Valley Pines

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Administrator James Heinan. During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured 6 resident living units. LPA observed each living unit had available bedding and clothing storage areas and working lights. The bathrooms had working lights and available soap and paper towels. LPA observed the water temperatures in the bathroom sinks to be between 111-119 F. LPA toured the outside area and found it to be clear of obstructions. LPA tested two out of two carbon monoxide detectors and found them to function properly when tested. During visit, staff were not able to test the smoke detection system and were not able to provide a copy of the last smoke detection system inspection report. The emergency disaster drill log indicates the last drill occurred on 10/01/2025. See LIC809-C page for more information. 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 LPA reviewed the Centrally Stored Medication and Destruction Record (CSMDR) for 5 residents. Resident R1's CMSDR was missing 2 medications and R2 was missing 1 medication. Staff entered the missing medications into the CMSDR during visit. LPA reviewed 5 resident records. R2's resident record was missing an Appraisal/Needs and Services Plan and R3's resident record was missing an Admission Agreement. LPA reviewed 5 staff records. 4 out of 5 staff were missing a current first aid certification. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. An Advisory Note was issued. See LIC9102 for more information. LPA Marrufo requests that the following documents be updated and copies sent to the department by 12/17/2025: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility Liability Insurance LIC610 Emergency Disaster Plan This report was reviewed with Carolyn Heinan and a copy of this report and appeal rights were provided. Page 2 of 2.

It was alleged that the facility staff neglect resident by not providing services to include change the resident diapers leaving resident (R1) in soiled diaper all day resulting in a pressure injury. The review of records show that R1 does have history of skin breakdown to include skin breakdown in the sacral. Staff members were interviewed. Based on staff interview, it was stated that the facility had a former caregiver who left the facility on 08/31/2024, who provided all care to R1. Since that caregiver left, the facility staff was having difficulties in providing R1 care. Staff stated that the caregivers do try to assist R1 with changing his/her soiled diapers, however, R1 refuses to be changed most of the time. Staff stated that they cannot force R1 if he/she refuses but will be give the resident space and try again later. Staff stated that they observe the residents very frequently and assist with incontinent care, if needed. It was stated that if a resident's is observed soiled, they would assist the resident right away in changing the resident's diaper. Staff denied leaving any residents soiled. Resident (R1) was interviewed. Based on resident interview, R1 denied being left in soiled diapers for a long time. It was alleged that the facility does not have sufficient number of staff to meet the residents needs. It was alleged that on 09/08/2024, there was only 1 staff at the facility. Staff members were interviewed. Based on staff interview, it was stated that majority of the residents at the facility, besides R1, are are able to take care of their activities of daily living with minimal staff assistance. Staff states that they are able to take care of all the residents’ needs within their shift. The Licensee denied a staffing shortage. It was stated that they have at least 1-2 caregivers for the whole building per shift, as all their residents, besides R1, does not require additional care where they need more caregivers. Page 2 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 3 residents were interviewed. 1 out of 3 residents stated that the facility does not have enough staff. This resident stated that he/she always needs help getting in and out of bed, but because of the staffing sometime they come a little late if the staff are too busy. 2 out of 3 residents did not have any issues or concerns regarding the staffing levels at the facility. These residents stated that they get help from staff when needed. Based on review of the facility’s compliance history, there are no serious incidents reported that resulted from insufficient staffing numbers. It was alleged that the facility did not report R1’s change of condition of a toe infection to the resident’s responsible party. Based on record review, it was found that R1’s alleged toe infection was observed and reported by a vendor who provided manicures and pedicures for the residents. The vendor did not state that R1’s toe was infected but stated to have observed discoloration and advised R1’s family to seek medical advice. Based on interview with the Licensees, they denied the knowledge of R1’s toe being infected. 2 caregivers who were interview, denied the knowledge and observation of R1’s alleged toe infection. 2 staff denied being informed that R1 even had a toe infection. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensees, James and Carolyn Heinan and a copy of the report was provided. Page 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 It was alleged that facility staff are not treating residents with dignity by belittling and yelling at the residents. 