Westmont of Escondido.

Allegation #1: Staff are not properly trained. The complaint alleged that the staff was not properly trained. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegations and stated that all staff were properly trained. The department interviewed two Med Techs (MT1-MT2), who denied the allegation and stated that MT1-MT2, the caregiver, and the Housekeepers had all completed 12 hours of training from Relias and ongoing training. The department interviewed the RSD, who denied the allegation and stated that all staff were well-trained. The department interviewed the MCD, who also denied the allegation. The department interviewed five staff members (S1-S5), who all denied the allegation and stated that they were well-trained and had completed multiple Relias subjects. On the same day, the department interviewed six residents (R1-R6), all of whom denied the allegations and stated that the staff helps them when needed. On April 28, 2026, the department reviewed Relias staff training records dated 2024 and 2025. indicate that the staff was properly trained to assist residents. 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, therefore, the allegation is Unsubstantiated. Report Continued On LIC9099C 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 #2: The facility do not have adequate supplies to care for residents. The complaint alleged that the facility lacks necessary supplies to care for residents and that staff are not properly trained. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegations and stated that all staff are properly trained. The department interviewed two Med Techs (MT1-MT2), who denied the allegations and stated that the facility has sufficient supplies to address residents' scratches; however, the facility does not treat wounds or apply antibiotic ointment. Residents need a doctor's order to apply antibiotic ointment. The department interviewed the RSD, who denied the allegations and stated that all staff are well-trained. The department interviewed the MCD, who also denied the allegations. The department interviewed five staff members (S1-S5), who all denied the allegations and stated that the facility has several first-aid kits with fully stocked supplies. On the same day, the department interviewed six residents (R1-R6), all of whom denied the allegations and stated that the staff helps them when needed. On April 28, 2026, the department observed that the facility had first-aid supplies for residents in case of emergencies. 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, therefore, the allegation is Unsubstantiated. Report Continued on LIC9099C 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 #3: Staff does not ensure facility is free of pets. The complaint alleged a major ant infestation at the facility. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegations and stated that the facility has ORKIN, which visits the facility monthly to service the inside and outside. The department also interviewed two Med Techs (MT1 and MT2), who denied the allegations and stated that the facility doesn’t have any ant infestation.. The department interviewed the RSD, who denied the allegations and stated that all resident rooms are pets-free. The department also interviewed the MCD, who denied the allegations. The department interviewed five staff members (S1-S5), all of whom denied the allegations and reported not observing any ants, pets, or bed bugs in residents' rooms. On the same day, the department interviewed six residents (R1-R6), all of whom denied the allegations and stated that staff help them when needed. They also reported not noticing any pets or bed bugs in their rooms. On April 28, 2026, the department toured the first, second, third, and fourth floors and visited rooms 107, 218, 224, 301, 308, 322, 327, 338, 405, 429, and 442; no ants, pets, or bed bugs were detected. The department reviewed records of ORKIN pest control services at the facility on 9/4/25, 9/13/25, 10/9/25, 10/13/25, 12/8/25, 1/6/26, 2/5/26, 2/16/26, 3/5/26, and 3/20/26. Report Continued on LIC9099C 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 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, therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator, Austin Irwin.

