Merrill Gardens at Gilroy

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) office at a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include Garden House ( memory care unit), Plaza, common areas. There are 2 Med Techs and 4 caregivers in Assist Living for AM shift and PM shift. There are 4 caregivres and 1 Med Tech for Memory Care unit for AM shift and PM shift. LPA reviewed the facility's roster and observed the 11 staff members are associated to the facility. In Garden House, LPA randomly entered into rooms #101A, #100, #102A, #101B, #103, #104 and #106A with GM. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care with dementia. In Plaza, LPA randomly entered into rooms #227, #226, #225, #223, #222, $216, #214 with GM. No issues were noted. Residents who store their own chemicals, disinfectants and hygiene products are able to store these items per their physician's report/records. Continue on LIC809-C. Page 1 of 2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed all training topics stated on the non-compliance plan was completed with signature log - fall policy; resident rights, toxic chemicals, and fire & alarms; and change of condition and mandated reporting. 5 random resident files were reviewed and observed complete. 5 resident files contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited today. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas. There were 7 staff members total on schedule during the AM shift in the Garden House. LPA reviewed the facility's roster on Guardian and observed the 14 staff members are fingerprint cleared and associated to the facility. In Garden House, LPA randomly entered into rooms 127, 126B, 126A, 125B, 120, 115A and 101A with the Garden House Director. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care with dementia. In Plaza, LPA randomly entered into rooms 304, 302, 203, 202, 209, 211 with the GM. No issues were noted. Residents who store their own chemicals, disinfectants and hygiene products are able to store these items per their physician's report/records. Page 1 Out of 2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed all training topics stated on the non-compliance plan was completed on September 17, 2025 - fall policy; September 13, 2025 - resident rights, toxic chemicals, and fire & alarms; and September 15, 2025 - change of condition and mandated reporting. 5 random resident files were reviewed and observed complete. 5 resident files contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided. Page 2 Out of 2. END OF REPORT.

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with General Manager (GM) Billy Mitchell and Health Services Director (HSD), Jocelyn Bailon Saloche. During visit, LPA toured the facility with the HSD to include the common areas, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained between 71 to 74 degrees F. All emergency exits were clear of obstruction. Activities calendar and menu posted in a visible area. It was observed that the only elevator in the facility that goes to Plaza (2nd and 3rd floor) had "out of order" signs posted. GM stated the elevators broke down yesterday on 09/24/2025 around 3:00pm. GM stated that they immediately called the vendor and had a technician come to the facility the same day around 4:30pm - 5:00pm. They were informed that the elevator is still functional however, the doors will not automatically close on its own but the elevator can be operated manually. GM states as of today, if any of the residents want to use the elevator, they need to call a staff to assist them in the elevator. GM states all the staff are trained on how to operate the elevator manually. In addition, they residents (who are able) and staff are using the stairwells. LPA observed the stairwells are equipped with evac chairs. GM states that they are offering in-room dining for residents who rather stay in their rooms and activities on the 2nd and 3rd floor of Plaza. GM is actively working with the vendor to fix the elevator. Page 1 of 2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Kitchen is supplied with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Items inside the refrigerator observed covered and labeled. Refrigerator temperature maintained at 39 degrees F. Freezer temperature was maintained at 8 degrees F. Staff stated they had the freezer opened which may have affected the temperature. The kitchen staff showed a log of the freezer temperatures which they monitor every morning, and logged below 0 degrees F. Toxins, chemicals and disinfectants are secured and stored separately from the food supply. A total of 9 resident bedrooms were observed. 9 resident bedrooms are equipped with beds, linens, night stands, dressers, and adequate lighting. Oxygen in use signs posted on the doors of residents who are using oxygen per physician's orders. Between 11:20AM - 12:30PM, the hot water temperature was measured in rooms #125B, 120, 118B, 203, 209, and 306 which measured between 132.6 - 136.4 degrees F. The maintenance personnel stated they had their water boiler serviced recently. During visit, facility had a plumber who was actively working on reducing the hot water temperature. At 4:26PM, the hot water was measured and observed maintained at 115.5 degrees F. 7 resident records were reviewed and observed complete and up-to-date. 5 out of 7 residents were on medication management. The 5 residents centrally stored medications and records were reviewed and all medications were accounted for. 5 staff files were reviewed and observed complete and up-to-date to include a background clearance. The staff are provided annual training on topics to include but not limited to dementia, Alzheimer's, prohibited and restricted health conditions, hospice, pressure sores, medications, caregivers, and blood borne pathogens. The facility is equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 4/26/2025. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake/elopement drill log was reviewed and drills are being conducted quarterly. The last drill was conducted in August and September 2025. Facility has an updated emergency disaster plan and infection control plan. No deficiencies were cited today per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell and Health Services Director (HSD) Jocelyne Bailon Saloche. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas. There were 14 staff members total on schedule during the AM shift in Prom/Plaza, and Garden House. LPA reviewed the facility's roster on Guardian and observed the 14 staff members are fingerprint cleared and associated to the facility. In Garden House, LPA randomly entered into rooms 111A, 116B, 120, 125B, 126A, and 126B with the Garden House Director. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care with dementia. In Plaza, LPA randomly entered into rooms 203, 209, 211, 301, 304, and 309 with the HSD. No issues were noted. Residents who store their own chemicals, disinfectants and hygiene products are able to store these items per their physician's report/records. Page 1 of 2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed all training topics stated on the non-compliance plan was completed on 02/19/2025 - fall policy; 06/19/2025 - resident rights, toxic chemicals, and fire & alarms; and 07/17/2025 - change of condition and mandated reporting. The training document contains the topic, date, name and signatures of the participants. LPA advised the GM to ensure all staff (including new staff members) are provided annual training on these specific topics per the non-compliance plan. 5 random resident files were reviewed and observed complete. 5 resident files contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and Health Services Director, Jocelyne Bailon Saloche and a copy of the report was provided. Page 2 of 2.

