Almond Heights.

On 3/23/26, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived unannounced to conduct the annual inspection. LPAs met with Director of Health Services, Eva Bowlin and explained the purpose of the visit. LPAs toured facility with to ensure the health and safety of residents in care. LPAs toured residents rooms, medication room, bathrooms, kitchen, dining room, common areas and activity areas. LPAs observed residents in common areas participating in activities and in the dining room having lunch. The facility was found to be clean, safe, sanitary and in good condition. LPAs observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. Inside temperature was 72-74 degree F. Hot water measured between 113-117 in three different areas at facility was in required range 105-120 degree F. Facility was conducting fire and disaster drills per requirement. LPAs reviewed eight (8) residents files and five (5) staff files. Staff records reviewed indicated training completed and other required paperwork. Residents files found to have required documentation. LPAs observed that medications were secured and were inaccessible to residents. LPAs completed the full care tool and no deficiencies were observed or cited per Title 22 Regulations. Exit interview conducted and a copy of the report was left at the facility.

Allegation- Staff are not properly addressing scabies outbreak. UNFOUNDED Based on observation, record review, and statement reviewed, the facility was following universal precautions. As a precaution, during the first sign of a rash, facility puts out PPE outside the resident room, notifies staff of the potential of scabies, and an in-service to staff is reviewed on proper handwashing and universal precautions. Facility encouraged residents to stay in their rooms during the episode. It was observed facility had required PPE outside the residents rooms. Furthermore, facility notified all required agencies and followed local health department guidelines to address this matter, therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Allegation- Staff not ensuring proper hygiene of resident. Staff did not provide privacy for resident in care. UNFOUNDED Based on staff interviews, resident interviews, and department observation, the department observed the facility to be clean and sanitary. During department visits on several occasions, including on 3/23/26, the department did not observe any issues regarding facility and was not following regarding proper hygiene of residents. The facility did not observe to be unsanitary including resident rooms, common areas and restrooms. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job. Staff interviews indicated that the facility is kept clean and sanitary without any concern. Residents and staff interviews indicated that staff treat residents with respect and dignity and there were no concerns; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.

Allegation- Staff did not follow infection control protocols.-UNFOUNDED Based on observation, record review, and statement reviewed, the facility was following universal precautions. As a precaution, during the first sign of a rash, facility puts out PPE outside the resident room, notifies staff of the potential of scabies, and an in-service to staff is reviewed on proper handwashing and universal precautions. Facility encouraged residents to stay in their rooms during the episode. It was observed facility had required PPE outside the residents rooms; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Allegation- Staff did not ensure that facility is free of pests. UNFOUNDED Based on documents obtained and statements reviewed, the department determined that there was insufficient evidence that the facility is not kept free of pests. The facility representative stated that the pest control company comes in monthly, and more often as needed. The department reviewed Pest Control dates for the monthly visits for 2025, 2026 which did not indicate any concerns. The pest control company is continuing to monitor any pest activity. Four (4) staff and four (4) residents were interviewed and stated they have not seen any pests at the facility. During the department visits, the facility was toured and there were no concerns that were noted about this area. Therefore, the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Allegation- Staff are not meeting residents' needs. Staff did not seek medical attention for residents. UNFOUNDED Based on interviews with four (4) staff and four (4) residents, the Department determined that there are enough staff present to meet the needs of the residents in care and that staff seek timely medical attention. Staff stated they know the protocol on how to address any medical intervention, and residents had no concerns with timely medical attention. Therefore, the allegations are UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 11/25/25 to conduct a case management inspection to follow up on a choking incident on 11/10/25 and 11/12/25 for resident, R1 at the facility. LPA met with Staff, LVN Eva Bowlin and explained the purpose of the visit. Facility submitted incident report (LIC624) to department on 11/17/25 about resident, R1 who had choking incident on 11/10/25 during outing (1st incident ) and 11/12/25 (2nd incident) in the main dining room around 10.00am. On 11/10/25, R1 choked on candy while in store and facility staff called emergency services (9-1-1) for R1 when R1 returned from outing and R1 was sent to local hospital to get medical assistance. On 11/12/25, R1 choked at facility in the dining room. Facility staff took appropriate measures and performed Heimlich Maneuver on R1. Medical assistance was offered but declined by R1 due to this incident on 11/12/25. R1 was back to their baseline after this incident. Facility notified R1s family, physician and other required agencies as required. During today visit, LPA interviewed R1 and staff. After reviewing the incidents reports and information gathered, it has been determined that facility took appropriate measures to address R1s choking incidents . No citations were observed or cited per Title 22 Regulations. Exit interview conducted and copy of the report has been provided.