Allegation: #1 Staff do not ensure the facility is kept free from mal odors for residents in care. The complaint alleged that the 3rd and 4 th floors of the facility have a bad odor; the housekeeping staff does not clean the rooms on those floors. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that the housekeepers clean the rooms once a week and as needed. On the same date, the department also interviewed two Medical Technicians (MT1 and MT2), who denied the allegation and also stated that the rooms do not smell. Additionally, the department interviewed five staff members (S1-S5), all of whom denied the claim and stated that the rooms are cleaned once a week. If a resident has an accident or spills something, the housekeeper will clean it right away. The staff members also stated that the facility has a hallway air freshener dispenser on the 2nd, 3rd, and 4th floors. The department interviewed the Maintenance staff member (M), who denied that the hallway had a bad odor. M also stated that M is on call 24/7 and will be called if anything needs to be done, and will take care of it. The department interviewed six residents (R1-R6), all of whom reported that their rooms are cleaned once a week . Reports continued on LIC9099C 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 R6 also stated that when something was spilled, the housekeeper cleaned it right away. On April 28, 2026, the department visited rooms 107, 218, 224, 301, 308, 322, 327, 338, 405, 429, and 442; no odor was detected. During the facility tour, there were no odors on the first, second, third, or fourth floors. 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, therefore, the allegation is Unsubstantiated. Allegation: #2: Staff do not ensure residents rooms are kept in clean, sanitary conditions. The complaint alleged that the “housekeeper refused to clean the rooms in memory care, when residents have accidents and spills get on the floor from urine and feces.” On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that the housekeepers clean the rooms once a week and as needed. When a resident spills something on the floor, the housekeepers clean it right away. On the same date, the department also interviewed two Medical Technicians (MT1 and MT2), who denied the allegation and stated that the rooms are cleaned regularly and that, if any residents or staff members noticed anything, they would report it. Reports Continued on LIC9099C 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 Additionally, the department interviewed five staff members (S1-S5), all of whom denied the claim and stated that the rooms are cleaned once a week. If a resident has an accident or spills something, the housekeeper will clean it right away. The department interviewed the Maintenance staff member (M), who denied that the hallway had a bad odor. M also stated that M is on call 24/7 and will be called if anything needs to be done, and will take care of it. The department interviewed six residents (R1-R6), all of whom reported that their rooms are cleaned once a week. R6 also stated that when something was spilled, the housekeeper cleaned it right away. On April 28, 2026, the department visited rooms 107, 218, 224, 301, 308, 322, 327, 338, 405, 429, and 442; no odor was detected. During the facility tour, there were no odors on the first, second, third, or fourth floors outside the hallway. 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, therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator, Austin Irwin.

The investigation revealed the following: Allegation: Facility staff did not dispense medications as prescribed. The detail of the complaint alleges R1’s medication was not dispensed as prescribed. Discontinued medication was allegedly given to R1. On April 8, 2026 at 12:30pm, the Department interviewed Executive Director (A1), who denied the allegation on the basis that R1 does not live at the facility, nor has R1 ever lived at the facility. It should be noted that the complaint did not provide a date of birth for R1. The department reviewed the current roster and could confirmed that R1 doesn't appear on the roster. Through the interview process, with A1, the department found that there was a resident with a similar name [one letter off]--who resided in the facility during time of the complaint, however that resident did not match the detail of the complaint. On April 8, 2026 the Department interviewed the Resident Services Director (S1), who also stated that there was no resident by R1's name who resided in the facility. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today's visit. Exit interview conducted and copy of report provided. Page 2 of 2

On 12/11/2025, Licensing Program Analyst (LPA) Valerie Flores made an unannounced visit to the facility for the purpose of conducting a case management - incident visit. LPA met with Executive Director, Austin Irwin, whom was informed the purpose of the visit. During the visit, LPA collected pertinent documentation and conducted interviews with relevant parties. On 12/11/2025 at approximately 10:30AM, LPA received a call from Executive Director Austin Irwin informing LPA of a possible suicide. Upon arrival, information received reported that Home Health nurse was conducting a routine visit with Resident #1 (R1). Home Health nurse entered into R1's bedroom and did not observe R1 to be present inside the bedroom. Home Health nurse further observed R1's oxygen cord lying on the floor. Home Health nurse followed the cord which lead out to R1's second floor balcony and observed R1, who was lying on the flowerbed at ground level. Home Health nurse immediately called emergency services and notified Executive Director. It was reported that Home Health Nurse, Executive Director, and Resident Service Director ran out to assess R1. R1 was observed to be unresponsive and without a pulse. R1 resided in a shared unit but had their own bedroom. R1 was residing at the facility for approximately two months. During the time of stay, staff did not observe any changes of behaviors. R1's physician report conducted on 10/3/2025 divulged that R1 did not have suicidal ideations and did not require constant supervision. Resident #2 (R2), who shares a common wall with R1, reports that R1 and R2 went down to eat breakfast together that morning. Upon returning to their shared unit, R2 reports that they did not hear nor observe anything out of the ordinary. At this time, the death determination is still pending autopsy. LPA requested a copy of the death certificate once it has been available to the facility. During today's visit, LPA did not observe any health and safety concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator, Austin Irwin.

