Montera, the.

(Continued from LIC9099) Regarding the allegation staff mishandled a resident’s medication. More specifically, the reporting party (RP) alleged that staff brought two medication pills to the Resident #1(R1) instead of one. Department staff interviews revealed staff described following EMAR procedures and stated they administer medications according to the physician’s order and documented schedule. Staff #1(S1) denies a medication error around the time of the alleged error. Department records review revealed R1's physician’s orders reflecting the resident’s prescribed regimen. EMAR documentation was also reviewed for dates surrounding November 21, 2025 and no documented medication error was noted. Department LPA observations revealed medication carts were organized and medications were stored appropriately at the time of visit. LPA also revealed EMAR system was accessible, functioning and medication for R1 has been documented by staff. Regarding the allegation that staff did not follow infection control requirements. More specifically, RP alleged that Staff #1(S1) used a tissue and needed direction to wash their hands from the RP. Department staff interviews revealed multiple staff consistently reported they wash their hands before and after medication assistance, they discard tissues immediately after use, they wash their hands often and Staff reported they had not observed coworkers keeping tissues on their body in an way that may cause infection control issues. Department outside source interview revealed multiple witness to infection control practices by staff members. Department records review revealed Facility Infection Control Policy and staff training records confirming annual and task specific infection control training. LPA observations revealed staff observed performing hand hygiene and using gloves appropriately during the LPA visits and PPE supplies available and accessible. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, both allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Karinna Topete, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058, 03/22) were provided.

(Continued from Lic9099) Staff interviews revealed that the caregiver was positioned near the bathroom shower, consistent with the resident’s care plan and facility protocols. The caregiver responded when called for assistance. Staff interviews reveal medical care following the incident was provided. Resident #1(R1) interview confirmed that the caregiver was present and responded, and that they were medically evaluated and received medical assistance following the incident. Records review of service plan (dated 1/14/2025), showed that the facility was providing care consistent with the resident’s plan. Further review of documentation revealed R1 received a medical evaluation after incident. Interview with an outside source indicated no concerns with the health and safety of the resident and an understanding of the facility’s policies regarding care and supervision. LPA observations confirmed the studio layout supports caregiver proximity and that the resident was ambulatory and not in distress. 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 allegations are UNSUBSTANTIATED. An exit interview was conducted with Operations Specialist Turner, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

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 concierge Jacqueline Aceves.  LPA Rodgers stated the purpose of the visit and reviewed the basic elements of the visit with Associate Executive Director Aileen Spence. This visit is in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on November 21, 2025.  The IR stated that there was an incident that transpired on Monday, November 17, 2025, with resident #1 (R1 – see LIC811 for confidential names list) who eloped from the facility.  The facility made notifications to R1’s responsible party, their Medical Doctor (MD), and the Department. During today's visit LPA Rodgers briefly toured the facility, spoke with staff and R1, and requested and obtained relevant documents pertinent to this incident.  LPA Rodgers verified R1 eloped from the facility, but staff found R1 within about 10 minutes from notification that R1 was absent without leave (AWOL).  Records showed that a wander guard (exit alert pendant) was placed on R1 on 11/17/2025, the same day of AWOL.  R1 responsible person was present while wander guard was presented to R1. (Continued on LIC809C) 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 LIC809) R1’s service plan was updated on 11/17/2025.  Preplacement Appraisal did not indicate R1 had issues with elopement prior to admission.   According to interviews R1 has never attempted to leave the facility.   The incident on 11/17/2025 was R1’s first AWOL from the facility since their move to the facility.   R1’s Elopement Plan states that if a resident, such as R1, is not found within the initial sweep of the community and immediate surrounding area, notifications should be made to the local police, residents’ physician and responsible party.    In review of the procedure and staff interviewed, the facility’s elopement procedure was followed. No deficiencies were cited during today’s visit. An exit interview was conducted with Associate Executive Director Aileen Spence, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided at the conclusion of the visit.  The signature below confirms that the documents were received.

