Heritage Hills.

(Continued from LIC9099C, Page 3) Records Review demonstrated that facility staff put in work orders for maintenance for R1's hospice equipment on 01/23/25, 01/28/25, 04/10/25, 08/23/25, and 09/05/25. Per the Hospice Inventory item pickup, dated 11/19/2025, R1 had the following equipment for use from 04/10/25 until R1 moved out of the facility on 11/19/25: two fall pads, hospital bed, over bed table, two half rails, mattress, recliner, 2 foot rests, high back wheelchair, and a pommel cushion. 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. On 08/12/2025 it was alleged that "Staff did not dispose of waste in a proper manner" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and records review. Regarding the allegation, "Staff did not dispose of waste in a proper manner", it was alleged that facility staff do not clean the room on a regular basis which resulted in leftover fecal wipes in a resident's room. Interviews with staff demonstrated that staff are aware of the housekeeping schedules and proper sanitation requirements when providing care for residents. S1 stated, "twice a week that rooms are deep cleaned." With regards to continence care, fecal wipes are disposed in resident waste baskets and after each brief change, the plastic bag goes with caregivers to be delivered to the trash room. Interviews with Residents conflicted on the cleanliness within the facility. R2 stated that facility staff do not keep the facility clean but clarified that meant staff don't change the linens often enough. R3 stated that the facility was clean and stated their observations that staff are "always sweeping the hallways" or "cleaning up R3's room" when they provide care for them. Records review of housekeeping records demonstrated that care staff regularly cleaned R1's room during the time period of the complaint. (Continued on LIC9099C, Page 5) 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, Page 4) LPA observed resident rooms as part of the investigation. Resident rooms did not have trash on the floor, the walls and windows were not dusty or dirty, and the linens appeared clean meaning they did not have noticeable crumbs, dirt, or stains. 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 Executive Director Mike McCoy, 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 LIC9099C, Page 2) Interviews with staff demonstrated knowledge of the rights of residents. Staff consistently reported room temperatures were to stay in compliance range around 74 degrees. S1 stated that when staff perform their checks on residents, they check the thermostat and shut/open windows depending on how the room feels and with consent from residents. Interviews with Residents corroborated staff interviews. In an interview with R3, they stated that the temperature changes in their room but it's not bad. R3 additionally reported that staff supplemented them with an oscillating fan to help regulate the temperature even more. LPA observations revealed temperatures of rooms of residents were within regulatory compliance. Based on interviews and direct LPA observations a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. On 08/12/2025 it was alleged that "Staff did not follow resident’s care plan." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, and records review. Regarding the allegation, "Staff did not follow resident's care plan", it was alleged that facility staff did not ensure that hospice bed rails were maintained on R1's hospice bed. Interviews with Staff consistently reported that any equipment brought in from hospice as a part of a resident's care plan must be maintained by the hospice provider and cannot be worked on by staff per hospice policy. S1 stated that as a result of an observation from R1's family about their bed rails, S1 placed a work order for R1's half bed rails to receive maintenance and encouraged the family of R1 to call hospice as well. According to staff, R1's family claimed the half bed rail placed against the wall on R1's hospital bed was loose/not attached. S3 stated they inspected the bed rail without adjusting it per hospice policy and that it was attached to the bed. LPA asked staff if R1 had the strength or capacity to push themselves and their bed away from the way to which staff replied that no, R1 was at no risk or strong enough to create that situation and fall between the wall and the bed. Additionally, S1 spoke to R1's family about their request for full bed rails on R1's hospice bed. S1 warned against that and the family's suggestion to put R1's wheelchair against the bed when R1 slept as those accommodations would be considered restraining R1. (Continued on LIC9099C, Page 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 (Continued from LIC9099, Page 1) Interviews with staff confirmed that Resident 4 (R4) and Resident 5 (R5) have engaged in sexual relations with consent with each other prior to the occurrence witnessed by the reporting party. S1 stated that both R4 and R5 display behaviors such as "inappropriate touching" and "disrobing in public" and that care staff are to redirect residents when they witness these behaviors occurring. S1 stated that the relationship is consensual as both R4 and R5 will seek each other out and that R4 and R5's families are aware of the behaviors. When R4 and R5 express these behaviors, staff follow the care plan (stated as redirection, and offering alternative activities) and report events to the families of the residents. Records Review was consistent with staff interviews. The physician's report for R4 lists diagnosis as follows: Dementia with behavioral disturbance, cognitive communication deficit, hemiplegia - affecting L nondominant side, and type 2 diabetes mellitus without complications. The service plan report subsection "Behavioral Management Service Plan" states that care staff will provide reorientation within the community and redirection as needed to manage behaviors and that staff will provide close supervision and frequent monitoring, especially in common areas and during interactions with other residents. The care notes for R4 dated from Jan 2025 to Nov 2025 consistently report when R4's condition of exhibiting behaviors as described above and staff's response. The notes include caregivers following the behavioral management service plan when R4 exhibits behaviors. The physician's report for R5 lists diagnosis as follows: Unspecified dementia unspecified severity, psychotic disturbance, mood disturbance, anxiety, and unspecified mood disorder. The service plan report subsection "Behavioral Management Service Plan" states that care staff will redirect resident promptly and respectfully when flirtatious or inappropriate behavior is observed. 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. On 08/12/2025 it was alleged that "Staff did not maintain comfortable temperatures for resident" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff and residents. (Continued on LIC9099C, Page 3)

The outside advocacy agency confirmed having no knowledge or evidence to support the allegation, and records review revealed no documentation or evidence to substantiate the claim. The resident could not be interviewed due to passing away prior to the investigation. An outside healthcare agency noted occasional resident conflicts and described R1 as sometimes lonely with communication challenges and fluctuating orientation. The hospice nurse stated staff were attentive, responsive, and never observed treating residents disrespectfully. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore, the allegation is unsubstantiated.