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management visit. LPA met with General Manager (GM), Billy Mitchell. The purpose of the visit was to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical. S1 was not currently working in the facility. It was stated that S1 only worked in the facility a couple times during the summer of 2024. The immediate exclusion letter was handed to the GM. The GM was informed to remove S1 from any contact with residents and not allow S1 to be physically present in the facility. GM stated understanding. The Business Office Director (BOD) was advised to separate S1 from the facility roster. BOD stated understanding. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided.

On 04/04/2025, the facility was provided R1’s hospital discharge summary which listed multiple changes to R1’s medication regimen. On 05/31/2025, a staff from the facility called R1’s responsible party asking if he/she was okay with the change to R1’s medication (M1) as stated on the updated LIC602. Upon reaching out to R1’s primary care physician (PCP), it was discovered that no changes were made since 04/03/2025. During the investigation, it was found that a staff (S2) had called R1’s responsible party to inform him/her about a change in R1’s medication (M1) per a new physician’s report that was received on 05/30/2025. Based on interview with S2, S2 admitted to misspeaking about the medication change during the call with R1’s responsible party. It was stated that S2 was confused about R1’s PM (M1) medication order because S2 only works AM shifts and was not familiar with R1’s PM medication regimen. Upon further reviewing R1’s medications, S2 then realized that R1 did not have a change in medication order. S2 states that R1 continued to receive his/her medication as normal and no changes to his/her medication regimen was actually made. Based on interview with staff (S1), S1 corroborated S2’s statement. The review of records shows that R1’s medication (M1) order did not change and R1 continued to receive his/her medication as prescribed by the physician. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon Saloche and a copy of the report was provided. Page 2 of 2.

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell and Health Services Director (HSD) Jocelyne Bailon Saloche. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas, and the courtyard. There were 9 staff members total on schedule during the PM shift in Prom, Plaza, and Garden House. 9 out of 9 staff members are fingerprint cleared and associated to the facility. In Garden House, LPA randomly entered into rooms 101A, 102A, 103, 110, and 115 with the Garden House Director and HSD. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care. In Plaza, LPA randomly entered into rooms 207, 210, 211, 212, and 203 with the HSD and GM. No issues were noted. Residents who store their own chemicals, disinfectants, and medications are able to store these items per their physician's report/records. Page 1 of 2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed all training topics stated on the non-compliance plan was completed on July 18, 2024. The training topics includes resident rights, mandated reporting, changes of condition, toxic substances and sharp objects. Staff were also provided in-service training on personal rights in December 2024 and toxic chemical storage in February 2025. The training document contains the topic, date, name and signatures of the participants. LPA advised the GM to ensure all staff (including new staff members) are provided annual training on these specific topics per the non-compliance plan. 5 random resident files were reviewed. 5 resident files reviewed contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. Page 2 of 2.

