Cottages at Hemet.

LPA reviewed R1’s admission agreement dated 08/27/2025. Administrator confirmed that R1 moved out of the facility on 02/14/2026. LPA reviewed R1’s physician’s report dated 08/27/2025 documenting R1 exhibits memory loss and the “Able to Administer Own Prescription Medications”, “Able to Administer Own PRN Medications” and “Able to Store Own Medications” categories are marked “No”. Administrator was interviewed and reported the following information. R1 was not prescribed any medications upon admission to the facility. While residing in the facility, R1 was prescribed routine medication which staff administered as prescribed. The facility has a contract with Yorba Linda Pharmacy (YLP) who is responsible for creating an electronic Medication Administration Record (MAR) profile for residents. Facility staff then use the electronic MAR to log the residents’ medication administration while residing in the facility. If a resident uses a different pharmacy, facility staff will fax YLP a request to profile the medication for MAR purposes only. If the resident is not listed in the electronic MAR, facility staff are responsible for generating a paper MAR until the resident’s electronic MAR is created by YLP. After a resident leaves the facility for thirty days, facility staff no longer have access to the resident's electronic MAR and are required to contact YLP to request a copy. Administrator contacted YLP to request a copy of R1’s electronic MAR for LPA’s review, but YLP staff was unable to locate a MAR profile for R1. Two (2) of two (2) staff interviewed refuted the allegation and reported R1 received their medication as prescribed which was documented in R1’s electronic and paper MARs. Two (2) of two (2) staff interviewed reported observing multiple paper MARs on file for R1. However, administrator was only able to locate one (1) paper MAR from September 2025. Administrator was unable to locate a paper MAR for each medication prescribed to R1 during their stay in the facility. LPA was also unable to make contact with the facility's former memory care director or R1’s responsible person for an interview. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to Administrator Bogoje.

A review of records revealed that R1’s Physician Report with exam date of 08/15/2024, indicated cognitive impairment, dementia, confusion, and disorientation. The Physician’s Report, under category Able to Communicate Needs, it reads “unknown.” Facility charting notes were reviewed. The charting note dated 04/21/2025 revealed R1 was found on the floor in the hallway. Caregiver reports that R1 stated they did not hit their head and R1 was not complaining of pain or discomfort. Charting note dated 04/22/2025 revealed R1 was their normal self and was not complaining of pain or discomfort. Charting note dated 04/23/2025 revealed there were no complaints of pain or discomfort. Charting note dated 04/26/2025 revealed staff noted discoloration on R1’s left arm. The note further reads there no reports of R1 falling. This note has a time of 12:21pm. The next charting note dated 04/26/2025 with a time of 3pm, read R1’s arm was swollen and bruised and R1 was sent to the hospital. An interview with medical staff who responded to the facility, reported that during their assessment of R1’s injuries, they observed bruising and swelling on the left arm. It was described as a purple and green bruise starting on the left arm, extending to the bicep, elbow and chest area of R1. The medical staff further reported R1 complained of pain but due to their cognitive condition, R1 could not explain what happened. They added that during checks for movement, R1 could not use their arm. Based on their medical experience, the injuries appeared to have occurred a couple of days prior, based on how much bruising was sustained. R1’s medical records dated 04/26/2025 were reviewed, which revealed R1 was seen for an upper extremity injury. Medical records revealed a diagnosis of humeral fracture, possible c-spine fracture. Therefore, the allegation is SUBSTANTIATED, which means the preponderance of evidence standard has been met. A copy of this report along with 9099D, and Appeal Rights were provided to Executive Director, Barbara Bogoje. 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 An interview with the Executive Director, Barbara Bogoje, she reports there is not a policy on timely checks. She further reported that checks should be done every one to two hours. The Executive Director explained that caregivers do not document these checks. Interviews with caregivers revealed they check on residents every hour to hour and a half. Records were reviewed. A review of R1’s Needs and Services Plan, with an effective date of 08/15/2024 was completed. The review revealed the plan was not signed by neither the resident, the resident’s responsible party nor a facility representative. The review of this document revealed relevant information under various categories. Under the category of Activities of Daily Living, it reads “Independent” and the note reads “uses walker outside of building”; under the category of Falls, it reads “No”; under the category of Ambulation, it reads “Independent”. A review of R1’s Physician Report with exam date of 08/15/2024, revealed R1 was able to independently transfer to and from the bed and was considered ambulatory for purposes of a fire clearance. The investigation did not reveal that R1 was a fall risk or was on increased supervision checks. Therefore, the allegation is unsubstantiated, meaning the preponderance of evidence standard has not been met. A copy of this report was explained and provided to Executive Director, Barbara Bogoje.

