Cogir of Folsom

the PTAC in R1’s room was functioning and had a temperature range that could be adjusted between 60-86 degrees F. LPA and LTCO attempted to interview R1, who did not express any concerns regarding the PTAC and indicated that it works. Interviews with the Executive Director (ED) and Maintenance Director (MD) indicated that the PTAC in R1’s room had been replaced as well as the filter. MD also indicated that the PTAC temperatures have a specific range to ensure safety of residents operating the units. Allegation: Staff do not provide appropriate care and supervision for a cognitively impaired resident Interviews with staff (S1 and S2) indicated that they provide care and supervision to residents in R1’s wing of the facility. S1 indicated that R1 opens and closes their window throughout the day. S1 and S2 indicated that staff are notified when a resident opens their window. S2 indicated that if a resident wants their window open and it is the appropriate temperature outside, staff will keep it open. S1 and S2 indicated they will adjust the PTAC, if needed, during resident checks or upon request to ensure residents' rooms remain at a comfortable temperature. S1 and S2 indicated that they believe the facility provides good care and supervision to the residents and that they have enough staff per resident to provide monitoring. S1 indicated that staff will provide checks on residents every two (2) hours. S1 and S2 indicated that most residents will be in the common areas throughout the day. ED indicated that the facility has enough staff on schedule to provide care and supervision for the residents. LPA has been receiving monthly schedules from the facility indicating the facility is fully staffed during all shifts. Based on observations made, interviews conducted, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.

LIC 9099-C Interview conducted with Executive Director revealed that hamburger at the facility may be served a certain way but request of the resident. Interview conducted with resident (R1) revealed that R1 cannot recalled being served undercooked hamburger. With the information obtained, the allegations are unsubstantiated. As a result of this investigation, it was determined the allegations are to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Exit interview and a copy of the report was provided.

indicated that the other caregivers on duty at the time of the incident were assisting other residents and the med tech was in the medication room. Interviews with staff indicated that they were not short staffed and there was no lack in care or supervision at the facility. According to the staff schedule, the facility was fully staffed on the date of the incident. R1’s After Visit Summary and Progress Notes indicated that R1 returned to the facility from the hospital on November 19, 2025. There were no injuries reported and R1 had a change in their medication. According to R2’s Behavioral Expression Monitoring Log, R2 had incidents of aggressive behaviors towards other residents on October 27, 2025, October 28, 2025, and October 31, 2025 without injuries. The facility responded to the incidents by conducting a care conference with R2’s responsible party and reassessing them with the update in behaviors, which was signed on October 30, 2025. Between October 30, 2025 and November 12, 2025, the facility was in communication with R2’s physician and their responsible party to ensure they address R2’s changes in behaviors. The facility provided documentation indicating that R2’s physician had made adjustments to medications for behaviors as well as included antibiotics for Urinary Tract Infection (UTI). One medication utilized to reduce behaviors was increased on November 12, 2025 as well as another Urinalysis ordered for monitoring of UTI. Due to the November 16, 2025 incident, the facility immediately implemented one on one care to provide additional care and supervision for R2. The facility provided invoices indicating the dates of service from November 17, 2025-November 23, 2025. Based on interviews conducted and documentation obtained, 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. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Liz Cruz, to conduct a case management visit. The purpose of today's visit was to amend reports from a visit conducted on February 3, 2026. The department has determined that, due to the citation issued on February 3, 2026, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 will be assessed for a violation that the department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted. No additional citations issued. Exit interview conducted. Copy of report provided.

