Park View Estates.

Lack of supervision resulted in resident sustaining an unwitnessed fall Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.

Residents sustained injuries while in care Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Due to lack of supervision resident sustained multiple falls Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff left resident unattended Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff failed to provide appropriate transportation Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated.. Staff failed to safeguard resident's personal belongings Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff failed to provide resident's authorized representative with an incident report Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated.. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.

This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering amended findings for Complaint Control Numbers 22-AS-20250829102755 and 22-AS-20250919161621. LPA met with Administrator (AD) Peggy Ulland and explained the reason for today’s inspection. During the inspection, LPA and AD reviewed and discussed the previously delivered findings and the amended findings and LPA delivered the amended reports to AD. An exit interview was conducted and copies of this report and the amended reports were discussed with and provided to facility representative.

On April 13, 2026, Licensing Program Analysts (LPA) Eboni Bentley arrived at the facility unannounced for the purpose of conducting the Required 1 Year Annual evaluation. LPA was greeted and granted entry by staff after stating the purpose of the visit. The Executive Director Peggy Ulland was out on vacation. Health Services Director Hanofi Edogiawerie was present and assisted with the inspection. The facility has a resident census of 148 residents in care. The facility is a two-story building, with a memory care wing on the first floor. In the middle of the building is a courtyard, for Assisted Living, with shaded patio seating and a fountain. Memory Care unit has a garden courtyard of its own in the back of the building, that is secured. The delayed egress doors around memory care were tested and found to be operational. A sample of fifteen resident records were reviewed during the visit. Background clearance and association to the facility was verified for staff members on the roster. Interviews were conducted with residents and staff. LPA toured the physical plant with Maintenance Director Matt Yem and inspected a total of seventeen resident apartments. All rooms contained the required furnishings, and bathrooms were found to be operational, with grab bars secured in place. The hot water temperature measured between 116.8 and 118.6 degrees Fahrenheit in fifteen bathrooms used by residents in care. All common areas were inspected including the kitchen, dining, and courtyards. There were ample supply of clean towels and linens. Toxins, disinfectants, sharps, and medications were secured and inaccessible. The interior and exterior portion of the facility were observed clean. The outdoor passageways were free of obstruction with sufficient seating and shading. CONTINUE LIC809-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 First aid kit is maintained and contains all the necessary elements. The smoke/carbon monoxide detectors were tested last on April 10, 2026 per Maintenance Director and proof of service will be submitted to LPA by April 24, 2026. Evacuation chairs were observed at each stairwell. The facility has several fire extinguishers that were charged throughout the facility, all last serviced on or around May 5, 2025. LPA observed insufficient amount of emergency food and water for 148 residents and additional for staff on duty. Due to insufficient time, a deficiency will be cited during the continuation annual visit. Background clearance and association to the facility was verified for staff members on the roster. Interviews were conducted with residents and staff. Based on the observations made during today's visit, no deficiencies are being cited, however a continuation visit is needed and additional records will be requested. An exit interview was conducted and a copy of this report was provided to Health Services Director, Hanofi Edogiawerie

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit to the facility to amend Complaint Report No. 22-AS-20220421153926. Upon arrival, LPA Haddadin was greeted and granted entry by Executive Director (ED) Peggy Ulland. LPA explained the purpose of the visit. An exit interview was conducted with the Executive Director, and a copy of this report was provided.

LPA interviewed five residents who confirmed they get three meals a day and they have access to additional food in fridges located in lounge & memory care unit. LPA toured the facility and observed two refrigerators: one on the first floor near the lounge area containing food items such as sandwiches, pudding, apple juice, and orange juice, and another refrigerator in memory care unit offering the same. The facility menu was observed and found to reflect residents’ dietary plans. A review of the facility’s quarterly dietitian report, completed by the Dining Manager, showed that the facility received a passing score of 47.5 out of a possible 52 point Regarding the allegation that staff are not meeting residents’ toileting needs, the investigation determined as follows: LPA interviewed five staff members who reported they conduct resident checks approximately every two hours and more if required. Staff members further reported residents have the ability to call for assistance if needed. Two of the five staff interviewed reported direct knowledge of R1. Progress notes dated July 2, 2021, documented that staff attempted to assist R1 with hygiene and a shower, but R1 refused care and repeatedly asked staff to leave the room. LPA interviewed five residents who reported if they required help, they would receive it from facility staff. Residents reported staff check on residents throughout the day. Facility records confirmed that staff maintain a log for memory care resident two-hour checks. Facility does not maintain a log for facility Assisted Living resident checks. LPA tested facility pull cords in residents rooms and observed staff responding timely during visits. Regarding the allegation that staff failed to prevent inappropriate behaviors between residents, interviews were conducted with five staff members of which two reported knowledge of a verbal altercation between R1 and resident 2 (R2). Staff reported when the incident occurred residents were separated and no further incidents occurred. Staff denied that any physical interaction occurred between the two residents. LPA also interviewed five residents, all of whom stated they had no knowledge of any physical or verbal altercations between residents. A review of the facility’s Progress Notes revealed no evidence to support the allegation. Additionally, Progress Notes for Resident 1 (R1) showed no further incidents of aggression toward peers or staff. {***CONTINUE 9099C***} {***THIS IS AN AMENDED REPORT***} 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegations that facility walls and floors are dirty, LPA interviewed five staff members who reported the facility has housekeeping and maintenance. Housekeeping cleans resident rooms, common areas and bathrooms daily and clean additionally as needed. LPA interviewed five residents, who reported their rooms are cleaned regularly and have no observed dirty walls or floors. Resident rooms are cleaned on a schedule. LPA toured the facility and observed that the walls and floors were clean meaning free of graffiti and no chipped paints. LPA observed the facility to be free of odors. Review of housekeeping and maintenance logs indicated the facility follows a scheduled cleaning routine performed by designated maintenance staff. Based on the investigation, there was insufficient evidence to prove that the alleged violations occurred. Therefore, the allegations: Staff did not prevent inappropriate behaviors between residents,” “Staff are not providing adequate food service for residents,” “Staff are not meeting residents’ toileting needs,” “Facility walls are dirty,” and “Facility floors are dirty” are deemed Unsubstantiated. An exit interview was conducted with Executive Director (ED) Peggy Ulland and a copy of this report was provided to the facility representative. {***THIS IS AN AMENDED REPORT***}