LPA conducted interviews with seven (7) residents, all of whom stated that the shower chairs have been clean all the time. LPA conducted an interview with an outside agency personnel member who stated that the facility has always appeared to be clean whenever they visited the facility for their patients. LPA’s observations of the facility corroborated the statements from the staff members, residents and the outside agency personnel. LPA conducted a tour of the facility and observed the shower room and the shower chairs to be in clean condition. Based on interviews conducted and observations, the allegation that facility does not provide clean equipment for resident is unsubstantiated . It was alleged that facility does not have sufficient staffing. Information received indicated that all cottages of the facility are short staffed. LPA conducted an interview with memory care director who stated that they have not experienced short staffing. The memory care director explained that there are 3 caregivers for 2 memory care units, one (1) medication technician for two (2) memory care units, one (1) caregiver for each assisted living unit, and one (1) medication technician for four (4) assisted living units. LPA’s interview with other seven (7) staff members corroborated the memory care director’s statement. LPA conducted interviews with seven (7) residents, all of whom stated that they have not experienced staff shortages. LPA’s review of staff schedules corroborated the statements from the memory care director and the staff members interviewed. LPA conducted a tour of the facility, observed, and verified that those stated number of staff members were on duty. Based on interviews conducted, observation, and record reviews, the allegation that facility does not have sufficient staffing is unsubstantiated . A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.

On October 13, 2025, Licensee Program Analyst (LPA), Venus Mixson made an unannounced Health and safety visit in order to obtain additional information regarding information received via several Unusual Incident/Injury Reports. Information received was pertaining to an elopement. During the investigation process LPA conducted interviews, record reviews, and made observations pertaining to the elopement. LPA conducted a tour of the facility along with the Memory Care Director, Dawn Pracapio and made observations pertaining to the listed incident reported on October 10, 2025. Community Care licensing received information stating a resident eloped from the facility on two separate occasions. There were no Health and/or Safety concerns observed during today visit. LPA was informed by the Memory Care Director the facility has put a care plan in place to lessen the behavior. The plan includes relocation of resident to a more structured cottage, and a calmer atmosphere, along with higher supervision. An exit interview was conducted, and a copy of this report was given to Memory Care Director, Dawn Pracapio.

On 08/28/25 Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Executive Director Barbara Bogoje, where LPA explained the purpose of the visit. The facility consists of (6) single story cottages with fifteen bedroom/bathroom units in each cottage. There is a total of (4) cottages dedicated to assisted living residents and (2) cottages dedicated for memory care residents. LPA conducted a review of both staff and resident record files. LPA reviewed five (5) resident files that were observed to have the required documents such as medical assessment, needs and services plan. Staff files reviewed had the Department's required training records and valid first aid/CPR certification. LPA reviewed the facility's Fire Drill logs and noted the facility's last fire drill was conducted on 08/05/25. The kitchen which is in the main building was observed to be clean, and clutter free. There was plenty of cookware, dishes and utensils to serve the residents in care. The facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items. All meals are prepared in the kitchen and delivered to each cottage. Each cottage has an dining room, which consists of a kitchenette that was observed to have food warmers, refrigerators, and pantry. The resident bedrooms were observed to be clean and odor free, the cottages were at a comfortable temperature. The hot water was tested and found to be within regulatory limits measuring 105.4-114.2 degrees Fahrenheit. The medications are locked inside medication carts. The facility uses electronic Medication Authorization Records (MAR)s. Each cottage was observed to have a fully charged fire 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 fire extinguishers. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided.

Regarding the allegation the licensee is overcharging resident fees, it was alleged the facility was requiring the resident to pay a second one-time Community Fee that had previously been paid in August of 2023. The ED reported a request for residents to sign a new admission agreement was introduced solely to reflect the facility’s name change. Although the new admission agreement reflected the language of the one-time Community Fee, staff were not requiring residents to pay the community fee, as it had already been paid. LPA attempted to contact both R1 and their responsible party but was unsuccessful. Additional residents were selected at random and interviewed. Three of six residents interviewed reported that their families handle the financial aspects including monthly payments and administrative matters. Additionally, the remaining three of six residents reported that facility staff have never pressured or forced them to sign any documents. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided.