LIC 9099-C For the allegation of, Facility staff did not provide resident medications at prescribed, the Department conducted file reviews of R1’s medication list, narcotic count record, medication release record, and emergency paper medication administration record. Records revealed that on the medication list effective January 24, 2025, R1 was prescribed PRN Ativan 0.5mg one tablet by mouth twice a day as needed. Then effective February 3, 2025, PRN Ativan 0.5mg was changed to one tablet by mouth three times a day as needed. File review of narcotic count record revealed that after R1’s first dose given on February 1, 2025, there was a remaining of 87 tablets of Ativan 0.5mg and after the last dose given on February 10, 2025, there was a remaining of 68 tablets. From February 1, 2025 to February 2, 2025, R1 received maximum of one tablet per day as needed. From February 3, 2025 to February 10, 2025, R1 did not receive more than three tablets per day, compliance to R1’s physician order of the PRN Ativan. Medication release record revealed it was signed off by R1’s responsible party that Ativan 0.5mg was entrusted to R1’s responsible party with the total count of 68 tablets. Therefore, allegation is unfounded. Based on the information obtained, the Department concluded that the allegations are unfounded. A finding that an allegation 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 the report was provided. 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 LIC 9099-C(1) For the allegation, Facility staff did not ensure that resident's showering needs are being met, the Department conducted several interviews. Interview conducted with resident (R2) revealed that staff does assist R2 with showering. When asked if R2 is having any issues with staff not meeting R2's showering needs, R2 indicate R2 does not think there is any issues. R2 stated R2 cannot remember much but think they are getting all their showers. File review of R2's LIC 602 revealed that R2 has dementia. Interview conducted with resident (R3) revealed that R3 has recently moved in the facility but really likes the staff. R3 denied having any issues regarding showering needs, and expressed that R3 is satisfied at the facility. R3 receives showering twice a week. Interview conducted with resident (R4) revealed that R4 does not need much assistance from staff with showering but likes stand-by assist. R4 does not know if there are any concerns with showering needs. File review of R4'sLIC 602 revealed that R4 does have dementia. Interview conducted with R5 revealed that R5 receives assistance with showering. R5 does not believe there are any issues with staff not meeting resident's showering needs. Due to the lack of information the Department was able to obtain, the allegation is unsubstantiated. The allegation of, Facility staff did not intervene in verbal altercation between residents, the Department conducted extensive interviews. Interview conducted with Health and Wellness Director revealed that when residents are having a verbal altercation, staff are to assist with de-escalating the situation. Staff are to isolate the aggressor to see if they want to do any activities. Interview conducted with Executive Director revealed that the facility is a memory care facility where residents are often having behaviors. If residents are engaged in an altercation, staff should intervene to ensure the health and safety of residents in care. The facility has several corners where if guests or visitors are observing an altercation, they are to report the incident to staff for staff to redirect. Executive Director reported that this alleged incident was not brought to their attention and there was not enough information to investigate further. There were no known witnesses to such an incident. Interview conducted with R2, R3, R4 and R5 reported they feel safe at the facility. Therefore the allegation is unsubstantiated. Please continue on LIC9099-C (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 LIC 9099-C(2). For the allegation of, Facility staff spoke inappropriate to resident, the Department conducted interviews to investigate the following. Interview conducted with Health and Wellness Director revealed that R1 was new at the facility and was very dependent on R1's roommate for social interaction and activities but staff did not speak to R1 in any ill manner. Interview further revealed that staff are to assist and motivate R1 with integrating into the community and ensuring R1 feels comfortable with other residents in care. Interview conducted with R3 revealed that R3 has not witnessed staff speaking to residents inappropriately. Interview conducted with Executive Director revealed that the alleged incident was brought to her attention by a family member but there was no information on what day this occurred, no information on which staff member allegedly spoke inappropriately to R 1 and/or other residents. Due to lack of information available for the Department to investigate, the allegation is unsubstantiated. As a result of this investigation, it was determined the allegations are to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Exit interview and a copy of the report was provided.

On September 16, 2025 at 3:30 PM, a virtual office meeting was held with Sacramento North Regional Office using Microsoft Teams. Present in the meeting was Community Care Licensing representatives: Regional Manager, Alycia Rayner; Licensing Program Manager (LPM), Maribeth Senty; and Licensing Program Analyst (LPA), Cassie Yang. Present in the meeting was Licensee representatives: Senior Vice President of Care and Compliance, Holly McMurray; Senior Vice President Operations Northern CA, Kristina Munoz; Assistant Chief Operating Officer, Justin Stein; National Director of Resident Care, Kimberly Eldridge; Regional of Health and Wellness, Karen Silva; and Legal representative, Joel Goldman. The purpose of today's meeting was to discuss the recent non-compliance at the facility. Topics discussed during this meeting were: Significant leadership changes Continuation of staff training Observation of residents behavior expressions Appropriate oversight at the facility Additionally, a follow-up office meeting will be scheduled in three months to discuss the progress of new facility implementation. A copy of this report was emailed to Senior Vice President of Care and Compliance Holly McMurray, following today's meeting. A signed copy will be returned to the LPA by close of business September 16, 2025. There are no deficiencies issued in this report.

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced on to conduct case management visit regarding a SOC 341 received. LPA met with Regional Executive Director and explained the purpose of the visit. A SOC 341 was submitted by facility regarding a sexual incident between residents, R1 and R2. Additionally, Facility notified law enforcement, long term care ombudsman (LTCO) and residents' responsible parties regarding this incident. Facility has implemented 1 on 1 care and supervision for R1 to ensure the safety of residents in care as R1 is pending further medical evaluation. No deficiencies cited. Exit interview conducted and copy of the report left at facility.

