Primavera Gardens

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. The purpose of this visit it deliver the final report on a case management that was initiated on 08/25/2025 regarding an elopement that occurred on 08/20/2025. LPA met with Administrator, Lisa Lanford. On 08/21/2025, the Department received a verbal report regarding resident (R1) who eloped from the facility on 08/20/2025. It was reported that R1 was found by a neighbor around the corner of the facility (about 450-500 feet away) around 2:00PM. The neighbor called 911 and when 911 arrived, R1 was observed disoriented and was taken to the hospital where it was found that R1 was diagnosed with an infection. It was stated that R1 did not sustain any injuries during the elopement. Based on interview with staff (S1), around 4:15PM it was reported by another staff (S2) that R1 was missing when they were gathering all the residents for dinner time. Staff immediately went to look for R1 in all the rooms, interior and exterior of the facility but was unable to location him/her. Around 4:25PM, S1 called 911 and reported a missing resident. S1 states that while walking around the neighborhood, the police was driving by and informed S1 that R1 was found after 2:04PM and was found with no injuries. S1 states that R1 was sent to the hospital by the police due to confusion and unable to describe what happened. S1 stated that R1 returned to the facility on the same day. Page 1 of 2. 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 S1 stated to believe that R1 exited through the main entrance which is unlocked and does not alarm during the day. S1 stated that this was the first time this happened with R1, as R1 does not have any history of elopement. S1 denied any other residents having a history of elopement. LPA observed that there are cameras throughout the common areas. S1 stated to have went through all the camera footage and did not find footage of R1 leaving the facility. Based on record review, R1 diagnosed with a neurocognitive disorder and is not able to leave the facility unassisted. After the incident, the Administrator updated R1's appraisal/needs and services plan to include the change of behaviors after the elopement. The Administrator also provided staff with an in-service training on topics of elopement and behavior management. Going forward, the Administrator will always have a staff standing in the common areas which is facing the main entrance to supervise the residents and main entrance. Administrator states the main entrance door will continue to be unlocked and not alarmed because they have many visitors throughout the day going in and out of the facility. The Administrator states future plans to install an electric gate that will require a code to enter. Based on the facility's compliance history, the facility does not have any reported history of resident's eloping. No deficiencies were cited per California Code of Regulations, Title 22. A technical violation was provided per Title 22 Section 87219(i). This report was reviewed with Administrator, Lisa Lanford and a copy of the report was provided. Page 2 of 2.

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit regarding an elopement that occurred on 8/20/2025. LPA met with Resident Care Supervisor (RCS) Lisa Lanford and stated the purpose of the visit. On 8/21/2025 RCS called the Department and spoke with LPA Christine Kabariti to report the elopement of Resident R1 on 8/20/2025. RCS stated R1 was located outside of the facility on 8/20/2025. RCS stated R1 returned back to the facility that same day and did not sustain injuries during this incident. RCS stated the facility has not submitted an LIC624 Unusual Incident Report/Injury Report and the SOC341 to the Department as of 8/25/2025. LPA requested RCS to submit the LIC624 and SOC341 to the Department on or before 8/27/2025. LPA interviewed 3 staff and toured 1 resident room. LPA requested pertinent documentation to include but not limited to physician's reports, service plans, and resident emergency contacts. LPA determined this case management needs further investigation. No deficiencies cited during today's visit. An exit interview was conducted with RCS Lisa Lanford and a copy of this report was provided.

On 08/22/2023 LPA Monter toured the facility including resident bedrooms. LPA observed all facility bathrooms in good condition. LPA observed facility kitchen in good condition. LPA did not observe the facility in disrepair. LPA Monter interviewed 9 residents and 4 staff regarding the allegations. 6 out of 9 residents were happy with the facility's cleanliness and had no complaints. 1 spouse of a non verbal resident did not have complaints regarding the facility's cleanliness. 3 out of the 9 residents are not verbal and could not answer LPA's questions. 4 out of 4 staff stated the facility maintains the bathrooms clean based on shift; AM, PM, & NOC. Staff also stated they have a bathroom cleaning schedule. Based on the interviews conducted with clients & staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Licensee does not prevent the presence of pests in the facility On 01/18/2023, LPA Dolores toured the facility, including resident bedrooms and kitchen during a complaint investigation. LPA did observe pests in the facility. ADM provided LPA with pest control invoices. On 08/22/2023 LPA Monter toured the facility including resident bedrooms and kitchen. LPA did not observe pests during the tour of the facility. LPA Monter interviewed 9 residents and 4 staff regarding the allegations. 5 out of 9 residents stated the facility had no pests such as cockroaches and had no complaints. 1 spouse of a non verbal resident stated he/she has not seen pests such as cockroaches. 3 out of the 9 residents are not verbal and could not answer LPA's questions. 1 out of 9 residents could not remember and answer LPA's questions. 4 out of 4 staff stated the facility does not have a pests such as cockroaches. Based on the interviews conducted with clients & staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Page 2 out of 2 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 On 08/22/2023 LPA Monter toured the facility including resident bedrooms, bathrooms, dinning area and kitchen. LPA did not observe residents disheveled or unattended. Residents rooms were well maintained. LPA did not observe the facility in disrepair. LPA Monter interviewed 9 residents and 4 staff regarding the allegations. 6 out of 9 residents stated the facility has enough staff to attend to their needs and had no complaints. 1 spouse of a non verbal resident stated he/she is happy with the care being provided. 3 out of the 9 residents interviewed are not verbal and could not answer LPA's questions. 4 out of 4 staff stated the facility has sufficient staff to meet the residents needs. The Department has completed the investigation of the above allegations. Based on observation & interviews conducted, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Licensee does not ensure that medication records are accurate On 01/18/2023, LPA Dolores observed residents Medication Administrator Record (MAR). LPA observed the PM medications were already signed off by staff. Staff S1 stated if a resident refuses medication, then the staff are supposed to circle their pre-signed initial and write what happened in the nurses note located on the back of the MAR. S1 states the facility does not have any issues with residents refusing their medication. LPA Monter interviewed S1. S1 stated the procedure is the medtech on duty will pre-pour the meds for that day and signs off on the mars once they are given. If the residents refuse then he/she will take it back to med room and re-try again. S1 stated the facility's residents don't refuse their medication. S1 stated if they still refuse he/she will document it on the nurses note section. Page 2 out 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 On 08/22/2023, LPA Monter reviewed medication records for 3 residents. LPA did not observe any discrepancies when cross referencing the medications and the log for the 3 residents reviewed. The Department has completed the investigation of the above allegations. Based on observation & interviews conducted, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited at this time. Page 3 out of 3.

