Watermark at Rosewood Gardens, the

On 6/28/2021 at 11:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Business Director, Chelsea Espinoza. While LPA was at the facility conducting another visit, the following deficiency was observed. During visit, LPA tested delayed egress doors in Memory Care Unit. LPA observed that one of the delayed egress doors in the Memory Care Unit opens without the 15 seconds hold. LPA tested the delayed egress doors in the presence of a staff member (S2). The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.

On 12/15/2025 at 3:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 12/7/2025. LPA met with Executive Director, Chelsea Espinoza and explained the purpose of the visit. LPA received death report on 12/7/2025 for resident (R1). Death report revealed that R1 ate a few bites before walking around and suddenly sat down on a chair in the hallway. Staff noticed R1 turned pale and became unresponsive. Staff called 911 and began CPR until paramedics arrived. Paramedics continued CPR and unable to revive R1. Local police indicated no foul play and R1 died of natural causes. During visit, LPA reviewed R1's file and obtain emergency information, physician's report, care plan, staff contact information, and local police officer's information. LPA may return at a later time. Exit interview conducted. A copy of this report provided.

On 8/14/2024 at 9:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation. LPA met with Executive Director, Chelsea Espinoza and explained the purpose of the visit. During visit, LPA reviewed 5 residents' files and 5 staff files. LPA observed resident's files were complete and staff files were complete. Staff have current first aid and CPR training. LPA observed staff completed training which includes dementia, food safety, resident rights, medication, ADL (Activities of Daily Living) care, and other topics. Last disaster drill was conducted on 5/24/2024. LPA reviewed a sample of resident's medications at around 4:15PM. LPA interviewed 4 residents and 4 staff starting at 1:00PM. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report were provided.

On 7/21/2021 at 8:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Business Director, Chelsea Espinoza and explained the purpose of the visit. Upon entry, LPA was asked to check-in from automated system where temperature and COVID-19 questionnaire was completed. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to residents' bedrooms, bathrooms, hand washing stations, kitchen, and common areas. LPA observed physical distancing and mask wearing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed that staff had fit testing for N95 respirator completed. Facility have been conducting surveillance testing for staff. LPA observed PPE, food supplies, and paper supplies are sufficient. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

Allegation: Facility staff have not received required training prior to assisting with medications Investigation Finding: Unsubstantiated During investigation, medication technicians' staff (S2, S3) confirmed with LPA that they completed all required medication administration training (shadowing & Relias trainings) prior to independently working as full time medication technicians. ADM stated that new medical technicians are required to complete 16 hours of medication administration on the job shadowing with experienced medical technicians. ADM stated each medical technician is also required to complete a Medication Pass Fundamentals Video Training which covers the safe preparation, security and proper administration of controlled substances, prescriptions and over the counter medications. Staff (S1) oversees the completion of each medical technicians' required on the job training and signs off on the medication pass certifications prior to releasing each new medical technician for work duty. At 1PM, LPA reviewed staff (S1, S2, S3, S4, S5, S6) medication administration training records dated 01/01/23 to 03/01/24. LPA observed that all medical technicians completed their required job training certifications prior to working as full time medical technicians. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility staff have not received required training prior to assisting with medications is unsubstantiated. No deficiencies observed during visit. Exit Interview conducted and a copy of this report provided.

On 7/31/2024 at 3:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Executive Director, Chelsea Espinoza and explained the reason for the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication carts located in med rooms. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 1/5/2024. There were evacuation chairs in the stairwells. One week of nonperishable and 2-day of perishable food supplies were available. Facility orders food twice a week. Freezer’s temperature was registered at -2 degree F while the refrigerator’s temperature was recorded at 40 degrees F. Hot water temperature was measured at 120 degrees F in a resident's bathroom. Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction. LPA will return at a later time to complete the inspection. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

Facility did not meet resident's hygiene needs while in care. Interview with staff revealed that R1 would refuse assistance with shower and dressing. LPA observed R1's assessment dated 9/29/2021 indicated that R1 does not need assistance with grooming, bathing, dressing, eating, toileting, and transferring. Facility did not ensure that resident's nails were cut while in care. Interview with residents revealed there was services residents can sign up for to get assistance with finger and toe nails trimming. R1's assessment dated 9/29/2021 did not indicate that R1 needed assistance with finger and toe nails trimming. Facility did not seek resident medical attention for an infection while in care. Interview with residents revealed that when call button is activated, staff would come and assist residents. S2 stated there's no recollection of R1 having an infection that needed medical attention. R1's assessment and 24 hour reports does not indicate that R1 had a change in condition. There was lack of evidence to prove facility did not seek medical attention for R1. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegations are UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

On 11/8/2023 at 2:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 10/27/2023. LPA met with Executive Director, Chelsea Espinoza and informed her the reason for the visit. Based on the incident report received on 10/27/2023, resident (R1) was given the incorrect medications. Facility called 911 and R1 was sent to the hospital for evaluation and returned back to the facility the same day. R1's family and doctor was notified. Med tech received additional training to avoid medication errors. During visit, LPA reviewed R1's file including discharge documents, care notes, incident report, and training materials. Interview with R1 revealed that R1 is doing well after taking incorrect medications. Interview with S1 revealed that S1 had hands on training after medication error. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

Resident sustained multiple falls while in care Interview staff and witness revealed that R1 does not have a history of falls. Witness stated that R1 have loss balance and fallen, but staff would encourage R1 to use the walker to prevent falls. LPA reviewed fax correspondence with doctor and observed that staff notified doctor when R1 had a fall. Resident sustained multiple unexplained injuries while in care Interview with staff revealed R1 had bruises and was unaware how R1 sustained injuries. Staff stated that R1 often hit the doors and walls to wander out of facility. LPA reviewed fax correspondence with doctor and observed that staff notified doctor when injuries were discovered on R1. R1's family was notified of R1's injuries. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.

On 11/29/2022 at 3:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Associate Executive Director, Chelsea Espinoza. LPA received an email regarding a 3-day eviction notice that was given to R1 on 11/11/2022. LPA was informed that a written approval was not obtained from CCLD. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights 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 Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.

On 7/29/2022 at 9:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Executive Director, Will Pringle and explained the purpose of the visit. Upon entry, LPA was asked to check-in from automated system where temperature and COVID-19 questionnaire was completed. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to residents' bedrooms, bathrooms, kitchen, and common areas. LPA observed physical distancing, signs & symptoms, and mask wearing signs were posted in the common areas. All bathrooms were equipped with soap, paper towel, and garbage can with lid. Hand washing posters were posted at bathrooms. During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed that staff had fit testing for N95 respirator completed. Facility have been conducting surveillance testing for staff. LPA observed PPE, food supplies, and paper supplies are sufficient. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

On 9/29/2022 at 12:15PM, Licensing Program Analysts (LPAs) G. Luk and J. Sampair arrived unannounced to conduct a case management inspection. LPAs met with Associate Executive Director, Chelsea Espinoza. While LPAs was at the facility conducting another visit, LPAs observed the following deficiency. LPAs were informed that Executive Director (ED), Will is no longer working at the facility. It was identified that ED had left over a month ago and facility have not notified CCLD for change of administrator. LPAs collected documents for facility change of administrator. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.