(Continued form LIC9099) Regarding the allegation, the Staff are not following the resident’s admission agreement. More specifically, on two recent occasions, the resident was reportedly not checked as required, missed a scheduled medication, and did not receive assistance with food preparation due to staffing issues and shift changes. Staff interviews confirmed that Resident #1 has an individualized care plan in place and that staff are expected to follow it. Records reviewed did not indicate any medication errors, and staff schedules were provided for Department review. LPA observations during multiple unannounced visits confirmed that residents were supervised during activities and meals. Interviews with various outside sources revealed no concerns regarding staff adherence to residents’ admission agreements. This same allegation was previously investigated in March and April 2025 and found to be unsubstantiated. The Department re-evaluated the concerns during the current investigation. Regarding the allegation, Staff did not respond to the resident’s need for help in a timely manner. More specifically, it was reported that staff delayed in assisting a resident. Additionally, during a recent evening visit, the reporting party stated they waited over an hour while seeking help before the resident was assisted and put to bed. Staff interviews revealed that radios and cellphones are used to communicate and respond to resident needs. In the memory care unit, staff also heavily rely on consistent observation to monitor residents. Staff reported they were attending to other residents at the time and denied any delays. Former Executive Director Allen stated that response times are prioritized and monitored according to protocol. Interviews with outside sources, including evening visitors, revealed no concerns about staff responsiveness. A review of records showed no documentation of delays or complaints on the date in question. A records review of staffing, specifically the memory care unit, revealed the licensee operate the facility in accordance with the terms specified in the plan of operation. LPA observations during multiple unannounced visits confirmed that staff responded promptly to residents’ needs. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Associate Executive Director Aileen Spence, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099) On 11/13/2025, the Community Care Licensing Division (CCLD) received a complaint alleging that staff retaliated against a resident. More specifically, the reporting party submitted a letter from the Licensee corporate office. The letter addressed the residents’ family members history of filing complaints and included statements that the facility believed the resident’s family member actions were disruptive and misleading. The reporting party expressed concern that the letter was retaliatory and intimidating, particularly given the residents’ family member role in assisting other families with filing complaints. The department conducted interviews with residents and family members. Residents generally reported feeling comfortable communicating with staff and indicated that they are treated respectfully. While some noted that response times may vary depending on the situation, no significant concerns were raised regarding staff attentiveness or behavior. Family members interviewed did not report any issues related to intimidation or retaliation when seeking information or expressing concerns. Overall, both felt that the staff were responsive and supportive. No observations during the visit indicated any adverse interactions or inappropriate conduct by staff. The overall environment appeared calm, and residents were observed participating in daily activities. The letter issued by the facility was reviewed. It included language referencing the resident’s family member conduct and history of complaints. No documentation was found indicating that the resident’s care, services, or treatment had changed. 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 Operations Specialist Turner, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from Lic9099) The department conducted a Records Review and reviewed the email chain submitted by the RP, which was identical to the documentation submitted in prior complaints and was previously investigated in February and July 2025. No new incident or evidence was introduced. Based on records and interviews, the allegation that the Licensee failed to provide the responsible party with call button logs is UNFOUNDED, meaning it is false, could not have happened, and/or is without a reasonable basis. The Department has therefore dismissed this allegation. An exit interview was conducted with [Administrator/Designee Name], to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC9099) The Department’s interviews with R1 revealed that they experienced delayed pendant responses on multiple occasions, including a specific incident on October 12, 2025, during which they stated that staff did not respond for over 90 minutes. R1 also reported a retaliatory comment from a staff member. R1 further revealed they had requested Staff #1 not to be assigned to help them and one time R1 witnessed Staff #1(S1) in the hallway outside their room. The Department conducted a records review over a random 10-day period for the floor where Resident #1 (R1) resides as well as the R1's own call log. During this time, call logs showed average response times ranging from 10 to 13 minutes for the floor on which R1 resides. R1 activated their call light 81 times, with an individual average response time of 12.19 minutes. As part of the review, it was noted that on October 12, 2025, R1 requested assistance using the call light four times between 5:00 a.m. and 8:30 a.m., with an average response time of 14.25 minutes for those calls. The department also conducted Interviews with other residents on the same floor and they revealed very little concern with call response times , stating they occasionally will experience more delay in the morning, and they feel the delayed response may be due to the number of residents getting up at the same time and needing assistance . The department interviewed staff and they confirmed S1 is not assigned to the resident but may occasionally may be stationed or work outside the room of R1.  Staff also revealed that routinely , two caregivers are assigned to respond to R1 requests to ensure staff safety and accountability. The department interviewed multiple care staff, and they denied they made retaliatory comments to R1. Interviews conducted with other residents on the same floor as well as residents within the community revealed no concerns with staff behavior when they need assistance nor have they witnessed retaliatory comments from staff. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Operations Director Emily Turner, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced case management visit to conduct follow up regarding an incident. LPA was greeted by, identified herself to, and explained the purpose of the visit with Operation Specialties Emily Turner and Associate Executive Director Aileen Spence. On 11/16/2025, the Department received a self-report incident from the licensee that described an incident that occurred on 11/6/2025. The incident report described that Resident 1 (R1) had a fall in the common room, staff assessed resident and called 911. [General Manager provided with LIC811 Confidential Names List to identify R1] R1 was transported to the hospital, received medical treatment, and was returned the same day. During today’s visit, LPA observed residents in care, spoke with Operational Manager, and reviewed and obtained facility records. Additional visits may be necessary in regards to this incident. No deficiencies were cited on today’s date. An exit interview was conducted with Associate Executive Director Aileen Spence., whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).

Licensing Program Analyst (LPA's) Amy Rodgers and Amy Rodgers conducted an unannounced Case Management visit. Upon arrival, LPA introduced herself and explained the purpose of the visit to Operations Specialist(OS) Emily Turner and Aileen Spence. The visit was in response to Incident Reports submitted by the facility regarding a COVID-19 outbreak. During the visit During the visit, LPA Rodgers reviewed infection control procedures in detail due to the COVID outbreak. OS Turner has been working with the Department of Public Health since the onset of the outbreak. During today's visit clients were in isolation and and the LPA was advised all PPE was in place as well as notifications to residents and family. No violations were cited during today's visit. An exit interview was conducted with OS Turner 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 Collateral visit.  LPA was greeted by, identified herself to, and discussed the purpose of the visit with Aileen Spence, Associate Executive Director. During today's visit, LPA reviewed residents files and typed interviews. An exit interview was conducted with Aileen Spence, Associate 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. (Please note that LPA stepped out of the facility to have lunch and returned within an hour.)

(continued from LIC 9099) Although R1 has cognitive impairment, documentation showed that staff made reattempts to administer the medications, which R1 continued to refuse. Staff followed internal medication protocols and documented the refusals appropriately. There was no evidence that staff failed to administer medications as prescribed or disregarded resident refusals. Based on interviews 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 Noe Romero, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPAs), Ramin Hashemi and Amy Rodgers conducted an unannounced case management visit. LPA was greeted by, identified themselves to, and explained the purpose of the visit with Executive Director Cathy Allen. The facility self-reported an incident that occurred on September 26, 2025, involving two involving Resident #1 (R1) and Resident #2 (R2). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].. Additionally, The facility self-reported another incident that occurred on September 29, 2025, involving Staff #1 (S1) inappropriately confining Resident #3 to wheelchair. The facility discontinued S1's involvement in resident care. During today’s visit, LPAs briefly toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed staff and residents. There were no deficiencies cited during today's visit. However, these incidents may require further follow-up visits. An exit interview was conducted with Executive Director Cathy Allen, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to.

