of residents. S1’s qualifications, including CPR certification and state nursing license, manage the health and wellness of residents. In addition, S1 works closely with other staff members, including the Residential Care Director and the Sales Director, to ensure that all assessments and care plans are reviewed thoroughly and adjusted as necessary. Through interview, the assessment process involves multiple levels. S1 discussed the process involved in assessing residents. S1's role includes making recommendations based on assessments of residents' activities of daily living (ADLs). These recommendations are passed on to the administrator (AD), who further reviews the information and ensures the resident’s needs are met appropriately by the facility. After the administrator’s assessment, the recommendations are sent to corporate overseers for final approval. This multi-step approach ensures that every aspect of a resident's needs is addressed and verified. Interview also indicated that along with other staff members such as the Residential Care Director, actively assist with residents' care when needed, especially during times of staff shortages. S1 and the Residential Care Director, occasionally provide hands-on care to residents if necessary. Furthermore, S1 is responsible for assessing situations that require medical attention, such as minor injuries, and providing appropriate care. If more specialized care, such as home health or hospice services, is required, those needs are handled by external agency staff, ensuring that the resident receives the best possible care for their specific circumstances and needs. Based on the gathered information, there is no preponderance of evidence that staff are not properly assessing residents. Therefore, this allegation is UNSUBSTANTIATED. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Exit interview was conducted with Alyssa Sellers and Carley Taylor. A copy of this report and appeal rights were provided. {2 of 2}

Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced Case Management - Annual Continuation visit today at this facility to continue with the annual inspection initiated on 12/10/2024. LPA met with Administrator/Executive Director, Alyssa Sellers, and stated the purpose of this visit. LPA continued with facility visit to ensure facility is in compliance with Title 22 Regulations. Review of 9 resident files (R1 - R9) which include review of Admission Agreement, Medical Assessment, Needs and Services Plan, and Ambulatory Status. LPA did not conduct medication review during this visit. Review of 9 staff files (S1 - S9) which include review of background clearance, First Aid and/or CPR, Health Screen, Initial and Ongoing Training. It was noted that some staff completed their 1st aid training from Relias. At this time, LPA need to verify the validity of the training and may have to return for a case management visit. Facility conducts quarterly disaster drill. Facility has a dementia and infection control plan. Advisory was provided to update their plan of operation, if necessary, to ensure compliance with the new dementia regulation. Administrator provided the following documents during this visit: current Liability Insurance Certificate, LIC 610E, LIC500 and LIC308 to the Department. No deficiencies are being cited at this time. Exit interview was conducted and a copy of this report were provided.

On 12/10/2024, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct their required annual visit. LPA met with Executive Director/Administrator Alyssa Sellers (ADM) and stated the purpose of the visit. This facility currently approved to retain/accept 10 hospice residents and fire cleared to retain/accept 24 bedridden residents. Note that bedrooms and non-ambulatory bedrooms are interchangeable. The LPA and ADM toured the facility to verify compliance with Title 22 regulations. The facility is a two-story building, with memory care located on the first floor. It has a capacity of 160 residents, serving both assisted living and memory care. The LPA inspected the first and second floors, activity rooms, dining room, cinema room, elevator, and resident apartments/units. Each floor is equipped with a medication room, and medications were found to be securely stored, locked, and inaccessible to residents. The resident apartments/units are spacious enough to accommodate personal furnishings, and all 4 observed units were clean, sanitary, and free of obstructions. Each observed bedroom had a smoke and carbon monoxide detector, and the memory care rooms were equipped with electronic monitoring systems installed on the ceiling to detect falls and notify staff. Memory care also has delayed egress doors. The LPA observed the kitchen area to be clean and sanitary. The facility maintains a minimum of two days’ worth of perishable food and seven days’ worth of non-perishable food. The LPA reviewed the menu and activity calendar, and the Administrator confirmed that each resident is provided with a copy of both. During the visit, kitchen staff were preparing dinner. The LPA noted a shaded area in the yard with tables and chairs, and the outdoor activity area is secure for dementia residents. The outdoor passageways, walkways, driveways, and steps were free from obstructions and hazards. The facility does not have any bodies of water. Water temperatures in 4 selected bathrooms (within resident apartments/units) were recorded between 113°F and 114°F. Room temperatures in the 4 observed resident apartments/units ranged from 69°F to 78°F. Due to time constraints, this annual visit will require a continuation visit. An exit interview was conducted with the Alyssa Sellers and , and a copy of this report was provided.