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. This visit is a follow-up to a case management visit conducted at the facility on 05/29/2024. LPA met with General Manager, Billy Mitchell. On 05/23/2024, the Department was informed of resident (R1)’s death that was observed by staff during morning check-ins with the residents. The Department was investigating the allegation of neglect/lack of supervision resulting in R1 committing suicide while in care. During the investigation, it was found that at approximately 0945 hours, staff checked in with R1 as R1 did not check in with the front desk by 0830 hours based on the facility’s policy. When staff entered R1’s bedroom, staff found R1 deceased inside his/her bedroom by apparent suicide. A note was found stating that R1 acted alone without any assistance. The facility staff immediately called 911. Staff members and resident were interviewed. Based on interviews, R1 never made any suicidal statements and/or had suicidal ideations. R1 was independent and did not require any kind of assistance. Based on record review of R1’s file, documents did not indicate or notate any signs of depression or suicidal behaviors. Facility staff did not provide and could not state how R1 obtained items used to aid in his/her death. Page 1 of 2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The review of the police report records indicated that there were no signs of trauma or foul play. The Department has investigated the allegation to be unsubstantiated, meaning, although the incident may have happened and/or did occur, there is not a preponderance of evidence to prove a Title 22 violation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Billy Mitchell and a copy of the report was provided. Page 2 of 2.

The review of R3’s records indicates that R3 is paying for shower services as R3 requires moderate assistance with showers. Based on interview with R3, it was stated that upon admission in the facility (April 2024) R3 was refusing showers due to a fall incident that occurred in another care facility. R3 states he/she was not comfortable with showers yet and refused the shower service. R3 denied the facility missing a shower week, besides one week when the facility did not have hot water which R3 received a shower the week after. R3 states that he/she receives shower weekly and did not have any complaints about the services he/she is receiving. It was alleged that resident (R4) is being charged for showers and laundry but R4’s family does the laundry and R4 showers him/herself. The review of R4’s records indicates that R4 is not paying for shower services and requires minimal assistance with showers. Records show that R4 is paying for weekly laundry services. Based on interview with R4, it was stated that R4 shower him/herself. R4 stated that the staff does his/her laundry weekly and did not have any complaints about the services he/she is receiving. It was alleged that resident (R5) is receiving shower services but is being charged for dressing services, when R5 can dress him/herself. The review of R5’s records indicates that R5 is paying for shower services as R5 requires moderate assistance with showers. R5 is independent in dressing and is not paying for this service. Page 2 of 4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on interview with R5, it was stated that R5 received weekly shower services since the day R5 has moved in. R5 denied the staff missing a shower week. R5 states he/she is able to dress him/herself daily but sometimes may need assistance from the staff. R5 did not have any complaints about the services and care he/she is receiving and states the facility is meeting his/her daily needs. It was alleged that the facility staff are falsifying documents because the staff are making the residents sign documents that has been written by staff to be completely untrue. It was also alleged that staff are falsifying documents as they are told by S1 to not to document everything because it leaves a paper trail. 4 residents were interviewed. Based on resident interview, 4 out of 4 resident’s denied staff falsifying their documents. 4 staff members were interviewed. Based on staff interview, it was stated by staff (S3) that a former staff was told not to document everything because it leaves a paper trail and S1 does not want a paper trail. Another staff stated that S1 instructed S2 to falsify other documents (pendant log) during a licensing visit. Based on interview with S1 and S2, both staff denied falsifying documents. S1 stated that a former staff was claiming that he/she was told not to document anything, when the documentation actually needed to be completed by another staff member. S1 also denied instructing S2 to falsify the pendant logs. Based on interview with the former staff, it was stated that he/she was told by another staff (name unknown) that S1 had directed the other staff to falsify documents. Based on interview with S2, it was stated that S2 was helping to print the pendant logs. S2 denied S1 instructing him/her to falsify the pendant log by changing the times and believes they are not able to modify the times in the pendant system. Page 3 of 4. 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 staff (S1) did not keep resident’s information confidential by disclosing a resident’s death to other residents. 3 staff members (S2 – S4) were interviewed. Based on staff interview, 3 out of 3 staff stated that the residents found out about another resident’s death by staff (S1). It was stated that S1 disclosed the information to resident (R1) and (R2). Based on interview with S1, S1 denied disclosing a resident’s death to other residents. 2 residents (R1 – R2) were interviewed. Based on resident interview, R1 and R2 denied staff disclosing a resident’s death to them. R1 and R2 states they found out about the resident’s death through other residents at the facility, and not by the staff. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. Page 4 of 4.