On 09/23/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct case management visit follow up regarding an incident that occurred on 09/16/25 as facility reported on 09/17/2025. LPA met with Administrator Stephen MacDonald and explained the purpose of the visit. The visit was in response to a report from the facility regarding an incident that occurred on 09/16/25. According to the report, on 09/16/2025, at around 9:00PM, staff went to resident, R1s room to give their medication but found R1 to be unresponsive. The facility contacted local law enforcement and emergency services, but R1 was pronounced deceased approximately 09:38 PM by emergency staff. The facility notified all relevant parties involved regarding R1 passing. During the visit, LPA is requesting relevant documents related to the incident. All these requested documents shall by submitted via email to LPA Bains by 09/24/25 by 5PM. At this time, this incident is under review and the department will do follow up if warranted. Exit interview conducted and copy of the report left at facility.

On May 14, 2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains conducted an unannounced case management visit . This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPAs met with Administrator Stephen MacDonald and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective May 14, 2025 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.

***Report continued from 9099-A.... Allegation- Staff are not ensuring that resident is properly fed.-Unfounded The department conducted facility observations, interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were assisting residents who require assistance with their meals and there were no issues. Residents’ interviews indicated that staff were assisting them with their dietary needs and there were no concerns. During department visit on 04/15/25, it was noted that staff were attentive to residents who require help with their meals and there were no concerns. Based on gathered information, this allegation was found to be Unfounded. Allegation- Staff left resident in dirty clothing for a long period of time.-Unfounded The department conducted facility observations, interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were changing residents’ clothes daily and as needed, not leaving residents in dirty clothes and there were no issues to address. Residents’ interviews indicated that staff were assisting them with their care needs and there were no concerns. During department visit on 04/15/25, it was noted that residents were well groomed and in good care and there were no concerns. Based on gathered information, this allegation was found to be Unfounded. Allegation- Staff did not pick resident up from the hospital in a timely manner. - Unfounded The department conducted interviews with four staff to investigate this allegation. Staff interviews reflected that facility was not arranging any transportation services for any residents once they were ready to return to facility after ER or hospital visit, and it is arranged by ER/Hospital staff. Record review for resident R1 did not indicate any incident, where staff did not pick R1 from hospital in timely manner. Based on this information, this allegation was found to be Unfounded. Allegation- Staff did not clean resident's room. -Unfounded The department conducted facility observations, interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were providing laundry and housekeeping service as agreed in residents’ admission agreements and there were no issues to address. Residents’ interviews indicated that staff were assisting them with laundry and housekeeping tasks in timely manner and there were no concerns. During department visit on 04/15/25, it was noted that facility was clean and odor free and there were no concerns. Based on gathered information, this allegation was found to be Unfounded. ***report continued...... 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 ***Report continued from 9099-A.... Allegation- Staff are over medicating a resident in care. -Unfounded The department conducted record review, interviewed residents and staff to investigate this allegation. Four residents’ interviews indicated that staff were giving them medications per their physician’s orders. Four staff interviews reflected that staff were following resident’s physician’s orders and not mismanaging residents’ medications. Record review for R1s medications indicated that staff were administering R1s medications per their physician’s orders and there were no issues identified. Based on gathered information, this allegation was found to be Unfounded. Allegation- Staff did not safeguard resident's personal belongings. -Unfounded The department conducted interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were safeguarding residents’ belongings per facility protocol and there were no issues to address. Residents’ interviews indicated that staff were safeguarding their personal items, assisting them to locate any missing items as needed, and there were no concerns. During department visit on 04/15/25, it was noted all personal belongings for R1 was labeled and secured in R1s room. Based on gathered information, this allegation was found to be Unfounded. A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility.