Licensing Program Analyst (LPA) Amy Rodgers conducted a Plan of Correction (POC) visit regarding a deficiency that was cited on 8/14/2025. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Director of Environmental Services Gerrit Hoevers. On 8/14/2025 LPA cited a deficiency due to the facility having a locked perimeter without fire clearance. A a plan of correction (POC) date of 8/15/2025 was implemented.. LPA briefly toured the perimeter fence surrounding building B and took photos. All permitter fences are no longer locked. The tour as well as photos were presented as proof of correction. The POC has been cleared. An exit interview was conducted with Director of Environmental Services Gerrit Hoevers to whom a copy of this report and the POC Clearance letter, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management discuss the purpose of delayed egress and locked perimeter and tour facility. LPA met with Executive Director Cathy Allen and informed them of the purpose of their visit. No citations were issued during today visit. An exit interview was conducted with Executive Director Allen to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to offer an Amended Report for a visit conducted on 7/16/2025. LPA met with Executive Director Cathy Allen and informed them of the purpose of their visit. During today's visit, LPA obtained Executive Director Allen's signature on the amended report LIC 9099D (8/4/2025). An exit interview was conducted with Executive Director Allen to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

LIC9099 2 of 4 On February 12, 2025, LPA Domingo observed a bulletin that informed the residents and family regarding a resident council meeting located near the lobby of the facility on a television screen. Outside Source 1 (OS1) was interviewed and they were aware of a resident council meeting. OS1 stated that there is a calendar that has the resident council meetings posted. OS1 stated that there are also bulletin boards with the date and time in the facility. During an interview with Outside Source 2 (OS2), they stated that they were aware of a resident council meeting. Outside source 3 (OS3) interviewed, and they were aware of a resident council meeting because they viewed the facility calendar, which has the resident council meeting posted. During an interview with Staff 1 (S1), S1 revealed that there were calendars with the resident council date and time of the meetings. Staff 2 (S2) was interviewed, and they stated that there is an appointed designated staff liaison responsible for aiding the resident council, and that is usually the activities director. S2 also stated that the resident council meetings were posted on the facility calendar, and there is a bulletin that has the resident council meetings. During an interview with Staff 3 (S3), they stated that there was a staff liaison for the resident council meetings but at times they are asked to step out of the meeting and the staff liaison steps out of the meeting out of respect but is readily available when the resident council requests any assistance. It was alleged that the facility did not assign a designated staff liaison to aid the family council. OS2 was interviewed and stated they were not sure of a designated staff liaison to aid with the resident council, but they do know that a staff member assists the resident council with a room to meet in and any supplies needed for the meeting. OS2 stated that they were sure the facility staff provided a room for the residents to meet, and that meant that the staff were the liaison. 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 4 Records were reviewed and Resident 1’s (R1’s) records were not updated with the resident council meetings that started on July 14, 2024. Records reviewed of three newly admitted residents, Resident 2 (R2), Resident 3 (R3), and Resident 4 (R4) and there was not any up dated information shared with the residents or their designee regarding the newly established family council meetings or of a designated staff liaison to aid the resident council. During an interview with Resident 2 (R2) and Resident 3 (R3) they stated that they were aware of the resident council meetings by word of mouth, but they were not aware of any information by any other means, R2 and R3 were unaware of a designated a staff liaison to aid the resident council. It was alleged that the facility did not accord resident dignity in their relationship with staff. Regarding the allegation that the facility did not accord resident dignity in their relationship with staff, interviews with residents revealed the staff accorded them with dignity and respect. None of the residents reported being spoken to or overhearing other staff speak in different languages. The residents stated that they feel the staff can speak in any language when they are on a break or leaving the facility. The residents did not state that the staff speak in a different language when assisting them. Interviews with outside sources who frequent the facility did not report any concerns with the facility not according to residents with dignity in their relationship with the staff. Lastly it was alleged that the facility did not accord safe, healthful and comfortable accommodations. Regarding the allegation that staff the facility staff did not accord safe, healthful and comfortable accommodations. Interviews with residents revealed them feeling their call lights were being answered in a timely manner and staff follow the wake-up schedule in the morning. Records reviewed showed that the pendant alert system for the residents were answered with no complaints. The residents stated that most of the time the staff will let the residents know if they are behind schedule. The resident's interviewed stated that they appreciate the staff communicating when there will be a little bit of a wait. Usually, another staff will assist as needed so there are no concerns. Staff corroborated the wake-up times that are requested and verified that if they will be later than scheduled, they will inform the resident or have another staff assist them. 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 LPA observations of various rooms during unannounced facility visits did not raise any concerns regarding the call light response time or the residents' wake up schedule in the morning. The department has investigated the complaint alleging the resident council rights are not posted in a prominent place at the facility. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Aileen Spence Associate Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