(Continued from LIC 9099) LPA investigated the allegation that staff neglect resulted in the death of resident. Resident #6 moved into the facility on February 12, 2021, and passed away on March 28, 2023. Per Park View Estates Move In Record dated February 12, 2021, and Medication Administration Records, R6 had diagnoses of Type 2 Diabetes Mellitus without complications, Vascular Dementia, unspecified severity and Essential Hypertension. R6 resided in Memory Care (MC). It was alleged that the oxygen concentrator was not working at time of R6’s time of death and that staff failed to check if it was working. Per initial interview with the hospice agency, R6 was receiving hospice services at the time of death and R6 passed away due to natural causes. The hospice agency provided the oxygen concentrator and if there were issues, a vendor would be called for repair. LPA interviewed a second witness who provided the death certificate. The cause of death for R6 was Heart Disease unspecified. Per interview with Witness #2 (W2) the resident passed away naturally and hospice was present. Thus the allegation that staff neglect resulted in the death of the resident is Unsubstantiated. The Department investigated the allegations that the resident was not provided prescribed medication and that the facility was falsifying medication charts. It was alleged that Resident #5 (R5) went into seizures due to staff not ordering the medication. It was reported that staff would mark the Medication Administration Record (MAR) that the medication was given when it was not. R5 was not able to be interviewed since they no longer resided at the facility at time of visit. LPA reviewed Unusual Incident Reports and noted a seizure incident that occurred on August 23, 2022. It was noted on the Unusual Incident Report, submitted to the Department on August 24, 2022, that the resident took the anticonvulsant medication daily. LPA reviewed the MAR and noted that the anticonvulsant medication was given daily and initialed by various medication technicians (med techs). LPA interviewed one of one staff and one of one witness who had knowledge of the incident. One of one staff denied the allegation. One of one witness stated the name of a former med tech who would falsify records and initial given medications. LPA confirmed the med tech named by the witness was the med tech initials on the Medication Administration Record for the incident on August 23, 2022. LPA was unable to interview the MedTech in question. When LPA asked the witness about the particular incident, the witness could not remember this happening. LPA interviewed one of one staff member present who could not recall the specifics of the incident. Thus the allegations that: Facility did not ensure resident was provided prescribed medication and Facility falsifying medication chart are Unsubstantiated. (Cont'ed on LIC 9099-C1) 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 9099-C) It was also reported that the facility was not responding to a resident’s call light in a timely manner and took longer than thirty minutes due to insufficient staffing. LPA interviewed staff and witnesses regarding staffing in Memory Care. Three of three staff could not confirm, nor deny the allegation that call lights were not answered properly. One witness recalled being short staffed in 2023 but did not confirm that call lights were not answered in a timely manner. The facility conducted an in-service training on May 21, 2025, regarding call pendant procedures. Thus the allegations that facility is not responding to resident’s call light timely is deemed Unsubstantiated. It was alleged that Unqualified staff were administering insulin to residents. LPA interviewed three of three staff members who denied this allegation. LPA obtained the facility policy regarding injection administration. Only a nurse, such as the licensed vocational nurse (LVN) can administer medications. The facility employs a LVN; as well as the Health Services Director (HSD) who both have a valid LVN license. The allegation stated that med techs were administering insulin to residents. LPA reviewed four of four resident Medication Administration records who received insulin at the time of complaint received. Only one of the four residents still resided at the facility. LPA interviewed Resident #1 (R1) who stated they self-injected their insulin and that, for four to five months, staff did assist with injections. R1 could not confirm if the staff member was a nurse or a med tech, but that R1 prefers to self-inject themself. LPA attempted to interview three of five med techs from 2023. Three were no longer employed by the facility and did not have working phone numbers or emails. Two of the five med techs interviewed denied the allegation. LPA also reviewed five of five staff electronic files which include training and in-services. Staff members’ training records document five of five staff completed medication administration training. Thus the allegation that unqualified staff were administering insulin to residents was Unsubstantiated . Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations that: Staff neglect resulting in death of resident, Facility did not ensure resident was provided prescribed medication, Facility falsifying medication chart, Facility not responding to resident's call light in a timely manner and Unqualified staff administering insulin to residents are Unsubstantiated . An exit interview was conducted with Hanofi Edogiawerie, Health Services Director and a copy of this report was provided to the facility.

This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering amended findings for Complaint Control Number 22-AS-20250919161621. LPA met with Staff #1 (S1) Hanofi Edogiawerie and explained the reason for today’s inspection. During the inspection, LPA and S1 reviewed and discussed the previously delivered findings and the amended findings and LPA delivered the amended report to S1 who signed the amended report on behalf of Administrator (AD) Peggy Ulland. An exit interview was conducted and copies of this report and the amended report were discussed with and provided to facility representative.

On December 5, 2025, Licensing Program Analyst (LPA) Eboni Bentley and Licensing Program Manager (LPM) Lourdes Montoya arrived unannounced for a Case Management – Other visit for the purpose of obtaining access to resident records stored electronically. LPA and LPM introduced self and stated the purpose of the visit to Executive Director (ED) Peggy Ulland. During today's visit, LPA and LPM were provided full access to R1’s paper and electronic records. No deficiencies were cited during this visit. An exit interview was conducted with Executive Director Peggy Ulland, and a copy of this report was provided at exit.

THIS REPORT HAS BEEN AMENDED TO REMOVE LIC809-D PAGE. On November 12, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for a Case Management – Other visit for the purpose of obtaining all resident records stored electronically, that were not obtained during the case management visit on November 4, 2025. LPA introduced self and stated the purpose of the visit to Executive Director (ED) Peggy Ulland. During today's visit, LPA obtained hard copies of all residents’ progress notes, In-service training on Catheter, hospice record for one resident, staff roster and resident roster. An exit interview was conducted with Executive Director Peggy Ulland, and a copy of this amended report was provided.

On November 4, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for a Case Management – Other visit for the purpose of conducting an additional investigation for Complaint Control No 22-AS-20250929104833 . LPA announced self and stated the purpose of the visit to Executive Director (ED) Peggy Ulland. During the visit, LPA requested full viewing access to facility records in Point Click Care (PCC) and was provided with a new password. ED stated LPA had limited access to records as LPA was not performing or supervising care tasks. Due to insufficient time and information, this case management requires further investigation and a subsequent visit will follow. An exit interview was conducted with Executive Director Peggy Ulland, and a copy of this report was provided at the end of the visit.