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 02/12/25 to do case management visit . LPAs met with Administrator , Stephen Macdonald and explained the purpose of the visit. Incident for Resident, R1 - Department followed up on SOC 341 sent by facility on 02/07/25 stating that resident, R1 and family reported to staff that $360 in cash was missing on two separate time frames. Family noticed in December of 2024 that $200 was missing and also in mid January that another $160 was missing from R1's room. R1's family has initiated search of the room for the missing funds and facility also initiated search of the room. Facility notified LTCO and responsible party regarding this matter. Department conducted interviews with 1 residents and 3 staff during today's visit. At this time, this incident is under review and department will do follow up if warranted. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.

A virtual meeting was conduct on 10/07/24 with the facility to discuss a situation at the facility regarding resident, R1. Facility Executive Director (ED) , Stephen MacDonald, Facility’s representatives and CCL staff, Regional Manager, Alycia Rayner , Licensing Program Analyst Talwinder Bains, and Licensing Program Manager, Anthony Perez were present. Also in attendance today are representatives from the Long-Term Care Ombudsman (LTCO), Byron Toliver. Department has been made aware that R1 was not paying their share of cost for monthly charges and was given 1 st written notice by the facility on 07/12/2024 which indicated the amount of $5464.80. R1 did not take any action on 1 st notice, so facility issued a 2 nd written notice to R1 on 08/20/2024 per admission agreement and facility’s policy. R1 was non complaint with facility’s payment policy, therefore, facility issued a 30- day Eviction Notice to R1 on 09/26/2024. LPA spoke to R1 regarding this matter in August and September 2024, by thyself and with Long Term Care Ombudsman, Byron Toliver and each time the conversation went for 30-45 minutes. During these interactions with R1, R1 acknowledged the issues with their pending payments with facility and were aware that it can lead to possible eviction if not being addressed in timely way. Record review and gathered information indicated that R1 was not taking necessary steps to resolve this matter despite being provided with different resources and assistance by LPA, LTCO and Facility Staff. At this point , it appeared that R1 might have a undiagnosed health condition which is causing them a delay not to take required actions to take care of their health and financial needs which can effect their well being and possible eviction. During this meeting, it was discussed that the facility will send a request to Sacramento County for possible appointment of legal conservator for R1 to ensure their health and safety needs. No citations were issued per Title 22 Regulations. Exit interview is conducted with ED via phone. Copy of the report was sent via email and ED will sign and send it back to LPA via email by 10/08/24 by 5pm.