Regarding allegation: Staff left residents in soiled bedding or briefs. LPA Wesley Interviewed 8 residents who said they are never left in soiled bedding or briefs and LPA Wesley interviewed Staff #1 who said she ensures staff meets the schedule for changing the residents briefs which is every two hours or as needed, depending on the residents level of care. Staff #1 said when a resident takes their shower their bedding is changed, some residents require more changes than the other depending on how often the bed is wet. Regarding allegation: Staff did not make sure resident’s restroom was clean. LPA Wesley interviewed staff #1 who said the residents rooms are lightly cleaned daily, they caregivers take the trash out, dust and clean the residents bathroom. LPA Wesley interviewed residents 1-8 and they did not have a problem with their bathroom being cleaned or their trash being emptied by the staff or hospice providers. One resident said she takes out her own trash to have something to do. Staff #1 said she hasn't heard any problems with the staff not doing their duties. Regarding allegation: Staff did not answer residents call pendants in a timely fashion. LPA Wesley toured 2 of the resident cottages and pressed the pendants of the residents neck and the residents night stand, and the staff answered it within a decent time frame. LPA Wesley interviewed 8 residents who said their call pendants are answered, sometimes it could take longer depending on what they are doing for other residents. LPA Wesley asked what's the longest time you had to wait, and it was under 20 minutes. LPA Wesley asked staff do they answer call pendants in a timely manner and they answered yes it is usually 30 minutes or less depending on what the resident is calling for. Based on interviews conducted and records reviewed, there is insufficient evidence to support the 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 UNSUBSTANTIATED. A copy of the LIC 809/809C was given during the exit interview.

In regard to the allegation “Facility issued a rate increase for a falsified change of condition”, it is alleged that a change of condition was given that was not needed for R1 therefore a rent increase was issued for services not needed. During interviews with residents eight (8) out of the nine (9) residents stated that they have never received a rate increase that they didn’t know about. R7 stated that everything goes up, but they are always given notification of an increase. During interviews with Administrator and staff all four (4) stated that all residents and person responsible for residents are notified of any rate increase. Administrator stated that the nurse and physicians make the assessment if any change of condition has occurred and base the rate on the type of care residents need. During file review LPA observed that there was a change of condition for R1. In regard to the allegation” Facility falsified paperwork”, it is alleged that the signature on signed contract is falsified. During interviews with administrator and staff four out (4) out of five (5) staff state that they have never heard of any falsified documentation. During interviews with residents eight (8) out of nine (9) stated they have had no issues with their contracts to their knowledge. LPA reviewed admission agreement and resident assessment documentation and were all signed by both resident and responsible party LPA found no discrepancies. Based on interviews conducted and records reviewed, there is insufficient evidence to support the 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 UNSUBSTANTIATED. An exit interview was conducted with Med-Tech Jocelyn Constante. A copy of the report was provided.