This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting additional investigation for Complaint Control Nos. 22-AS-20250829102755 and 22-AS-20250919161621 . LPA met with Administrator (AD) Peggy Ulland and explained the reason for today’s inspection. During the inspection, LPA interviewed AD, staff, and obtained and reviewed resident records. Facility representative was advised that at this time further investigation is required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced Case Management visit to the facility. Upon arrival, LPA was greeted and granted entry. LPA met with Executive Director Peggy Ulland and explained the purpose of the visit. The purpose of this visit was to amend a previously issued complaint report under complaint number #22-AS-20220131170149. The amended report was reviewed and signed by the Executive Director along with this Case Management report. A copy of both reports was provided to the Executive Director for facility records.

(Continued from LIC 9099) It was alleged that the: Resident sustained injuries while in care, Staff did not properly assess resident's change in condition and Staff refused to seek medical attention for resident. LPA reviewed Unusual Incident Reports for R1 from 3/07/2022, 3/30/2022 and 04/05/2022. On 3/7/2022 R1 shoved Resident #2 (R2) in the hallway near the theater. R2 also had a diagnosis of dementia, It was documented and Power of Attorney (POA) was notified. In the report it stated POA would notify physician regarding aggressive behavior. On 3/30/2022 R1 had another incident with R2 in the dining room; hitting R2 with a book. 9-1-1 was notified and R1 and R2 were transported to the Emergency Room for further assessment. POA for R1 was notified and the facility Health Services Director (HSD) faxed physician of R1's continued behavior. On 4/05/2022 a third incident occurred where R1 pushed R2 to the ground. 9-1-1 was called and fire department and paramedics arrived. Police officers also responded and gathered witness statements. R1's POA was notified. In the incident report it is documented that R2 never provoked R1, and that a family conference was requested. On 4/06/22 R1's POA picked up resident and brought R1 to the hospital for a psychiatric evaluation. R1 did not return to the facility. After the first incident on 3/7/2025, the resident returned with new medications. The Executive Director spoke directly to the POA regarding a personal companion and requested an evaluation with a neurologist regarding behaviors to conduct a re-appraisal of R1's change of condition. HSD stated the POA never took R1 for assessment and that a statement made by POA made HSD realize R1 had a history of physical aggression that was not disclosed per Physician's Report. Medical Technicians (MedTechs) continued to communicate with the Primary Care Physician (PCP), per incident report and HSD interview, regarding R1's behavior. Per HSD interview, R1 did not sustain injuries and that is was R2 who sustained injuries due to R1's behaviors. The allegations that: Resident sustained injuries while in care, Staff did not properly assess resident's change in condition and Staff refused to seek medical attention for resident are Unsubstantiated. (Continued on LIC 9099-C1) 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 9099-C) It was alleged that: Resident's shower bench is in disrepair, Staff did not meet resident's laundry needs, Resident's bathroom is dirty and Resident's rugs are dirty. LPA reviewed housekeeping schedules. There are six housekeepers with two assigned to Memory Care. Housekeeping and laundry are scheduled seven days per week. Each housekeeper has a daily housekeeping inspection form; which include checking off if vinyl/carpet and shower/tub/ fixtures are in working order. Comments are written on the daily inspection list for follow-up such as: laundry to be done. LPA interviewed five of five staff members and the current Maintenance Director regarding housekeeping and laundry. Four of the five staff members were working during the time period of the incident. Per interviews, staff members stated resident bathrooms were cleaned and maintained since the Memory Care residents were encouraged to be in the common areas for socialization and activities, as well as dining. Housekeepers stated that in 2022 there were not a lot of memory care residents so it was easier to maintain resident rooms. LPA asked if any of the staff recalled the condition of R1's bathroom or laundry. Staff recalled the resident but stated if there was a broken shower chair, dirty rugs, an unclean bathroom or laundry that needed to be done, that it would have been noted and cleaned. None of the staff members interviewed remembered if R1's laundry was not cleaned since it was almost three years ago. LPAs Fred Arias and Rose Ruppert toured the Memory Care unit on December 30, 2024 and entered three random resident bathrooms while residents were at lunch. All bathrooms were clean and in working order. An interview with the Maintenance Director stated that Memory Care is usually clean and repairs are handled promptly. On 2/11/2025 LPA toured the laundry room and interviewed housekeeping and care staff regarding laundering procedures Housekeeping staff clean bedsheet linens and towels once a week per schedule; or as needed. Care staff cleaned residents' personal belongings once a week, or as needed. Thus the allegations that the: Resident's shower bench is in disrepair, Staff did not meet resident's laundry needs, Resident's bathroom is dirty and Resident's rugs are dirty are Unsubstantiated. (Continued on LIC 9099-C2) 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 9099-C1) It was alleged that Staff did not shower resident Per Physician's Report dated 09/09/2021, R1 had the capacity for self care which included: bathing, dressing/ grooming, feeding self and being able to care for toileting needs. Interview with the HSD stated staff did not shower R1 but would remind R1 to take a shower. Staff could not force R1 to shower if resident refused. This allegation is Unsubstantiated. Based on LPA record review, observations and interviews, 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 that the: Resident sustained injuries while in care, Staff did not properly assess resident's change in condition, Staff refused to seek medical attention for resident, Resident's shower bench is in disrepair, Staff did not meet resident's laundry needs, Resident's bathroom is dirty, Resident's rugs are dirty, and Staff did not shower resident are Unsubstantiated. An exit interview was conducted with Peggy Ulland, Executive Director and a copy of this report and LIC 811 was provided to the facility.