Licensing Program Analyst (LPA) Cassie Yang arrived on August 19, 2025, to follow up on substantiated allegations resulting from a complaint investigation. Licensing staff met with Facility Representative, Liz Cruz, to discuss the Department’s findings. On December 23, 2024, the Department concluded a complaint investigation substantiating the following allegations: Due to facility staff's lack of care and supervision, resident sustained serious bodily injury, and facility staff's lack of care and supervision resulted in resident's death. The Licensee was cited for California Code of Regulations (CCR) Title 22, § 87468.2(a)(4) Personal Rights of Residents in All Facilities. At the time of the complaint investigation on December 23, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis of the following incident and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by facility staff’s inadequate supervision of residents in care, resulting in a fatal altercation between residents. Please continue on LIC 809-C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC 809-C Today, August 19, 2025, the Department will be issuing a civil penalty in the amount of $15,000 per Health and Safety Code §1569.49(e), for a violation that the Department determines to have resulted in the death of a resident. However, since an immediate civil penalty of $500 was previously issued on December 23, 2024, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. A signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the care tool. LPA met with Executive Director and explained the purpose of the visit. Prior to entering facility, LPA wore a N-95 mask due to reports of COVID-19 outbreak. Today's inspection, LPA and Executive Director discussed the six active cases at the facility. LPA will return at a later day to complete walk-through inspection. Additionally, LPA and Executive Director discussed staffing and COVID-19 protocols. Exit interview and a copy was provided.

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management annual continuation visit, utilizing the inspection tool. LPA met with Executive Director (ED), Deborah Taylor and explained the purpose of the visit. During today's inspection, LPA and ED conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: residents bedrooms, bathrooms, dining area, kitchen, activity rooms, medication room and the common areas. LPA observed residents bedrooms to have the required furnishing. LPA observed residents showers to have nonskid strips present. LPA observed facility temperature to be at a comfortable temperature of 74*F. LPA observed access to the kitchen to be locked with pin code entry. Kitchen was observed to be clean and free of pest. LPA observed ample supply of perishable and nonperishable foods available for residents in care. LPA observed exits to be free of obstructions. LPA observed activities available in the common areas for resident social interactions. LPA observed medication room to be occupied with medication technicians, assisting residents in care. In areas toured, LPA observed facility to be clean and in good repair. No immediate health, safety and/or personal rights violations was observed. File review was conducted for five resident records and five personnel records. LPA observed the required documents signed and completed on file. At this time, LPA is requesting a copy of facility liability insurance to be emailed to LPA by Friday, August 8, 2025. CARE tool was completed and no deficiencies was cited. Exit interview was conducted and a copy of the report was provided.

On May 29, 2025, a Non-Compliance Conference was held at the Sacramento North Regional Office located at 9835 Goethe Road Suite 100, Sacramento CA 95827. Present were in the office meeting were: Licensing representatives - Regional Manager, Alycia Rayner, Licensing Program Manager, Maribeth Senty, and Licensing Program Analyst, Cassie Yang. Facility Representatives - Senior Vice President of Operations, Phil Altman, Regional Vice President of Operations, Lyndee Whaley, Executive Director, Deborah Taylor, Health and Wellness Director , Shayla Hill, and Legal Counsel, Payam Saljoughian. A non-compliance plan was developed with the licensee on today's date as it relates to previous compliance history. The licensee was in agreement with the drafted non-compliance plan. Due to the improvement of the compliance and new procedure implementation at the facility, no citations are issued as a result of today's meeting. Exit interview was conducted and a copy of the report was provided.

LIC 9099-C Allegation: Staff left resident unattended for an extended period of time resulting in hospitalization. File review of R1's medication order on March 13, 2024, it revealed R1 has a previous medical history of hypertension and CKD (chronic kidney disease) stage G3b/A1. Incident report submitted for R1 revealed R1 was sent to the hospital for evaluation due to discoloration around mouth and high temperature. File review of R1's hospital discharge document, it revealed R1 was treated fro acute kidney injury. Document stated the cause of injury may be due to "heart and blood vessel disease". Based on information gathered from R1's physician report it revealed R1 has a primary diagnosis of dementia and secondary diagnosis of atrial fibrillation. Interview conducted with Health and Wellness Director revealed residents in care are checked during rounds every two hours. Health and Wellness Director denied any observation of sunburns on R1. Therefore, allegation is unfounded. Allegation: Staff are not meeting residents needs The Department conducted extensive file reviews for the following allegation. File review of R2's care plan conducted on February 22, 2024 revealed R2 is a "one to two" person assist with transfer. File review of R2's care plan conducted on June 13, 2024 revealed R2's level of care has changed which R2 is now a two person assist with mechanical lift. Interview with Health and Wellness Director revealed hospice agency has trained fcaility staff how to use mechanical lift. For new staff, Health and Wellness Director then train staff through demonstration. File review of staff training revealed training was completed by Health and Wellness Director and Suncrest Hospice regarding Safe Transfer with Hoyer Lift, with approximately 17 staff present in attendance. Therefore, allegation is unfounded. Based on information obtained, the following allegations of: Staff left resident unattended for an extended period of time resulting in hospitalization, and Staff are not meeting residents needs, are UNFOUNDED. Unfounded meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was provided.