***Report continued from 9099..... Allegation- Staff mistreated the resident in care. Unfounded The Department conducted record review, interviews with staff and residents to investigate the allegation. From record review, it was learnt that resident, R1 was behind with their co-payment with facility and first reminder notice regarding that was given to R1 on 07/12/24 which indicated that R1’s pending balance was $5464.80 . Furthermore, facility staff followed up with R1 on 08/16/24 regarding this matter and R1 was given verbal reminder only and written second notice regarding pending payment was given to R1 on 08/20/24. Four (4) staff interviews indicated that staff was only discussing R1s pending payment issue with R1 on 08/16/24 in a professional manner and did not mistreat R1 in any manner. During resident, R1’S interview, R1 indicated that they were upset during payment issue discussion which occurred on 08/16/24 and took that meeting in negative manner but realized later that facility staff were doing their job and did not mistreat R1 and were fine at the facility. Based on gathered information, this allegation was found to be UNFOUNDED. Allegation- Illegal Eviction. Unfounded The Department conducted record review , interviews with staff and residents to investigate the allegation. From record review, it was learnt that resident, R1 was behind with their co-payment with facility and first reminder notice regarding that was given to R1 on 07/12/24 which indicated that R1’s pending balance was $5464.80 . Furthermore, facility staff followed up with R1 on 08/16/24 regarding this matter and R1 was given verbal reminder only and written second notice regarding pending payment was given to R1 on 08/20/24. Four (4) staff interviews indicated that staff was only discussing R1s pending payment issue with R1 on 08/16/24 and there was no Eviction Notice issued to R1. During resident, R1’S interview, R1 indicated that they have received two notices from facility regarding their pending co-payment balance , first one on 07/12/24 and second one on 08/20/24 but facility did not issue any Eviction Notice to them, Based on gathered information this allegation was found to be UNFOUNDED. A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/05/24 to do case management visit . LPA met with Administrator , Stephen Macdonald and explained the purpose of the visit. Incident for Resident, R1 - Department followed up on Incident Report and SOC 341 sent by facility on 07/19/24 stating that resident, R1 reported to staff on 07/18/24 around 8AM that staff, S1 was rough with them while providing care to R1 on 07/18/24 during morning shift care. Facility notified law enforcement regarding this incident and there were no findings. Facility also notified R1s physician, LTCO and responsible party regarding this incident. Facility Nurse checked R1 for any injurers and none were present. Incident for Residents, R2 and R3 - Department followed up on Incident Report and SOC 341 sent by facility on 07/22/24 regarding an incident which happened between 2 residents (R2,R3) during dinner time around 6pm on 07/21/24. Incident report stated that R2 was at dining room table, when R3 walked up and began to move the cups around. R2 began to yell at R3 to get away from the table. R3 was observed throwing a cup at R2 and it hit R2 above their lip, causing a small cut. R3 was redirected to another area. Med tech was notified, and the cut was cleaned and covered for R2. Facility notified R2s and R3s physician, LTCO and responsible party regarding this incident. Department conducted interviews with 3 residents during today's visit and requested documents from staff,S1s file and facility shall send all requested documents to LPA via email by 08/06/24 by 5pm. At this time, these incidents are under review and department will do follow up if warranted. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/29/24 to do case management visit . LPA met with Administrator, Stephen Macdonald and explained the purpose of the visit. Department followed up on SOC 341 sent by facility on 05/24/24 for date -05/20/24 regarding resident, R1 where R1 alleged that R1 fell into the bed on 05/20/24 around 10.30pm when staff S1 and S2 were assisting them. Facility notified R1s responsible party, law enforcement and long term care ombudsman (LTCO) regarding this incident. Per facility records, there were no visible injuries to R1 after this incident. Per facility’s staffing records, S1 was not working on 05/20/24. LPA conducted interview with resident, R1 regarding this incident during today’s visit. LPA attempted to interview S2 but found out that S2 was not working today. LPA requested documents related to this incident and facility will submit all documents by 05/31/24 by 5pm. At this time, this case in under review and department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.

