Vineyard Place.

LPA’s interview with the Administrator did not reveal any information about how R1 developed sepsis. The Department’s investigation did not provide enough information to corroborate the allegation that resident developed sepsis while in care. Based on records review and interview conducted, this allegation is unsubstantiated . It was alleged that staff served cold food to resident. Information received indicated R1’s food was served cold on one (1) occasion. R1’s relevant party asked a staff member to re-heat the food, but they did not do so without any explanation. LPA conducted interviews with eight (8) staff members, all of whom denied serving cold food to residents. LPA’s attempt to conduct interviews with six (6) previous staff members who worked in year 2022 were unsuccessful. LPA also conducted interviews with two (2) residents who were with their relevant parties, all of whom denied receiving cold food. The Department’s investigation did not provide enough information to corroborate the allegation that staff served cold food to resident. Based on interviews conducted, this allegation is unsubstantiated . It was alleged that resident is not served an adequate amount of food. Information received indicated that Resident #1 (R1) ate their meal in about 2 minutes, so R1’s relevant party asked a staff member for another dish, but the staff member never came back with another dish. LPA conducted interview with eight (8) staff members, all of whom stated any resident can ask for additional plate of food if necessary. LPA’s attempt to conduct interviews with six (6) previous staff members who worked in year 2022 were unsuccessful. LPA conducted an interview with the Administrator who stated R1 often ate double portions, and staff members have provided additional plate of food upon request from R1. LPA conducted interviews with two (2) residents who were with their relevant parties, all of whom stated they had received more than enough food. The Department’s investigation did not provide enough information to corroborate the allegation that resident is not served an adequate amount of food. Based on the interviews conducted, this allegation is unsubstantiated . It was alleged that facility is unsanitary. LPA toured the interior and exterior areas of the facility and found them to be clean and well organized without any foul odor in any of the hallways. LPA conducted an interview with the Administrator who denied the facility ever being in unsanitary condition. The Administrator stated that all caregivers and housekeepers have cleaned the facility on daily basis. Continued on LIC9099-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 The Administrator also stated that no one has complained about the facility being unsanitary. LPA conducted interviews with eight (8) staff members, all of whom denied the facility ever being in unsanitary conditions. LPA’s attempted interviews with six (6) previous staff members who worked in year 2022 were unsuccessful. LPA conducted interviews with two (2) residents who were with their relevant parties, all of whom stated the facility had been in very clean condition. The Department’s investigation did not provide enough information to corroborate the allegation that facility is unsanitary. Based on observations and interviews conducted, this allegation is unsubstantiated . It was alleged that facility is not allowing resident to receive phone calls. LPA conducted an interview with the Administrator who stated that R1’s relevant party set up a phone in R1’s room. The Administrator stated that there was no way any staff members could restrict phone calls to R1. For the residents who do not own a phone, anyone can call the front desk who transfers the phone calls to medication technicians who then hand the phone calls to the residents. The Administrator stated that most residents do not own phones due to their cognitive condition. LPA’s interviews with eight (8) staff members corroborated the Administrator’s statements. LPA’s attempted interviews with six (6) previous staff members who worked in year 2022 were unsuccessful. LPA conducted interviews with two (2) residents who were with their relevant parties, all of whom stated that staff members have never restricted phone calls. The Department’s investigation did not provide enough information to corroborate the allegation that facility is not allowing resident to receive phone calls. Based on interviews conducted, this allegation is unsubstantiated . A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.