LIC 9099-C (1) Allegation: Staff do not respond to resident calls for assistance. The Department conducted interviews and file review regarding the allegation. Based on interview conducted with R1 on March 22, 2024, it revealed R1 likes the staff at the facility. R1 stated staff are helpful and responds to calls as needed. R1 stated R1 has a slight cognitive impairment but is sharp for the most part. Interview conducted with Executive Director on April 3, 2024 revealed the call system is an alert at the front receptionist desk, which indicates which room is in need for assistance which receptionist then call caregivers to the room. Executive Director stated there is no systematic program that collects data of the alerts trigger by room cord plugs. Executive Director stated all rooms are installed with fall detection camera which will record videos of each fall, and alert the facility via telephone. File review of standard report of March 2024 call response data provided by room camera system revealed there was a total of 14 falls detected, the median time to respond was one minute and 14 seconds with the average time to respond to be one minute and 43 seconds. File review further revealed time to respond less than five minutes was the total of 92.31%. Interview conducted with Executive Director on February 5, 2025 revealed when a call for assistance is activated from a room, it will create a ring which cannot be deactivated until staff go to the resident room to turn it off when they respond. The allegation above is unfounded. Allegation: Staff do not meet resident toileting needs. Based on LPA's observation to seven bedrooms on April 3, 2024 and five bedrooms on June 21, 2024, there was no indication of incontinence mal odor. Interview conducted with R1 on March 22, 2024 revealed R1 does not have any issues with staff not fulfilling resident toileting needs. Interview conducted with R2 revealed R2 is happy and does not have any current issue regarding incontinence care. Interview conducted with Health and Wellcare Director revealed that she does not have any issues with staff not assisting residents with toileting and/or incontinence care. Health and Wellcare Director stated residents in care are changed and/or assisted with toileting needs before bed. Night (NOC) shift are not to disturb residents while they are sleeping to check their depends unless residents wake up in the middle of the night, and notify staff for a change. Health and Wellcare Director stated when morning shift starts it is usually when residents are waking up for the day which will require toileting/incontinence assistance. Residents may have had a bowel movement in their sleep at night but it does not mean residents were neglected. The allegation is unfounded. Please continue on LIC 9099-C (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 LIC 9099-C (2) Allegation: Staff did not seek medical attention for resident in a timely manner. Incident in question indicated that on February 26, 2024 during night shift, staff failed to seek medical attention for R1. Based on file review, it revealed on February 17, 2024 at approximately 9:10 p.m, R1 was vomiting after given PRN medication. Hospital documents revealed R1 was admitted to Mercy Hospital of Folsom for vomiting on February 17, 2024. File review of incident report submitted on February 28, 2024 revealed on February 25, 2024 at approximately 11 a.m, R1 informed staff R1 had an episode of emesis, and was transported to Mercy Hospital of Folsom for evaluation. During time of the faxed incident report, R1 has not been discharged from the hospital to the community. File review of R1's hospital documents confirmed R1 was admitted to the hospital on February 25, 2024. File review of submitted incident report revealed on March 11, 2024, R1 had an episode of emesis and was transported to Mercy Hospital of Folsom for evaluation. Hospital documents confirmed R1 was admitted to the emergency room on March 11, 2024. Therefore, the allegation is unfounded. Allegation: Staff are not properly training to meet resident needs. The Department conducted file review of medication training. File review revealed S1 was hired as an employee in August 2022, then scheduled for training to be a medication technician starting February 21, 2024. S1 completed the mandated training of 8 hours of instruction on February 23, 2024 and completed 16 hours of hands-on shadowing training on February 27, 2024. S2 was hired as an employee in December 2023, and completed the mandated medication administration training of 8 hours of instruction on January 1, 2024 and completed 16 hours of hands-on shadowing training on February 27, 2024. S3 was hired as an employee in December 2023, and completed the mandated medication administration training of 8 hours of instruction in February 2024 and completed 16 hours of hands-on shadowing training on December 31, 2024. Therefore, the allegation is unfounded. Based on information obtained through file review and interviews, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left at the facility.