(Continued from LIC9099, Page 1) Interviews with staff revealed that during mealtimes, residents have the option of eating in the dining room, eating in their room, or refusing meals. Staff 1 (S1) and Staff 4 (S4) stated that residents who choose to eat in their room are not given food at the same time as residents in the dining hall, nor do they receive help from caregivers until the residents in the dining hall who require assistance are done eating. This can delay mealtimes for R1 who requests food in their room and require staff to assist with feeding. S4 stated that with regards to R1, they will check on them in their room during mealtimes, ask if they would like to eat with everyone in the dining room, and if not, they will offer a meal supplement/snack before R1’s dinner to help with the wait until they can finish assisting with dining room residents. Staff consistently stated that R1 will refuse meals and instead eat a meal supplement provided by their family. S4 told the LPA they believed it was possible that R1’s weight loss could be the result of R1’s eating habits at the facility (“R1 will only eat a couple of bites of their meals”) or a PRN medication’s side effects R1 takes daily. Additionally, S4 will ask R1 if they would prefer help with finger foods or sandwiches and assist based on R1’s preference. Interviews with residents revealed that there are times when food service is not prompt nor are staff present to assist if food is delivered to their room. R1 stated that staff are not consistent with bringing food on time and as a result R1 must rely on a supply of supplemental meals provided by their family to eat (this is not related to R1’s right to refuse meals which they will exercise on occasion). R1 told the LPA that there have been times when staff have delivered food to the room but will not stay to help feed them. This corroborates staff interviews. Interviews with outside sources revealed that Outside Source 2 (OS2) and Outside Source 3 (OS3) have observed R1’s experiences with the facility’s meal management. OS2 stated that they have called the facility in the past on an almost daily basis to check and confirm that R1 is fed at the beginning of mealtimes. OS2 and OS3 confirmed separately that there have been times they were with R1 at the facility and care staff did not provide notification or check on R1 for meal services. During those visits, OS2 has telephoned the staff from R1’s room asking if R1 was fed and reported that staff stated, “R1 refused food today.” OS3 told the LPA they were concerned about R1’s weight loss of 40 pounds during their time at the facility as a result of meal service inconsistencies. (Continued on LIC9099C, Page 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 LIC9099C, Page 2) LPA observations of the facility revealed that when the LPA arrived to interview R1, R1 was receiving a meal service with assistance of a care staff member. Records review revealed that R1’s physician’s report from October 2025 states that R1 is able to feed themselves but requires assistance and supervision. R1’s physician’s reports dated from February and October of 2025 show that R1 lost 40 pounds which corroborates outside source interviews. 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. On 12/09/2025 it was alleged that " Staff leave resident in bed for an extended period of time.” The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff leave resident in bed for an extended period of time," it was alleged that facility staff do not check in on R1 frequently enough or offer activities and opportunities for Resident 1 (R1) to leave their room. Interviews with staff revealed that residents can participate in activities at the facility including walks around the neighborhood and planned events coordinated by the staff. Staff 2 (S2) stated that there are activities planned every day at the facility and that residents are welcomed and encouraged to join. Staff 4 (S4) stated that they try to encourage R1 to come out for meals and activities, but R1 typically refuses. In an interview with R1, it was stated to the LPA by R1 that they are dependent on staff to transfer to their chair. However, by R1’s own admission, they “stay in their room mostly by choice” and that staff “don't refuse to get [them] out of bed." This corroborates staff interviews. Records review revealed in physician’s reports that R1 is not bedridden and can ambulate around the facility with the use of a walker or cane. (Continued on LIC9099C, Page 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 (Continued from LIC9099C, Page 3) 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 ED Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. On 12/09/2025 it was alleged that "Staff yell at resident” The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff yell at resident," it was alleged that facility staff do not treat Resident 1 (R1) with respect by yelling at them while receiving care at the facility. Interviews with staff revealed that staff unanimously agreed that they had not heard or witnessed other staff members yelling at residents. Staff 3 (S3) stated that the only time they’ve heard staff raise their voice to a resident was out of surprise and trying to redirect a resident’s behavior. Interviews with residents revealed that staff do not normally yell at residents. R1 stated "No, caregivers don't yell at me,” and that, “care staff are normally friendly and helpful." This corroborates staff interviews. 