On 04/05/2024, 5 staff members were interviewed. Based on staff interview, it was stated that staff check in on R1 at least 2 times per day for medications, however caregivers check in on R1 about 2 or 3 times more per shift. It was stated that there were no incidents reported for R1 on 03/01/2024. The number of times staff check in on R1, was depending on the staff. S2 stated to check in on R1 about 3 – 5 times per his/her shift. S3 states to check in on R1 at least 4 times per his/her shift. S4 states to check in on R1 about 4-5 times per his/her shift. Based on record review, on 03/01/2024, there were no progress notes written by staff on this day. On 03/02/2024, it was noted that R1 requested for pain reliver medication due to pain. From 03/02/2024 – 03/04/2024, R1 was on alert charting due to a change of condition and was being monitored for his/her pain. On 03/03/2024, staff mentioned concern that R1’s pain could be a cause of a fall. On 03/04/2024, R1 was taken to the hospital by his/her family member where R1 was seen for a swollen ankle. The review of records show that R1 is a high potential for falls but does not require assistance with ambulation, mobility, escorting, and transferring. On R1’s service plan, it states that R1’s family member has been evaluated by the community to be at risk for injury which may cause permanent disability or be life threatening. Interventions were put in place for R1’s safety, however, based on record review there was no indication on R1’s service plan that staff were required to check in on R1 every hour. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. Page 2 of 2.

On 12/15/2023, 6 staff members were interviewed. Based on staff interview, there were a couple residents who were diagnosed with scabies on separate occasions (10/26/2023 and 11/06/2023), but as of 12/15/2023 the residents no longer had scabies. It was stated that some residents did not have a confirmed diagnosis of scabies and were experiencing symptoms of itchiness. These residents’ physicians were notified and prescribed a PRN medication. The review of records show that R1 was noted to have itchiness and redness on 10/26/2023. Based on staff interview, R1 was diagnosed with scabies. R1’s hospice nurse was notified and R1 was prescribed and applied a PRN medication. Staff noted R2 was experiencing symptoms of itchiness. R2’s doctor and authorized representative was notified, and R2 was prescribed a PRN medication. R2 was also being seen by a home health agency for another condition. Staff stated that R3’s itching was caused by dry skin. R3’s doctor was informed and prescribed a PRN medication. Staff denied the observation of R3’s skin being red and bumpy. R4 was noted to be under hospice care. Staff stated that R4 was not exhibiting any symptoms. The review of R4’s records did not include notes of a diagnosis of scabies or symptoms of itchiness. Staff stated that R5 was being seen by a home health agency and was not experiencing any symptoms of scabies. The review of R5’s records did not include notes of a diagnosis of scabies or symptoms of itchiness. It was alleged that staff are not discarding PPE gowns after assisting residents who are under isolation or quarantine because they were not told to discard it. It was also alleged that residents who were experiencing symptoms of scabies were not placed under quarantine. Page 2 of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 12/15/2023, 6 staff members were interviewed. Based on staff interview, 6 out of 6 staff members stated they discarded the PPE gowns after every use. Based on review of the facility’s infection control plan, it’s stated that items and equipment that are single-use shall be disposed of in an appropriate waste container with a tight-fitting cover. Based on staff interview, the gowns being used are disposable and they are disposed in the trash bin upon exiting the resident rooms, which is located next to the isolation room. Staff stated that resident’s who were suspected to have scabies and were experiencing symptoms of scabies were placed under isolation until they were informed of a diagnosis from the resident’s physicians. Those who were experiencing itchy skin due to a condition not related to scabies (example dry skin), were not placed under quarantine . Based on review of the facility’s infection control plan, it’s stated there shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report was provided. Page 3 of 3.