***Report continued from 9099....... Allegation- Staff do not respond to resident's call for assistance in a timely manner.-Unsubstantiated The Department conducted interviews with six (6) residents and five (5) staff members regarding the allegation cited above. Residents’ interviews indicated that staff were assisting with their care needs and responding to the call lights in timely way however there were some delay times if staff were assisting other residents. Staff interviews indicated that staff were trying their best to respond to resident’s call light in the best possible way and tried to prioritize their response per resident’s needs. Record review conducted for call light log March 2024 revealed some dates and times with extended response time without any definite reason. Although record review revealed there were some dates and time with long call response, California Code of Regulation, Title 22, does not specify a time frame of when facility is to assist to a non-emergency call. Additionally based on interviews with staff, it revealed that facility staff has the tendency to "forget to reset the system at the conclusion of the service they are doing". Therefore, the allegation cited above is Unsubstantiated . A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility. 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 **Report continued from 9099-A..... Allegation- Staff are caring for residents without adequate training. Staff do not transfer residents that require 2 person assistance in a safe manner. -Unfounded The Department conducted interviews with five (5) staff members and reviewed record regarding the allegations cited above. Staff interviews revealed that staff have adequate training (on boarding and ongoing) regarding residents safe transfers techniques and there were no issues. Staff interviews also reflected that they were feeling safe regarding any residents who required 2 persons assist with transfers. Six (6) residents interview indicated that staff were properly trained, and residents felt safe with staff’s care without any problems. Record review indicated that facility has all required documentation regarding staff’s training's regarding Residents Transfers Techniques and other Care Provision per Requirement, therefore these allegations were found to be Unfounded. Allegation- Staff do not rotate residents as required to prevent pressure injuries.- Unfounded The Department conducted interviews with six (6) residents and five (5) staff members regarding the allegation cited above. Residents interview indicated that staff were providing care per their care needs and there were on issues including those residents who required staff to turn and reposition. Staff interviews revealed that staff were aware which residents needs turning and repositioning per their care needs and were providing that care and documenting it timely. Based on information gathered, this allegation was found to be Unfounded. Allegation -Untrained staff dispensing medications to residents. -Unfounded The Department conducted interviews with five (5) staff members and reviewed record regarding the allegations cited above. Staff interviews revealed that facility has trained staff who were managing residents’ medications and has access to medication room. Staff interviews denied that any unauthorized person was dispensing residents’ medications. There were some staff who were cross trained to do other duties and those staff also fill-in to do Med Tech job as needed per facility’s staffing needs. Record review indicated that facility has proper documentation of resident’s medication administration and there were no discrepancies. Based on information gathered, this allegation was found to be Unfounded. A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. No citations were issued. Exit interview conducted.A copy of this report has been provided to facility.

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 04/24/24 to do case management visit . LPAs met with administrator Stephen Macdonald and explained the purpose of the visit. Department followed up on Incident Report and SOC 341 sent by facility on 04/19/24 for date -04/18/24 regarding resident, R1. Facility notified law enforcement and long term care ombudsman (LTCO) regarding this incident. Department conducted interview with resident, R1 regarding this incident during today’s visit. LPAs requested documents related to this incident and facility will submit all documents by 04/25/24 by 5pm. At this time, this case in under review and department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.

On 04/15/24, LPA Talwinder Bains conducted a plan of correction (POC) visit to follow-up on citations issued on 03/20/24. LPA met with administrator, Stephen MacDonald and explained the purpose of the visit. Although the facility submitted documentation to clear the citations issued on 03/21/24, the Department will not be accepting the staff training sign-in sheets due to discrepancies with the date, time and attendance of staff at the training. As of this date, the plan of correction for the citations issued on 03/20/24 are outstanding. Should the facility fail to provide adequate documentation to satisfy the plan of corrections as agreed by 04/18/24, COB, the Department may assess civil penalties for failure to correct deficiencies. Exit interview conducted and copy of the report was provided.

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 04/10/24 to do case management visit . LPAs met with administrator Stephen Macdonald and explained the purpose of the visit. Department followed up on Incident Report and SOC 341 sent by facility on 03/20/24 stating that resident, R1 reported to staff on 03/19/24 around 4pm that staff, S1 hit R1 with hard towel on their face while providing care to R1 on 03/18/24 during night shift. Facility notified law enforcement regarding this incident and there were no findings. Facility Nurse checked R1 for any injurers and none were present. Department conducted interviews with 3 residents and 3 staff members regarding this allegation. At this time, this case in under review and department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.

