Grossmont Gardens Memory Care.

(Continued form LIC9099) The records review included Medication Administration Records (MARs) and Physician’s Orders for three residents (R1, R2, R3) residing in the facility, focusing on scabies-related treatments such as Permethrin and Ivermectin. Department records from an outside treating facility indicate that Residents #1–3 were treated for rash symptoms; a formal diagnosis of scabies was never documented, however, precautionary treatment was performed by the outside treating agency. The facility’s Infection Control Plan was reviewed and noted as last updated on July 7, 2023. The Department’s annual inspection in May 2024 revealed that extra linens, hygiene supplies, and Personal Protective Equipment were present. Interviews with multiple staff and residents during May 2024 did not reveal concerns that the facility was failing to follow its infection control plan. Further interviews with staff and an outside source indicated that staff were following infection control protocols. The MARs and Physician’s Orders reviewed showed that R1, R2, and R3 received rash directed therapy in June 2024, including Permethrin (topical) and Ivermectin (topical and oral). Orders specified full-body topical application from neck to toes with shower-off instructions and repeat dosing intervals, consistent with commonly accepted scabies treatment practices. Times of treatments were documented for several residents. The records alone do not confirm or refute communication practices with families, staff, or visitors. Due to the nature of cognitive abilities in a memory care setting, isolation measures would not typically be part of the Department’s or the facility’s protocol. The presence of timely treatment orders and administrations for multiple residents demonstrates the facility’s action to address residents with infectious conditions. With li mited documentation beyond medication records, there is insufficient evidence at this time to establish that the facility failed to notify families or failed to follow infection control procedures. Based on the records review, interviews with staff and an outside source there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the allegation is: UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott- Kaplioff , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Collateral visit.  LPA was greeted by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg, Executive Director. During today's visit, LPA observed residents during mealtime/Activities, reviewed residents files and typed interviews. There were no deficiencies observed during this visit. An exit interview was conducted with Natalie Carlborg, Executive Director, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Collateral visit.  LPA was greeted by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg, Executive Director. During today's visit, LPA observed residents during mealtime/Activities, reviewed residents files and typed interviews. There were no deficiencies observed during this visit. An exit interview was conducted with Natalie Carlborg, Executive Director, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Collateral visit.  LPA was greeted by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg, Executive Director. During today's visit, LPA observed residents during mealtime, reviewed residents files and typed interviews. There were no deficiencies observed during this visit. An exit interview was conducted with Natalie Carlborg, Executive Director, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced visit to initiate a case management visit. LPA Rodgers identified herself and was granted entry by Executive Director Natalie Carlborg and stated the purpose of the visit. The incident involved Resident #1 (R1) (see LIC 811 – Confidential Names List), who experienced an unwitnessed fall in R1’s room on October 18, 2025. R1 reported to staff that they may have fallen and complained of pain. Staff contacted emergency services, and R1 was transported to the emergency department, where they were diagnosed with a broken femur. R1 subsequently underwent surgery on October 19, 2025. R1’s responsible party and primary care physician were notified of the injury and the transport to the emergency department, in accordance with reporting requirements. Later in the day on October 18, 2025, staff were escorting Resident #2 (R2) to their room when R2 reported that they had been in an altercation with R1. Later that evening, R2 also reported conflicting details regarding the altercation; however, some of these claims were determined to be not plausible given R2’s condition and circumstances. Record review reveals that R2 had a recent medical diagnosis involving an infection. The Department reviewed the physician reports for both R1 and R2, which confirmed that both residents have a diagnosis of dementia. During today’s visit, Licensing Program Analyst (LPA) Rodgers interviewed staff, toured the facility, and requested and obtained documents relevant to the incident. LPA informed (ED) Carlborg that additional follow-up via telephone or in-person visits may be necessary. No deficiency were noted or cited during the visit. An exit interview was conducted with ED Carlborg. A copy of this report, the LIC 811, and the Licensee Appeal Rights (LIC 9058) were provided at the conclusion of the visit. The signature below confirms receipt of these documents..