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 ED Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099, Page 1 ) Interviews with staff demonstrated knowledge of the rights of residents. Staff consistently reported no knowledge of other staff members who were rough or caused injuries to residents. Staff consistently reported that they observe aggressive behaviors from residents and know that acting aggressive or rough in return will only exacerbate the problem. Interviews with Residents corroborated staff interviews that staff are not physically aggressive when caring for residents. Resident 2 (R2) stated that care staff are normally friendly and helpful in their daily life. Interviews with Outside Sources corroborated staff and resident interviews noting that staff are not physically aggressive with residents. Outside Source 2 (OS2) reaffirmed that they have not witnessed physical or rough mannerisms from staff when caring for residents, however they have noticed that staff can become exacerbated when communication between staff and residents breaks down during care services. LPA Observations of the staff interacting with residents revealed that staff are patient, helpful, and attentive when helping residents in their activities of daily living. Record review revealed that Resident 1 (R1) is legally blind, with a dementia diagnosis, and requires help in many of their activities of daily living. 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 Business Office Director Amanda Togia , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099, Page 1) Interviews with staff revealed that residents are taxied in the van if they are scheduled for a doctor's appointment or if they had signed up for an activity that took place off property. Staff 1 (S1) confirmed that R1 was not signed up for any activities that day and did not have a doctor's appointment scheduled. Staff 2 (S2) stated that they were present when R1 was found near the van and reported that R1 had not been scheduled for a doctor's visit that day and instead had tried to elope from the facility through the stairwell leading to the parking garage. Interviews with Outside Source 1 (OS1) revealed that R1 was found near the van in the parking garage on the facility grounds. OS1 was able to stay with R1 until they could ask S2 to come and retrieve R1 and return them to the building. OS1 did not report seeing R1 inside the van at the time of discovery. Records review confirmed that R1 has a history of Alzheimer's disease. An activities calendar for November showed a scheduled outing for November 18th, 2025 at 1:30pm titled, "Oceanside Coffee Date." On the Sign up sheet for the outing R1's name is absent which corroborates staff interviews. 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 Executive Director Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Interviews with staff revealed that residents are taxied in the van if they are scheduled for a doctor's appointment or if they had signed up for an activity that took place off property. Staff 1 (S1) confirmed that R1 was not signed up for any activities that day and did not have a doctor's appointment scheduled. Staff 2 (S2) stated that they were present when R1 was found near the van and reported that R1 had not been scheduled for a doctor's visit that day and instead had tried to elope from the facility through the stairwell leading to the parking garage. Interviews with Outside Source 1 (OS1) revealed that R1 was found near the van in the parking garage on the facility grounds. OS1 was able to stay with R1 until they could ask S2 to come and retrieve R1 and return them to the building. OS1 did not report seeing R1 inside the van at the time of discovery. Records review confirmed that R1 has a history of Alzheimer's disease. An activities calendar for November showed a scheduled outing for November 18th, 2025 at 1:30pm titled, "Oceanside Coffee Date." On the Sign up sheet for the outing R1's name is absent which corroborates staff interviews. 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 Executive Director Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099, Page 1) Interviews with staff demonstrated knowledge of the rights of residents. Staff consistently reported no knowledge of other staff members who were rough or caused injuries to residents. Staff denied forcing residents to go to bed early. When asked about forcing residents to bed, S3 stated that it was counterproductive for the facility to force residents to bed as it increases a resident's likelihood to practice exit-seeking behaviors. S3 stated, "residents are happier when we provide choices and freedoms for them." Interviews with Residents corroborated staff interviews that caregivers do not tell residents to go to bed early or that they physically force residents to go to bed against their will. With reference to injuries from showering, in an interview with R1, they stated that even though they know they are not supposed to shower without help due to a history of falls, they attempted to shower by themselves before they were found by care staff and assisted. Records review confirmed that R1 has a history of Dementia, Major Depressive Disorder, and Anxiety Disorder. The care notes for R1 stated on 10/17/2022, (10 days prior to the initiated complaint), R1 "demanded to go to bed at 3pm." When staff came back to check on R1 an hour later, they found R1 on the floor. Staff did a safety check to ensure there were no injuries and helped them back into their bed. Additionally, R1's care plan corroborated that R1 required assistance with showering. 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 ED Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Regarding the allegation staff hit a resident in care. There were no witnesses or documentation indicating that any staff physically harmed the resident. The facility reported the resident often exhibited aggressive behavior due to dementia, but staff utilized de-escalation methods and denied using force. The DPOA reported visiting frequently and expressed confidence in the care provided. Medical documentation showed no injury pattern consistent with assault. Law enforcement found no evidence of abuse when contacted. 