Licensing Program Analysts (LPAs) Steve Chang and Emanuel Monter conducted an unannounced annual inspection visit, and met with Administrator Assistant (AA) NICK ELSOUSOU. LPAs checked 3 residents files and 3 staff files. LPA's interviewed 4 staff and 8 residents. LPAs toured the facility inside out with AA. License and Personal Rights posters were observed at the main entrance. Living room, dining room, kitchen, 13 resident bedrooms, 1 staff room, i office, 4 restrooms, and laundry room were inspected. Nonskid pads were observed in the restrooms. Medication closet, detergent closet, and knives closet were observed locked. All the bedrooms were observed with window screens. First Aid kit was observed in facility. Two day perishable food supplies and Seven day nonperishable food supplies were observed sufficient. Room temperature was observed at 78 degree F. Hot water temperature was measured to range from 118-119 degree F. Refrigerator temperature was observed at 40 degree F. Freezer temperature was observed at 0 degree F. Fire extinguisher was serviced on 05/08/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. LPAs toured backyard and front yard with AA. There is no obstruction to block exit at the backyard. No deficiencies were noted today. Exit interview was conducted with AA. The report was provided to AA for signature. A copy of the report was provided to AA.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection to focus on infection control and met with Lead Supervisor, Lisa Lanford. During visit, LPA toured the facility to include the living room, dining room, resident rooms, bathrooms, and exterior. Toxins and sharp objects observed secured. All staff observed to be wearing a face mask. Facility has a designated entry point for symptom screening and temperature check for all visitors and staff. LPA advised to include the full list of symptoms for the visitor symptom screening log. Hand sanitizer made available at entry. Bathrooms supplied with hygiene products, paper supplies, and hand washing signs. LPA observed the facility's Personal Protective Equipment (PPE) supplies. LPA advised to obtain a 30 day supply of PPE. Staff have been provided training on infection control. Staff clean and disinfect multiple times daily and as needed. The facility has procedures to isolation, testing, and visitation. Staff have not been provided N95 fit-testing. The following posters observed to include feeling ill, special visitors, social distancing, cough etiquette, and cleaning for COVID. No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Lisa Lanford and a copy of the report was provided.

Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan conducted an unannounced annual required inspection. LPAs met with Lisa Lanford, MedTech/Caregiver, and Claudia Elias, Patient Care Supervisor. During today's visit LPAs toured the facility inside and outside. LPAs observed a central entry point and screening area for all visitors and staff. Bathrooms have supplies of paper towels and soap available for staff, residents, and visitors. Trash cans were observed covered with lid. LPAs observed the following posters, cough etiquette, social distancing, visitor policy, hand washing, and COVID-19 everyday precaution. Facility has a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility has a mitigation plan in place to prevent the spread of COVID-19. During tour LPAs observed disinfectant and cleaning supplies under bathroom sinks in the hallway. Toxins were removed and secured during time of visit. Advisory note provided. No deficiencies cited during today's visit per California Code of Regulations, Title 22. This report was reviewed with Claudia Elias, Patient Care Supervisor. Copy of this report was provided.

Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Lead Staff, Claudia Elias. During visit, LPA conducted a Facetime tour of the facility with Program Clinical Coordinator (PCC) Helen Shi and Licensing Program Manager (LPM) Jackie Jin. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. Lead Staff, Claudia Elias reports that there are currently 6 COVID-19 positive residents and 1 COVID-19 positive staff. LPA toured the facility inside and out to include: entry point, common sitting area, dining room, resident rooms, green zone, red zone, bathrooms, and outdoor seating. LPA observed hand-washing signs in the bathrooms, visitor/staff screening logs, donning and doffing posters outside each residents room, and sufficient PPE supplies. During today's tele-visit, the following recommendations were made to the facility by PCC Helen Shi: 1. Always keep COVID-positive resident rooms closed, at all times 2. Place plastic shield/covering separating red and green zone 3. Place trash can with lid next to exit door in the red zone 4. Designate a back door for staff entrance and exit in red zone 5. Place a trash can with lid on the outside of COVID-positive room for disposal of N95 masks in green zone 6. Post COVID-19 postings throughout facility 7. Monitor residents who are asymptomatic every 4 hours 8. Monitor residents are who symptomatic more often, as needed See LIC-809C for more information. 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 visit, Lead Staff Claudia Elias closed all COVID-positive resident doors. Manager also placed trash can with lid outside the door of COVID-positive resident in green zone area. No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via tele-visit and email copy was provided to Lead Staff, Claudia Elias, for signature.