LIC 9099-C(1) Allegation: Staff did not provide showers to residents in care Based on file review conducted for the facility shower sign off sheet for March 2024, it revealed residents in care was provided showers. Shower sign off sheet revealed R1 was showered total of nine (9) times on the following days in the month of March 2024: 2nd, 9th, 12th, 16th, 21st, twice on 22nd, 24th, and 27th. Shower sign off sheet revealed R2 was showered eight (8) times on the following days in the month of March 2024: 3rd, 4th, 6th, 10th, 13th, 17th, 21st, and 27th. Interview conducted with Executive Director on February 5, 2025 revealed since change of Executive Director, documentation has changed where facility will document on shower logs if there was any refusal and/or exceptions. Residents in care organized in scheduled showering schedules twice a week. The following allegation is unfounded. Allegation: Staff did not ensure residents were kept clean Based on interview conducted with Co-Reporting Party, it revealed Co-Reporting Party has observed residents in care having a dirty shirt on while eating or food on their faces. Co-Party Reporting stated that staff should utilize a bib for residents who are messy eaters. Interview conducted with Executive Director on April 3, 2024 revealed that there are a few residents in care who has mobility limitations with self-feeding. Executive Director stated facility cannot enforce residents in care to wear bibs. Executive Director stated after meals, staff assist with wiping food off resident’s clothing and may ask the residents if they want to change, but residents still have the rights to decline. Based on LPA's observation on April 3, 2024, facility staff were observed to be assisting residents in care with cleaning after meal. Interview conducted with Executive Director on February 5, 2025 revealed that facility are providing independent eaters with garment covers during meal times. The following allegation is unfounded. Please continue on LIC 9099-C(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 LIC 9099-C (2) Allegation: Staff did not provide transportation services to residents in care. Based on interview conducted with Executive Director on April 3, 2024, it revealed that the facility bus is utilizing for extracurricular activities such as city tours. Executive Director explained that the registration tag on the bus has expired therefore the bus cannot be utilized at this time. Executive Director stated that if residents in care needs transportation to medical and/or dental appointments family members are to pick up the resident from the facility to the appointment. If family members are unable to, facility staff can assist residents to an appointment when notified in advance and at an additional charge. Interview conducted with Executive Director and Health and Wellness Director on February 5, 2024 revealed that the facility bus is currently in the shop, but if residents in care are in need for transportation services, facility will provide third party transportation such as Heart of Gold. If family is unable to escort the residents then facility will schedule additional staff for escorting when notified in advance and with additional charge for the staffing. The allegation is unfounded. Based on information obtained through interviews, file review and observation, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left at the facility.

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit. LPA met with Executive Director and explained the purpose of the visit. Today's visit, LPA is requesting a copy of S1 and S2's 2023 and 2024 Training documents. Please provide to LPA the following documents by end of day via email. No deficiencies cited. Exit interview.

On 8/13/2024 at 8:30AM, an informal conference was conducted virtual via Microsoft Teams Meeting. The purpose of this informal conference meeting is to discuss the pending open investigations. Present in the meeting is, Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Cassie Yang, and Licensee representatives: - Deborah Taylor, Executive Director for Cogir of Folsom - Lyndee Whaley, Regional VP of Operations for Cogir Senior Living - Phil Altman, Senior VP of Operations for Cogir Senior Living - Kim Eldridge, Regional Director of Health & Wellness for Cogir Senior Living - Holly McMurray, Senior VP of Care & Compliance for Cogir Senior Living The informal conference process was explained during this meeting. Topic discussed: - Staffing concerns At this time, the Department agreed to monitor facility. Additionally, Facility will provide the Department proof of staff training on personal rights of residents. No deficiencies cited. Exit interview conducted. Informal meeting concluded and a copy of report will be emailed. Facility Representative Signature is expected to be signed and returned to LPA by close of business, 8/13/2024.

Allegation: Licensee denied resident's hospice worker entry to the facility The Department conducted extensive interviews. Based on the interview conducted with hospice agency supervisor, it revealed that facility had informed supervisor of potential conflict of interest and asked if hospice nurse will no longer provide services at the facility. Interview revealed that hospice nurse was not denied at the facility to enter. Based on interview conducted with hospice nurse revealed hospice nurse was informed by their supervisor that facility had requested hospice nurse to not return to the facility and hospice agency agreed to comply. Hospice nurse stated they were not denied at the door, the request was asked after a visit. Interview conducted with Executive Director and Health and Wellness Director revealed that the request was made after observations during a visitation and no denial of entry was made. Based on information above, the department concluded that the allegation is unfounded . A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies cited. Exit interview was conducted and a copy of the report was provided.