[Continued from LIC 9099] The allegation regarding medication mismanagement did not specify any residents to whom it was occurring to or a timeline. Records review of multiple resident medication records over a period of 3-6 months around the complaint date did not reveal major discrepancies in medication administration, however, it was noted that occasionally when a new prescription is written for a resident, it takes 1-3 days for the medication to be physically present at the facility for residents. Staff interviewed corroborated that med-techs order medications or notify resident families if the resident is not enrolled with the facility's pharmacy. A few staff interviews also corroborated that medication delays come from those who's family manage orders. Resident interviews did not reveal any concerns about their medications, aside from one who indicated they experienced delays in medication refills. Review of that resident's medication record showed no delays by the facility, instead revealing that the resident refused medications. Outside sources interviewed revealed no concerns about medication management, and one expressed appreciation that the facility was strict about requiring prescription orders for all medication. Regarding the allegation of improperly assessing a resident, records review of resident files were noted to include regularly updated resident assessments. LPA reviewed the assessment tool utilized for resident assessments and the point scale used for pricing. Staff interviews revealed that residents are assessed prior to move-in, 7 days after move in, 30 days after move in, and then every 6 months thereafter and/or if the resident experiences a change in condition in between those 6 months. Resident interviews revealed no concerns about the level(s) of care provided to them. Outside source interviews revealed that the facility was transparent and informative on the assessment procedures and breakdown of changing costs. Regarding the allegation of wound care, the complaint only stated that appropriate wound care is not being provided. Staff interviews corroborated that the facility does not provide wound care as it is not a medical facility, and only basic first aid is provided and referrals to appropriate wound care providers. Resident and outside source interviews did not reveal any concerns about the facility's responsiveness to incidents or ability to provide necessary care. Records review indicated which residents received wound care and all were enrolled with appropriate outside agency care providers. Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Allen to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to offer an Amended Report for a visit conducted on 6/23/2025. LPA met with Associate Executive Director Aileen Spence and informed them of the purpose of their visit. During today's visit, LPA obtained Associate Executive Director Spence's signature on the amended report LIC 9099D (7/18/2025). An exit interview was conducted with Associate Executive Director Spence to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

Continued from LIC9099 OS1 reviewed the documentation available to show the days and times R1 was visited and what treatment was completed. LPA Domingo interviewed Outside Source 2 (OS2), and they verified that R1 was being seen four (4) times a week or more when the open area was first observed. OS1 reviewed the documentation available to show the days and times R1 was visited and what treatment was completed. Outside Source 3 (OS3) was interviewed, and they stated that the facility and staff that cared for R1's wound care communicated any changes and provided updates regarding the progress of R1's wound care. Records reviewed revealed the physician involved with R1's care was notified of the wound care and the progress of the wound. The records contained the type of wound care treatment and the description of the wound with each visit. On May 1, 2025, a complaint was received alleging the licensee failed to facilitate medical care for the resident. Staff 1 (S1) was entering R1's room to administer bedtime medications. S1 observed that R1's family members were digitally removing R1's bowel movement. S1 told the family members to stop immediately. S1 explained that there were no physician orders for anyone to remove bowel movements from R1. S1 observed R1 to be moaning and grimacing. Staff 2 (S2) was interviewed, and they stated that for the safety of R1, they will be requesting the family members who were in the room only to visit R1 in the common areas. At no time did S2 deny family members' visitation for R1. S2 explained to the family members that the visitation restrictions were implemented due to the family providing care to R1 without a physician's order. Records reviewed revealed there was no physician's order to remove R1's bowel movements digitally. Outside source 4 (OS4) was interviewed, and they agreed that due to the family members' actions, they should only visit R1 in the common areas. Records reviewed from the facility and Hospice, and all care providers provided the appropriate medical care for R1. 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 3 of 3 Interviews and records review did not support any evidence that the staff are not providing appropriate medical care for R1. Interviews with staff and outside sources revealed the licensee did not fail to facilitate medical care for the resident. This agency has investigated the complaint alleging that the licensee failed to protect the resident from harm and the licensee failed to facilitate medical care for the resident. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report and licensee rights (LIC 9058 03/22) was provided. Gerrit Hoevers Director of Environment Service signature on this form confirms receipt of these rights.

(continued form LIC9099) Food service meal attendance logs were reviewed and appeared consistent with providing all residents with meals throughout the day. Staff interviews confirmed that several residents who were unable to feed themselves were assisted while seated in the dining room, and residents who could not attend meals in the dining room were provided alternative support when meals were delivered to their rooms.  Observations by LPAs over several visits demonstrated that the residents were receiving appropriate nutritional intake and mealtime monitoring as required by their individual care plans.  Outside sources' interviews further reveal that staff attend to residents' needs during meal time in the dining room as well as at the bedside. An exit interview was conducted with Aileen Spence Associate Executive Director. A copy of this report was provided and their signature on this report confirms receipt.