The review of R1’s service plan states that R1 has full dentures but refuses to wear the dentures. 4 staff members were interviewed. Based on staff interview, 4 out of 4 staff did not remember R1 using dentures. It was stated that R1 moved from Assisted Living to Memory Care and staff did not remember R1 moved into memory care with dentures. Based on record review of R1’s safeguard of personal property and valuable form, there were no items to include the dentures that was entrusted to the facility. The word “waived” is written across the form and the form was signed and dated by R1’s responsible party on 03/17/2021. It was alleged that the facility staff did not ensure that R1’s hygiene needs were met while in care as it was observed that R1 was filthy after not being bathed for a week. It was alleged that R1’s hygiene needs were not met because the facility was short staffed. The date of this encounter is unknown. Based on record review, R1’s showers were scheduled twice a week and required staff hands on assistance. 4 staff members were interviewed. Based on staff interview, 4 out of 4 staff denied R1’s hygiene needs being neglected by the staff. Staff states that R1’s family did not bring up any concerns that R1 wasn’t showered for a week. Staff states the facility was short staffed around July 2023 but denied the shortage of staff reflecting on the shower schedule. Staff states the residents were still being provided their showers on their scheduled days. The review of the facility’s staffing schedule shows that there were at least 3 staff scheduled in memory care, in the AM and PM. It was alleged that staff did not ensure R1 had clean linens while in care as there was a day where R1’s responsible party and R1’s social worker needed to change R1’s bedsheets because they were soiled. Page 2 of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The date of this encounter is unknown. 4 staff members were interviewed. Based on staff interview, 4 out of 4 staff were not able to recall a time where R1 had soiled linens. It was stated that if staff were to observe that a resident’s sheets are soiled, the staff would immediately change the sheets and put new ones. It was alleged that staff did not follow safe sanitation practices as a staff who wore disposable gloves for cleaning was touching other surfaces and items with the same glove on. It was stated that when R1’s responsible party placed R1’s soiled items outside R1’s bedroom door for laundry service, the staff picked up the soiled linens with possibly the same disposable gloves. It was stated that the staff did not serve R1 any food. The reporting party did not indicate that the staff provided any care to the resident or other residents with the same gloves used during cleaning. 4 staff members were interviewed. Based on staff interview, it was stated that they spoke with the alleged staff who did not follow safe sanitation practices, and the staff denied the allegation. It was stated that facility staff are provided training on infection control. Staff state that they can use gloves when cleaning but they are trained to change out their gloves before they provide any care to the residents. It was stated that staff are trained to change their gloves after every resident when assisting them with ADL (activities of daily living) care. Based on record review, infection control training was completed on 05/25/2023. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report was provided. Page 3 of 3.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Health Services Director, Jocelyne Bailon. The purpose of the visit was to follow-up on a physical abuse incident that occurred at the facility the night of 12/02/2024. On 12/03/2024, the Department was informed of an incident that occurred between staff (S1) and resident (R1). On 12/03/2024, the community was made aware that R1 was treated in an aggressive manner by S1 the night of 12/02/2024. The incident was captured on the facility's fall detection video system. After the community was made of the incident, S1 was escorted out of the building on 12/03/2024. S1’s employment was terminated on 12/04/2024. The facility also conducted an internal investigation with all the staff involved and who have witnessed the fall detection video footage. On 12/04/2024 and 12/05/2024, the facility conducted an in-service training with all staff (AM/PM/NOC) to include topics of understanding the importance of “see something say something”; mandated reporters; the steps to take to ensure residents safety and well-being; and understanding resident rights. HSD states the training also included proper intervention and techniques for redirection, de-escalation, and dementia. Documents were obtained to include the in-service training sheet/materials and 4 staff member’s job application. A copy of the fall detection video was provided to LPA Dolores via a USB stick. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report was provided.