LPA requested copies of incident reports, and medication destruction logs for the past three months, medication training for 2 medication technicians(Med-Tech), personal rights training, training on dementia care and activities of daily living for 2 caregivers. LPA reviewed medication for 5 residents. On 4/5/25 LPA delivered findings. The investigation revealed the following: Regarding allegations: Resident sustained injuries due to a fall. It is alleged around December 2022, R2 sustained an unwitnessed fall which left R2 with bruises and lacerations. Interviews conducted with residents revealed 4 out of 8 residents were unable to answer due to cognitive skills. 2 out of 8 residents stated to have fallen and staff provided assistance right away and 2 out of 8 residents stated to not fallen while in care but are certain staff will assist them right away if it happens. Interviews with staff revealed facility has a protocol for residents falls. Per staff if a resident falls Med-Techs are called. Med-techs evaluate the resident and if the resident is laying on their back or hit their head they are send out to the hospital for further evaluation. Staff stated that they have staff checking on residents and are aware of residents that need assistance. Those residents that need additional assistance are maintain within supervision range. Documents review revealed the following, per physician’s report dated:12/16/21, R2 is non-ambulatory and there were no notes of being a risk fall. Per needs and care plan dated 12/22/21 R2 requires a 2 person assist escort and total assistance with transferring. Medical records reviewed revealed R2 was seen on 10/13/22 due to a hematoma. On 11/7/22 R2 was seen at the hospital due to a mechanical fall. On 12/13/22 R2 was seen by a physician due to a fall. R2 was not under hospice or home health care. Medical record dated 10/13/22 notes R2 was seen for a hematoma. However, it does not note whether the reason was a fall. There were no incident reports to review for the falls above. Therefore, although R2 did sustained 2 falls per medical records and a hematoma is unclear whether those were due to lack of supervision. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff leave residents unattended in dirty diapers for extended periods of time. It is alleged residents are left unchanged for an extended period of time. Interviews conducted with residents revealed 3 out of 8 residents do not need assistance with incontinence care and stated staff assist with care as needed. 3 out of 8 residents were unable to answer due to cognitive skills and 2 out of 8 residents stated facility staff assist residents with going to the bathroom and changing as needed. (CONTINUED ON LIC 9099C) 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 Interviews with staff revealed 4 out of 7 staff stated caregivers who assist residents with incontinence care check residents every two to three hours and check residents as needed. 2 out of 7 staff were not aware of concerns with incontinence care. 1 out of 7 staff stated that a resident was found wet with a full pull up in the morning recent. The incident was report it to management. Administrator stated staff was given a written warning a copy of warning was reviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Staff mismanage resident’s medication. It is alleged staff mix up the residents’ medication and the facility keep the deceased residents’ medication. Interviews with residents revealed 5 out of 8 residents do not have concerns regarding medication management. 3 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed 4 out of 7 staff interview stated medications have not been mixed and medications are properly after a resident leaves or passes away. Medication is destroyed by placing them in a destruction container with a witness, staff destroying medication signs destruction medication log, and the destroyed medication in secure container are picked by contractor at least every three months. Medication review did not reveal errors or mismanagement of current residents’ medications. LPA observed the medication destruction container and did not observe old medications stored. LPA reviewed medication destruction logs for 7 residents were reviewed. Last medication training was provided on 4/3/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Staff failed to treat residents with dignity and respect and Staff handle residents in a rough manner. It is alleged a resident was treated with force when the resident refused to shower. Interviews with residents revealed 6 out of 8 residents stated staff treat them with respect when providing care. 2 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed staff have not mistreated or observed staff mistreating residents in care. Administrator and staff were unable to identify the resident in question. Administrator searched through stored records. However, there were no resident found with the name provided or incident described. Last Resident Rights training was provided to staff on 12/17/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. (CONT.LIC9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding allegation: Staff do not ensure residents are hydrated. It is alleged most of the residents are dehydrated as the staff do not make sure to give the residents enough drinking water. Interviews conducted with residents revealed 6 out of 8 residents stated facility provides proper care. 2 out of 8 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed staff provide care with all activities of daily living and residents are encouraged to drink water throughout the day. During facility’s tour LPA observed large water dispensers supplied with cups in each dining area and in the admission building. Staff were last provided training on dementia care on 1/21/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility is unkempt . It is alleged facility is dirty and sometimes the residents have feces on their beds. Interviews conducted with residents revealed 6 out of 8 residents interviewed stated the facility its clean and their bedding is changed often. 2 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed facility is maintained clean and the bedding is changed at least every three days or as needed. Per Annette Harris concierge residents provide their own bedding supplies. During facility’s tour LPA observed the facility’s common areas were clean and each bed observed had clean sheets and bedding supplies. LPA observed memory care cottages had additional bedding supplies in the laundry room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Barbara Borgoje Administrator and a copy of this report was email for signature.

