Mesaview Senior Assisted Living.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Rodgers was welcomed by, identified herself to, and discussed the purpose of the visit with Genovea Guerrero. According to the facility’s license, the facility has a maximum capacity of forty (40) residents, ages 60 years and over, all of whom may be non-ambulatory and five (5) of whom may be bedridden. A hospice waiver for eight (8) residents has been approved. LPA, accompanied by licensee’s staff, 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. 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 and hot water temperature at taps accessible to clients were all compliant. 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. 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. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. No Citations were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Guerrero, to whom a copy of this report were provided during the visit.

(Continued from LIC9099) R1, was wheelchair-bound, required total assistance for all activities of daily living, followed a pureed diet, exhibited behavioral disturbances, and had a catheter in place incrementally. R1 was also was transported daily to a healthcare facility for insulin care. Department review of email correspondence reveals on June 6, 2025 the facility reported observing blood drops from the R1's genital area during a brief change and notified R1's clinic. On June 17, 2025, the facility emailed the clinic reporting a skin tear near the catheter site. The clinic responded with instructions to clean the area, adjust the catheter securement device to reduce tension, and monitor the resident, noting that the resident was on blood thinners. Department review of the facility’s Unusual Incident/Injury Report dated June 24, 2025, revealed on June 24, 2025, the resident attended a routine appointment at R1's clinic, the facility documented receiving a call from the clinic nurse stating that trauma related to the catheter was observed and the resident was sent to the hospital for further evaluation. Department review of hospital records dated June 24, 2025, revealed the resident was examined for a genital injury and diagnosed with erosion of the urethra related to catheter use. The documentation does not reference external trauma or abuse. Department review of Training Log dated, 05/29/2024 revealed staff had training on Skin care and pressure ulcer training and staff also received instruction on proper catheter care procedures and communication protocols to ensure compliance with care standards. Facility records show staff communicated with clinic and family regarding catheter care, followed instructions provided, and reported the incident to CCLD as required. Based on interviews and document review a preponderance of evidence does not exist to support the allegation that staff abused a resident resulting in serious bodily injury. The allegation is therefore unsubstantiated. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Genoveva Guerrero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Amy Rodgers conducted a case management - Licensee Initiated visit regarding Resident #1, who is presenting as a fall risk.LPA was greeted by, identified himself to, and discussed the purpose of the visit with Genoveva Guerrero. LPA A. Rodgers discussed fall prevention strategies and reviewed the resident’s current care plan to ensure appropriate interventions are in place. Recommendations included: Assessment Review: Confirm that the resident’s fall risk assessment is current and accurately reflects their condition. Environmental Safety: Ensure clear walkways, adequate lighting, and removal of tripping hazards in the resident’s living area. Assistive Devices: Verify that the resident has access to and is using appropriate assistive devices (e.g., walker, grab bars). Staff Monitoring: Reinforce staff awareness and monitoring protocols, especially during transfers and ambulation. Care Plan Updates: Incorporate fall prevention measures into the resident’s care plan and communicate changes to all staff. An exit interview was conducted with Administrator Genoveva Guerrero and a copy of this report along with Licensee/Appeal Rights (LIC 9058) was provided at the conclusion of the visit.

Continued from LIC9099 Staff also reported assisting the resident with grooming and dressing daily. Records review of the resident’s care plan confirmed that hygiene assistance is part of the resident’s individualized care plan. Bathing logs and staff notes documented regular hygiene care. LPA interviewed three (3) residents, Resident 2 stated, staff help me with showers and getting dressed. They’re respectful and come when I ask. Other residents interviewed also reported receiving hygiene assistance as needed and expressed satisfaction with the care provided. LPA interviewed three (3) outside sources who reported that the residents appear well cared for and that staff communicate effectively regarding the resident’s condition and needs. No concerns were raised about the facility’s ability to meet the resident’s needs. During the visit, LPA observed residents to be clean, appropriately dressed, and well-groomed. No odors or signs of neglect were noted. Staff were observed assisting residents in a timely and respectful manner. 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 Ileana Castro Assistant Manager, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099) It was alleged that staff did not prevent residents from engaging in inappropriate behaviors and were not providing a comfortable environment for resident #1(R1). More specifically, R1 reported during an interview that they feel people at the facility are threatening them and that they feel uncomfortable due to weird looks.  Physician’s Report dated March 31, 2025, states (R1) is diagnosed with schizophrenia with a history auditory hallucinations. R1 has been a client at the facility since June 30, 2023. Interviews with the reporting party confirm that R1 frequents a day program and has been observed reacting to feelings of being watched and becoming upset when they perceive others are not friendly toward them. They further noted R1 has a cognitive impairment and a history of misinterpreting social interactions The Long term care ombudsman interview revealed they are not aware of any incidents involving threats or mistreatment at the facility and expressed no current concerns regarding R1’s safety. Interviews with R1 denied any physical contact and stated others at the facility made them feel uncomfortable. Interviews with staff deny that residents threaten each other. It was also alleged that s taff did not safeguard R1's personal belongings. More specifically, R1 reported during an interview that someone stole clothes a few years ago at the facility. Multiple residents and staff interviews were conducted. The interviews reveal they have no concerns with items missing from residents' rooms. Multiple staff and client interviews also reveal they have no concerns over theft in the facility. Based on interviews and observations a preponderance of evidence does not exist to support the above allegations. The allegations is therefore unsubstantiated. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Rodgers was welcomed by, identified herself to, and discussed the purpose of the visit with Genovea Guerrero. According to the facility’s license, the facility has a maximum capacity of thirty (30) residents, ages 60 years and over, all of whom may be non-ambulatory and five (5) of whom may be bedridden. A hospice waiver for eight (8) residents has been approved. LPA, accompanied by licensee’s staff, 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. 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 and hot water temperature at taps accessible to clients were all compliant. 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. 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. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. No Citations were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Guerrero, to whom a copy of this report were provided during the visit.