On 9/18/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced 1-year required visit to the facility. LPA Flores was greeted by receptionist Karolina whom contacted the Clinical Service Director, Nikki Hultquist. LPA informed Nikki of the purpose of the visit and a tour of the facility was conducted. LPA observed the following during the visit: The facility has a census of (57) fifty-seven residents to which (3) three residents were out of the community. The facility is licensed for (82) eighty-two non-ambulatory residents to which (20) twenty may be bedridden. The facility is a single-story structure which consist of (64) sixty-four bedrooms along with shared, Jack and Jill style, bathrooms. Resident bedrooms are equipped with the required bedding, lighting, seating, and furniture. The shared bathrooms were observed to have the required grab bars and slip-resistant properties for each toilet and shower areas. The facility kitchen was observed to be in clean and sanitary condition. Facility food supply met the required (2) two-day supply of perishables foods and (7) seven-day supply of non-perishable foods. A monthly activities calendar is posted near the dining room area. There is a locked location for chemicals and sharp items in the kitchen. Medication was observed to be locked and inaccessible to residents. During the visit, LPA observed facility staff orchestrating a planned activity for the residents. There are no bodies of water located on the property. The facility remains free of odor. Indoor/outdoor passageways are kept free of obstruction. LPA observed a covered patio with sufficient seating. Per Executive Director, TJ Taylor, there are no firearms and/or ammunition on the premises. (Continue to 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 (Continuation from LIC809) LPA Flores conducted resident records review of (5) five residents. Resident files included but not limited to identification and emergency information, pre-appraisal assessments, admission agreement, physician reports, TB test results, safeguard for personal property/valuables, and personal rights notification. LPA conducted a staff records review. Staff records included but not limited to valid first-aid/CPR certification, criminal record clearance, health screening and TB test results, employee rights, and training's relevant to provide care and supervision to residents at a Resident Care Facility for the Elderly. LPA reviewed the Medication Administration Record for (5) five residents and did not observe any discrepancies. During today's visit, no deficiencies were issued. An exit interview was conducted where a copy of this report was provided to Executive Director, TJ Taylor.

frequently if needed. The police department was contacted to request records; however, no reports were found involving R1 or the facility. There were no documents or photos submitted with the complaint and the Department was unable to obtain any additional information regarding the allegation. The information obtained during the course of the investigation from the hospice agency revealed the hospice and wound care nurses denied the allegation to be true. They indicated that there was no indication of maggots on R1’s pressure injury or body. Additionally, the wound care and progress notes were obtained. The progress notes, specifically on the date of the allegation, 10/12/2023, annotated that wound care services were rendered, and no unusual skin changes were noted. The facility staff denied the allegation of neglect/lack of care and never observed any maggots on R1’s body. Based on the Department’s investigation, the allegation is deemed Unfounded at this time. A finding of Unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, where a copy of this report, LIC811-Confidential names list, was reviewed and provided to Angela Jackson, Community Relations Director.

On 05/01/25 at 1:30pm Licensing Program Analyst (LPA) Javina George made an unannounced case management Incident visit to the facility. LPA met with Executive Director Thomas Taylor, and explained the purpose of the visit. During today's visit LPA verified the whereabouts of Staff #1 and obtained an update in regards to the status of the internal investigation that is being conducted. Per Executive Director Thomas the investigation should be concluded tomorrow 5/2/25. LPA conducted interviews, reviewed as well as requested documentation pertaining to the alleged incident. Additionally during today's visit LPA followed up on the facility's unpaid annual fees that were due September 2024. No deficiency was cited as the fees were paid during today's visit. LPA was provided a copy of the receipt verifying that the outstanding balance of $2,601.00 had been paid. An exit interview was conducted and a copy of this report was reviewed and provided to Thomas Taylor, Executive Director.

Licensing Program Analyst (LPA’s) Armando Perez and Kathleen Banrasavong made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA's were greeted by reception and contacted the Administrator Thomas Taylor Jr to meet with LPA's. The LPA's informed the Administrator of the purpose for the visit. The inspection included the following: The facility has a census of 53 residents and is a single-story unit consisting of 64 bedrooms with private bathrooms. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. LPA's observed a kitchen with large refrigeration unit and a dinning area with sufficient setting and space for activities. A monthly activities calendar is kept in the dinning area. A laundry room is on site with locked cabinets. There are no bodies of water located on the property. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. LPA's observed two outdoor covered patios with seating. LPA's began review of client records. 10 records were reviewed. LPA's reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA's began review of employee records with 7 records were reviewed. LPA's reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 04/20/2025. LPA's observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. 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 Medications is stored in two separate secured locations. There is a locked cart inside the room allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA's made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were previously tested found to be operational on 10/10/23. The facility is conducting emergency disaster/fire drills monthly. Based on the information received during this visit today in the areas reviewed, there are no deficiency that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.