The investigation revealed the following: Regarding allegations: Resident sustained injuries due to a fall. It is alleged around December 2022, R2 sustained an unwitnessed fall which left R2 with bruises and lacerations. Interviews conducted with residents revealed 4 out of 8 residents were unable to answer due to cognitive skills. 2 out of 8 residents stated to have fallen and staff provided assistance right away and 2 out of 8 residents stated to not fallen while in care but are certain staff will assist them right away if it happens. Interviews with staff revealed facility has a protocol for residents falls. Per staff if a resident falls Med-Techs are called. Med-techs evaluate the resident and if the resident is laying on their back or hit their head they are send out to the hospital for further evaluation. Staff stated that they have staff checking on residents and are aware of residents that need assistance. Those residents that need additional assistance are maintain within supervision range. Documents review revealed the following, per physician’s report dated: 2/15/22, R2 is non-ambulatory and there were no notes of risk fall. Per needs and care plan dated 6/20/22 R2 requires a 1 person assist escort and total assistance with transferring. Medical records reviewed revealed R2 was seen on 10/13/22 due to a hematoma. On 11/7/22 R2 was seen at the hospital due to a mechanical fall. On 12/13/22 R2 was seen by a physician due to a fall. Hospice records show that R2 was being provided hospice services since 3/12/21, plan of care notes dated 3/12/21, note R2 must have precaution care for falls/injures. Hospice notes between September and December 2022 do not note concerns or falls. Medical record dated 10/13/22 notes R2 was seen for a hematoma. However, it does not note whether the reason was a fall. There were no incident reports to review for the falls above. Although R2 did sustained 2 falls were medical records it is unclear whether the falls were due to lack of supervision. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff leave residents unattended in dirty diapers for extended periods of time. It is alleged residents are left unchanged for an extended period of time. Interviews conducted with residents revealed 3 out of 8 residents do not need assistance with incontinence care and stated staff assist with care as needed. 3 out of 8 residents were unable to answer due to cognitive skills and 2 out of 8 residents stated facility staff assist residents with going to the bathroom and changing as needed. Interviews with staff revealed 4 out of 7 staff stated caregivers who assist residents with incontinence care check residents every two to three hours and check residents as needed. 2 out of 7 staff were not aware of concerns with incontinence care. (CONTINUED ON LIC 9099C) 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 1 out of 7 staff stated that a resident was found wet with a full pull up in the morning recent. The incident was report it to management. Administrator stated staff was given a written warning a copy of warning was reviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Staff mismanage resident’s medication. It is alleged staff mix up the residents’ medication and the facility keep the deceased residents’ medication. Interviews with residents revealed 5 out of 8 residents do not have concerns regarding medication management. 3 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed 4 out of 7 staff interview stated medications have not been mixed and medications are properly after a resident leaves or passes away. Medication is destroyed by placing them in a destruction container with a witness, staff destroying medication signs destruction medication log, and the destroyed medication in secure container are picked by contractor at least every three months. Medication review did not reveal errors or mismanagement of current residents’ medications. LPA observed the medication destruction container and did not observe old medications stored. LPA reviewed medication destruction logs for 7 residents were reviewed. Last medication training was provided on 4/3/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Staff failed to treat residents with dignity and respect and Staff handle residents in a rough manner. It is alleged a resident was treated with force when the resident refused to shower. Interviews with residents revealed 6 out of 8 residents stated staff treat them with respect when providing care. 2 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed staff have not mistreated or observed staff mistreating residents in care. Administrator and staff were unable to identify the resident in question. Administrator searched through stored records. However, there were no resident found with the name provided or incident described. Last Resident Rights training was provided to staff on 12/17/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . (CONTINUED ON LIC 9099C) 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 allegation: Staff do not ensure residents are hydrated. It is alleged most of the residents are dehydrated as the staff do not make sure to give the residents enough drinking water. Interviews conducted with residents revealed 6 out of 8 residents stated facility provides proper care. 2 out of 8 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed staff provide care with all activities of daily living and residents are encouraged to drink water throughout the day. During facility’s tour LPA observed large water dispensers supplied with cups in each dining area and in the admission building. Staff were last provided training on dementia care on 1/21/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility is unkempt . It is alleged facility is dirty and sometimes the residents have feces on their beds. Interviews conducted with residents revealed 6 out of 8 residents interviewed stated the facility its clean and their bedding is changed often. 2 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed facility is maintained clean and the bedding is changed at least every three days or as needed. Per Annette Harris concierge residents provide their own bedding supplies. During facility’s tour LPA observed the facility’s common areas were clean and each bed observed had clean sheets and bedding supplies. LPA observed memory care cottages had additional bedding supplies in the laundry room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Brittney Walsh Sales Director and a copy of this report was provided.