(Continued from LIC9099) During the investigation, interviews were conducted with multiple residents and staff. The interviews reveal they have no concerns with items missing from residents rooms. Multiple staff and client interviews also reveal they have no concerns over theft in the facility. Interviews with Administrator reveal belongings of any value are kept in a basket in a locked cabinet, accessible to residents upon request. Interview with R1 reveals they cannot confirm timelines nor did they mention any staff or other residents taking items, only that the two items were not in their possession. Based on interviews and observations a preponderance of evidence does not exist to support the allegation that staff did not safeguard resident’s belongings. The allegation is therefore unsubstantiated. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced collateral visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Genoveva Guerrero, Administrator. This visit is to Amend a visit with Resident 1. The administrator informed LPA that the Resident was currently out in the community. LPA Domingo thanked the administrator for her time and did not conduct a tour or any interviews at this time. 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 Genovea Guerrero. According to the facility’s license, the facility has a maximum capacity of thirty (30) residents. During today’s inspection, there were a total of twenty nine (29) residents in care. The facility is licensed to serve 30 residents, ages 60 years and over, all of whom may be non-ambulatory and five (5) of whom may be bedridden. A hospice waiver for eight (8) residents has been approved. The facility currently has six (6) resident receiving hospice care. LPA, accompanied by licensee’s staff, 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 71 degrees F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 113 degrees F, Bathroom #1 sink was 113 degrees F, and Bathroom #2 sink was 113 degrees F. Refrigerator temperature was 40 F and freezer temperature was -2 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 licensee's staff, 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 multiple staff and clients. 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 Genoveva Guerrero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Outside source interviews revealed R1 reported they are drinking 3 oz of water daily. The outside source confirmed R1 was forgetful due to their medical condition but able to determine if they drank water, just not the accurate amounts. The facility’s Hydration Log dated 09/21/20 through 10/07/20 confirmed R1 was drinking water, coffee, milk and refusing fluids on multiple occasions. Staff interviews confirmed R1 was offered water multiple times a day but refused at times and requested milk or coffee. Further staff interviews revealed two (2) bottles of water were kept on R1’s night stand next to their bed and R1 was capable of drinking on their own. It was also alleged staff are retaliating against R1. It was reported staff are calling 911 for R1, which was unnecessary and costly, and not allowing visitation. Outside source interviews revealed it’s costly when the facility contacts 911 for R1. Outside sources also indicated they believe it was unnecessary and the facility was purposely contacting 911 so that R1 will incur costs. Staff interviews showed its facility policy if a resident complains of pain, hits their head and/or does not look well, they ensure the resident receives timely medical attention. On 09/28/20, R1 reported to staff they were not feeling well and very weak. Staff observed R1 was having difficulty bearing weight, so they had R1 sit down under the covered patio area and offered R1 a cup of water. The staff also recorded a video of R1 appearing lethargic and encouraging R1 to drink water. The facility provided R1’s responsible party with the video to show R1 was not well and required medical attention. Staff interviews revealed R1’s responsible party did not agree R1 required medical attention after reviewing the video. Outside source interviews identified R1’s responsible party believed staff should have placed R1 in an air-conditioned room and provided R1 with water, instead of contacting 911. Staff interviews confirmed R1 was in an air-conditioned room for many hours and provided water. Staff felt it necessary to send R1 out for evaluation as a precaution and ensure they meet R1’s needs. R1 was diagnosed at the hospital with dehydration. Therefore, the medical visit was necessary and not for retaliation purposes. Facility visitations were restricted during Covid-19 Pandemic. The facility had a visitation area that was enclosed, which allowed for only one (1) resident to visit their visitor at a time. A visitor came to visit R1 but R1 refused the visit. Also, one evening a visitor was visiting a resident when another visitor wanted to visit with another resident. However, the covid 19 restrictions for the facility allowed only one (1) visitor, which upset the other visitor. The visitor was not told they cannot visit, just needed to wait their turn. The facility followed Covid-19 visitation requirements. Continued on an 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 During the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and 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) were provided to Assistant Manager, Ileana Castro whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]

Multiple staff members were interviewed to ascertain the accuracy of the allegations. All staff members denied any knowledge of the facility failing to provide medications or meals to the resident. They confirmed that the facility has protocols in place to ensure medication administration and meal provision. Medication Administration Records: The resident's medication administration records were reviewed. The records indicated that medications were consistently administered as prescribed, with no documented issues or missed doses. The facility's environment was observed during the investigation. It was noted that the facility had a medication cart, indicating the availability of medications for residents. The dining area was also observed to be clean and well-maintained, with staff actively serving meals to residents. Based on the interviews conducted, review of medical records, and observation of the facility, the allegations that the facility failed to provide medications and meals to the resident were found to be Unsubstantiated. The resident confirmed receiving medications as prescribed and the resident received all scheduled meals and snacks, with no documented instances of missed meals.  A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Ileana Castro Vazquez, Assistant Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Assistant Manager and her signature on this report confirms receipt of the Licensee Rights.