On 7/25/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the LIC 624 Unusual Incident/Injury Report the Department received. LPA met with new Executive Director, Deborah Taylor, and Regional Director, Davina Barker, and explained the purpose of the visit. The incident occurred when R1 was eating lunch in the common dining room when S1 observed R1 to be choking. S2 then helped dislodged meat out of R1's throat. R1 was sent out for evaluation. Incident report stated primary care physician was notified. R1 returned to the facility with no changes. LPA and Regional Director discussed and confirmed that R1's responsible party was notified via "voice to voice". It was further discussed that R1 was not on special diet but after the incident, R1 is now on a new order of mechanical soft diet. Facility reported no staffing issues and/or additional concerns. As a result of today's visit, no deficiencies cited. Exit interview conducted an a copy of the report provided.

On 7/25/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the LIC 624 Unusual Incident/Injury Report the Department received. LPA met with new Executive Director, Deborah Taylor, and explained the purpose of the visit. The incident occurred on 7/17/2024 when R1 reported to staff that S1 had threatened R1 to stop utilizing the call light or else S1 will rip the call lights out of the wall. R1 disclosed R1 is afraid to utilize call light after this incident. Facility conducted an investigation and S2 confirmed the incident had taken place as S2 was a witness of the encounter when S1 stated that if R1 does not stop pulling the call lights, S1 will move R1's bed. Facility has since placed S1 on suspension, and S1 is no longer working at the facility. Facility notified Community Care Licensing, Long Term Care Ombudsman and responsible party of this incident. LPA and Regional Director discussed that S1's last shift was the date of the incident. As a result of the incident of S1 violating CCR Title 22, Section 87468.1 Personal Rights of Residents in All Facilities, please see LIC 809-D. Exit interview conducted an a copy of the report and appeal rights provided.

Allegation: Facility did not notify responsible person of an increase in monthly rent rates. The Department conducted an extensive file review regarding the allegation above. Based on file review conducted, a letter of Annual Care Level Rate Adjustment Notice was provided to responsible party on October 31, 2023 with effective date of January 1, 2024. File review revealed that care service for Level 1 is $2550, with additional care level at $600. File review additionally revealed a reassessment service plan was conducted on 01/03/2024 by Health and Wellcare Director Nurse where R1's level of care changed from Memory Care 02 to Memory Care 06. Document revealed that responsible party signed the updated service plan on 01/18/2024. File review revealed on 03/08/2024, a letter was addressed to responsible party to inform of annual base rent increase from $4875 to $5216, effective date of 06/01/2024. File review further revealed in Levels of Care Price list, Memory Care Level 2 ranged from 426 to 525. Memory Care Level 6 ranged from 826 to 925. File reviewed revealed in the initial assessment conducted on 06/23/2023, grand total of R1's care was 590. In most updated assessment conducted 01/03/2024, grand total of R1's care was 940. Based on information above, the department concluded that the allegation is unfounded . A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies cited. Exit interview was conducted.

On 6/21/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Executive Director, Davina Barker, and explained the purpose of the visit. Today's census is 22 residents with eight (8) residents on hospice services. Facility is licensed for 66 residents, hospice waiver of 16. Executive Director reported no staffing concerns. LPA was informed there are three care staff and one med tech for AM and PM shift and with two care staff for NOC shift. LPA and Executive Director conducted a tour the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: five residents bedroom, Tahoe Room, main dining, kitchen, laundry room, activity room and the common areas. LPA observed facility to have 2+ days of perishable and 7+ days of non-perishable foods. LPA observed the facility to be at a comfortable 72* degree. LPA observed facility to have ample supply of linens. LPA observed residents in care to be in the activity room, listening to music with care staff. During today's visit, LPA observed facility to be clean, sanitary and in good repair. File review was conducted for 5 residents and 5 personnel files. LPA observed files to be completed. Inspection tool completed and found facility to be in substantial compliance. No deficiencies cited. LPA observed facility liability insurance to be current and active. Exit interview conducted and a copy of report was provided.

On 6/21/2024, Licensing Program Analyst (LPA) Cassie Yang arrived to the facility unannounced to conduct a required annual inspection. LPA met with Executive Director and explained the purpose of the visit. Today's visit, LPA is conducting an annual inspection today but this report is being generated to clear the Post-Licensing inspection in the system. There are no citations issued on this report. Exit interview. Copy of report provided.