The investigation revealed the following. Regarding Allegation: Staff did not administer resident's medication as prescribed – It is alleged on 01/10/2023, R1’s medications were discontinued by the facility physician. Five (5) out of the five (5) staff interviewed denied this allegation. Seven (7) out of the eight (8) residents interviewed denied this allegation. LPA Ramirez attempted to contact R1 for an interview, but R1 was not available for an interview. LPA Ramirez reviewed R1’s facility file and it revealed R1 was admitted into the facility in August of 2021. Review of R1 Physician’s report dated 01/05/2023, revealed R1’s physician documented R1 was non-compliant with medication recommendations. Review of R1’s Physician’s report dated 02/21/2023, revealed R1’s physician noted R1 was “Resistant to medication management and wants to choose what medications to take and never accepts medical advice.” LPA Ramirez reviewed a prescription medication change order by R1’s physician dated 01/06/2023. On 1/6/2023, R1’s physician ordered R1 discontinued twelve (12) medications and ordered R1 be administered four (4) new medications. Staff interviewed revealed medication technician's administer and or discontinue medications according to the physician's order. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No violations were cited for this investigation. Exit interview was conducted. A copy of this report was provided via email.

that R1 was being provided with because R1 sometimes instructs the staff to get out of the room. Staff do not want to violate R1s personal rights, so they abide by R1’s wishes. LPA conducted a records review of narrative charting for R1 which revealed that on 3/10/22 staff was trying shave R1 when they attempted to bite staff. On 02/17/22 when staff was conducting a check on R1, R1 reportedly told staff to get out and tried to kick and punch the staff. A further review of resident’s shower sheet form dated 2/28/22 revealed that R1 stated that “nobody here knows how to give a shower”. The form also noted that R1 had forgotten that staff already cleaned their head and hair, so staff repeated the task. Per an interview with current Executive Director the residents have a shower schedule and depending on the resident, the days assigned can range from 1-3 times a week and as needed. The staff make charting entries for showers completed, refused and if laundry was needed to be cleaned. Due to insufficient evidence to corroborate or refute the allegation of facility staff are not ensuring resident is thoroughly cleaned is unsubstantiated. Facility staff are not assisting resident with toileting. It was alleged that although R1 wears adult briefs, R1 is reported to be able to use the bathroom with staff assistance, as well as communicate the need to use the restroom, but staff do not provide them assistance. Per an interview with R1, R1 stated that there are times when they are being assisted with toileting and getting their adult brief changed and that if they want staff out, they will instruct staff to leave them alone. Per a review of narrative charting dated 02/17/22 R1 is noted as being aggressive with staff when staff was attempting to conduct a check on them. R1 is noted as telling staff to get out and tried to kick and punch the staff. Per an additional review of the end of shift reports from February 2022 it is noted that staff conducted checks as well as provided R1 with toileting assistance. Per interviews conducted with the current executive Director Barbara Bogoje, the residents are checked at beginning of shifts, throughout the shifts and during last rounds. Due to insufficient evidence to corroborate or refute the allegation of facility staff are not assisting resident with toileting is unsubstantiated. Resident does not have pendant/call button It was alleged that R1 did not have a pendant/call button. LPA conducted a review of narrative charting which revealed that R1 did not have a pendant from 2/3/22 to 2/10/22. A further records review revealed that R1 noted to have allegedly destroyed (4) pendants, which included R1 putting their pendant inside a cup of water on separate occasions. It was further alleged from a third-party witness the directive was given to not 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 issue R1 another pendant, and to increase the checks on R1. LPA conducted a records review of narrative charting which indicated staff had increased checks on R1 every 30 minutes beginning 02/06/22. Per an interview with R1, R1 admitted to breaking their pendant, and they use the alarm cord in the bathroom or yell when they need assistance. Per an interview with current Executive Director “If a pendant becomes lost or stolen, a replacement is given to the resident, and there is no limit to replacing the pendants”. Based on observations interviews and records review the allegation of resident does not have a pendant/call button is unsubstantiated. Resident is not provided assistance in a timely manner It was alleged that R1 is not being provided assistance in a timely manner. Interview R1 revealed that staff have a difficult time understanding them and that frustrates them and R1 will demand staff to leave their room. During LPA interview with R1, R1 was observed to be difficult to understand as they were speaking in a low voice and mumbling. It was further alleged from a third-party witness to not issue R1 another pendant, and to increase the checks on R1. R1 was reported to often yell and scream at staff while demanding they leave them alone. LPA conducted a records review of Narrative charting that revealed staff had increased checks on R1 every 30 minutes, beginning on 02/06/22. Interview with R1 revealed they use the alarm cord in the bathroom or yell when they need assistance. R1 further stated that they are given the “red carpet treatment”. Based on observations, interviews and records review the allegation of resident is not provided assistance in a timely manner is unsubstantiated. A finding that the complaint 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(s) occurred. An exit interview was conducted and a copy of this, and LIC811-confidential names list was provided to Executive Director Barbara Bogoje .