An Non-Compliance conference was conducted on 04/04/24 at Sacramento North Regional Office, located at 9835 Goethe Road, Suite 100. Present in the meeting were facility’s representatives- Stephen MacDonald-Executive Director, Courtney Lane- Regional Director of Operations, Dan Williams-Regional Director of Health, Denise Munoz- Corporate Director of Administration, Joel Goldman- MBK Counsel and CCLD staff, Regional Manager (RM), Alycia Berryman, Licensing Program Manager (LPM), Laura Munoz, and Licensing Program Analyst (LPA), Talwinder Bains. This Non-Compliance conference has been scheduled today as the Department has identified some substantial compliance issues with the facility. It is the goal of today’s meeting to discuss the noncompliance and develop a plan in assisting to get the facility back into compliance. This conference does not in any manner excuse past problems or resolve the Department’s case against the licensee if the problems are not corrected. The Non-Compliance Conference may be the last step prior to initiating administrative action following unsuccessful attempts by the Department to gain compliance. The following topics were discussed during today's meeting: · Staffing · Record keeping · Reporting responsibilities · Lack of Care and supervision (falls and AWOLs) · The facility has had 4 residents AWOL from the facility. · Severity of the falls (multiple falls reports) · Staff aware of care plans · Medication administration · Overall leadership and accountability · Internal audits and quality assurance **Report continued on 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 The facility has stated they will do the following to achieve continued and substantial compliance: · The facility shall send in monthly staff schedules to the Department for 6 months to ensure the facility is meeting staffing requirements. · The facility shall develop and implement a quality assurance plan to ensure resident and facility staff records are complete and updated. The plan shall be sent to the Department for approval. · The facility shall develop and implement a plan on how the facility will ensure staff that care for residents are knowledgeable of the resident’s needs and limitations. The plan shall be sent to the Department for approval. Once approved, the facility shall train staff in plan and document training. · The facility shall develop and implement training for staff who administer medications that include but not limited to ensuring correct medications are dispensed to the correct resident and documenting any medication errors. Training shall be conducted quarterly and documented. · Facility shall develop and implement a plan addressing facility’s reporting requirement responsibility. The facility shall designate a member of staff whose responsibility it is to ensure all reportable items are reported to the Department based on Title 22 regulations. · Facility will develop and implement a plan on how facility staff will assist residents who are documented fall risks and how staff will mitigate falls for residents in care. The facility shall obtain an outside agency to train all facility staff on fall mitigation. · Facility shall train staff on recognizing if a resident AWOLs the facility who is unable to leave unassisted. Facility leadership shall have a communication process developed for staff to report resident AWOLs. The Compliance Plan is a demonstration of the licensee’s intention to make a good faith effort to comply and remain in substantial compliance with licensing regulations and statutes. If the licensee fails to maintain compliance with the conditions established in the plan, revocation action may be pursued. A follow up meeting will be scheduled between facility and department. The Department may increase monitoring at your facility. In an effort to assist you with coming into compliance, the Department would like to request the above documents by 05/04/24. An exit interview was conducted, and a copy of this report was provided.

A virtual meeting was conduct on 04/03/24 with the facility to discuss a situation at the facility regarding resident, R1. Facility Executive Director (ED) , Stephen MacDonald, Facility’s representatives and CCL staff, Regional Manager, Alycia Berryman, Licensing Program Analyst Talwinder Bains, and Licensing Program Manager, Laura Munoz were present. Also in attendance today are representatives from the Long-Term Care Ombudsman (LTCO) , Sacramento County Adult Protective Services (APS), and Department of Justice (DOJ) . Prior to this meeting, the facility notified the Department that R1’s responsible party has not paid R1’s board and care rate since September 2023 till date. Facility also notified that R1 was admitted to facility in July 2023 and R1s responsible party paid the board and care for July and August 2023. The facility has indicated they have attempted to contact R1’s responsible party but have been unsuccessful. Adult Protective Services and the Long-Term Care Ombudsman has been involved in that it is believed that there is financial misuse of R1’s finances by R1’s responsible party. Facility has issued 30 days eviction notice to R1 due to nonpayment. During this meeting, it was discussed that APS and CCL will work together to enroll R1 to Assisted Living Waiver (ALW) program so R1 can move to another facility as current facility does not accept residents with the ALW program. It was also discussed that R1 will stay at the facility until appropriate placement is found for R1 per their care needs. No citations were issued per Title 22 Regulations. Exit interview is conducted with ED via phone. Copy of the report was sent via email and ED will sign and send it back to LPA via email by 04/03/24 by 5pm.