emergencies, including the use of on-call staff and agency personnel when necessary. The facility maintains documentation of initial and ongoing training, including topics such as resident rights, supervision, and behavioral management. Staff interviewed demonstrated knowledge of their responsibilities and resident care needs. LPA interviewed three (3) residents, none of whom reported feeling unsafe or unsupervised. Residents stated that staff are generally available and responsive. No residents reported being bothered by others due to a lack of supervision. LPA interviewed three (2) outside sources, none of whom reported feeling unsafe or unsupervised. Residents stated that staff are generally available and responsive. No outside sources reported their loved ones being bothered by others due to a lack of supervision. During the visit, LPA observed staff actively supervising residents in common areas. No incidents of resident-to-resident conflict were observed, and residents interviewed did not report concerns about supervision. On 12/6/23, it was alleged that staff are not assisting residents with eating. LPA interviewed [#] staff members, all of whom stated that residents who require assistance with eating are identified in their care plans and are assisted during meals. Staff demonstrated knowledge of residents’ dietary needs and assistance levels. Training records reviewed confirmed that staff received instruction on providing assistance with activities of daily living, including eating, as required LPA interviewed three (3) residents, including those identified as needing assistance with eating. Residents reported that staff are available during meals and provide help when needed. No residents expressed concerns about being neglected or not receiving assistance during mealtimes. LPA interviewed two (2) outside sources that reported there are staff available during meals and provide help when needed. No outside sources expressed concerns about their loved ones not receiving assistance during meal times. LPA observed staff assisting residents in a timely and respectful manner. Residents were seated comfortably, and staff were seen offering verbal prompts, physical assistance, and monitoring residents as appropriate. No concerns were noted during the observation period. The Department has investigated a complaint with the above allegation. The Department has found that although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted with the Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

LIC9099C 2 of 3 The facility maintains a posted schedule that meets or exceeds the minimum staffing requirements based on the number and needs of residents. Resident care logs reflected timely assistance with activities of daily living (ADLs), medication administration, and supervision. Staff 1 (S1) confirmed that staffing levels are reviewed weekly and adjusted based on resident acuity and census changes. Staff 2 (S2) reported that staffing is sufficient to meet resident needs and that additional support is brought in when needed. Staff 3 (S3) stated that medication passes and care routines are completed on time and without delay due to staffing. Resident 1 and 2: Reported that staff are available when needed and provide timely assistance with personal care and supervision. Outside source 1 (OS1) and Outside source 2 (OS2): Expressed satisfaction with the level of care and stated that staff are responsive and attentive. LPA observations during the visit, staff were observed assisting residents promptly, engaging in supervision, and maintaining a calm and organized environment. No signs of resident neglect, delayed care, or under staffing were observed. On 12/05/2023, the department received a complaint alleging Staff did not ensure the resident was assisted in getting dressed. Record review of R1's appraisal/Needs and Services Plan indicated the need for assistance with dressing due to limited mobility. Daily care logs for the past 30 days documented consistent assistance with dressing during morning care routines. No incident reports or complaints were documented regarding refusal or failure to assist with dressing. S1 confirmed that R1 requires and receives assistance with dressing daily. Staff are assigned specific ADL tasks during each shift. S2 reported that they assist R1 each morning and that the resident is cooperative and appreciative of the help.S3 stated that the resident is always dressed appropriately and has not expressed concerns about lack of assistance. 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 LIC9099C 4 of 4 OS1 and OS2 confirmed that staff help them get dressed every morning and that they are satisfied with the care provided. OS1 and OS2 reported no concerns and stated that the resident is always well-groomed and appropriately dressed during visits. LPA observed residents to be clean, well-groomed, and appropriately dressed at the time of the visit. Staff were observed assisting other residents with Activities of Daily Living (ADLs) in a respectful and timely manner. On 12/05/2023, the department received a complaint alleging resident was left in soiled clothing for an extended period of time. Record Review of R1's Appraisal/Needs and Services Plan indicated the need for assistance with toileting and hygiene due to limited mobility. Daily care logs documented routine checks and assistance with toileting and clothing changes, including overnight care. No incident reports or internal documentation indicated that the resident was left in soiled clothing or experienced skin breakdown due to neglect. S1 stated that staff are assigned to conduct regular incontinence checks and assist residents with hygiene as needed, including during night shifts. S2 reported that