On 12/2/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of following up on a self-reported SOC341 provided to the department by the facility. LPA met with Executive Director Austin Irwin and informed him of the purpose of the visit. Information received alleged Staff #1 (S1) physically assaulted Resident #1 (R1). The visit consisted of interviews and observations. On 12/1/2025 at 9:30AM, Resident #1 (R1) who resides in Assisted Living shared unit 222B reported to Staff #2 (S2) that R1 was punch in the face by Staff #1 (S1). Interview with R1 and facility staff reported that R1 requested that S1 assist R1 with a brief change. It was reported that S1 became aggressive and struck R1 near the right jaw/chin area. Administrator contacted Escondido Police Department. A police report number was provided for the incident, but law enforcement did not detain and/or arrest S1 as they did not have sufficient basis to arrest S1. Facility staff reported that R1 did not have marking's and/or bruising from the incident but S1 was placed on leave, undergoing an internal investigation. Administrator provided LPA a termination letter for S1. The termination letter has yet to be provided to S1 by 12/3/2025. During the health and safety check, LPA did not observe any bruising and/or redness to R1’s face. Due to insufficient evidence, LPA could not corroborate that the incident took place. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. No deficiencies were observed or cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Executive Director, Austin Irwin.

On 9/23/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced 1-year required annual visit. LPA was greeted by facility staff and was granted entry. LPA advised Administrator, Austin Irwin, of the purpose of the visit. A tour of the facility was conducted. LPA Flores observed the following during todays visit: The facility is a five story structure with a lock perimeter memory care unit on the first floor. The facility is licensed for (200) two hundred non-ambulatory residents to which (10) ten residents may be bedridden. The facility is currently approved for (15) fifteen hospice waivers. LPA observed the facility to be clean and in good repair. Lighting is sufficient for safety. Laundry is done in the designated laundry room on each floor, as well as the location located in the garage’s parking structure. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the Housekeeper’s closet. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The facility maintains a current emergency disaster plan is maintained. There are no fireplaces at this facility. There is (1) one indoor pool at the facility which has an enclosed and secured perimeter. There are gates located in the front and back of the building. Resident bedrooms had the required bedding, furniture, seating, and lighting. Bathrooms were equipped with grab bars and slip resistant mats in the shower area. Food prep areas are clean and organized. Food supply meets the requirement of (2) two-day supply of perishable and (7) seven-day supply of non-perishables foods. There are food deliveries that come three days out of the week. (Continue to LIC809C...) 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 (Continuation from LIC809) Facility maintains a sufficient amount of emergency food and water supply. There is a secured location for knives and other sharp items located in the kitchen. LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. The facility is maintained at a comfortable temperature for the residents. Per Administrator, Austin Irwin, there are no firearms and/or ammunition on the premises. LPA conducted records review for (10) ten residents. Resident records included but not limited to identification and emergency information, preplacement appraisals, admission agreement, medical assessment, and TB test results, safeguard for personal property/valuables, and personal rights notification. LPA conducted records review for (5) five staff. Staff records included but not limited to first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Austin Irwin Administrator’s certificate expiration date is 05/08/2026. During today's visit, LPA did not observe any health and safety concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator, Austin Irwin.