with doing so. Interview with 10 of 10 residents stated that they get the care they need, get the assistance they ask for, and they don’t have a problem with getting care. It is alleged that staff does not ensure residents have access to clean water for consumption. LPA Martinez conducted a tour of the facility on April 30, 2024, and on October 8, 2025, and did not observe the water containers used for water are clean and clear of any mold, or dirt. LPA did not observe any issues with the water that is used for consumption or available to residents. Interview with executive chef stated We have a water container in the memory care unit where we clean it out twice a day. Generally, it has slices of fruit in the water for flavor. That is available for residents all the time and the water containers are changed out often for fresh water. Interview with 10 of 10 residents stated that they have not noticed the water to be dirty and they can ask for a cup of water at any time and get it. It is alleged that staff does not ensure cleaning supplies are safely secured from residents. LPA Martinez conducted a tour of the physical plant of the facility on the following dates: April 30, 2024, and October 8, 2025, and did not observe any toxins, cleaning supplies or chemicals in any common spaces or the kitchen of the facility. LPA inspected that facility has a centralized storage unit for toxins located in the back hallway of the facility which residents do not have access to, the toxins are kept in the storage unit as well as in the maintenance director’s office. Entry door to the hallway is by the entry of the dining room and only access by a key card. Interview with staff stated that when the housekeepers or any other staff need cleaning supplies or toxins that they retrieve from the storage unit and then return to the same unit. Each housekeeper has a cart that they load toxins and unload at their end of shift in the storage unit. Interview with 10 of 10 residents stated that they don’t have access to the kitchen and they have not seen any toxic chemicals just laying around in the facility. It is alleged that staff does not ensure discontinued medication are properly discarded. LPA conducted a facility visit and toured the medication room for the facility on April 30, 2024, and October 8, 2025, and observed that in the medication room there is a container that is used to discard medication. The container is in a room that requires a key card to enter. Interview with lead med tech stated that there is a container to discard discontinued medication in the medication room. Container is a one way entry and you cannot retrieve Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 the medication once it is dispensed in the container. Once medication is disposed there isn’t a way to retrieve the medication or remove it from the container. Once the container is full there is a shipping label adhered to the box with a phone number that is called for pick up by a vendor. It is alleged that staff does not dispense medication as prescribed. Record obtained for MAR (medication administrator records) for March and April of 2024 revealed that all medication was given accordingly and there are no missed dosages. Interview with staff stated that medication is given then logged out in the computer system to indicate that it was given. Interview with 10 of 10 residents stated that they get their meds and they haven’t not had issue with not getting the medication. Staff comes to them and gives them medication at the time that it is due. It is alleged that staff do not ensure residents records are properly maintained. A review of 13 resident records revealed that all resident files contained required documentation including updated physician reports and care plans and are complete. Interview with staff stated that all records are kept electronically and they also have a physical file on hand in the event it is needed for review. At the time of visit records requested were made available to LPA. It is alleged that staff do not ensure residents are provided with personal privacy. LPA toured the facility and observed that resident bedrooms are apartment style units with a main door for entry. Interview with 10 of 10 residents stated that they feel like they have privacy at the facility and in their bedroom. They stated that they have privacy at the facility in their bedroom, common spaces and with their relationships with other residents. It is alleged that staff does not ensure reporting requirements are followed. Record review revealed that CCLD has on records as receiving LIC624 unusual report about the staff and residents at the facility. CCLD has received reports such as falls, staff, and elopements to name a few incident types received. Interview with staff stated that they report out any incident no matter if it is with residents or staff. Staff stated there was an incident with staff last month (March of 2024) that as reported to CCLD and LPA Rosie came out and did a visit for it. stated stated they knew that they need to report incidents to the department. It is alleged that licensee does not ensure facility records are safely secured. LPA Martinez conducted a facility visit April 30, 2024, and requested to view records. LPA toured the facility and observed that records Continued on LIC9099-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 for staff are kept locked in the Executive Director’s office and resident records are located locked in the first floor medication room and/or on each floor where resident resides. Facility also has electronic records that are kept in their system with a passcode locked. Interview with staff stated that records can be accessed by staff with a key if they have access to them. Employee records are only accessed by the business office director, resident records only have access by med techs, but financial documents are separated, and they don’t have access to that section of records, and caregivers have access to the PCC system that is used for electronic files. It is alleged that staff do not ensure update food menus are made available to residents. LPA conducted a tour of the facility on various dates and observed that there is a monitor mounted on the wall of the entry of the dining room displaying menus digitally, menus for specials physically displayed outside the dining, printed menus on tables, and menus in the reception area of the lobby. Interview with kitchen staff sated there is an always available/regular menu on the tables in the dining room, 24 hours specials that are on the dining room TV that run 7 days of specials lunch and dinner and snack menu that are given at 10:00am/2pm/7pm for 7 days a week, staff print out menus to cover all residents each Monday morning. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegations is deemed Unsubstantiated. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.

It was alleged that the facility retaliated against R1 by adding additional unnecessary and non-medical care for R1, which was duplicative of the care provided by the facility’s staff and charged R1’s responsible party without their approval. The investigation revealed that R1 was admitted to the facility with a foley catheter and subsequently had surgery to replace insertion of the foley catheter with a suprapubic catheter. R1’s Medical Records document that R1 needed daily cleaning and bandage changes for their suprapubic catheter, which must be performed by a skilled professional. However, R1’s Home Health Records and interviews revealed that this skilled care was provided approximately twice a week. The facility advised R1 that their needs were not being met, they needed a higher level of care, and that one-on-one supervision would be required. R1’s family believes the requirement of one-on-one supervision was retaliation due to issues they had raised with the facility. However, the facility’s policy and R1’s Admission Agreement indicate temporary one-on-one supervision would be instituted at the resident’s expense when it has been determined that a resident needs a higher level of care. The facility retained an outside agency to provide one-on-one supervision to R1, but the service was never provided as R1’s family refused and obtained their own private caregiver. Based on gathered information, R1 requires a higher level of care, due to their suprapubic catheter which required daily cleaning, bandage changes and frequent showers. In addition, R1 required additional supervision to prevent R1 from picking at their catheter site, which was observed to be red and irritated. There is no evidence to support that these care requirements were imposed in retaliation. Based on LPA’s observation, interviews conducted, and records reviewed, there was not sufficient evidence to support the above allegations. 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 deemed UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was discussed with and provided to facility representative. This is an amended report. 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 This is an amended report. 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 It was alleged that on August 8, 2025, R1 was observed to have a blood-stained catheter bandage, but that staff did not notice the stain or report it to R1’s doctor or responsible party, R1 was taken to the hospital, the hospital determined no additional treatment and R1 was able to return to the facility with no special care or changes in medication required. Per R1’s family, on August 4, 2025, R1 had surgery to replace a foley catheter with a suprapubic catheter. R1’s family stated that on August 8, 2025, R1 was observed with a blood-stained catheter bandage, which was not noticed or reported by staff. When interviewed, AD stated that the blood observed was only a small amount and was to be expected after surgery, paramedics arrived and agreed with AD’s assessment, but R1’s family insisted on taking R1 to the ER and R1 returned a few hours later. However, R1’s family stated it was actually AD who thought the blood was a major issue and wanted to send R1 to the hospital, R1’s family did not have concerns about the blood stain, and R1 returned from the hospital with no concerns or changes of condition noted by the doctor. R1’s Medical Records dated August 8, 2025, corroborate that R1 was seen at the ER, no treatment was needed, and there was no change in condition. No information was obtained corroborating that R1 had a change of condition or that the blood stain noted on R1’s bandages was unexpected after R1’s surgery. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