R1 was checked every two hours and changed promptly when needed. No delays in care were reported. S3 confirmed that the resident has not had any skin issues or hygiene related complaints. OS1 and OS2 denied being left in soiled clothing and stated that staff respond quickly when assistance is needed. OS1 and OS2 reported no concerns about hygiene or care and stated that the resident is always clean and well cared for during visits. LPA observed residents to be clean, well-groomed, and appropriately dressed at the time of the visit. Staff were observed assisting other residents with toileting and hygiene in a timely and respectful manner. The Department has investigated a complaint with the above allegations. The Department has found that although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations are unsubstantiated . An exit interview was conducted with the Executive Director,  to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099) ( Page 2 of 3) It was alleged that staff did not meet the incontinence care needs of residents. More specifically, the Reporting Party (RP) reported that during the night, they found seven residents double diapered and very wet when providing incontinence care. RP stated that despite reporting this to management, the issue persisted. Staff interviews revealed that incontinence care was provided per schedule and that double-diapering was not a standard practice. Resident interviews revealed no concerns regarding incontinence care. Records review revealed that incontinence care schedules and staffing assignments were consistent with regulatory requirements. The Department’s observations revealed that residents were not observed in soiled or double-diapered conditions during visits conducted around the time of the allegation. It was further alleged that staff did not meet residents’ bathing needs. More specifically, RP stated that staff were not assisting residents with showers. Staff interviews revealed that showers were being provided according to the facility’s schedule. Resident interviews revealed no concerns regarding bathing assistance. Records review revealed that shower schedules and hygiene documentation were consistent with regular bathing practices. The Department’s observations revealed that residents appeared clean and well-groomed during visits conducted around the time of the allegation. It was further alleged that staff did not ensure residents had clean linens. More specifically, it was alleged that management instructed staff not to change soiled linens for two to three days due to excessive laundry. Staff interviews revealed that while one staff member reported delays in linen changes due to laundry volume, no staff confirmed that this was a directive from management. Resident interviews revealed no concerns regarding the cleanliness of their bedding. Records review revealed that laundry schedules and linen inventory logs for July 2023 did not reflect any service delays. The Department’s observations revealed that resident beds had clean linens with no visible soiling or odors during visits conducted around the time of the allegation. (Continued on LIC9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC9099C) (Page 3 of 3) It was further alleged that there was insufficient staff to meet the care needs of residents. More specifically, RP stated that the facility was understaffed, particularly during the night shift, resulting in unmet care needs, including management of behavioral issues. Staff interviews revealed that while there were occasional challenges during shift transitions, particularly between evening and night shifts, these were temporary and did not result in unmet care needs. Staff also reported that management was responsive and made adjustments when necessary. Resident interviews revealed no reports of unmet care needs or delays in receiving assistance. Records review revealed that staffing schedules for the relevant timeframes were consistent with the facility’s Plan of Operation and regulatory staffing requirements. The Department’s observations revealed that staff were present and engaged with residents, and no immediate health or safety concerns were noted during visits conducted around the time of the allegation. Based on interviews, direct Department observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegations are determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Natalie Carlborg , to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

(LIC9099C 2 of 6) Interview with Staff 1 (S1) confirmed that the resident was receiving appropriate care and supervision in accordance with their care plan. Staff responded immediately when the resident was found unresponsive and contacted emergency services. Interview with Staff 2 (S2) described the events leading up to the incident and confirmed that the resident had not expressed any new complaints or symptoms prior to the event. Interview with Staff 3 (S3) verified that all medications were administered as prescribed and that the resident’s condition was stable during the days leading up to the incident. Interview with Outside source 1 (OS1) stated they were satisfied with the care provided and had no concerns about staff attentiveness or neglect. Confirmed that the resident’s death was consistent with their known medical conditions and not indicative of neglect. LPA observed the facility appeared clean, organized, and appropriately staffed at the time of the visit. Staff were observed following care protocols and referencing resident care plans during shift transitions. On 07/05/2023, the department received a complaint alleging that medication was not given as prescribed. LPA reviewed R2’s physician orders dated included prescriptions for R2's medical