On 06/12/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received on 6/11/2024. LPA met with Interim Executive Director and Health Wellcare Director Nurse and explained the purpose of the visit. According to the incident report received, it stated local law enforcement arrived to the facility on 6/10/2024 to conduct a welfare check on R1 due to a recent fall R1 sustained. LPA, Executive Director and Health Wellcare Director Nurse discussed the following incident. LPA was informed by Health Wellcare Director Nurse that on 6/3/2024 R1 had a "guided fall" at approximately 2:40 AM. Health Wellcare Director Nurse informed LPA that in the middle of a transfer between Health Wellcare Director Nurse, S1 and R1, R1's legs became weak and needed to be placed on the floor temporarily to rest before Health Wellcare Director Nurse and S1 assisted R1 back to the commode. After R1 was placed back on the recliner, Health Wellcare Director Nurse provided first aid to R1 as R1's elbow was observed to have a skin tear. When asked for the incident report of the incident, Health Wellcare Director Nurse informed LPA LIC624 was not created and submitted as R1 did not have a fall, it was a guided fall, and no injury was sustained, R1 was not sent to the hospital. LPA was provided a copy of internal incident report. This incident is currently under review, No deficiencies cited today. Exit interview conducted and a copy of the report was provided.

On 04/26/2023 at 9:30 AM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the CARE Inspection Tool. LPA met with Executive Director (ED), Cassiana Bush, and explained the purpose of the visit. At 9:40 AM, LPA, ED, and Memory Care Director Wendy Middleton toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, medication room, and courtyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. The hot water temperature was measured in the bathroom at 105 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguishers were last serviced on 03/01/2023. Fire drill is scheduled to be conducted on 05/31/2023. LPA observed medications to be locked and inaccessible to residents in care. At 10:05 AM, LPA reviewed a total of five (5) residents' files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for five (5) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of five (5) staff record. Staff has training in medications, first aid and CPR, and other various areas of care provision. No deficiencies being cited during today's inspection. Exit interview conducted and report provided.

Staff shoved a pill into resident’s mouth. The department conducted record review, interviews, and facility observation to investigate this allegation. From the 3 residents and 5 staff interviews conducted, it has been learned that facility was giving medication to all residents per their doctor orders without any issues. Additionally, it has been learned that facility was not forcing any medications to residents against their will. During department inspections on 11/22/22 and 3/1/23, all staff were attending to resident care needs without any problems. From the record review it has been concluded that facility was documenting medication refusals (if applicable) and notified residents responsible parties and doctors as needed. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED. Staff failed to assist resident into bed. The department conducted record review, interviews, and facility observation to investigate this allegation. From the 3 residents and 5 staff interviews, it has been learned that facility staff was assisting all residents for their ADL care needs per their Needs and Service plan in a timely manner. During department visits on 11/22/22 and 3/1/23 it has been observed that facility staff was attentive to residents’ care needs and all residents appeared to be well groomed and in good care. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED. Exit interview was conducted with Memory Care Director and a copy of this report was provided to the facility. The signature of the Memory Care director on these forms acknowledges receipt of these documents. 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 violating resident’s privacy by listening to conversation without consent. During the course of the investigation LPA obtained facility documentation, conducted interviews, and inspected facility grounds. During department visits on 11/22/22 and 3/1/23 it has been observed that residents’ privacy was respected, and no listening devices were observed in residents’ rooms nor was staff being observed around residents’ rooms when family was visiting. Furthermore, no interviews indicated that any residents have any concern with private time with their family members/visitors or experienced any problems in this area. This agency has investigated the complaint alleging staff system was not operational. We have found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Signal system was not operational. During the investigation LPA obtained facility documentation, conducted interviews, and inspected facility grounds. LPA investigated the allegation, "Signal system was not operational." LPA toured the facility on 11/22/22 and 3/1/23 and observed the call light system was fully operational. During tour staff pulled approximately 3 different call lights in resident rooms and caregivers responded in a timely manner. Staff interviews indicate that call lights are answered within minutes even when other care is being provided. The facility was observed to be equipped with operational pull cords in the resident rooms and bathrooms that are used to notify staff. This agency has investigated the complaint alleging staff system was not operational. We have found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with Memory Care Director and a copy of this report was provided to the facility. The signature of the Memory Care Director on these forms acknowledges receipt of these documents.