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit regarding an update of an incident that took place on June 2, 2024. LPA spoke with Barbara Bogoje, Executive Director and obtained the information. LPA conducted a health, safety and welfare check of residents in care, there are no issues at this time per ED. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to the Executive Director, Barbara Bogoje.

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit regarding an update of an incident that took place on June 2, 2024. LPA spoke with Barbara Bogoje, Executive Director and obtained the information. LPA conducted a health, safety and welfare check of residents in care, there are no issues at this time per ED. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to the Executive Director, Barbara Bogoje.

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit regarding an update of an incident that took place on June 2, 2024. LPA spoke with Barbara Bogoje, Executive Director and obtained the information. LPA conducted a health, safety and welfare check of residents in care, there are no issues at this time per ED. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to the Executive Director, Barbara Bogoje.

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit regarding an update of an incident that took place on June 2, 2024. LPA spoke with Barbara Bogoje, Executive Director and Mariam Issa, Resident Services Director and obtained the information. LPA conducted a health, safety and welfare check of residents in care, there are no issues at this time per ED. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to the Executive Director, Barbara Bogoje.

Interview with R1 was not conducted due to R1’s passing in August 2021. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Continuous Improvement Specialist Kim Henson.

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility regarding the department receiving an SIR of an incident that took place on June 2, 2024 of medications that were taken during a robbery. LPA spoke with Administrator Mark Pacia and obtained additional information. LPA toured the area accompanied by the Administrator. LPA conducted a health, safety and welfare check of residents in care and Administrator confirmed that no residents were identified that were victimized, injured or harmed during the incident. Administrator confirmed the staff that were present and victimized have been offered resources by the facility. LPA received an inventory of medications that were taken. Administrator confirmed the medications that were taken have been replaced and no resident had a lapsed in receiving their medications on time. Administrator confirmed that emails and letters were sent to resident's family or responsible parties regarding the incident. Administrator confirmed that the police were notified and investigation is on going. Administrator confirmed with LPA that preventative measures are going to be implemented for the safety of all residents, staff and visitors. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to the Executive Director, Marc Pacia.

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced case management visit to the facility to follow up on additional information for resident's death that occurred on 9/14/2023. LPA spoke with RSD, Yolanda Garcia and gathered documentation. No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report LIC 809 were provided to Yolanda Garcia.

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced case management visit to the facility. On 9/14/2023, CCLD received report of a resident's death. The visit was to follow up on resident #1 (R1)s death. LPA met with Executive Director Mark Pacia and Resident Services Director Yolanda Garcia and explained the purpose of today's visit. During LPA's visit, LPA reviewed and obtained copies of pertinent documentation and interviewed two (2) staff. LPA was informed by Resident Services Director regarding the events that led up to R1's death whom passed away on September 14, 2023. LPA was informed that R1 had not been feeling well since the morning prior to her passing and R1 refused to be sent out to the hospital when asked by staff. The preliminary cause of death is unknown at this time. LPA advised Mark Pacia and Yolanda Garcia to send a copy of the death certificate to the department as soon as it is available. No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report (LIC 809) and LIC 811 (confidential names list), were provided to Mark Pacia and Yolanda Garcia.

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Executive Director, Marc Pacia, who was informed of the purpose of the visit. At the time of the visit there was (10) staff and (80) residents present. The facility is a community with 6 cottages with fifteen units in each cottage. Four (4) cottages are for assisted living residents and two (2) of the cottages are for memory care. The community does not contain bodies of water, firearms, and ammunition. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following: Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Physical Plant: LPA observed the cottages, resident units, bathroom, and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational and are inspected annually. LPA checked the water temperature in Aspen unit # 5 and had a temp reading of 108.3F. LPA checked the water temperature in Cedar's bathroom and had a temp reading of 112.8F. LPA checked the water temperature in a vacant unit in Elm and had a temp reading of 113.8F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Facility receives food deliveries twice a week on Mondays and Thursdays. 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 Care & Supervision / Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate. Record Review and Resident/Staff Files: LPA reviewed six (6) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Twelve (12) resident files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All resident medication is kept locked in medication room in Cedar Cottage and is handled by the medical technicians. LPA reviewed medications for (12) residents and found all medication listed on eMARS and all required labeling was found to be in place. No medication errors observed at this time. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills which was conducted on 07/25/2023, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Executive Director, Marc Pacia.