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. Regarding the allegation staff did not dispose of residents’ diapers. Facility staff denied failing to dispose of diapers and stated that soiled briefs are immediately placed in designated waste bins. The DPOA reported that the facility maintained cleanliness and had no concerns about hygiene. No supporting documentation or witness statements corroborated the allegation. Due to the resident’s passing in July 2025, direct observation was not possible, and no evidence was located to support that neglect occurred. Although the allegation may have occurred 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. Regarding the allegation Staff are not allowing a resident to receive phone calls. Interviews were conducted with the Resident Service Director and the Durable Power of Attorney (DPOA). The facility Resident Service Director stated facility Medication technicians reported when Reporting Party called the facility it was mainly to yell at the medication technicians and Reporting Party would not even ask to speak to Resident 1. Resident Service Director stated facility staff never intentionally denied Resident 1 from speaking to Reporting Party. There was no evidence that staff isolated the resident. Although the allegation may have occurred 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. No deficiencies cited Per Title 22 Regulations. Exit interview conducted with and a copy of this report provided.

Records collected corroborated R1’s request for a private room. Outside source records revealed that as of October 31, 2024, R1 was receiving antibiotics for undisclosed medical diagnosis. Such records also revealed that R1 was admitted to hospital on November 11, 2024 for a viral infection and previous antibiotics were stopped. Based on this information, R1 was only at the facility for two days prior to being hospitalized. It was also alleged that in February of 2025, R1’s room had feces on the floor and was often messy. Records collected revealed that R1 lived at the facility from October 28, 2024, until November 9, 2024, a total of nine days. Records collected also showed R1 was not present at the facility as of November 6, 2024, when responsible party removed R1 and did not return. LPA facility observations made on today’s date did not reveal any information to prove facility is not sanitary or unclean. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Michael McCoy, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Assistant Resident Service Director Starsha Borja. Executive Director Mike McCoy and Resident Service Director Evalyn Valaile arrived during the visit. Today's visit was in response to a self-reported incident of Resident 1 (R1) found chewing on two pencil sharpeners during arts and craft resulting in staff finding two single razor blades in R1's mouth. [See LIC811 Confidential Names List.] During today’s visit, LPA performed a brief facility tour and welfare check on R1. LPA also collected copies of and reviewed R1's care and medical records. According to their latest LIC602 Physician’s Report, R1 was diagnosed with Alzheimer's disease and Dementia. Due to their baseline memory loss, R1 was not able to serve as a reliable historian/interviewee for this case. Staff interviews unanimously showed: Resident's are not to be allowed access to pencil sharpeners due to safety concerns. Sharpeners were to be used by staff to sharpen resident's pencils. Staff interviews further show: R1 has a history of putting inedible objects into their mouth and there is no consensus on how R1 obtained the sharpeners. Direct cares staff were supervising R1's floor (the first floor), activity staff were on the second floor conducting a different activity. One (1) deficiency was cited per California Health and Safety Code. An exit interview was conducted with Executive Director Mike McCoy and Resident Service Director Evalyn Valaile, to whom a copy of this report, the LIC811 Confidential Names List, the LIC809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was allowed entry and discussed the purpose of the visit with Resident Services Director (RSD) Evalyn Valaile. According to the facility’s license, The facility is approved to serve seventy eight (78) elderly residents. Of which sixty eight (68) may be non-ambulatory and ten (10) may be bedridden. Hospice waiver approved for twenty (20) residents. LPA, accompanied by RSD toured the interior and exterior of the facility, and inspected several resident rooms on the first and second floor of the facility. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature was measured in the facility at 115 degrees F. The ambient temperature inside the facility was measured at 75 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no pools/bodies of water on the premises. Per RSD, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [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 LPA reviewed multiple staff and resident records/files. Records review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Evalyn Valaile whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

The facility has an infection control plan in place that includes isolating covid positive residents during their infectious period. This protocol was reviewed and found to have been followed appropriately in the cases reported. Interviews with staff confirmed that the positive residents were isolated, and proper protocols were implemented once covid cases were identified, including; two hour checks, food delivered to resident's rooms and covid testing for symptomatic residents. Records review revealed incident reports were submitted to CCL on August 14, 2024. The incident reports indicated that five residents tested positive for Covid-19 and were immediately placed in quarantine with a "PPE isolation cart" placed outside of their door. A transmission precaution sign was also placed on each of the resident's door. All of the covid positive resident's responsible parties and Physicians were notified. LPA interviewed several of the residents that were previously covid positive. All of the residents interviewed stated that they were instructed by facility staff to self isolate in their rooms. One of the residents interviewed stated that the covid positive residents had their meals delivered to their rooms while they were sick and infectious. While residents were encouraged to wear masks and utilize PPE, it was noted that adherence to these guidelines varied, particularly among residents with cognitive impairments who may not fully understand the necessity of such measures. An interview with an outside source (OS) revealed no knowledge or evidence to substantiate the allegation that staff did not take appropriate actions to prevent the COVID outbreak. OS noted that the facility seemed to be following recommended protocols. LPA interviewed Business Office Director (BOD) who stated that when a covid case occurs at the facility the resident is placed on isolation and PPE supplies are placed outside of their room. Meals are served in resident's room and disposable plates and utensils are utilized until the covid case is resolved. Vitals are taken "Q-shift" and PRN. Residents with covid symptoms are tested and all staff, visitors and residents are encouraged to wear masks. The investigation indicates that while the facility faced challenges inherent in caring for residents with cognitive impairments, it followed its established infection control protocols. 