needs. The Medication Administration Records (MARs) for the past 30 days showed consistent documentation of medication administration with no missed doses or discrepancies. Centrally stored medication logs were complete and matched the medications on hand. Interview with S1 confirmed that all staff responsible for medication administration are trained and certified. Stated that MARs are reviewed weekly for accuracy. Interview with S2 demonstrated knowledge of Resident 1’s medication regimen and described the facility’s double-check system for medication passes. Interview with S3 reported no issues with medication refusals or errors for R2. Outside Source 1 (OS1) stated they receive their medications daily and have not experienced any missed doses. Responsible Party: Reported no concerns regarding medication administration and confirmed that the resident’s health has been stable. LPA observed medications were observed to be properly labeled, stored in a locked cabinet, and organized by resident. Staff were observed following proper procedures during a medication pass, including verifying the resident, medication, dosage, and time. 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 LIC9099C 3 of 6 On 07/05/2023, the department received a complaint alleging improper transfer resulting in injury. Record review R5’s Appraisal/Needs and Services Plan indicated the need for two-person assist with transfers and use of a gait belt. There was no Unusual Incident/Injury Report due to no fall was reported. The report indicated no fall occurred and that the transfer was completed per protocol. Interview with S1 confirmed that staff involved in the transfer were trained and certified in proper transfer techniques. Interview with S2  stated they use a gait belt and followed the two person assist protocol. They denied any deviation from the resident’s care plan. Interview with S3 reported that the resident was assessed immediately after the complaint of pain and that the responsible party and physician were notified. Interview with OS2 reported being notified promptly and expressed no concerns about the staff’s handling of the situation. LPA observed staff were observed assisting another resident using proper body mechanics and transfer techniques, including the use of gait belts and verbal cues. Transfer equipment (e.g., gait belts, walkers) was available and in good condition. On 07/05/2023, the department received a complaint alleging the facility retained a resident against their will. Review of R5’s Admission Agreement and Needs and Services Plan did not include any legal restrictions or conservatorship limiting their ability to leave the facility. No documentation was found indicating that the resident was placed on any form of hold or restriction. The facility’s Resident Rights Policy clearly states that residents may leave the facility voluntarily unless medically or legally restricted. Interview with S1 stated that R5 has not expressed a desire to leave the facility. Interview with S2 confirmed that the resident was not physically or verbally restrained and that staff only encouraged the resident to wait until a responsible party could be contacted. Interview with S3 reported that the resident was calm and cooperative and that no intervention was required. OS2 stated there has not been any signs or symptoms of R5 expressing they are being kept against their will. OS2 confirmed they are always contacted by the facility when there are changes in R5's behavior and appreciated that staff ensured the resident’s safety while respecting their rights. LPA observed Facility posted Resident Rights in a visible location, including the right to leave the facility voluntarily. No signs of restraint, isolation, or coercion were observed during the visit. 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 LIC9099C 4 of 6 On 07/05/2023, the department received a complaint alleging staff does not have medication training. Records Reviewed of staff training files reviewed for five staff members responsible for medication assistance included: Certificates of completion for initial 6-hour medication training. Documentation of 8 hours of annual medication training. Competency assessments signed by a qualified professional Training logs were current and matched the staff schedules for medication administration. S1 confirmed that all staff who assist with medications have completed the required training and are monitored for ongoing compliance. S2 provided a copy of their training certificate and described the procedures followed during medication passes. S3 confirmed they do not assist with medications and are aware of the facility’s policy regarding medication handling. LPA observed staff administering medications using proper procedures, including: Verifying resident identity, checking medication labels and MARs. Documenting administration immediately after delivery. Medications were stored securely and labeled appropriately. On 07/05/2023, the department received a complaint alleging that staff drank alcohol while on duty. Records Reviewed of staff personnel files included signed Code of Conduct and Drug-Free Workplace Policy agreements. There were no disciplinary actions, incident reports, or documentation indicated staff impairment or alcohol use while on duty. The Facility policy strictly prohibits the use of alcohol or controlled substances during work hours. S1 denied any knowledge of staff consuming alcohol on duty and confirmed that all staff are trained on the facility’s substance use policy. S2 denied the allegation and stated that alcohol is not permitted on the premises. Both appeared alert and professional during the visit. S3 confirmed that staff are subject to disciplinary action and possible termination if found under the influence while working. R5 and R5 reported no concerns about staff behavior or professionalism. Both stated that staff are attentive and respectful. OS1 expressed satisfaction with the care provided and stated they had never observed or been informed of any inappropriate staff conduct. 