3 residents were interviewed. 3 out of 3 residents denied staff not treating the residents with dignity by belittling and yelling at the residents. 3 witnesses were interviewed. 3 out of 3 witnesses denied the observation of facility staff not treating the residents with dignity by belittling and yelling at the residents. 7 staff members were interviewed. 7 out of 7 staff members denied facility staff not treating residents with dignity by belittling and yelling at the residents. It was alleged that the facility staff violated the resident’s personal rights by forcing them to stay in the room and leave the bedroom door open. 3 residents were interviewed. 3 out of 3 residents denied being forced to leave their bedroom door open. Residents states they voluntarily leave their bedroom door open sometimes. 3 witnesses were interviewed. 3 out of 3 witnesses denied the observation of resident’s being forced to leave their bedroom door open. 7 staff members were interviewed. 7 out of 7 staff members denied forcing the residents to leave their bedroom door open. It was stated that the residents are able to leave their doors open or closed and the facility does not have any rules about that. It was alleged that the facility did not provide R1 with reasonable accommodation to R1’s request of only female caregivers to provide care to R1. Resident (R1) was interviewed. Based on resident interview, R1 prefers women caregivers. R1 denied male caregivers providing care to him/her. R1 states there is a male staff who only assists him/her out of bed but R1 consents to it. The Department has investigated the above allegations. Based on interviews, the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensees, James and Carolyn Heinan and a copy of the report was provided. Page 2 of 2.

Based on interview and record review, R1’s care plan was not updated prior to LPAs visit on 09/16/2024, to indicate that R1 required a 2-person assist. It was stated that the Licensee was not part of the assessment with R1’s family member and home health agency on 09/06/2024 and was unsure of their discussion / care plan developed. On 09/09/2024, R1’s private caregiver through a home health agency, started services at the facility to help with R1’s care needs. Based on interview with the private caregiver (W1), it was stated that W1 was trying to put R1 to bed but was unable to transfer R1 from wheelchair to bed by him/herself and needed a second person for assistance. W1 described themselves as a small and petite individual who did not receive any training from the home health agency nor have any caregiving experience prior to providing care to R1. W1 states that he/she called the Licensee for assistance, but the Licensee was unable to assist with the transfer due to back pain. W1 stated that the Licensee advised W1 to call 911 for a “lift-and-assist” as the facility staff were unable to provide secondary assistance to transfer R1 from the wheelchair to bed. W1 stated to have called the lift-and-assist who shortly arrived at the facility. On 09/16/2024, 4 staff members were interviewed. The Licensee stated that there was a caregiver who left the facility on 08/31/2024, who knew how to care for R1. This caregiver provided training to a facility staff before departure, however, this facility staff stated that due to back pain and safety reasons, the staff was unable to transfer R1 by him/herself. Based on staff interview, 4 out of 4 staff members stated that due to safety reasons, R1 requires a 2-person assist to get R1 in and out of bed. It was stated that R1 is in a lot of pain and is unable to bear weight during transfers making it difficult for one person to assist R1. The licensee stated that upon departure of the staff who was providing care to R1, they had spoken with R1’s family member regarding the inability to assist with transferring R1 due to the lack of capable staff, back pain and the licensees age. The licensee stated to have advised family to find R1 a new placement who can better meet R1’s needs. Page 2 of 4. 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 It was alleged that the licensee mentally abuses R1 by putting it into R1’s mind that R1 has dementia and would deny R1’s reality of the actual events. It was alleged that on 09/09/2024 the fire fighters, paramedics and police were at the facility and when R1 asked the licensee if the police were there, it was alleged that the licensee would deny the reality and put it into R1’s mind that R1 has dementia. Based on record review, R1 is diagnosed with mild cognitive impairment. Based on R1’s service plan, its indicated that R1 has mild forgetfulness. 4 witnesses were interviewed. Based on interview, 3 out of 4 witnesses denied the observation of the licensee stating R1 has dementia. 3 out of 4 witnesses denied the observation of the licensee confusing R1’s reality. 