On 08/22/2023, 1 witness was interviewed. Based on witness (W1) interview, it was stated that the facility is short staffed mostly everyday. It was stated that the morning and afternoon shift has 2 caregivers and 1 medtech. W1 states that on 08/22/2023, there was only 2 staff. W1 states that he/she is constantly looking for staff to help R1. W1 states if he/she is really complaining the staff come within 10-15 minutes. W1 stated that on 08/22/2023, staff came after 45 minutes and apologized for not coming sooner as the staff needed to take a lunch. W1 states it doesn’t happen often. On 08/22/2023, 8 staff members were interviewed. Based on staff interview, 7 out of 8 staff stated the facility’s memory care has sufficient staff to meet the needs of the residents. It was stated that there are 4 staff (3 caregivers and 1 medtech) in the morning shift, 3 staff (2 caregivers and 1 medtech) in the evening shift, and 2 staff for the overnight shift. It was stated that the staff used to wash dishes around December 2022 time, however, since August 2023 the kitchen staff does all of the dishes. It was stated that the staff are assigned to groups, and they help each other out as a team. It was stated that the medtech also assist with care giving duties, when needed. 1 out of 8 staff stated they need more staff in memory care. On 08/22/2023, LPA Dolores entered the memory care unit around 11:50am and observed 2 staff were working in memory care, 1 caregiver and 1 medtech/caregiver. Based on interview with staff, the third caregiver was on break and the fourth caregiver was somewhere in the building but could not be located at that moment. LPA Dolores observed 3 housekeeping staff. After a few minutes, LPA observed the third caregiver walking down the hallway. LPA interviewed the fourth caregiver who states to be late to work. LPA Dolores observed lunch started at 12:10PM and observed 2 staff assisting the residents with dining. Based on record review, there were 30 residents residing in memory care. PAGE 2 OF 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on record review of the facility’s staffing schedule, in July 2023 the AM and PM shift had 3 caregivers and 1 Medtech scheduled and 2 staff for NOC shift. There was only 1 day of the month (Saturday 07/22/2023) where there was only 2 caregivers and 1 Medtech scheduled in the PM. In August 2023 the AM shift had 3 caregivers and 1 Medtech, PM shift had 2 caregivers and 1 Medtech, and NOC shift had 2 staff scheduled. On 08/22/2023, the schedule shows 3 caregivers and 1 Medtech in the AM and 2 caregivers and 1 Medtech in the PM. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicated that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. PAGE 3 OF 3.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager, Billy Mitchell. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with GM to include garden house, assisted living, common areas, and courtyard areas. During the tour, LPA observed 9 staff members who are fingerprint cleared and associated to the facility. All sharp objects, chemicals, disinfectants, and garden supplies observed secured. Based on the non-compliance plan, training was scheduled to be completed by a certain date for reporting requirements; change of condition and observations of decline in condition or ability; personal rights of a resident; reappraisals; and care of persons with dementia as it pertains to toxic substance and sharp objects. LPA observed all training topics stated on the non-compliance plan was completed by the expected dates. The training document contains the topic, date, name and signatures of the participants. GM states a plan to complete the training bi-annually. Page 1 of 2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 5 resident files were reviewed. The files reviewed contained a signed personal rights form, physician’s report, and a signed up-to-date appraisal/needs and services plan. 5 staff files were reviewed. 5 staff are associated to the facility and fingerprint cleared. 5 staff are provided training on personal rights as of 10/29/2024. LPA Dolores advised to ensure all new staff review and receive instruction regarding resident rights upon hire and the training must be documented in the staff’s file. LPA Dolores advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided.

On 04/12/2023, 7 residents were interviewed. Based on resident interview, 7 out of 7 residents did not have any complaints of staff not treating them politely. 7 out of 7 residents denied staff being verbally and physically abusive to them. 7 out of 7 residents denied the observation of staff being verbally or physically abusive to other residents. On 10/07/2024, 5 staff members were interviewed. Based on staff interview, 5 out of 5 staff member denied the observation or knowledge or staff not treating residents politely. 5 out of 5 staff denied the observation of staff being verbally or physically abusive to the residents. Based on record review, the Department did not receive any reports relating to these allegations. The Department has investigated the above allegations and based on interview, record review and observation the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided. PAGE 2.