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 LIC9099C 5 of 6 During unannounced visits, staff were observed performing duties appropriately, with no signs of impairment. No alcohol or related paraphernalia was observed in staff areas or common spaces. On 07/05/2023, the department received a complaint alleging that staff used drugs while on duty. Records Reviewed of staff personnel files included signed Code of Conduct and Drug-Free Workplace Policy agreements. No disciplinary actions, incident reports, or documentation indicated staff impairment or alcohol use while on duty. Facility policy strictly prohibits the use of alcohol or controlled substances during work hours. S1 denied any knowledge of staff consuming drugs on duty and confirmed that all staff are trained on the facility’s substance use policy. S2 denied the allegation and stated that alcohol is not permitted on the premises. Both appeared alert and professional during the visit. S3 confirmed that staff are subject to disciplinary action and possible termination if found under the influence while working. R5 and R6: Reported no concerns about staff behavior or professionalism. Both stated that staff are attentive and respectful. OS2 expressed satisfaction with the care provided and stated they had never observed or been informed of any inappropriate staff conduct. During unannounced visits, staff were observed performing duties appropriately, with no signs of impairment. No drug or related paraphernalia was observed in staff areas or common spaces. On 07/05/2023, the department received a complaint alleging that staff did not provide residents with medical treatment. Resident records reviewed for five randomly selected residents showed documentation of timely physician visits, medication administration, and follow-up care. Incident reports and progress notes reflected appropriate staff response to changes in condition, including contacting physicians and responsible parties. No documentation indicated delays or refusals to provide medical treatment. 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 LIC9099C 6 of 6 On 07/05/2023, the department received a complaint alleging that staff did not provide residents with medical treatment. Resident records reviewed for five randomly selected residents showed documentation of timely physician visits, medication administration,

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management Visit.  LPA was greeted by and met with Resident Care Coordinator, Lima Taiti to discuss the purpose of the visit. Today's visit is in response to a complaint that was unrelated to the facility. LPA briefly interviewed staff and conducted a brief records review. An exit interview was conducted with Resident Care Coordinator, Lima Taiti, who was provided with a copy of this report. Their signature confirms receipt of these documents.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg, Executive Director. According to the facility’s license, the facility has a maximum capacity of sixty four (64) clients, all of whom must be ambulatory. During today’s inspection, there were a total of fifty six (56) clients in care. Age range 60 and over, 56 non-ambulatory, of which 15 may be bedridden. Hospice waiver for 15. Approved delayed egress/secured perimeter LPA Domingo, accompanied by Executive Director, Natalie Carlborg, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 72 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 118 F, Bathroom #1 sink was 110 F, and Bathroom #2 sink was 110 F. Refrigerator temperature was 34 F and freezer temperature was -3 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed/observed staff and residents. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Natalie Carlborg, Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

(Continue from LIC9099) Interviews revealed staff did not let the residents stay in a soiled brief, and staff will provide incontinence care as needed. LPA observations revealed a sufficient amount of incontinence products in the facility. LPA also observed that the facility was not malodorous of urine or feces. LPA Domingo did not observe any residents during the visit who needed incontinence care. It was alleged that staff did not meet residents' food service needs. Interviews revealed that the staff assist residents with meals as needed and when the residents' service plans stated that there is a need to assist the residents during meals. The residents have meals in the room when requested. Records reviewed that R1 was independent with meals. R1 was able to push the meal tray and move the tray on their own. Records reviewed showed meals were provided and delivered to R1's room upon request. The resident was admitted on October 16, 2024, and previously resided at the family residence. On November 13, 2024, a Safety/Wellness check, police came, and they did not file a report, nor were there any findings that R1 needed any assistance. The resident moved out of the facility on November 15, 2024, per family request, and no known address was shared with the facility. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements, and the information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated . An exit interview was conducted, and a copy of this report, along with Licensee Rights (LIC 9058 03/22), was provided to Natalie Carlborg, Executive Director whose signature below confirms receipt of these rights.