It was alleged that the facility retaliated against R1 by adding additional unnecessary and non-medical care for R1, which was duplicative of the care provided by the facility’s staff and charged R1’s responsible party without their approval. The investigation revealed that R1 was admitted to the facility with a foley catheter and subsequently had surgery to replace insertion of the foley catheter with a suprapubic catheter. R1’s Medical Records document that R1 needed daily cleaning and bandage changes for their suprapubic catheter, which must be performed by a skilled professional. However, R1’s Home Health Records and interviews revealed that this skilled care was provided approximately twice a week. The facility advised R1 that their needs were not being met, they needed a higher level of care, and that one-on-one supervision would be required. R1’s family believes the requirement of one-on-one supervision was retaliation due to issues they had raised with the facility. However, the facility’s policy and R1’s Admission Agreement indicate temporary one-on-one supervision would be instituted at the resident’s expense when it has been determined that a resident needs a higher level of care. The facility retained an outside agency to provide one-on-one supervision to R1, but the service was never provided as R1’s family refused and obtained their own private caregiver. Based on gathered information, R1 requires a higher level of care, due to their suprapubic catheter which required daily cleaning, bandage changes and frequent showers. In addition, R1 required additional supervision to prevent R1 from picking at their catheter site, which was observed to be red and irritated. There is no evidence to support that these care requirements were imposed in retaliation. Based on LPA’s observation, interviews conducted, and records reviewed, there was not sufficient evidence to support the above allegations. 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 deemed UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was discussed with and provided to facility representative. This is an amended report. 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 This is an amended report. 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 It was alleged that on August 8, 2025, R1 was observed to have a blood-stained catheter bandage, but that staff did not notice the stain or report it to R1’s doctor or responsible party, R1 was taken to the hospital, the hospital determined no additional treatment and R1 was able to return to the facility with no special care or changes in medication required. Per R1’s family, on August 4, 2025, R1 had surgery to replace a foley catheter with a suprapubic catheter. R1’s family stated that on August 8, 2025, R1 was observed with a blood-stained catheter bandage, which was not noticed or reported by staff. When interviewed, AD stated that the blood observed was only a small amount and was to be expected after surgery, paramedics arrived and agreed with AD’s assessment, but R1’s family insisted on taking R1 to the ER and R1 returned a few hours later. However, R1’s family stated it was actually AD who thought the blood was a major issue and wanted to send R1 to the hospital, R1’s family did not have concerns about the blood stain, and R1 returned from the hospital with no concerns or changes of condition noted by the doctor. R1’s Medical Records dated August 8, 2025, corroborate that R1 was seen at the ER, no treatment was needed, and there was no change in condition. No information was obtained corroborating that R1 had a change of condition or that the blood stain noted on R1’s bandages was unexpected after R1’s surgery. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

Interviews with staff, witnesses, and R1 revealed that R1 was scheduled to go to the bank with the Long Term Care Ombudsman (LCTO), to assist with withdrawing money to make a payment towards R1’s rent bill, however the visit to the bank never occurred due to R1 not showing up. Per documentation review, of R1’s financial ledger, R1 was admitted to the facility in November 2024, and is currently residing at the facility. In addition to the record review of R1's ledger, there were only a total of 2 checks issued to the facility from the day of R1's admission date to present day, however, the additional checks issued to the facility were never processed due to insufficient funds, or due to the payment being stopp ed or cancelled by the individual who wrote the check, therefore totaling R1’s current due balance to $42,774.41. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with HWD Edogiawerie. A copy of this report was explained and provided.

On July 3, 2025 at 8:00am, Licensing Program Analysts (LPAs) Eboni Bentley and Rose Marie Ruppert made an unannounced case management visit to monitor compliance assurance following Non-Compliance Conference on 5/28/2025. Upon arrival, LPAs stated the purpose of the visit to Life Enrichment Director Tina Tanus and Concierge Paige Pheng, who contacted the administrator. Executive Director Peggy Ulland arrived a short time later. During the visit, LPAs obtained resident and staff rosters, staff schedule, and confirmed census of 150 residents in care. LPA Bentley inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. Staff training and audits are in order, there was enough staff to supervise all the residents during the time of the visit, and all records reviewed are within the conditions agreed to with CCL. All other areas from NCC plan agreement were reviewed and the facility was in compliance at the time of LPA's visit. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director Peggy Ulland, and a copy of this report was provided at the end of the visit.

(Continued from LIC 9099) The eviction date was moved to June 10, 2025. Based on LPA's conversation with R2, R2 understood that the notice was for non-payment and that R2 had until June 10, 2025 to pay or to vacate. LPA interviewed four of four witnesses and two of two staff during the complaint investigation who were aware of R2's situation. LPA obtained a witness statement regarding R2's eviction. This agency has investigated the complaint that: Staff did not provide authorized representatives with a 30 day eviction notice . We have found that the complaint was unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Peggy Ulland, Executive Director, and a copy of this report was provided to the facility.