(Continued from LIC9099 2 of 3) OS1 reviewed the documentation available to show the days and times R1 was visited and what treatment was completed. LPA Domingo interviewed Outside Source 2 (OS2), and they verified that R1 was being seen four (4) times a week or more when the open area was first observed. OS1 reviewed the documentation available to show the days and times R1 was visited and what treatment was completed. Outside Source 3 (OS3) was interviewed, and they stated that the facility and staff that cared for R1's wound care communicated any changes and provided updates regarding the progress of R1's wound care. Records reviewed revealed the physician involved with R1's care was notified of the wound care and the progress of the wound. The records contained the type of wound care treatment and the description of the wound with each visit. On December 27, 2024, a complaint was received alleging staff do not allow visitors privacy when visiting with resident. The complainant alleged that the licensee did not allow Resident 1 (R1) to visit with their family in R1's room.  The complainant claimed that the resident's visitation rights were being denied without any valid reason. On December 26, 2024, at 7:22 pm, when Staff 1 (S1) was entering R1's room to administer bedtime medications. S1 observed R1's family members were digitally removing R1's bowel movement.  S1 told the family members to stop immediately. S1 explained that there were no physician orders for anyone to remove bowel movements from R1.  S1 observed R1 to be moaning and grimacing. S1 reported what they observed to their supervisor.  When S1 requested the family members to leave the door ajar so that other staff could provide supervision for R1, the family members immediately closed the door. The appropriate care providers were made aware, and they will be sending staff to check on R1's medical condition.  The staff members interviewed stated that they are aware of facility policies and procedures related to visitation rights.  They did not deny the family members from visiting. (Continued on LIC9099 3 of 3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC9099 3 0f 3) Staff 2 (S2) was interviewed, and they stated that for the safety of R1, they will be requesting the family members who were in the room to only visit R1 in the common areas. At no time did S2 deny family members' visitation for R1. S2 explained to the family members that the visitation restrictions were implemented due to the family providing care to R1 without a physician's order. Records reviewed revealed there was no physician's order to digitally remove R1's bowel movements. Outside source 4 (OS4) was interviewed, and they agreed that due to the family members' actions, they should only visit R1 in the common areas. It was alleged that staff are not following the resident's special diet.  Review of resident 1’s (R1) medical records revealed that R1 requires food cut, chopped, pureed, or otherwise prepared. R1 requires staff assistance with all activities of daily living, including eating meals, bathing, dressing, and toileting. Record review revealed that R1’s medical condition has declined, and R1 is currently under hospice care.  Interviews and record review revealed that R1 had declined in meal intake care and had poor meal intake while under hospice care. Interviews and records review did not support any evidence that staff are not following the resident's special diet. Interviews with an outside source revealed they have not had any issues with the facility or with the meals/foods being served. Interviews with staff also revealed that some clients eat different meals depending on their preferences or dietary restrictions. This agency has investigated the complaint alleging that staff did not ensure the resident's wound care needs were met, staff are not providing incontinence care to the resident, and staff restricted the resident's visitation rights. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report and licensee rights (LIC 9058 03/22).  Executive Director, Cathy Allen's signature on this form confirms receipt of these rights.

(Continued from LIC9099 2 of 3) R1 had an unwitnessed fall on March 1, 2025, with no visible injuries. R1 was admitted to hospice care on March 13, 2025. R1 was prescribed Lorazepam 0.5 mg 1 tab by mouth every four (4) hours for restlessness, mood swings, and agitation. On March 14, 2025, R1's records revealed they were sleepy and lethargic. R1's new order starting March 14, 2025, was Lorazepam 0.5 mg six (6) times a day. On the morning of March 15, 2025, documents revealed that R1 was very sleepy and weak but did not sleep well and was aggressive when staff tried to help R1 lie down in bed. By midmorning on the same date, R1 was found sitting on the floor with a raised hematoma to the back top of their head and a small skin tear to the right cheek. R1 was sent to the hospital for further evaluation. R1 returned to the facility on the same day. R1's Lorazepam was discontinued, and hospice was notified of R1's return to the facility. The diagnosis upon R1's return was a Subdural hematoma with Subarachnoid bleed. On March 16, 2025, during the evening hours, R1 was unresponsive to touch and voice. On March 17, 2025, R1 had a change of condition with labored breathing. On March 19, 2025, R1 was given Lorazepam 2 mg every 15 minutes for 3 doses until seizures stop. On March 20, 2025, R1 passed away. Records reviewed revealed that upon admission to the facility on February 13, 2023, R1 was able to transfer themselves, feed themselves, and socialize well with other residents. The following year, the Physician's report on April 15, 2024, documented that R1's dementia had progressed, and R1 needed more assistance, and they were more restless with mood swings and agitation during the evening hours. The Physician's report also had an additional notation of having a fall without fracture. On February 6, 2025, a resident assessment assessed R1 at a level 4. R1 required additional support due to multiple behavioral interventions. There were no unusual incident reports filed with the Department regarding the March 1, 2025, fall documented in the resident charting notes. There were no unusual incident reports filed with the Department for the March 15, 2025, fall. The facility addressed and documented R1's increased need for assistance. There was daily documentation by the facility staff communicating R1's changes with outside sources, the medical physician, and Hospice. On March 25, 2025, Community Care Licensing (CCL) received a complaint alleging that the Facility staff are not coordinating hospice services appropriately to ensure resident safety. 9Continued on LIC9099 3 of 3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC9099 3 of 3) Outside source 1 (OS1) was interviewed and stated they did not sign the admission forms to be admitted to hospice services. OS1 also stated they did not agree upon the medication for restlessness. OS1 stated they knew R1 would not do well with the medication for restlessness. OS1 stated that the fear of using the restlessness medication was an increase in falls. OS1 stated R1 would have a higher chance of falling when taking the restlessness medication. Outside source 2 (OS2) notified the facility and R1's medical physician that the restlessness medication was excessive and R1 was increasingly over groggy. Review of records revealed that the facility and hospice acknowledged and followed OS2 request to lower the number of times the restlessness medication was to be given. Records reviewed revealed the facility staff and the hospice staff provided daily documentation on R1's condition and notified the medical physician of changes with R1. The medications for R1 that were adjusted for their comfort were documented on R1's daily charting, along with the hospice documentation. Staff charting and hospice charting notified OS1 and OS2 of any changes with R1. This agency has investigated the complaint alleging the above allegations. The Department has found that 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 Executive Director, Cathy Allen, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analysts (LPA) Amy Domingo conducted an unannounced collateral visit as a follow-up for an unrelated complaint investigation for another facility. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director . During the visit, LPA reviewed document with LPA Golbakhsh regarding a few clients. An exit interview was conducted with Executive Director Cathy Allen to whom a copy of this report was provided. Their signature below confirms receipt of this document.