1 out of 4 witnesses stated that the licensee has told R1 that he/she has dementia and denies R1’s reality that is causing R1 to become confused. W4 states that R1 questioned if the firemen and paramedics were real, in which W4 confirmed the reality. W4 stated that the licensee has commented to R1’s face stating that R1 does not know what he/she is talking about, is too much trouble, and threatened to put R1 into the streets. On 09/16/2024, 7 staff members were interviewed to include the licensee. The licensee denied the allegation and denied stating that R1 has dementia to his/her face. Licensee stated that R1 has forgetfulness. The Licensee denied intentionally yelling or hurting R1’s feelings and denied threatening to put R1 into the streets. The licensee states that R1 and the licensee jokes in German, which the tone can be heard as loud, but the conversations were always friendly. The Licensee stated that he/she does not remember R1 asking about the incident that occurred the night of 09/09/2024. The remainder of the staff interviewed denied the observation of the licensee mentally abusing R1 and other residents in care. Page 3 of 4. 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 09/16/2024, R1 was interviewed. Based on interview, R1 stated that the staff treat him/her nicely. R1 stated that the licensee treats him/her nicely and had no complaints about the licensee. R1 states that he/she likes to speak German with the licensee and states to have playful conversations with the licensee. R1 denied the licensee saying mean things or confusing R1. When LPA asked R1 about the night the paramedics arrived to assist R1 to bed, R1 stated that nothing happened that day and did not elaborate further about the incident. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee / Administrator Carolyn Heinan and and James Heinan and a copy of the report was provided. Page 4 of 4. 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 09/09/2024, R1’s private caregiver through a home health agency, started services at the facility to help with R1’s care needs. Based on interview with the private caregiver (W1), it was stated that W1 did not receive any training from the home health agency nor have any caregiving experience prior to providing care to R1. W1 states that he/she was unable to transfer R1 from the wheelchair to bed alone and asked the licensee for assistance, which the licensee was unable to provide due to back pain. W1 was instructed by the licensee to call for a “lift-and-assist”. W1 stated that the fire fighters arrived and was unable to move R1 to bed because R1 would scream anytime they tried to lift him/her. W1 stated that because R1 refused to be moved, the fire fighters left and stated that they could not force R1. Based on interview with the licensees, it was stated that the fire department showed up at the facility around 7:30pm but because R1 refused to be moved from the wheelchair to bed, the fire department left. The licensee stated to have checked in on R1 around 10pm, however, R1 still refused to go to bed. R1’s family member was informed of the situation. Around 12am, the licensee called 911 and paramedics were able to assist R1 to bed. The licensee states the reason for the delay was because they did not want to upset R1’s family members and they were waiting for a response from the family members on what to do, as R1 was refusing to be lifted to bed. The licensees denied impeding in the transfer. Based on interview with W1, W1 denied the licensees impeding in the transfer between the fire fighters. W1 stated that all parties were trying to get R1 to bed, but R1 was refusing. W1 denied the licensee impeding in R1’s transfer and stated that R1 needed secondary assistance to move R1 from wheelchair to bed. It was alleged that the facility does not have an awake night staff or security checking the residents throughout the night. Page 2 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 Based on interview with the licensees, it was stated the staff are consistent and know their hours of work, in which they do not write a staffing schedule. It was stated that one of the licensees covers the night shift and the licensee’s do not clock in and out of work as they are the owners of the business. On 09/16/2024, 7 staff members were interviewed. Based on interview, 7 out of 7 staff stated that the facility has an awake night staff and live-in staff available on-call. It was stated that one of the licensee covers the night shift. Based on record review of the facility's staffing record that was submitted to the Department, the facility has a night shift staff scheduled to cover from 9:00pm - 7:00am. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee / Administrator Carolyn Heinan and and James Heinan and a copy of the report was provided. Page 3 of 3.

On 12/30/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Carolyn Heinan and explained the purpose of the visit. LPA toured the facility inside and outside including a random sample of resident rooms, common areas, activity room and kitchen area. While touring the facility it was observed that the temperature was at 72 deg F. Hot water was also tested in the resident rooms and the temperature was 112 deg F. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floor. Resident call buttons are functioning. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. Five resident records and three staff records were reviewed. Resident records are updated, complete and signed. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA requested the following to be emailed: Liability Insurance. LPA received a copy of Deed.. No deficiencies are cited at this time. Report is reviewed and a copy is provided.

Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin arrived unannounced to conduct a case management visit to deliver an immediate exclusion letter for staff (S1). LPA met with Administrator/Licensee James Heinan. LPAs provided a letter "Order to Licensee/Facility of Immediate Exclusion From Facility" that the department determine that S1 engaged in conduct inimical as a staff in a facility. ADM was informed to remove S1 from any contact with residents and S1 may not be physically present in any facility. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator/Licensee James Heinan and a copy of the report was provided.

On 08/29/2023, 2 staff were interviewed. Based on interview, on 08/24/2023 around 04:00am, resident (R1) exited the facility without notice. R1 was found at a traffic light within steps of the facility continuously pressing the pedestrian button. A concerned citizen contacted the police and the licensee was notified of the incident. S1 states to have gone to tend to R1 until police arrived. The police officers escorted R1 back to his/her bedroom. Based on record review, R1 is able to leave the facility unassisted. S1 states to have worked the NOC shift and did not hear R1 leaving the facility. Based on interview, R1 is able to store his/her own medications per R1’s physician’s report. Due to R1’s observed behaviors, the facility had concerns regarding R1’s health and safety of storing his/her medications. R1’s responsible party was contacted in which they agreed to have the facility store/administer R1’s medications for R1’s health and safety. S1 states, R1’s medications were being administered daily, however, R1 refused medications for one day. Based on record review, R1 is able to store his/her own medications. Records show the facility’s attempt to contact R1’s physician for an updated physician’s report and physician’s orders. On 08/29/2023, 3 witnesses were interviewed. Based on interviews, the facility was provided consent by R1’s responsible party to store/administer R1’s medications for R1’s health and safety. It was believed that R1 had refused to take his/her medications from the staff. The facility was in frequent communication with R1’s case manager regarding R1’s medications, however, the facility was not receiving timely response by R1’s doctor. On 08/29/2023, 3 residents were interviewed. 3 out of 3 residents state they are provided their medications daily by staff. The Department has investigated the above allegations. Based on interview, record review and observation, the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid there is a not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensees and a copy of the report was 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 On 08/29/2023, 2 staff were interviewed. Based on interview, on 08/24/2023 around 04:00am, resident (R1) exited the facility without notice. R1 was found at a traffic light within steps of the facility continuously pressing the pedestrian button. A concerned citizen contacted the police and the licensee was notified of the incident. S1 states to have gone to tend to R1 until police arrived. The police officers escorted R1 back to his/her bedroom. After the incident S1 sat in the hallway of R1’s bedroom to provide R1 supervision and ensure R1’s safety. 2 out of 2 staff denied forcing the resident to stay in bed. 2 out of 2 staff denied confiscating R1’s cellular phone. On 08/29/2023, 3 residents were interviewed. 3 out of 3 residents were never forced to stay in bed by the staff. 3 out of 3 residents have never gotten their cellular phone confiscated by the staff. On 08/29/2023, 3 witnessed were interviewed. 3 out of 3 witnesses denied knowledge of R1 being forced to stay in bed. 3 out of 3 witnesses denied knowledge of R1’s cellular phone being confiscated by staff. W3 states the presence of R1’s cellphone in R1’s bedroom at the facility. 3 out of 3 witnesses state they were able to get a hold and contact R1. Based on record review, R1 signed and acknowledged his/her personal rights. The Department has investigated the above allegations. Based on interview, record review, and observation the above allegation is unfounded, meaning the allegation is false could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensees and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection to focus on infection control. LPA met with Administrator Carolyn Heinan. During visit, LPA toured the facility's interior and exterior to include the TV Room, dining room, resident rooms, resident bathrooms, hallways, staff bathrooms, and courtyard. Fire exits were free and clear of obstruction. LPA observed a central entry point and hand sanitizer for all visitors, staff, and residents. Facility has a special visitor sign at the front entrance. LPA observed the bathroom to have supplies of paper towels, and soap available for staff, residents, and visitors. Facility disinfect and sanitize high touch surfaces daily and as needed. All staff and residents are fully vaccinated. The Department will provide COVID-19 resources and PPE supplies for facility. No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory Notes provided. This report was reviewed with Administrator Carolyn Heinan and a copy of this report was provided.