It was alleged that the facility staff pureed resident (R1)’s food without authorization from R1’s responsible party. On 07/21/2023, 2 staff members were interviewed. Based on staff interview, S2 states that when R1 returned from his/her doctor’s appointment, R1’s responsible party provided the paper that states there was a change in diet to puree from R1’s doctor visit sometime in April 2023. S2 states that R1’s responsible party knew there was a change in diet because R1’s responsible party provided the facility with the diet order. S2 states R1’s hospice team was also informed of the diet change. Based on record review, R1’s physician signed a “diet order and dietary communication” form on 04/21/2023 for a puree diet. It was alleged that the facility staff are not accommodating to R1’s diet needs by not providing R1 with a nutritional beverage. The review of records show that R1’s physician’s report dated in March 2023 states a special diet for a nutritional beverage. On 07/21/2023, 2 staff members were interviewed. Based on staff interview, S2 states that they did not follow-up with R1’s physician in March to obtain the physician’s order for the nutritional beverage. S2 states despite the physician’s report in March 2023 stating R1 has a special diet for a nutritional beverage, the facility still requires an actual order from the physician. S2 states that since they did not have an actual physician’s order for the nutritional beverage, they were unable to provide the beverage to R1. S2 states they received an order in June 2023. The Department has investigated the above allegations. Based on interview and record review the above allegations are unsubstantiated. An unsubstantiated finding indicated that although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. However, a case management visit was conducted on 10/07/2024 due to a violation observed during the investigation. See LIC809 on 10/07/2024. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.

On 12/08/2022, 2 staff members were interviewed. Based on interview, in Garden House they normally have about 4 caregivers and 1 medtech per shift and NOC is normally 2 caregivers and 1 medtech. Staff from Assisted Living are pulled, if needed. It was stated that they utilize 1 agency staff in the AM shift at least 2-3 times a week and 2 agency staff in the PM shift at least 2-3 times a week. It was stated that agency staff are normally on the weekends. It was stated that if they are short staffed or have a call out, their staff either works doubles, leadership staff fills in to cover the shifts, or a staffing agency is contacted. 2 out of 2 staff stated the facility is constantly hiring, and the hiring of new staff is ongoing. Based on observation, on 12/08/2022 around 10:40AM, LPA Dolores entered the Garden House section. LPA observed 2 caregivers, 1 staff assisting with activities to a group of more than 10 residents, and 1 housekeeper on the floor. It was stated that 2 caregivers and 1 medtech was on break. Based on record review, there was 35 residents in memory care as of 12/08/2022. The facility’s Garden House schedule showed at least 3-4 caregivers and 1 medtech scheduled daily in the AM and PM. NOC shift shows at least 2 caregivers scheduled. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and Health Services Director, Jocelyn Bailon and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Executive Director (ED) Kim Golden. During visit, a complaint report for complaint control number: 26-AS-20220404161647 was amended. The amended report was reviewed and handed to the ED. On 06/12/2024, the facility was issued a civil penalty for a staff member working in the facility without a criminal background check clearance. On 06/12/2024, the wrong civil penalty assessment form was generated. During today visit, the correct civil penalty form (LIC421BG) was reviewed and signed by the ED. LPA obtained the hard copy of the LIC421BG. ED obtained a copy of the signed LIC421BG. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director Kim Golden and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with General Manager, Kippie Castronovo. During visit, LPA obtained a copy of resident (R1)'s records to include: face sheet, identification and emergency information, consent forms, physician's report, ID, needs and services plan, and progress notes. This case management visit will be pending investigation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Kippie Castronovo and a copy of the report was provided.

On 04/13/2022, the Administrator was interviewed. Based on interview, the facility did not have any current residents who have restraining orders or any unauthorized visitations. It was stated the residents have a right to see who they want and can have visitors if they consent to it unless there is a restraining order. It was stated that if a resident’s POA does not want a resident to see a certain visitor, the resident still has their right to consent to the visitation. Based on interview, R1’s POA did not want anyone to see R1. It was stated that R1 always wants to see his/her relative and can see his/her realize if he/she consents to the visitation. Staff (S2) stated R1's responsible party verbally stated they did not want R1's relative to visit, however, R1 always consented to seeing R1's relative. Based on record review, there is no documentation that R1 had any restraining orders nor was the facility provided a list of unauthorized visitors from the resident and/or resident's responsible party. Based on review of R1's POA (power of attorney) documentation, there is no documentation that allows R1's POA to restrict visitations. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Kim Golden and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Interim General Manager, Kippie Castronovo. The purpose of the visit was to deliver an amended LIC809-D that was issued on 01/31/2023. LPA reviewed the LIC809-D with IGM. IGM signed the amended LIC809-D and was provided a copy of the LIC809-D. This report was reviewed with Interim General Manager (IGM), Kippie Castronovo and a copy of this report was provided.