(Continued from LIC9099) Statements from staff who assisted R1 corroborate that R1 was found partially under the bed when found during safety checks. Further, medical records reveal no injuries indicative of a bed falling and landing on R1’s neck. Staff interviewed reported that safety checks are done four times a shift unless residents are noted for 2 hour checks. While R1’s records indicated needing assistance in transferring to and from bed, records did not indicate R1 needing additional checking throughout the night. Staff interviews corroborated the information The Department received from the facility documented on an Unusual Incident/Injury Report. Per the report and staff interviews, facility staff followed appropriate protocol once aware of R1’s fall. The Department has investigated the allegation of neglect/lack of supervision resulting in bed falling on resident and landing on resident’s neck. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate that R1’s fall and resulting injury was a result of neglect/lack of supervision, therefore this allegation is deemed unsubstantiated. An exit interview was conducted with Cathy Allen, Executive Director, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.

(Continued from LIC9099) Records reviewed revealed staff received their annual medication training. Interviews with med tech staff attested to undergoing medication training and staff demonstrated knowledge in the “Seven Rights of Medication Administration”. LPA observations of med tech staff did not raise any concerns. The Department has investigated the allegations that staff are not properly trained to administer medication. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Cathy Allen, Executive Director, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.

(Continued from LIC9099 2 of 3) It was alleged that staff sexually abused Resident 1 (R1). Review of R1’s medical assessment and appraisal documents dated July 22, 2022, revealed R1 has a history of forgetting words, disorientation, confusion, hallucinations, and nightmares. R1 can fluctuate from being non-verbal and non-ambulatory to verbal and ambulatory. There are days when R1 can communicate their needs and days when they cannot. Interviews with staff, outside sources and review of admission records revealed R1 was admitted to the facility on August 6, 2022, and occupied a single room at the memory care portion of the facility. Interviews with staff revealed R1 was mostly non-verbal, non-ambulatory, with hallucinations and confusion. The staff stated that R1 has not stated that anyone sexually assaulted them. Review of progress notes and interviews with staff and outside sources denied having reports from R1 regarding abuse. Interviews with staff, outside sources, and review documents received by the Department from the facility on 10/25/2022 revealed that R1 reported to Outside source 1 (OS1) that they were sexually abused by a staff member in the shower. R1 was not able to recall the dates or times the incident happened. OS1 reported the incident to the facility staff. The facility staff completed a body check, and there were no signs of abuse. R1 did not repeat the alleged occurrence when asked by outside sources or staff. Review of documents received by the Department revealed that facility management followed reporting requirements and submitted an incident report and report of suspected elder abuse to the Department on October 26, 2022, as well as notified R1’s responsible parties. It was alleged that staff are mismanaging the residents' medication. Review of records revealed that there has not been any medication mismanagement. Staff interviewed and there has not been any medication mismanagement. Outside source 1 (OS1) stated that there have not been any medication mismanagement. It was alleged that R1’s bed did have a mattress cover. LPA observed five (5) bedrooms, including R1’s bedroom. All five beds contained a mattress cover. All five (5) bedrooms have the appropriate bedding, lighting, closet space, and blankets. The rooms were not cluttered, and there were no foul odors. It was alleged that R1’s bed did have complete sheets. LPA observed five (5) bedrooms, including R1’s bedroom. All five beds contained complete sheets. All five (5) bedrooms have the appropriate bedding, lighting, closet space, and blankets. The rooms were not cluttered, and there were no foul odors. Lastly, it was alleged that the licensee is not meeting R3’s dietary needs as they require chopped food, and they are a vegetarian. Interviews with residents revealed that if they need a special diet, the facility will accommodate their needs or special requests. Interview with staff established that R1 was provided with their specific dietary needs. An interview with an outside source established that there have been no issues 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 3 of 3 observed with residents’ food accommodations. Records review showed that R1’s dietary needs were documented and staff followed R1’s dietary needs. Based on LPA's interviews and record reviews, there is no preponderance of evidence to prove that the alleged violation occurred; 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 (LIC 9058 03/22) were provided.

[Continued from LIC9099] R1 was admitted to the hospital on December 2, 2024, for a laceration on their head after another resident pushed them. However, the injury did not result in any fractures or abnormalities, and R1 was fully alert and oriented following the injury. R1 was admitted to the hospital on December 6, 2024, due to having left sided weakness and facial droop. R1 was diagnosed with having a stroke as well as cardiomyopathy and arrhythmia, aside from the extensive medical history they already had. On December 9, 2024, R1 was having trouble following commands and consuming food. Due to their rapidly declining condition, it was agreed to have them return to the facility with comfort directed care under Hospice. R1 returned to the facility on December 11, 2024, and was seen daily by Hospice until they passed away on December 14, 2024. R1 had an extensive medical history, which contributed to death as listed on the death certificate. The immediate cause of death listed was Cerebral Infarction, which developed over several years with the underlying causes being Congestive Heart Failure and Hypertensive Heart Disease. All of these were illnesses that, based on their medical records, they had been struggling with for years. It was alleged that the facility had a lack of supervision, resulting in resident-to-resident altercation.  The interview with Staff 1 (S1) revealed the altercation in the activity room occurred on December 2, 2024, not November 2024, as described in the complaint. S1 explained that R1 lost their balance and attempted to grab another resident’s arm.  Resident 2 (R2) pushed R1 away, causing them to fall. R1 sustained a laceration on their scalp as a result of the fall. R1 was evaluated, 911 was called, and they were transported to the Hospital where they were treated and returned to the community on the same day. There was no physical assault, as described by the reporting party in the complaint. The facility documented the incident on an LIC 624 Unusual Incident Report. Lastly, it was alleged that the facility did not report the incident.  Records show that the facility documented the incident on a LIC624 Unusual Incident Report, and the report was sent to the appropriate agency. Based on the Department's interviews and record reviews, there is not a preponderance of evidence to prove alleged violations occurred, therefore, the allegations are unsubstantiated . A copy of this report and Appeal and Licensee Rights (LIC 9058 03/22) were provided to the facility Executive Director.