On 11/12/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit regarding an incident occurred on 10/31/24. LPA met with the facility's Director of Health and Wellness (DHW), Ashley Melendez, and stated the purpose of the visit. Per incident, Resident (R1) attempted to take walker from another resident's space. Staff (S1) attempted redirection, then S1 and R1 got into a "scuffle" over the walker which resulted in R1 falling. R1 was taken to the hospital and was diagnosed with the following: D1, D2, D3, and D4. Further review of the incident indicated that facility investigated the incident and found that the fall was deemed to be suspicious and that local law enforcement and Local Long-Term Care Ombudsman were notified. During an interview with DHW, it was confirmed that they reviewed the surveillance footage of the incident and determined that R1 did not hit anyone, which contradicted the information recorded in R1's Progress Notes on 10/31/24. DHW explained that R1 had taken a walker from another resident's room and walked out. S1 then took the walker from R1, leading to a "scuffle" between S1 and R1, which caused R1 to fall. Following their internal investigation, DHW reported that S1 was terminated as a result. During this visit, LPA conducted a review of the surveillance footage of the incident on 10/31/24. LPA also conducted a review of R1's physician's report and Progress Notes dated 10/31/24 to 11/1/24. During today's visit, LPA obtained relevant documents related to R1 and S1 for further review. LPA also obtained copy of the following facility file including a personnel report, the staff schedule for the week of 10/26/24 to 11/1/24, and staff contact information. Additionally, LPA recorded part of the surveillance footage from 10/31/24. Based on today's visit, further investigation is needed. Exit interview was conducted with Ashley Melendez and a copy of this report was provided.

On 8/13/24, at 2:38pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit regarding an incident report received by the Department on 6/26/24. LPA met with Alyssa Sellers, Executive Director (ED), and stated the purpose of the visit. Incident Description: On 6/20/24, a resident in care (R1) reported to the care staff that they were being abused by their friend. R1 claimed that their friend was drugging them and attempting to kill them. R1 requested assistance to call 911 and to be transported to the hospital. Actions Taken: R1 was promptly transported to the hospital for evaluation and treatment. The police were notified and conducted a visit to the facility. Adult Protective Services (APS) and the Ombudsman were also informed and initiated their investigations. Hospital Findings: A drug test conducted at the hospital indicated the presence of opiates and fentanyl. These substances were consistent with R1’s current medications prescribed per hospice orders. Follow-Up Actions: On 6/21/24, a hospice nurse conducted a follow-up visit to adjust R1’s medications. Review of R1’s medication list from 8/25/23, confirmed the use of a fentanyl patch. R1’s Needs and Services Plan dated 4/9/24, confirmed that R1 was under hospice care due to a malignant condition. Progress and Final Outcome: Progress notes from 6/21/24, to 7/26/2024, documented ongoing hospice care and medication adjustments. R1 experienced increasing confusion due to the progression of their illness. R1 passed away on 726/24, during a hospice nurse visit. {1 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 Summary: The incident involving R1's report of abuse was thoroughly investigated by different agencies, and subsequent medical and administrative reviews confirmed that R1's medication use was appropriate as per hospice guidelines. The progression of R1’s condition and their eventual passing were consistent with the expected outcomes of their terminal illness and hospice care. Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection. An exit interview was conducted with ED and Caryl Ridgeway, Management Company representive and a copy of this report was provided. {2 of 2}