Resident sustained fractures due to staff neglect It was alleged that due to neglect/lack of care and supervision resulted in Resident 1 (R1) falling on 01/12/2022 and sustaining two femur fractures. During the course of the investigation LPA interviewed R1, witnesses, and prior Facility Director Heather Myers regarding R1's fall and injury on 1/12/2022 which occurred in their room and was unwitnessed. Witness statement indicated that R1 used their pendant to call for assistance to go to the bathroom. R1 got up on their own when staff did not respond in a timely manner, and R1 fell to the floor breaking both femurs. R1 stated they got out of bed on their own and went to the bathroom using their walker. When R1 was finished on the toilet, they stood up to get their walker and fell to the ground, breaking both of their femurs. R1 stated they could not recall using their pendant to call for staff assistance when they had finished using the toilet, nor when they were on the ground after the fall. R1 stated they screamed for help and staff arrived quickly. LPA reviewed the Unusual Incident/Injury Report related to this incident which states R1 told the Med Tech Staff 1 (S1) that R1 rolled out of their bed injuring their legs. LPA spoke with Heather Myers who was the Facility Director on 1/12/2022. Heather stated that R1 was brought a daybed and R1 would place their ankles under the foot rail. On the evening of 1/12/2022, it is believed R1 broke their legs when rolling out of bed with their ankles caught in the bedrail of the daybed. Heather stated when staff found R1 in their room, they were lying next to their bed still wrapped in their blankets. R1 was assessed by facility staff who immediately called 911 and notified a family member. R1 was transported to the hospital for further evaluation and diagnosed with femur fractures in both legs. S1 does not work at the facility any longer and LPA’s attempts to contact them were unsuccessful. Based on interviews and document review, there was no evidence to corroborate the allegation of neglect by staff resulting in R1's fall and injury. Therefore, the allegation of Neglect/Lack of Care and Supervision of Resident R1 falling on 1/12/2022 and sustaining two femur fractures will be unsubstantiated. **Continued on 9099-C2 page** 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 Resident fell multiple times due to staff neglect Neglect/Lack of Care and Supervision or Resident 1 (R1), falling on 8/6/2023, and sustaining a sprained ankle. On 8/6/2023, Resident 1 (R1) suffered an unwitnessed fall in their bathroom. Witnesses stated that R1 used their pendant to get assistance from bed to go to the bathroom and a staff member responded promptly and transferred R1 from their bed to the toilet. When R1 was done using the toilet, they used their pendant for assistance to get off the toilet and be taken back to bed. R1 waited a long time and when no one responded, R1 got up on their own and fell injuring their ankle. R1 stated they transferred themself from their bed to their wheelchair and got to the bathroom on their own. When R1 was done using the toilet, they used their pendant and emergency pull chain in the bathroom to call for assistance with getting up from the toilet and back to bed. R1's legs started to hurt, so they attempted to get from the toilet to their wheelchair and fell. R1 estimates they were on the bathroom floor for approximately 30 minutes before a staff member found them and assisted them back to bed. R1 stated they were not experiencing any immediate pain and there was no visible injury. R1 said they began to experience pain later in the day, did not notify staff of their pain. R1 stated staff wanted them to be sent to the hospital for evaluation, but R1 refused and wanted to wait and see if it got better on its own. R1 was taken to the hospital a few days later, and R1 was diagnosed with an ankle sprain. LPA requested pendent call logs for this incident to determine the length of time it took staff to respond and was advised that the system is only able to retrieve the previous week of calls. By the time LPA requested them, the logs were no longer available. LPA did review currently accessible call logs dated 9/1/2023 through 9/7/2023 and the majority of the requests were responded to in ten minutes or less. There was no evidence to corroborate the allegation of neglect by staff resulting in R1's fall and injury on 08/06/2023 or 01/12/2022. This allegation is unsubstantiated. **Continued on 9099-C3 page** 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 Unlawful eviction LPA reviewed a letter from the facility to R1’s POA dated September 01, 2023, which states the facility is serving a 30-day eviction notice to R1 based on a recent appraisal which determined that the facility could no longer meet the needs of R1. LPA reviewed an eviction notice dated August 24, 2023, and a Negotiated Risk Assessment for dated August 17, 2023, which states the POA for R1 has been advised that R1 is a high fall risk and the facility feels that R1 needs a higher level of care to avoid any future incidents of falls. R1 will need additional support to try to reduce the risk of falls. R1 may remain in the community until the facility reaches the point where it cannot provide care at all. Alternatives offered and/or attempted to decrease risk, including, but not limited to: Suggested higher level of care to support high fall risk. Attempted: Discussed this and was declined by POA. This allegation is unsubstantiated. Staff did not provide resident's authorized representative with itemization of fee increase LPA reviewed a letter from the facility addressed to R1 which states “Beginning 07/01/2023 your monthly total will be $5050.00 for rent and services. This will include all regular monthly items currently on your account. This notification lists R1’s current monthly charges of $4,410.00 with care charge of $420.00 for a total charge of $4,830.00 per month. Notification also included the proposed new charges of $4,630.00 and care charges of $420.00 for a total of $5,050.00 per month beginning on 07/01/2023. This letter serves as your 60-day written notice, as stated in your Rental Agreement. LPA also reviewed a Resident Statement dated 08/01/2023 for Resident 1 (R1). The statement lists R1’s monthly charge of $4,630.00 and a care charge of $420.00. This allegation is unsubstantiated. **Continued on 9099-C4 page** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Facility internet is in disrepair On 09/05/2023 LPA toured the facility and conducted interviews. On that day LPA determined that the internet was working in the facility. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.

(Continued from LIC 9099) pendant call. LPA obtained copies of R1's: ID and Emergency Information form, Physician's Report, Appraisal/Needs and Services Plan and a copy of the pendant log from February to May 20, 2025. LPA also obtained current resident and staff rosters. LPA reviewed the pendant log and found several dates and times where the response time was longer than two hours. Staff interviews stated caregivers know to clear pendants and will continue to work on this with staff. Family have been working with the facility regarding this matter and pendant logs show there has been improvement in the recent month and that most pendant calls are answered within a twenty minute period. Based on LPA observations, record review and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation that: Facility staff does not respond to the call system in a timely manner, is found to be Substantiated. A deficiency has been cited per California Code of Regulations. An exit interview was conducted with Cauleen Ritchie, Clinical Specialist and a copy of this report, LIC 858, LIC 9099-D and Appeal Rights were provided to the facility.

(Continued from LIC 9099) LPA interviewed resident, who was in the dining room, and asked resident to press pendant to make sure it is working properly. Pendant immediately showed R1's apartment number and location on the mobile app and staff immediately came to clear the pendant by deactivating it with a magnetic sensor. LPA asked three of three residents in the dining room if there were issues with pendants and all had working pendants. LPA obtained copies of R1's: ID and Emergency Information form, Physician's Report, Appraisal/Needs and Services Plan and a copy of the pendant log from February to May 20, 2025. LPA also obtained current resident and staff rosters. 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 that the resident call system was not operational is Unsubstantiated. An exit interview was conducted with Cauleen Ritchie, Clinical Specialist and Peggy Ulland, ED and a copy of the report was provided to the facility.

CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff do not meet a resident's catheter needs while in care , the following has been concluded: Per a review of resident R1's transitional information gathered prior to R1's move-in on October 30, 2024 as well as a review of R1's physician report and pre-admission appraisal, it is indicated that R1 moved into the facility with a foley catheter already in place. The transitional information indicates that the resident's plan of care calls for the foley bag to be emptied once it reaches a third to a half of its full capacity. Based on photographs provided by witnesses dated January 14, 2025, there have been instances during which the foley bag was not emptied timely as foley bag appeared to be almost full at the time of the photograph being taken. Another instance of the catheter bag not being emptied overnight was found upon a review of R1's chart for May 2025. R1 had a documented history of urinary tract infections prior to their admission at the facility, therefore it is unsure whether the catheter management is related to any active infection occurring. Per statements made by facility staff during the initial investigation visit, an in-service regarding catheter care and perianal care was conducted after the incidents evidenced above. As a result, the allegation is found to be Substantiated, meaning that based on the evidence gathered during this investigation, the preponderance of evidence standard has been met. A corresponding deficiency is being cited on the attached form LIC9099-D. An exit interview was conducted with facility staff. A copy of the report along with appeal rights were 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 CONTINUED FROM FORM LIC9099-A Regarding the allegation that Staff do not meet a resident's incontinence need while in care , the following has been concluded: On February 25, 2025, R1 attended an appointment with their urologist for a scheduled replacement of their catheter bag. Upon arriving at their health care provider's office, the resident was found to be in soiled diapers. Per the caregiver's assessment on the day of the visit, peri care was provided on the morning of the appointment prior to the resident being brought out to the dining hall, where she was then directly picked up by family, it is therefore not possible to establish whether the diaper was soiled due to insufficient intervention from facility staff. Regarding the allegation that S taff are not meeting a resident's medical needs while in care , the following has been concluded: an interview with R1 along with a review of R1's resident records demonstrated regularly scheduled medical appointments. Incidents such as a fall occurring in December 2024 were also adequately reported to the resident's primary care physician. Additional charting notes and transmission records were provided for a hospitalization event that occurred in April 2025. There is therefore insufficient evidence to show that facility staff is failing to meet the resident's needs. As a result, both allegations listed above are found to be Unsubstantiated, meaning that while the alleged incidents may have occurred, or the concerns may be valid, there is not a preponderance of evidence to prove that the alleged violations took place. An exit interview was conducted and a copy of this report was provided to a facility representative.

out of 4 staff stated they wait until the resident is done taking their medications to leave. All staff interviewed stated if a resident refuses a medication they will notate that in the MAR. 4 out of 4 staff stated none of the residents pocket or hide medications. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation Staff did not ensure that residents took their medication as prescribed is determined to be UNSUBSTANTIATED, meaning 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. An exit interview was conducted and a copy of this report was provided.

(Continued from LIC 9099) On February 13, 2025 LPA toured the Memory Care Unit and conducted four of four resident interviews. Two of the residents resided in Memory Care (MC) and two of the residents resided in Assisted Living (AL) and lived at the facility at the time of the incident. Four of four resident interviews denied the allegations. LPA reviewed the staff record of the employee in question and there were no disciplinary actions in their file. The employee no longer works at the facility and chose a different career opportunity in 2023. Based on LPA's record review and interviews conducted, 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. An exit interview was conducted with Peggy Ulland, Executive Director and Cauleen Ritchie, Clincial Specialist and a copy of this report was provided to the facility. *****This is an amended report.*****

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:00 AM, LPA Tea was greeted and granted entry into the facility by the front desk staff and explained the reason for the visit. Facility is licensed for 150 non-ambulatory residents, of which 44 may be bed-ridden, and a hospice waiver for 15 residents. Currently there are 133 residents and 11 are on hospice during today's visit. The Executive Director (ED), Peggy Ulland arrived shortly after to assist during the visit. LPA Tea reviewed thirteen resident files and eight staff files. Resident files and staff files contained all required documentation. LPA Tea along with ED Ulland and Maintenance Director Matt Yem toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a two-story building, with a memory care wing on the first floor. In the middle of the building is a courtyard with shaded patio seating with fountains. Memory Care unit has a garden courtyard of its own in the back that is secured. LPA tested delayed egress around the memory care garden to be operational. Staff came immediately within seconds when the alert for delayed egress went off. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. Last disaster drill was conducted December 12, 2024. LPA observed evac chairs in every stairwell in the facility for emergencies. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 117.6 F degrees and 116.7 F degrees. LPA pulled emergency pendants in resident’s bathrooms; staff came in the room as promptly as they could. Common areas were clean and clear of hazards, doorways were free of obstructions. Facility kitchen and dining area was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed emergency food and water supplies stored in storage areas in the facilities. Annual inspection continued on LIC809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA Tea observed residents playing bingo and partaking in activities in the activity room. LPA observed memory care residents partaking in bowling activities. The facility provides different activities for residents daily, which are posted throughout the facility. LPA reviewed medication storage and administration. Medications are stored in locked carts in each floor of the facility. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations An exit interview was conducted with ED Peggy Ulland and a copy of this report was given to the facility along with a copy of the LIC858, 858C; 859, 859C.

(Continued from LIC 9099) LPA conducted three of three staff interviews, reviewed resident file and the Physician’s Report dated January 21, 2022. it was determined, by the medical assessment, that the resident was able to follow instructions and self-feed. At the time of the incident, three of three staff interviews stated staff were nearby to assist resident and contacted emergency personnel immediately. Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation that facility staff did not provide adequate supervision to resident in care is Unsubstantiated. An exit interview was conducted with Peggy Ulland, Executive Director (ED) and a copy of this report was provided to the facility.

Licensing Program Analysts (LPAs) Rose Ruppert and Fred Arias made an unannounced case management visit and were greeted and granted entry into the facility by the concierge. The purpose of the visit was to deliver amended reports from August 15, 2024. LPAs met with Peggy Ulland, Executive Director (ED) at 2:30 PM. An exit interview and copy of this report, the amended LIC 9099s and LIC 9102-TV were provided to the facility.

(Continued from LIC 9099) members interviewed reported they did not have any issues with S1 and that S1 was a leader and always helped the team. LPA Quiroz interviewed S1 who acknowledged the facility lacked staffing at times and that some residents can be more difficult to assist than others. S1 denied having any knowledge of abuse happening within the facility and was aware of requirements to report if observed. LPA Ruppert requested and reviewed the employee file mentioned in the complaint and there were no disciplinary actions for this employee. S1 resigned from the facility in 2023 due to obtaining another job. LPA Ruppert requested staffing schedules from November and December 2022. Facility was unable to provide documentation since home office changed staffing software applications. A technical violation was given since records missing did not pose an immediate or potential health risk to persons in care. Since ED Ulland’s arrival the facility has implemented uploading monthly and daily staff schedules into SharePoint to archive documents. Although the above allegation may have happened there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation that staff failed to provide supervision resulting in not meeting residents’ needs is unsubstantiated. An exit interview was conducted with Peggy Ulland, Executive Director (ED) and a copy of this report and LIC 9102-TV was provided to the facility.