[CONTINUED FROM LIC 9099] Interviews of 5 of 5 direct care staff also showed that each person received multiple days of on-the-job practice and skills observation with a more experienced co-worker, before they were allowed to independently pass medications to clients. Interviews of the staff and clients in care revealed nothing to suggest that staff did not ensure resident received medications as prescribed. LPA also observed a medication pass and quizzed direct care staff on their understanding of both medication related terminology and best practices for accurate medication delivery; all staff interviewed displayed knowledge for safe and effective job performance, as far as medication assistance was concerned. Review of the clients’ MARs showed: Staff were consistent in documenting routing medications given. Staff also met documentation requirements as it related to as needed (PRN) medications. Interviews of 5 of 5 Resident showed there have not been any occurrence of staff not providing medications as prescribed. The Med Techs are very through and contentious of their job duty and they preform them very well. LPA reviewed 5 of 5 resident medication logs with no errors or missed medications. The records showed proper medication prescribed were given to the residents. Based on record reviewed and interviews, a preponderance of evidence does not exist to show that staff did not ensure resident received medications as prescribed. Therefore the allegation is Unsubstantiated , and no deficiencies were cited for them. An exit interview was conducted with AED Aileen Spence, 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 Case Management - Incident visit.  LPA identified herself and was granted entry into the facility by Aileen Spence Associate Executive Director, and Morgan Ware Interim Executive Director with whom LPA met and discussed the purpose of the visit. Today's visit was initiated in response to an LIC624 Incident which was received by Community Care Licensing (CCL) on April 7, 2025, in which licensee self reported an injury to a resident's back of he head that was witnesses. LPA briefly toured the facility, performed a welfare check on residents in care, interviewed staff, and obtained copies of pertinent facility records. No immediate health or safety risks were observed. Additional case management will be provided for this incident, including subsequent visits and staff interviews, as needed. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22) were leftwith the Associate 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 Associate Executive Director Aileen Spence. Today's visit was in response to an LIC624C Death Report, which licensee self submitted to the Community Care Licensing Department San Diego Regional Office on March 25, 2025. The LIC 624C report described a resident who was on Hospice care was being closely monitored by hospice after a recent fall with a brain bleed. LPA briefly toured the facility, performed a welfare check on residents in care, interviewed staff, and obtained copies of pertinent facility records. No immediate health or safety risks were observed. Additional case management will be provided for this incident, including subsequent visits and staff interviews, as needed. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22) were left with the Associate 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 Associate Executive Director Aileen Spence. Today's visit was in response to an LIC624 Incident Report, which licensee self submitted to the Community Care Licensing Department San Diego Regional Office on March 5, 2025. The LIC 624 report received on March 5, 2025 described a resident being Absent without leave (AWOL). At around 2:30 PM, Resident #1 (R1), who lives in the facility’s secured memory care unit, was briefly AWOL (Absent without leave). [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Staff #1 (S1) described how the facility managers and Medicine Technician (Med Tech) followed the protocol of physically searching for the resident with a photo of the resident. All the nearby apartment complex where shown a photo of the resident by the managers that went out looking for R1. After about twenty (20) minutes, one of the apartment complex resident walked R1 back to the facility because they were made aware of R1's AWOL a few minutes prior to seeing R1. R1 was AWOL for approximately 20 minutes. Review of records showed R1's responsible party and MD were both notified of the AWOL and return. During today’s visit, LPA briefly toured the facility and performed a welfare check, verifying that R1 was indeed unharmed/uninjured. LPA also was shown the new alarms on the two (2) gates that lead to the outside of the facility. The new alarmed gates were placed on March 7, 2025. LPA also collected copies of pertinent facility records, and interviewed relevant staff. 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 Associate Executive Director Aileen Spence, 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 Sanjay Kabadi Executive Director and Robin Mendez Director of Health Services. LPA Domingo toured the facility, performed a welfare check on residents in care, interviewed staff, and obtained copies of pertinent facility records. Today’s visit was in response to an incident which licensee self reported via an LIC624 Incident Report on February 4, 2025. The report described Resident #1 (R1) was found outside the community by a bystander who helped the resident back into the facility. R1 sits at the end of the facility property on their motorized wheelchair. R1 was picking up a dropped item and fell over and hit his head. The bystander saw R1 fall and brought R1 back into the facility. R1's LIC602 Physicians Report state that R1 is able to make decisions, no cognitive deficits, and they are their own responsible party. R1 has no restrictions with leaving the facility independently, but prefers to sit at the end of the property. R1 was not off the property when the bystander assisted them back onto their wheelchair and brought the resident back into the facility. The facility sent R1 to the hospital for evaluation, the appropriate people were made aware of the fall and the facility followed the fall protocol. Test were completed and R1 returned to the facility on the same day. R1 had an abrasion on their head. R1 did not have any sutures or open areas on their head. No immediate health or safety risks were observed and no deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report and Licensee Appeal Rights LIC 9058 (03/22) were left with the Executive Director, whose signature on this form confirms receipt of these documents.