(Continuation LIC9099..) Interviews conducted with R1 and relevant parties corroborated R1 did not report the fall to facility staff. Interview with R1 further confirmed R1 did not require medical attention from the fall. Information received alleged R1 is not being adequately fed. Records review conducted of the facility meal check confirmed R1 is offered (3) three meals a day. A record review conducted of the End of Shift reports documented on July 11th and July 21st of 2025, reported R1 refused lunch as R1 ate a late breakfast. A record review conducted of R1’s weight chart shows R1 has maintained static weight since being admitted into the facility. An interview conducted with R1 confirms the facility staff provide R1 with (3) three meals a day with snacks in-between. Interview with R1 confirmed R1 will refuse a meal from time to time when the previous meal was filling. Interviews conducted with relevant parties indicated R1 does not refuse meals often to lead to cause of concerns. Interview conducted with Resident #2 (R2) and staff reported that R1 often attends meals with R2 which encourages R1 to attend meals. Information received alleged R1 is not being assisted with showers. A record review conducted of R1 revealed R1 is independent and does not require shower assistance. The facility does not maintain a shower log for R1 as R1 is independent. A record review conducted for R1 physician report verified R1 did not require assisting with bathing, grooming, dressing, feeding, and/or tioleting. Interviews conducted with facility staff explained staff will ask R1 if R1 has showered and facility staff will offer verbal reminders. An interview conducted with R1 and relevant parties corroborated that R1 will refuse to shower at times but there is no cause of concerns. R1 is independent and does not require reassessment. Based on interviews and records review, the allegations of facility did not assist in seeking medical attention for a resident in a timely manner, resident is not being adequately fed, and resident is not being assisted with showering are unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator, Austin Irwin.

On April 18, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Case Management Incident visit, and met Austin Irwin, Executive Director. LPA introduced herself and explained the purpose of the visit. LPA Mixson toured the facility, along with Executive Director and made observations pertaining to the incident. There were sufficient staff present and 141 residents currently. There are no imminent health and/or safety concerns observed at the time of visit. LPA requested and received pertinent documentation. LPA Mixson did not observe any health and/or safety hazards inside or outside of the facility at the time of this visit. LPA observed the facility utilities to be operating without issue. LPA Mixson assessed the available food and observed there was a variety of food types available for the residents in care. The food supply meets the requirement of a two-day supply of perishable foods and a seven-day supply of non-perishable foods. The medications were found to be in sufficient supply, locked, and inaccessible to the residents in care. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. No deficiencies were observed or cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Executive Director, Austin Irwin.

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with Executive Director, Austin Irwin. LPA was informed that one hundred and forty residents (140) reside at this facility. LPA toured the facility and observed all facility utilities to be on and operating without issue, food supply is sufficient, there is no immediate concern for residents in care. The LPA conducted a visit in regards to an incident report the Department received on 03/25/2025. The incident that occurred on 03/24/23025. It was alleged that Staff 1(S1) punched Resident 1 (R1). The LPA requested and received pertinent documents regarding (R1) and (S1). The LPA requested copies of the S1's schedule, personnel file, as well as any disciplinary action taken by the facility. The Executive Director indicted that S1 no longer works at the facility as of the date of 03/28/2025. S1 voluntarily resigned. R1 retracted R1's statement regarding S1 punching them. Based on the information obtained during today’s visit, there are no deficiencies or civil penalties being cited per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Executive Director, Austin Irwin and a copy of this report is left with the Irwin, as evidence by his signature.