Staff do not ensure facility is free from bed bugs. An investigation was conducted into the allegation above. Interviews and records reviewed showed that on 12/19/2022, facility staff observed bedbugs in a room at the facility. Upon findings the bedbugs, facility staff showered the resident and relocated the resident in another room. Staff also washed all bedding with hot water and maintenance arrived to bomb the room. The licensee contracted with EcoLab and a Certified Bedbug Dog who came out on 12/20/2022 to assist in irradicating the bedbug infestation. The facility continues to utilize pest control services on a monthly basis. Although the facility did have bedbugs in the facility, the facility took all necessary steps to relocate the resident as well as contact pest control professionals in a timely matter to treat the bedbug room. Based on interviews and document reviews, the facility took steps to ensure the facility was free from bedbugs therefore the allegation is UNFOUNDED. This agency has investigated this complaint. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Memory Care Director and a copy of this report was provided to the facility. The signature of the Memory Care Director on these forms acknowledges receipt of these documents.

Facility is not following quarantine protocol. On 8/31/2022 LPA Muscan toured the facility. LPA observed all staff present were wearing masks. Covid signs were observed throughout the facility. This facility was monitored by Community Care Licensing as a Covid-19 positive facility. The facility was following all required Covid-19 positive protocols including but not limited to 10 day quarantine period (which may be extended depending on pending test results for all clients and staff.) Additionally, facility utilizes 2 dining rooms for those positive and those negative residents. Further, facility tries to keep residents in their rooms as much as possible. LPA received documentation of COVID protocol trainings by staff. This agency has investigated the complaint alleging the facility is not following Covid-19 protocols. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. Administrator is not present at the facility. The administrator stated that she is on the premises more than enough hours to permit adequate attention to the management and administration of the facility. Records reviewed shows Administrator is at the facility an adequate number of hours. Additionally, the administrator stated that she devotes additional hours in the facility to fulfill her responsibilities when the need for such additional hours is needed. This agency has investigated the complaint alleging the administrator is not present at the facility. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of Administrator on these forms acknowledges receipt of these documents.

Facility is not issuing a refund. During the investigation it was determined that the alleged allegations were prior to licensure of this facility. These allegations do not apply to the current Licensee. This agency has investigated the complaint. We have found the complaint was UNFOUNDED, meaning that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of Administrator on these forms acknowledges receipt of these documents.

Licensing Program Analyst (LPAs) Lavinia Muscan and Kerry Hiratsuka arrived at the facility unannounced to conduct an unannounced pre-licensing visit. This is a change of ownership. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Front Desk. LPA toured with Adebimpe Ekundare Executive Director. This building has 28 shared rooms and 10 private rooms. This facillity has delayed egress on all exit doors that residents can use to get outside as well as the gates for the courtyard that surrounds the back part of the building. There is an outside courtyard in the middle of the building that has no exit to the outside of the property. The doors leading to the courtyard have audio alerts. The courtyard has two water fountains that are placed in a permanent planter box that is roughly 12 inches higher than the ground. The fountains themselves are roughly two feet tall not including the planter box. The fountains are flat on top and are designed so the water does not pool on top and flows off the sides to the ground which is covered with large rocks that are spaced enough to let the water drain without pooling. The fountains do not cause any standing bodies of water. All doors to the rooms have key locks on them and all staff have a master key for the resident rooms. Each room has a motion sensor in the middle of the room, a pull cord for each bed, one for the bathroom, and a call button on the wall. The rooms have a drawer with a lock for the resident's use in the closet. All private rooms have bathrooms with showers and about half of the shared rooms have bathrooms with showers. The rest of the shared rooms have half bathrooms. There are four common full bathrooms; two have only showers and two have only spa tubs. There are two dining areas and two television rooms. There are several smaller activity areas and two sitting areas at the end of two hallways. All maintenance closets are locked. 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 There are several staff offices throughout the building. There's a health station to the left of the entrance to the resident's living area. This has the medication room behind it and the room is locked when no one is in there. The kitchen area is locked. Both dining rooms have small kitchenettes that have an oven and sink. The oven door has a lock and the oven itself has a secured shut off to prevent it from working when not in use. There is a front lobby that has a sitting area and a conference room to the left. This connects to the resident area through a secured door. Several resident rooms were inspected during this visit. LPA waived Comp III because Executive Director has worked at other facilities and the Applicant operates other facilities. . Several topics were discussed. This facility meets licensing requirements. LPA is going to submit this to applications specialist.

Facility Type: Residential Care Facility for the Elderly Application Type: Change of ownership Capacity: 66 Census (if any clients in care): 43 COMP II Participants: Adebimpe Ekundare Interview Method: Telephone interview On April 27, 2022, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readiness