On 11/09/2023, 4 staff members were interviewed. Based on interview, the facility staff was unaware of any concerns regarding R1’s feet and bunions. 4 out of 4 staff states R1 has never complained of any pain. 4 out of 4 staff denied any observation of redness on R1’s feet. 4 out of 4 staff state R1 is constantly walking around Garden House and has never complained of any pain. S4 states to observe R1 was limping one day and when asked if R1 was in pain, R1 denied any feeling of pain and continued to walk around Garden House. 4 out of 4 staff state R1’s family and/or visitor has not addressed any concerns regarding R1’s bunions and feet. On 11/09/2023, 1 witness was interviewed. Based on interview, R1 has been complaining that his/her feet were hurting for “quite a while”, however, the facility was not informed of that information when R1 moved in. Based on records reviewed, there was no indication of medical concerns relating to R1’s bunions and/or feet. There was also no indication R1 complained of any pain which may prompt facility staff to seek medical attention. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false could not have happened and/or is without a reasonable basis. This report was reviewed with Garden House Director, Jocelyn Bailon and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores arrived at the facility unannounced to conduct a Case Management - Other visit. LPA met with Executive Director, Nelson Rodrigues. The purpose of the visit was to deliver an immediate exclusion letter to exclude an employee (S1) at the facility. Based on record review, S1 is no longer an employee at the facility. The immediate exclusion letter was handed to the Executive Director during today's visit. This report was reviewed with Executive Director, Nelson Rodrigues and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores arrived at the facility unannounced to conduct a Case Management - Other visit. LPA met with Executive Director, Diane Atkinson. The purpose of the visit was to deliver an immediate exclusion letter to exclude an employee (S1) at the facility. The immediate exclusion letter and declaration of service was handed to the Executive Director during today's visit. This report was reviewed with Executive Director, Diane Atkinson and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores and Licensing Program Manager (LPM) Jackie Jin conducted an unannounced pre-licensing continuation visit from 8/20/2021. LPA and LPM met with Administrator, Diane Atkinson. During today's visit, LPA and LPM observed the following posters: personal rights, if you see something say something, ombudsmen, and resident right to counsel posted. Resident Admission Agreement and Death and Loss policy is available for the public to review upon request. LPA and LPM reviewed 13 resident files and 13 staff files. Facility staff are fingerprint cleared and associated to the facility. Resident files all consist of Admission Agreement, Medical Assessment with TB Information, Consent Forms, Care Plans, Safeguard for Personal Properties and Valuables, and Personal Rights. Staff files all consist of Personal Record, Health Screening with TB Information, and Criminal Record Statement. Component III is being waived because applicant has been a facility administrator since 11/1986. No issues noted during this pre-licensing inspection. LPA and LPM observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. This report was reviewed with Diane Atkinson, Administrator and a copy of this report provided.

Licensing Program Analyst (LPA) Christine Dolores and Licensing Program Manager (LPM) Jackie Jin arrived unannounced to conduct a pre-licensing visit. LPA and LPM met with Diane Atkinson, Administrator. There is currently residents living at the facility. The facility has three floors in assisted living, one floor memory care, and one transition memory care unit. The facility has an approved fire clearance for 199 non ambulatory and 15 bedridden residents. LPA toured the facility inside and outside including the apartments, bathrooms, kitchen, and common areas. Resident apartments were equipped with proper furniture and lighting. Resident apartment temperature was maintained between 75 to 77 degrees Fahrenheit. Bedding and linens are available to the residents and observed clean. Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and toiletry. Facility is equipped with cups, plates, utensils, and cooking supplies. Hot water temperature was measured between 105.4 to 114.2 degrees Fahrenheit in resident apartment bathrooms. The facility has designated medication rooms with locked medication cabinets. LPA and LPM reviewed centrally stored medication records with residents medications. LPA observed first aid kit with the following supplies: bandages, scissors, tweezers, and thermometer. LPA and LPM observed locked medications, sharp objects, and cleaning supplies. Continue on LIC-809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed 2 days worth of perishables and 7 days worth of nonperishable. Refrigerator temperature was maintained at 37 degrees Fahrenheit. Freezer temperature was maintained at 0 degrees Fahrenheit. Facility is equipped with smoke detectors, carbon monoxide detector, and fire extinguisher. Hallway and passageways were observed free of obstruction. LPA and LPM will return another day to complete pre-licensing visit. This report was reviewed with Diane Atkinson, Administrator, and a copy of this report is provided.