On 06/25/2023, R1 was sent out to an acute hospital by staff under the incorrect name. It was advised that R1’s family spent hours trying to locate R1 and was finally assisted by an emergency services operator. R1’s responsible party met with the Executive Director who confirmed that Staff 2 (S2) provided the paramedics with the wrong name. An interview with S2 indicated that S2 mistakenly verified another resident’s name and that the Med Tech confirmed it. S2 gathered the wrong paperwork while waiting for the ambulance. After the family contacted the facility to say they could not locate R1, the facility reviewed the records and realized the mistake. Responsible party was notified and able to locate R1. Regarding the allegation that staff did not provide records to the resident's authorized person, it was alleged that the facility did not provide Serious Incident Reports (SIRs) to R1’s responsible party. Information obtained from interview with additional witness stated on 03/18/2024 they requested copies of all SIRs, but only received a few. It was also reported that there was an incident in which R1 was choked by another resident and the responsible party was denied a copy of the report. Administrator stated that the Serious Incident Reports were provided to R1’s responsible party on the date of 03/18/2024. Regarding the allegation that staff did not provide language services for the resident as agreed, it was alleged that the facility did not provide German-speaking services to R1. It was advised that facility administration agreed to provide language cards in order to communicate with Resident, but they were never provided or used. Interviews with the Executive Director revealed that staff used language cards and an app on their phones to translate. Staff interviews indicated that the cards were rarely used. It was also reported that the app began to be used on 06/10/2024. Resident was placed at the facility on 02/28/2023. 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 Based on interviews and records review, the allegations of staff did not provide emergency personnel with the correction information for the resident and staff did not provide language services for the resident, the preponderance of evidence standard has been met. Therefore, the above allegations are SUBSTANTIATED. This poses a health and safety risk for clients in care. The facility will be cited. An exit interview was conducted. A copy of this report was discussed and provided to Executive Director Austin Irwin, along with copies of the LIC811, LIC9099D, and appeal rights. 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 regards to the allegation that Resident sustained unexplained injuries while in care, it was reported that Resident 1 sustained bruising and cuts on their body. Information obtained from interview with Administrator denied that any staff harmed R1. Administrator stated that he was unsure how R1 sustained the bruising, but noted staff receive ongoing in-service training and refreshers as needed. Information obtained from interview with Staff #1, (S1) revealed that R1 has experienced multiple falls and that the responsible party would be notified before any transfer to the hospital. The falls were documented on the facility’s charting. The falls were reported to Licensing during the time period of 06/28/2023 to 04/19/2024. Interviews with staff denied that R1 was physically abused by staff. Staff stated that Resident sustained injuries due to being in altercations with other residents, as well as unwitnessed falls during the course of R1’s residency at the facility. LPA was unable to obtain any additional information from Resident #1 regarding the allegation due to not obtaining contact. Regarding the allegation that staff did not seek medical attention for the resident in a timely manner, it was alleged that the facility did not seek medical attention for R1 in a timely manner. It was reported that an incident occurred on 03/18/2024. R1 fell off the couch. Staff notified R1’s POA of R1’s incidents at the facility. The POA confirmed that they declined immediate medical care and did not approve R1’s transfer to the hospital after an unwitnessed fall. The facility’s incident report showed that the family declined R1’s transport. The POA stated that they had a nurse come out, whom they contracted independently. The POA stated that they came to assess R1 and saw a large gash on R1’s elbow and a bruise on R1's thigh. The POA asked why they didn’t send R1 out, it was stated that the POA would take R1 to the hospital themselves. Interview with the care staff indicted that they contacted the POA as requested and the POA stated that they would have a nurse come check on R1. The Administrator indicated that it is the facility’s protocol to send R1 out if any head injury is suspected and that the responsible party is always contacted. Interviews with care staff revealed that the POA would request staff to contact them before calling for a transfer to the hospital. According to the facility policy, the Med Tech assesses the resident after an incident. 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 If the resident is able to move and communicate, they will be helped up or left on the floor, depending on the situation. The Med Tech will then call 911, and the responsible party will be notified of any incidents. Interviews were not able to be conducted with R1 regarding the incident, with four attempts to contact R1 on the same dates as above. Regarding the allegation that staff did not prevent an altercation between residents, it was reported that on December 13, 2023, there was an altercation between R1 and R2. It was reported that R2 pinned R1 under R1’s walker, causing R1 to sustain a skin tear. Information obtained from Administrator stated that R1 would get into altercations with other residents. Information obtained from interviews with staff stated that they did not observe the entire altercation, but separated, redirected, and increased supervision of the residents. Interview with R2 revealed no information due to R2’s diagnosis. Additional information was unable to be obtained from additional residents due to the residents’ diagnosis and residency in memory care. LPA was unable to interview R1 in regards to the allegation. The incident was reported to Licensing. Based on the information obtained during the investigation, the allegations that R1 sustained unexplained injuries while in care, staff did not seek medical attention for R1 in a timely manner, and staff did not prevent an altercation between residents are unsubstantiated. Although the allegations may have occurred or could be valid, there is not enough evidence to prove that the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was discussed with and provided to Executive Director Austin Irwin.