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 upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Evalyn Valaile. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Evalyn Valaile whose signature below verifies receipt of these rights.

Records review further revealed that the resident census on the 1st floor and 2nd floor had an average of 36 residents. The AM staffing ratio on both floors was regularly at; three caregivers and one med-tech. The PM staffing ratio was regularly at three caregivers and one med-tech . The NOC staffing ratio was regularly at two caregivers and one med-tech for both floors. The staffing schedule also revealed an outside agency had been utilized to assist with staff vacancies. Analysis of staffing schedules showed that the facility maintained adequate staffing ratios to address the needs of residents. LPA interviewed a 2nd floor resident who stated that they have lived at the facility for 2.5 years. Resident stated that they are very happy at the facility. Resident stated the facility staff are "wonderful" and they feel "blessed" to live there. Resident further stated that they get "fast help from staff" whenever needed. It was also alleged that the facility did not have adequate supplies to meet residents needs. It was reported that the facility was low on various sanitary and medical supplies. It was also reported that staff did not have access to the supply room during the NOC shift. LPA visited the facility on July 29,2024. LPA inspected two supply rooms on the second floor. One main supply room with large boxes and supplies that was locked and a second unlocked supply closet with various materials and supplies stored on shelves. LPA observed that the facility had an adequate supply of materials necessary for resident care, including medical supplies, personal hygiene items, and other essential resources. A review of facility records revealed a supply invoice dated July 5, 2024. The invoice included a sufficient amount of small, medium, large, and extra-large adult briefs, wipes, and gloves. Interview with Resident Services Director (RSD) revealed that the main supply room can be accessed by two other staff members and the maintenance worker. RSD stated that the supply closet is available to all of the staff members and the main supply room can be accessed any time of day if needed. RSD further explained that although she purchases supplies for all of the resident's, some residents' choose to purchase their own incontinence supplies, etc. RSD explained that the main supply room has boxes labeled for specific residents that purchase their own supplies and/or receive supplies from various programs. ED stated that as a result the main supply room must be closely monitored so that staff members do not disperse the various supplies incorrectly. 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 facility standardized admission agreement. The agreement revealed residents have the option of purchasing their own incontinence supplies or they can pay an additional monthly fee to have the facility provide the supplies. LPA interviewed outside agency (OA). OA also reviewed the facility’s supply inventory and agreed with the LPA’s assessment, confirming that the supplies available were sufficient to meet the residents’ needs. OA agency stated from their assessment the facility has sufficient staff to meet the needs of the residents. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. An exit interview was conducted with Amanda Togia. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Amanda Togia whose signature below verifies receipt of these right

Residents interviewed did not expressed concern regarding incontinence care being not satisfactory. A review of facility records revealed invoices for incontinence care products were regularly purchased for the facility residents. The invoice consisted of small, medium, large, and extra-large adult briefs, wipes, and gloves. Records also indicated that the facility staff did in-service training for incontinence care, which included how to properly change residents with incontinence care and care for incontinence needs in older adults. LPA observations revealed a sufficient amount of incontinence products in the backstock area. LPA also observed that the facility was not malodorous of urine or feces. Outside sources revealed that residents are well taken care of, and they had no issues with incontinence care for their client. This agency has investigated the complaint alleging staff left resident in a soiled diaper for a prolonged period of time. 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 occurred, therefore the above allegation is found to be UNSUBSTANTIADED. An exit interview was conducted, and report was reviewed with the licensee/facility representative.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Rob McFarlane, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) who was found with their arm wedged inside of guard rail resulting in a radial fracture. LPA interviewed staff and obtained facility records. R1 remained hospitalized at the time of the visit. No deficiencies were cited or observed on this date. An exit interview was conducted with Rob McFarlane, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.