Licensing Program Analysts (LPA) Amy Domingo, made an unannounced visit to conduct the required one year Inspection to ensure substantial compliance with Title 22 regulations. LPA Domingo was granted entry into the facility by Executive Director Sanjay Kabadi, after identifying herself and stating the purpose of the inspection. This facility serves two hundred twenty-five (225) non-ambulatory residents 60 and above; twenty (20) of whom may be bedridden. Delayed Egress in Building ‘B’. Hospice waiver approved for twenty (20). A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. There are three buildings in the complex with memory care on the 1 st floor of the ‘B’ building. There is large pond/water feature on site, made inaccessible to residents. Facility does feature delayed egress doors and a locked perimeter on the first floor. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. Annual Fire inspection is current. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. PPE supplies are on site. Passageways were free from obstructions. [CONTINUED ON LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] Facility has a two day supply of perishable food and a seven day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a review of In-service training procedures. Transportation procedures are compliant. There is designated gym area, designated art/craft room, two large activity rooms as well as gathering areas throughout the facility. At the time of visit, LPA observed two different large group activities in which many residents were participating. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No Deficiencies were issued at the time of visit, however, a technical violation was issued at today’s visit. An exit interview was conducted with Executive Director Sanjay Kabadi to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced case management visit.  LPA was granted entry into the facility by Sanjay Kabadi Executive Director with whom she disclosed the purpose of the visit. The case management visit is related to the complaint control number 08-AS-20240909102606 . During a complaint investigation, the LPA discovered the facility Executive Director, who is a mandated reporter, had knowledge of an incident that requiring reporting to the local ombudsman, the Department, and local law enforcement. Based on interviews, and records reviewed, it was determined the facility did not meet the required reporting requirements. Per California Code of Regulations, Title 22, LIC9102 Technical violation. A Plan of Correction was jointly formulated with the facility administrator. An exit interview was conducted with Executive Director, to whom a copy of the report and Licensee/Appeal Rights (LIC 9058 03/22) were provided to.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced case management visit.  LPA was granted entry into the facility by Robin Mendez, Director of Health Services, with whom she disclosed the purpose of the visit. Today’s visit was in response to an incident which licensee self reported via an LIC624 Incident Report received at the Community Care Licensing Regional Office on November  26, 2024. The report described Resident #1 (R1 – See LIC811 Confidential Names List for identification), complaint of pain during repositioning.  R1 had a previous unwitnessed fall and the appropriate procedure was followed and an incident report was completed. R1 did not have any complaints of pain at the time of the fall,  the Medical Doctor and responsible party were made aware and recommended at the time to remain at the facility due to R1's ability to complete activities of daily living with no pain. 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 Robin Mendez, whose signature on this form confirms receipt of these documents.

Interviews conducted revealed that the AED has been actively working the role of Memory Care Director in addition to their regular duties since September 6, 2024. Interview with Executive Director revealed that the position of Memory Care Director has been vacant since September 1, 2024 and coverage of such role has been filled by personnel with adequate qualifications. Lastly, interviews with multiple staff revealed that the Assisted Living Director and the Director of Health Services have been consistently on hand to assist in coverage to the Memory Care Director position. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Associate Executive Director Aileen Spence to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

It was alleged that Resident 1 (R1) (Please refer to LIC811 confidential names list), sustained a pressure injury due to staff neglect.  R1 was admitted to the facility on 02/18/2022. On 04/17/2024 R1 was admitted on to hospice care.  Review of R1's records showed that throughout R1's stay at the facility the staff communicated with the medical doctor when there were any changes of R1's condition. Outside source 1 (OS1) and outside source 2 (OS2) were interviewed and there were no concerns regarding R1's care throughout R1's stay at the facility.  Outside source 3 (OS3) was interviewed and medical changes were communicated and addressed in a timely manner.  Review of hospice documentation revealed medical staff and hospice staff closely monitored R1 medical changes including any skin issues.  OS1 was interviewed and stated that all staff communicated well with OS1 regarding R1's daily condition and changes.  Staff members including management staff were readily available to communicate with and there were no concerns regarding R1's care. Staff 1 (S1) was interviewed and reviewed R1's plan of care and medical records which showed continuous medical care by staff and hospice staff that addressed R1's changes in medical needs. Staff 2 (S2) was interviewed and reviewed schedules of staff and hospice staff visits for R1. It was alleged that staff did not ensure that resident's room was clean.  On 8/7/24 LPA Domingo toured the facility and a few rooms, there were observations of clean rooms.  The rooms were not cluttered,  the trash cans were empty,  the floors were clean and there were no odors.  On 8/16/24 LPA  toured the facility and a few rooms, there were observations of clean rooms.  The rooms were not cluttered,  the trash cans were empty,  the floors were clean and there were no odors.  On 9/18/24 LPA toured the facility and observed the room to be clean. The rooms were not cluttered, the trash cans were empty, the floors were clean and there were no odors.  OS1 and OS2 were interviewed and did not observed R1's room to be cluttered or odorous.  OS1 and OS2 stated that the facility was well kept and had no concerns regarding the facility or R1's room cleanliness. Outside source 4 (OS4) was interviewed and there were no concerns regarding the facility's cleanliness.  OS4 stated during visits to the facility the staff were always actively cleaning and disinfecting common and private areas. Based on LPA's interviews with staff, outside source interviews, and record reviews there is not a preponderance of evidence to prove alleged violation(s) occurred, therefore the allegations are unsubstantiated . An exit interview was conducted with Robin Mendez, Director of Health Services, 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 greeted by, identified herself to, and discussed the purpose of the visit with Robin Mendez, Director of Health Services. During today's visit, LPA interviewed staff and outside sources for a complaint investigation lodged against the facility licensed by Community Care Licensing. An exit interview was conducted with Robin Mendez, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 03/22) were provided via hard copy.

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 Sanjay Kabadi Executive Director. Today’s visit was in response to an incident which licensee self reported via an LIC624 Incident Report on September 25, 2024. The report described Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1), to be sent to the Emergency Room at 10:00 am on September 13, 2024, by R1's Primary Care Physician for uncontrollable back pain. LPA briefly toured the facility, performed a welfare check on residents in care, interviewed residents and staff, and obtained copies of pertinent facility records. No immediate health or safety risks were observed and no deficiencies were cited during this visit. Additional case management will be provided for this incident, including subsequent visits and staff interviews, as needed. 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.