Administrator spoke to R1 and their responsible party and relayed that R1 would need to be sent out each day for insulin injections or have a third-party company visit the facility to assist R1 with the insulin shots, at a cost of $150 to be paid by R1. Prior to this hospital visit, R1 managed their own medications. Administrator stated that they did not serve R1 with an eviction notice because R1 had not returned to the facility. Administrator stated that he would serve R1 with a 30-day eviction notice, as the facility is unable to meet R1’s needs. Information obtained from R1 admitted that they did use to manage their own medication and injections independently. After returning from the hospital visit, the facility conducted a reassessment, which revealed that R1 had a change in their level of care due to needing assistance with medication. R1 stated that they did not receive an official eviction notice. Information obtained from interviews with other pertinent parties corroborated that the facility did not serve R1 with a 3-day or 30-day eviction notice. During the course of the investigation, LPA verified that no eviction notices were generated for R1 or provided to R1 or their responsible party. Based on the information obtained during the investigation, the allegation that the facility unlawfully evicted the resident has been deemed unfounded, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to Business Office Director, Tasha Keller.

Information obtained from the interview with the Executive Director indicated that R1 has always had a call light device. Executive Director and staff members indicated that the pendant was obtained to be replaced with a handheld call light button. Interviews corroborated that R1 was provided the pendent the same day. During the initial visit, LPA verified that the call light button was operable. LPA observed and verified that the pendent was in working condition through a mock test. Information obtained from interviews with all pertinent parties corroborates the information provided to the LPA. Information obtained from interviews with additional witnesses revealed no issues or concerns regarding care or supervision. Based on the information obtained during the investigation, this agency has investigated the complaint alleging that staff took away resident’s call button. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was discussed with and provided to Executive Director, Austin Irwin.

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one hundred and twenty-eight (128) residents live at this facility. The Executive Director, Austin Irwin was advised of the annual and conduct and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration : LPA reviewed employee records. Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Austin Irwin Administrator’s certificate expiration date is 05/08/2026. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. There are food deliveries that come three days out of the week. Emergency food and water supply is present. There is a location for sharps in the kitchen. 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 Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the designated laundry room on each floor, as well as the location located in the garage’s parking structure. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the Housekeeper’s closet. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are no fireplaces at this facility. There is one (1) indoor pool at the facility, that has an enclosed and secured perimeter. There are gates located in the front and back of the building. LPA observed emergency supplies and first aid kits. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that staff` had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately. 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 made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed smoke detectors and carbon monoxide detectors throughout the facility. LPA observed fire extinguishers on site, date charged was 02/28/2024. The Escondido Fire Department came to inspect the facility on 07/25/2024. Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Executive Director, Austin Irwin.

Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced to the facility to conduct a required annual inspection. LPA met with Executive Director David Alspach at the front entrance and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. Facility is licensed for 200 non-ambulatory elderly residents; ages 60 and above; 10 of whom may be bedridden. Facility has a hospice waiver for 10 residents. During today's visit, LPA toured the facility inside and out, reviewed records, and interviewed staff, as well as residents. The physical plant was found to be clean, free of odor, and in good repair with no pathway obstruction; facility's temperature measured at 72 degrees; all cleaning solutions were observed in a locked secure area. Staff present have a criminal record clearance in file and are associated to the facility. Tour included: Physical Plant: front entrance, interior and exterior surroundings were observed to be clean with no pathway obstruction; facility's water temperature 115 degrees; all bathrooms were clean and equipped with grab bars. The facility's toilets were observed to be in working order. There is sufficient lightings and mattress pads in all of the residents’ bedrooms. There is also sufficient amount of personal toiletries available for the residents in care. Random smoke detectors were inspected and found to be in working order. LPA inspected the Fire Extinguishers throughout the facility and found them to be in compliance. The indoor swimming pool is available for residents who are not memory care and requires a check out key at the front desk. The facility does not have firearm and/or ammunition on grounds. Continued on LIC 809C 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 Food Services: 7 day non-perishable and 2 day of perishable food supply was observed and all food was properly stored and available to residents. Items reviewed/discussed: Random staff and residents' records were reviewed. Staff records reviewed have criminal record clearance in file and are properly associated to the facility. Random resident records reviewed have the required documents and are up to date. All required postings were posted near the facility entrance. Administrator certificate expires on 7/23/2025. Last fire drill conducted on 07/28/2023. Facility's medication/PRN logs were reviewed and residents’ medications were inspected for dispensing according to physician’s orders. No cited deficiencies per Title 22, Division 6 of the California Code of Regulations cited at this time. An exit interview was conducted and a copy provided to Executive Director David Alspach.