Continuation from LIC9099 According to staff present on date of first incident, July 5, 2024, R2 was having a behavior and injured R1 causing a minor bruise to the shoulder. Staff revealed they observed the incident and provided care for R1. Staff also revealed that on another date, July 7, 2024, R3 became upset at R1, resulting in R3 scratching at R1. Staff revealed that R1 received first aid and residents were separated immediately. According to interviews, staff observed both incidents. Interview with outside sources revealed that staff acts quickly in urgent events, and there is no issue with the supervision provided to the residents in care. Lastly, records reviewed revealed facility documented events properly and have also addressed R2 and R3’s behaviors to prevent future instances. During investigation, there was no corroborating information found to determine lack of supervision resulted in resident-on-resident altercations. Based on LPA's interviews with staff, outside source interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Resident Services Director Nae Brownell, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Resident Services Director Nae Brownell , and we discussed the purpose of the visit. Community Care Licensing received an incident report on 7/09/24 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 7/06/24. R1 left the community at approximately 11:18 am via GoGo Driver and returned to facility at approximately 12:24 pm. Per records reviewed licensee followed absentee notification plan as necessary. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. LPA Fulton observed auditory alarm installed in the memory care cottage. No deficiencies were cited during today’s visit. An exit interview was conducted with Resident Service Director Nae Brownell who was also provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rights

Licensing Program Analysts (LPAs) Ryan Fulton and Nacole Patterson conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Directors Stefanie Ancheta and Rob McFarlane. Today's visit was in response to an LIC624 Incident Report and a Soc341 Abuse Report which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/12/2024), involving Resident #1 (R1) and Resident #2 (R2). During today’s visit, LPAs performed a facility tour / welfare check and collected records. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Executive Directors Stefanie Ancheta and Rob McFarlane, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

(Continued from LIC9099 p.1) No staff interviewed had observed or been told that any resident was being forced to do something outside of their will. Staff interviews further revealed staff's awareness of residents' rights to have consensual intimate relations, per Title 22, Section 87468.1(b)(7)(A). Staff informed that R1 and R5 sometimes walk around the facility holding hands, and R3 and R6 had a close friendship that R6's family approved of. Outside source interviews corroborated staff statements regarding R3 and R6's relationship, stating they were happy about it and had no concerns. Resident interviews did not corroborate the allegation. No records were found to corroborate the allegation or that either alleged event occurred. Regarding the allegation, "Neglect/lack of supervision resulting in felony drug use", it was alleged that the Licensee allowed Resident 3 (R3) to bring illegal drugs into the facility. Staff interviews revealed that a substance was found among R3's possessions prior to moving into the facility, but it was discarded and not tested to confirm what the substance was. Staff members interviewed consistently denied that any resident had used illegal drugs at the facility, including R3. Resident interviews revealed that no resident had knowledge of any illegal drug use at the facility, including R3, who denied ever using drugs at Heritage Hills. Outside source interviews did not corroborate this allegation. No records were found to support that this alleged event occurred. Regarding the allegation, "Licensee retained residents who were incompatible with other residents in care", it was alleged that the Licensee had admitted homeless persons and drug addicted persons into the facility who did not have memory care issues. Records were reviewed regarding the residents in question- Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), and Resident 