(Continued from LIC 9099) Fountain Valley Fire Marshall to ensure the facility is able to demonstrate proper evacuation and disaster preparedness. Seven of seven staff interviews also stated that there are no staffing issues at the present time. At the time of the allegation in 2022, the corporate office stated that facilities experienced staffing shortages, due to the pandemic. LPA Quiroz obtained and reviewed facility staffing schedules to ensure there were staff scheduled to work. LPA Quiroz observed on September 21, 2022 that there were four staff members in Memory Care, five staff members for Assisted Living, two Medical Technicians (Med Techs), an Activity Director and a Resident Coordinator. LPA Quiroz observed three caregivers with fifteen Memory Care residents in the Activity Room participating in karaoke during the facility tour and residents were engaged in the activity. Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations that: facility staff are not trained to conduct the proper response to an emergency disaster and that the facility failed to provide adequate staffing to meet resident’s needs are unsubstantiated. An exit interview was conducted with Peggy Ulland, Executive Director (ED) and a copy of this report was provided to the facility.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to clear the deficiency cited during the 10-day complaint investigation conducted on September 25, 2024 from 7:32am to 12:30pm. LPA was greeted and allowed entry by Concierge Paige Pheng and notified the lead management staff on duty. LPA met with Life Enrichment Director Tina Tanus and explained the purpose of the visit. 87303 Maintenance and Operation(a) The facility shall be... in good repair at all times. - The elevator was tested at 7:47am. Malfunctioning issue resolved on September 26, 2024. Facility has complied with the terms of the plan of correction. The deficiency is now cleared. An exit interview was conducted with Life Enrichment Director Tina Tanus and Executive Director Peggy Ulland by telephone, and a copy of this report including the Letter of Deficiency Citations Cleared were provided at the end of the visit.

On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a subsequent Annual Required visit after conducting a 10-day visit for complaint control #22-AS-20240501091507. LPA was greeted and met with Cauleen Ritchie, Regional Clinical Specialist (RCS), Peggy Ulland, Interim Director (ID), Jamie Pyles, Health and Wellness Director (HWD) and discussed purpose of today's visit. Dawn Blankenship, Regional Director of Operations (RDO) arrived during today's visit. Administrator (AD) Maria Arriaga has an Administrator certificate with expiration date of November 7, 2024. The facility is licensed to provide services to residents age range 60 and over. Approved for 150 (One hundred and fifty) Non-Ambulatory residents of which 44 (forty-four) may be bedridden. Approved Hospice Waiver for 15 (fifteen) residents. There are currently 12 (twelve) residents receiving hospice care services. Between 10:57am-1:55pm, LPA Quiroz along with (ID) Ulland and (HWD) Pyles toured the interior and exterior of facility premises consisting of memory care unit and Assisted Living area. During and after the inspection tour, LPA Quiroz conducted interviews with residents and staff. The required two (2) day perishable and seven (7) day non-perishable food supply was observed. Toxic substances were locked and inaccessible to residents in care. LPA observed cooking areas to be maintained with cleanliness. LPA observed facility refrigerator and freezer to be operational and met regulatory requirements. Resident's bathrooms were observed to have working sinks, faucets and flushing toilets. LPA tested hot water temperatures which ranged between 107.0 degrees- 114.0 degrees Fahrenheit. Grab bars and non-skid mats were also observed in resident bathrooms. Personal hygiene items for resident use were observed in each bathroom. LPA observed all resident rooms to have required linens, furnishings, and adequate lighting. All linens and furnishings were clean and in good repair. The medications were inaccessible to residents in care, centrally stored and maintained in compliance. All pathways, doorways, and emergency exits were observed to be free of obstruction. (CONTINUED ON LIC 809 C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 CONTINUED...There were no bodies of water observed anywhere on the property. PPE stored in storage area on the second floor next to the medication room area. Between 2:05-3:30pm, LPA Quiroz reviewed ten (10) resident files and ten (10) personnel files. The residents and staff files were found to be in compliance. LPA observed staff answer facility telephone which verified a working telephone was maintained at the facility. Regulatory required postings were observed to be posted in the lobby area. Facility was operating within the allowed capacity. Fire extinguishers were charged, mounted throughout the facility and last serviced on April 30, 2024. Facility indicated Pest Control services facility monthly or as needed and last serviced on April 10, 2024. LPA verified that fire/disaster drills are conducted at least quarterly and on each shift by Maintenance/Safety Director. Last fire drill was conducted on May 2, 2024. The Emergency exit plans were posted and available for reference throughout the facility. Residents were accorded clean and comfortable accommodations. Based on the observations made during today’s visit, no citations were issued during today's visit. An exit interview was conducted with (ID) Peggy Ulland and (HWD) Pyles. A copy of today's report, LIC 858 and LIC 859 pages were provided at exit.

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Rosie Quiroz for the purpose of a health and safety check and to follow up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 03/05/24 regarding an incident involving Staff 1 #1 (S1). LPA was greeted by front desk receptionist and met with Jamie Pyles, Health Service Director (HSD) and Sacha Dunlap, Business Office Manager (BOM). LPA Quiroz called and spoke to Administrator (AD) Marissa Drinkhouse-Quintana and discussed the purpose of the inspection visit. During today’s inspection, LPA Quiroz along with (HSD) Jamie Pyles toured the interior and exterior of the facility premises and observed multiple staff and residents present throughout today's inspection tour. LPA conducted health and safety checks on the residents present and observed no imminent health and safety concerns. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations, the electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA Quiroz interviewed (AD) Drinkhouse-Quintana via telephone who indicated Ombudsman and local police department were notified of incident. LPA Quiroz was provided with cross reporting case number to Fountain Valley Police Department. There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with (HSD) Pyles and a copy of this report was discussed and provided at exit.

Licensing Program Analyst (LPA) Ruth Martinez made visit to this facility to conduct a case management visit. LPA arrived at facility was greeted and granted entry by receptionist. LPA met with Dawn Blankenship, Regional Director of Operations and explained the nature of the visit. LPA is conducting this visit as a follow up on an incident that was self reported an on September 07, 2023 regarding R1’s incident on September 06, 2023. During today’s visit, LPA interviewed staff and copies pertinent documents will be email to LPA. On September 06, 2023 at approximately 11:30am staff went to residents bedroom to help with ADL's and radioed for staff to send in assistance. R1 was found laying in the bathroom. Staff immediately assessed R1 and determined that 911 had to be called. Paramedics arrived to the facility assessed R1 and was sent to hospital for evolution. R1 still remains at hospital for observation. Facility notified R1's responsible party and primary care physician. Facility does not have an estimated date when resident will be discharged from hospital. LPA did not observe any immediate and/or safety risks in or out of the facility. This report was reviewed with facility representative and a copy of the report was provided and left at the facility.