(Continued form 9099) Although the reported party stated they observed residents who needed a higher level of care, residents with incontinence needs not being met, and very low staffing; outside sources, resident interviews and residents’ family members stated they felt their needs were being met. Staff interviews indicated that there are enough staff to meet the needs of the residents. A review of the schedule for the entire month of November and December 2024 also revealed the facility was adequately staff. A facility tour did not corroborate the insufficient staffing, residents were observed being assisted by care staff as appropriate on three (3) separate visits. Staff interviews also confirmed the practice of changing and toileting residents every two (2) hours. Records review as well as interviews with the licensee, staff, and medical personnel, were conducted and revealed that although some residents required more incontinence and toileting care, there wasn’t any documentation of concern for neglect, abuse, or non-accidental injuries were noted. A review of resident records that were assessed at a high level revealed residents were assisted by direct care staff as well as receiving assistance from outside sources, and no concerns were noted. Reporting party further stated they observed some of the residents rooms are unclean and unkempt along with the building in disrepair. Resident family interviews and LPA observations reveal residents’ clothes are cleaned and laundered several times a week. Additionally, staff interviews corroborated that the few residents who require it get their sheets laundered daily. Staff interviews revealed that the hallways, common area both inside and out are cleaned in a scheduled manner and as needed. Outside sources who frequent the facility were interviewed and they state resident rooms are mostly free from malodors and when concerns are addressed to the staff, the staff respond in an appropriate manner to address the malodors. A facility tour on three (3) separate visits did not corroborate the unclean or unkempt rooms or the building was in disrepair. The Department has investigated the above-mentioned allegation and based on observations, interviews conducted, and records reviewed there was insufficient evidence to support that the licensee did not provide sufficient staff to meet residents needs and licensee did not maintain a clean facility. Therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Natalie Carlborg to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Continued from LIC9099 Staff 1 (S1), (Please see confidential names on LIC811), was interviewed and verified that there were no residents given injectable medications at the facility.  S1 clarified that there was a conversation of oral medications that could possibly be given to hospice residents when they were unable to swallow crushed medications. S1 clarified that it was only a topic of conversation and there were no staff members asking medication technologists to administer any injectable medications to any residents at the facility. S1 clarified again that the topic of conversation was not injectable medication. Documents were collected which revealed the facility was not providing any residents injectable medications. Staff 2 (S2) provided documentation that the facility is not currently or has not in the past administered injectable medications to any residents.  The facility policy was reviewed and only licensed nurses or physicians are authorized to give residents injectable medications. The Department investigated the above allegation and was not able to meet the preponderance of evidence standard to prove that the alleged violation occurred. Therefore, the above allegation is unsubstantiated. An exit interview was conducted with Natalie Carlborg Executive Director, and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg, Executive Director. Today’s visit was in response to an incident which licensee self reported via an LIC624 Incident Report. On 11/8/24 the facility reported an AWOL of Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1). R1 was found uninjured, the family was notified, law enforcement also was notified all in timely manner. The staff followed the facility elopement/AWOL protocol and R1 is being evaluated for appropriate placement at the current facility. LPA briefly toured the facility, performed a welfare check on residents in care, interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22)  were left with the Executive Director, whose signature on this form confirms receipt of these documents.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg Executive Director. Today’s visit was in response to an incident which licensee self reported via an LIC624 Incident Report. The report described Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1)… LPA Domingo interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22)  were left with the Executive Director, whose signature on this form confirms receipt of these documents.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Suzette Johnson. According to the facility’s license, the facility has a maximum capacity of sixty four (64) clients, all of whom must be ambulatory. During today’s inspection, there were a total of fifty six (56) clients in care. Age range 60 and over, 56 non-ambulatory, of which 15 may be bedridden. Hospice waiver for 15. Approved delayed egress/secured perimeter LPA Domingo, accompanied by Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 72 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 118 F, Bathroom #1 sink was 110 F, and Bathroom #2 sink was 110 F. Refrigerator temperature was 34 F and freezer temperature was -3 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed/observed staff and residents. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Suzette Johnson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Suzette Johnson, Executive Director. Today's visit was in response to a self reported incident to the San Diego Regional Office on 09/12/2023 LPA briefly toured the facility and collected pertinent records. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Suzette Johnson, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Iby Strong made an unannounced visit to conduct a Health and Safety visit. LPA identified herself and disclosed the purpose of her visit. LPA met with R esident Service Director LaTasha Gates and discussed the purpose of the visit. Executive Director Suzette Johnson arrived shortly after. During the visit, LPA Strong toured the facility. On today's visit no deficiencies were cited. An exit interview was conducted and a copy of Licensee's Rights (LIC 9058 03/22) along with a copy of this report was provided to Executive Director Suzette Johnson.

Licensing Program Analyst (LPA) Marisela Garcia-Centeno made a Case Management visit to follow-up on an incident report. LPA identified herself and was granted entry by Nia Colman, Receptionist. LPA stated the purpose of the visit with Natalie Carlborg, Acting Executive Director. A Incident Report was received by Community Care Licensing (CCL) on August 8, 2023, informing that Resident #1 (R1) [staff was provided an LIC 811 that identifies the resident] sustained multiple injuries of unknown source. During today's visit, LPA Garcia-Centeno conducted a health and safety check and collected R1's records. No health and safety violations were observed during the today's visit. An exit interview was conducted with Acting Executive Director, Carlsborg to whom a copy of this report, and LIC811 Confidential Names report and the appeal rights (LIC9058 01/16), were provided at the end of the visit.