4 (R4). The records revealed that the residents in question had the following assessments and/or appraisals prior to being admitted into the facility: Physician's Report (LIC602), Pre-admission Assessment, Needs & Services plan. R1 and R3’s files contained an additional Resident Appraisal, while R2 and R3’s files contained an additional Mini Mental exam confirming cognitive impairments. The records found were consistent with pre-admission records for all other residents prior to being accepted to live in the facility. The LIC602 forms revealed that R1, R2, R3, and R4 were all diagnosed with memory issues and/or Dementia, which was consistent with the population that the facility serves as a memory care facility. (Continued on LIC9099-c p.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-C p.2) Staff interviews confirmed that R1, R2, R3, and R4 were assessed prior to living at the facility, upon moving in, and ongoing as their conditions changed, as any other resident in the facility would be. Staff members interviewed consistently affirmed that the residents in question were compatible for the facility based on their cognitive needs, care needs, and behavior levels. No staff interviewed informed that any of the residents in question were not an appropriate fit to live at the facility. Outside source interviews did not corroborate the allegation. Based on interviews, direct LPA observations and records review, the investigation did not yield a preponderance of evidence to conclude that the allegations of neglect/lack of supervision resulting in sexual abuse, neglect/lack of supervision resulting in felony drug use, and Licensee retained residents who were incompatible with other residents in care occurred. Based on the foregoing, the allegations are unsubstantiated. An exit interview was conducted with Amanda Togia, Business Office Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

noted that R1 was prescribed medication to address the seizure activity. The investigation did not yield evidence that indicated that immediate or emergency medical attention was needed each time R1 exhibited seizure activity or that R1 experienced a seizure following which needed medical attention was not sought. Additionally, the investigation produced no evidence that R1 experienced a seizure at the time of the alleged incident. Records retained relative to R2 reflected that R2 was at risk for falls. Interviews also yielded that the facility had procedures in place for staff to follow in response to resident falls. The investigation did not yield evidence of a fall sustained by R2, following which R2 was not assessed or that needed medical attention was not sought. Based upon the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Stefanie Ancheta, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to the Executive Director at the conclusion of the visit.

area and noted fresh linen in adequate numbers to provide residents with bedding. Based upon LPA observation, there was no evidence observed to support the allegation that the facility did not provide residents with adequate bed linens. LPA reviewed Resident 1 (R1)'s records as part of this investigation. LPA observed that R1 has Alzheimer’s and Dementia diagnoses. According to R1's appraisal and physician reports, R1 requires assistance with bathing, hair care, personal hygiene, medications, observation for wandering, cash resources and activity programs. Interviews and record reviews did not provide support that R1 did not receive assistance with the aforementioned Activities of Daily Living (ADL). LPA reviewed R1's appraisals and progress notes prepared by R1's primary care physician. LPA also reviewed R1's medication list and changes ordered by R1's primary care physician. Records provide consistent documentation that R1's physician noted no concerns with care provided by facility staff. R1's medication records did reflect changes in R1’s condition and medications were ordered to address them. The Department has investigated the allegations as mentioned above. Based on LPA observation, record reviews and interviews the investigation failed to produce sufficient evidence to corroborate the allegations. The preponderance of evidence standard was not met; therefore, the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Ms. Ancheta, whose signature below confirms receipt of these rights.