Information obtained also revealed that resident did not have a two-person assessment done at the time of admission. LPA was informed by Executive Director, Arlene Crawford who reported that while there was no mention of two assist in assessment, staff can request additional help if necessary. In regards to the allegation that the facility is in disrepair. It was alleged that the restroom doors are difficult to open and locked. LPA observed the restroom door and noticed it did stick, but was still functional. LPA's interviews with staff indicate they received no complaints about the bathroom doors sticking. Of the interviews with residents conducted, residents were not able to answer LPA's questions regarding the bathroom doors sticking due to their dementia state. It was also reported that the facility is unsanitary. It was alleged that the floors in resident’s bedrooms and in the dining room are sticky due to urine not being properly cleaned up. LPA observed select bedroom units and noticed a sticky substance on the floors, but it was determined to be a chemical substance used to clean the floors and not urine. LPA interviewed Maintenance Director, George Uhila, cleaning staff, and toured the cleaning station. LPA observed cleaning liquid used to clean the floors was a "wash and walk" substance meaning no rinsing was required. Staff indicated the floors to be sticky due to a build-up of the chemical substance and that the overnight shift conducts a hot water rinse nightly to remove the build-up. LPA attempted to interview Residents regarding this issue, but they were unable to answer LPA's questions due to their dementia state. LPA was informed by house keeping staff that cleaning of the floors is scheduled once a week and is additionally cleaned by Resident Care Assistant on their shifts, two times morning, once in the afternoon. It was also reported that the facility is malodorous. It was alleged that there is a smell of urine throughout the facility. LPA did observe a urine scent upon entry into the facility. LPA conducted interviews with Maintenance Director, George Uhila, housekeeping staff, and toured the cleaning area. 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 explained that the smell of urine throughout the facility is due to the type of residents the facility serves. It was further explained that in memory care, residents have incontinence issues and the facility has made efforts to keep the smell under control. LPA was provided records of cleaning schedules, cleaning stations, and observed air fresheners mounted throughout the facility and cleaning stations. Based on observation, interviews and information obtained, the allegations that the facility staff are not properly trained, facility is in disrepair, unsanitary, and malodorous is UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted where a copy of this report was provided to Nieves Villapando, Clinical Service Director .

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit for an annual inspection. LPA was granted entry and met with Staff Development Director Tiffany Querido to conduct the tour of the facility. Executive Director Arlene Crawford arrived during the visit to assist. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair and were present. The facility is approved for a secure perimeter and has working auditory door alarms for residents with dementia. The outdoor area was observed to be free of hazards. The facility has two courtyards with outdoor furniture and shaded area for residents. LPA observed the fire alarm panel showed all systems normal. The smoke detector and carbon monoxide are inspected annually. LPA recorded the hot water temperature in resident bathrooms at 109.2 F and the bathrooms located throughout the hallways at 106.7 F. The facility does not contain any pools or bodies of water, firearms, or ammunition on the property. LPA observed sufficient supply of hygiene items, linens, towels and blankets. The cleaning supplies and other toxins are stored in housekeeping closets. LPA observed sufficient lighting in each bedroom as well as all appropriate furniture such as beds, chairs, night stands, lamps and closet/drawer space. Facility's restrooms were clean and operational and contained grab bars and non-skid mats in all the bathrooms. 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 observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA was informed the facility receives two shipments of food a week. Adequate staff are present for the supervision of residents during the visit. LPA reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate. LPA reviewed five (5) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed and possessed all required paperwork. Resident medications are stored and secured in the North medication room and South Medication room. LPA observed the facility utilizes an eMARS for documentation of the distribution of medication. LPA observed all medications listed on eMARS and all required labeling was found to be in place. LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility conducts fire and earthquake drills monthly which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Executive Director Arlene Crawford.