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 03/20/24 to conduct a case management inspection to follow up on a choking incident on 03/11/24 for resident, R1 at the facility. LPAs met with Executive Director (ED), Stephan McDonald and explained the purpose of the visit. Facility submitted incident report to department on 03/18/24 about resident, R1 who had choking incident on 03/11/24 in the main dining room around 10.30am. Facility staff took appropriate measures and performed Heimlick Manuever on R1. R1 was back to their baseline after this incident. Facility notified R1s family, hospice agency, physician and other required agencies as required. After reviewing the incident report and information gathered, it has been determined that facility took appropriate measures to address R1s choking incident on 03/11/24. No citations were observed or cited per Title 22 Regulations. Exit interview conducted and copy of the report has been provided.

***Report continued from 9099..... Allegation- Staff did not properly supervise resident resulting in resident being sexually assaulted while in care. The department investigated the allegation listed above. On 01/24/24, it was reported that R1 was raped by an unknown male in the facility. Facility notified R1’s responsible party, physician, CCLD, LTCO, Law enforcement and other agencies as required. R1 was taken to the local hospital for a Sexual Assault Evidentiary Exam, and the results were found to be inconclusive. Medical exam indicated that there were no signs of sexual assault on R1. Department conducted interviews with staff and witnesses which indicated that there is no information that a sexual assault for R1 occurred at the facility on 1/24/24. As a result of this investigation, the department finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited per Title 22, CCR Regulations. Report reviewed with administrator and copy of report provided.

**Report continued from 9099........ Allegation- Licensee is not ensuring that resident(s) receive services as agreed to in the Admissions Agreement.- UNSUBSTANTIATED LPA conducted residents and staff interviews and reviewed records to investigate this allegation. LPA observed laundry being done during facility visit on 11/20/2023 and on 12/19/23 .LPA interviewed 4 residents and all, but 1 stated their linens get cleaned in timely manner. Record review indicated that the facility has documentation about residents’ schedule for laundry and housekeeping on a weekly basis, however schedule day can change to another day due to facility’s staffing needs. Based on interviews conducted, 3 residents stated that all laundry services are conducted by facility staff and staff wash resident’s sheets/linens at least once a week. 3 Residents interviewed stated that staff have never had any issues changing and washing their bed sheets more than once a week. Staff interviews indicated that there’s a schedule for laundry services for residents; however, staff would provide laundry services for those who need it and that is not scheduled. Based on this information, this allegation was found to be UNSUBSTANTIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility.