(Cont. from LIC9099) where a SOC341 was filed with the Unusual Incident Report, as required. These reports are an indication that incidents are reported to the appropriate parties. Specifically, Staff 1(S1) stated that she is the one who normally reports incidents to the appropriate parties, including the ombudsman, doctor and family of residents involved, Community Care Licensing Division and Law Enforcement, if necessary, once she is informed of an incident by her staff, who she said complete an internal report using a program called Point Click Care. S1 also said she is currently training Staff 2 (S2) to assist in completing all of the required reporting for unusual incidents and that S2 has done all the reporting required for some incidents, but is still being trained. S2 was able to state the external reporting requirements, as well as her internal ones, to LPA when asked. Although Interviews with residents revealed that they did not know what the reporting requirements were for staff when an unusual incident occurs, they did indicate that staff responded appropriately to unusual incidents. It was also alleged that staff do not meet residents' dietary needs. During a tour of the facility, LPA observed lunch being served to residents in the dining room, and the meal included hot dogs, French fries, fruit and beverages. Staff interviews confirmed residents are served three meals a day, plus snacks. LPA also reviewed the menu for a week, which showed three meals are served daily, along with two snacks. The breakfast meal consist of a variety of choices, including hot or cold cereal, along with eggs, a meat item, waffles or similar item, among other choices and beverages. The choices for lunch included, but were not limited to Philly Cheesesteak, Fried Shrimp, Chili dogs and Chicken Burgers served with fruit, beverages and other side items. Weekly dinner choices included, but were not limited to Pork ribs, beef stew, spaghetti with meatballs and chicken Parmesan served with vegetables and a starch like rice, beans, potatoes and/or bread, and other side items and a beverage of choice. LPA also reviewed an A La Carte Menu, which included a choice of sandwiches, eggs, burgers, fish, fruit and other items, and staff and resident interviews confirmed this optional menu was available to order from if residents did not want the items being served from the main menu. Interviews with residents and outside sources also confirmed that residents are served three meals a day, plus snacks, along with beverages, and all residents interviewed stated that the food was either really good or good, except for R1, who stated the food was fine overall, but could be better and was served at room temperature 80% of the time, but if R1 asked for their food to be reheated they said that request was met. (Cont. on LIC9099) 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 (Cont. from LIC9099) No other residents complained about the temperature of food served; however, S1 stated she had heard complaints about residents' food being cold, but said that problem was during a COVID Outbreak from 11/30/2023 to 12/21/2023 when residents were all being served meals in their rooms instead of using the dining room in order to limit the spread of COVID. S1 said meals were transported to rooms in "Hot Boxes", but the Hot Boxes slowly cool once they are unplugged from the wall, so residents served towards the end of a meal service, as opposed to at the beginning, were more likely to have meals served to them that had cooled. Interviews with residents and outside sources also supported the conclusion that the food variety was either good or very impressive. Interviews with residents and staff also supported the conclusion that fruits and vegetable are served daily and fresh fruits and vegetables are served as often as daily or when they are available. Based on LPA observations, interviews conducted and records obtained and reviewed, the allegation that facility staff do not meet residents' dietary needs and do not report incidents to appropriate parties is Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with Business Office Director, Amanda Togia. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to Director Togia, and their signature on this report confirms receipt of the report. .

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to observe the physical plant. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Culinary Director Seven Ennis. On 07/10/2023, the Licensee submitted an LIC200 Application to the CCLD San Diego Regional Office (RO) requesting to increase the facility's total licensed capacity from seventy four (74) residents up to seventy-eight (78) residents. The facility’s floor plan remained unchanged. On 09/15/2023, the local fire authority approved/granted an updated fire clearance, reflecting the facility was approved for seventy-eight (78) residents in total, of which up to sixty-eight (68) may be non-ambulatory and up to ten (10) may be bedridden. During today’s visit, LPA briefly toured the interior and exterior of the facility. LPA also inspected the four bedrooms (i.e., Rooms #205, #210, #212, and #215) which Licensee intends to turn from private to shared, finding that each of these bedrooms had sufficient space to comfortably house two residents and their required furnishings. The facility sketch/floor plan was consistent with the current layout of the facility. No deficiencies were observed or cited during today's visit. This portion of the application process has been completed. The Licensee will be sent an updated license to reflect the new fire clearance after CCLD management’s final review and approval. An exit interview was conducted with Ennis, 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 Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Administrator Stefanie Ancheta, after identifying herself and stating the purpose of the inspection. The facility serves 74 non-ambulatory residents, age 60 and above, of which 10 may be bedridden, and currently has 69 residents in care. There is an approved Hospice Waiver for 20 residents. This is a two-story complex, equipped with delayed egress and secured perimeters. LPA was accompanied by the Administrator Ancheta during a tour of the facility. Tour was conducted inside and out and included a sample of 4 resident units, the dining area, recreation rooms, and food storage areas. Signal system are in place and operational. The last disaster drill was conducted on October 8, 2023. No bodies of water are on premises. Passageways were free from obstructions. According to Administrator, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident unit and were tested for functionality. Delayed Egress and secured perimeter doors were also tested for functionality. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in locked hall closet. 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, however the resident’s rooms inspected did not have non-skid strips or mats. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C]t 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. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked areas.. The medication room is secured and has a locked medication cart, emergency supplies, and medications were labeled and kept in compliance with label instructions. Staff records review verified that all staff have a current First Aid certificate and at least one staff member, per shift, has a First Aide/CPR certificate, Criminal Record Clearance, Personnel Record, TB clearance, and Health Screening Report, and required training. Resident records reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. Conducted a thorough review of In-service training procedures. Transportation procedures were reviewed and complaint. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted, this report was discussed with Administrator Ancheta copy along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to the Administrator Ancheta .