**Report continued from 9099A..... Allegation- Staff do not address resident being harassed by other resident while in care - Unfounded During interviews with staff and residents regarding the allegation listed above. It has been determined that two residents who reside in the facility do not get along however based on interviews conducted, staff ensure that the facility provides a healthy and safe environment to all residents and there was no indication of harassment. Based on the information, the preponderance of evidence standard has not been met, therefore this allegation is unfounded. Allegation- Food services are inadequate. Staff do not adhere to resident's special diet - Unfounded. During the course of this investigation, LPA interviewed residents and staff, toured the facility, inspected the nonperishable and perishable food supply, and reviewed facility records. LPA finds staff provide adequate food service for residents in care. LPA reviewed weekly menus, food supply, and grocery receipts, confirming staff provide a well-balanced diet with fresh fruits and vegetables daily. Residents and staff interviews indicated that facility provides food to resident’s who require specialized diet orders. Residents and staff interviews indicated that they could report any dietary issues to management as needed however there are no issues with food services at this time. Based on this information, this allegation is unfounded. Allegation- Staff do not accord dignity to resident in care. Staff do not accord privacy to resident in care. .-Unfounded. LPA Bains interviewed 4 staff and 4 residents during complaint investigation on 09/12/23. The department conducted the investigation for the stated allegation from this complaint. The department conducted a tour of the facility on 09/12/23 and conducted interviews with residents and staff. Interviews did not indicate any residents, staff and/or witness observed that staff are not providing privacy to residents in care. Department observed during facility tour on 09/12/23 that facility staff appeared to be attentive to resident’s needs and providing them privacy while taking care of them and during resident’s personal time with families and visitors. During residents’ interviews, residents stated that facility staff are meeting their care needs and did not express any concerns with privacy or dignity. Residents’ interviews indicated that staff were treating all residents with dignity and respect and did not express any issues. Based on facility tour, interviews and observation, the department found this allegation is to be UNFOUNDED. Due to this information the department finds all above allegations to be UNFOUNDED - A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of the report left at facility. 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 **Report continued from 9099........ Allegation- Staff do not ensure that resident is administered their medications according to physician's instructions. - Unsubstantiated Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During these interviews, it was revealed that the facility dispensed all residents' medications on time and administered them as scheduled. Furthermore, a review of the records for the months of August and September 2023 indicated that the facility maintained a proper logs for all medications in the centrally stored medication log, following physician's orders, and documenting them in the Medication Administration Record (MAR) without any errors. Based on these findings, this allegation is considered unsubstantiated. Allegation- Staff are mismanaging resident's medical documentation. .-Unsubstantiated Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During the record review, it was revealed that the facility is properly documenting medical records for residents per Title 22 regulations. Residents and staff interviews indicated that the facility conducts medical documentation and assessment of residents in a timely manner. Based on this, this allegation is unsubstantiated. Allegation- Staff do not respond to resident's requests for assistance in a timely manner. .-Unsubstantiated The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During residents’ interviews, residents stated that staff respond to resident’s in a timely manner, however sometimes there is a delay in response due to staff assisting other resident’s needs. Interviews and record review indicated that resident’s ADL’s, which include, residents showering, incontinence and care needs are met as required and documented accordingly. Residents’ interviews indicated that staff were providing care in a professional manner and did not express any concerns. During interviews with facility staff and residents, it has been revealed that the facility is providing care to residents according to resident’s needs and service plans, therefore this allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility.

***Report continued from LIC9099........... Allegation: Facility is in despair. -Unsubstantiated. On 09/19/23, LPA Bains conducted a tour at the facility. LPA observed the facility to be clean, safe, sanitary, and in good repair. LPA Bains interviewed facility staff (S1,S2, S3) who indicated facility is in good repair. S1 stated facility has a maintenance director who works at the community as Full Time . S1 indicated if something needs to be repaired at the facility with high importance,the maintenance person would fix it right away. S1 also indicated that all other work orders were took care in timely manner without any issues. According to Maintenance Director, he is on call 24/7 and facility can reach him for any emergency issues. The Maintenance Director stated the only time it may take longer than a day to repair is if he needs to order parts. Furthermore, facility has opening for 1 Full Time maintenance assistant position which facility is actively looking for now. Residents interviews indicated that there were no issues with facility's housekeeping and maintenance services, therefore this allegation is Unsubstantiated. Allegation: Staff did not meet residents’ needs. -Unsubstantiated The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During residents’ interview, residents stated that staff respond in a timely manner, however sometimes there is a delay in response due to staff assisting other resident’s needs. Interviews and record review indicated that resident’s ADL’s which includes residents showering, incontinence and care needs are met as required and documented accordingly. Residents’ interviews indicated that staff were providing care in a professional manner and did not express any concerns. During interviews with facility staff and residents, it was revealed that facility is providing food with different menu choices on daily basis and there were no concerns. During department visits, department observed that residents appeared to be well groomed and in good care. Furthermore, LPA observed facility found to be clean and odor free during visit on 09/19/23 and residents interviews indicated no issues with housekeeping at the facility, therefore this allegation is found to be UNSUBSTANTIATED. Due to the information above, LPA finds all the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with administrator and copy of report was provided.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/12/23 to conduct a case management inspection to follow up on a recent AWOL for R1 at the facility. LPA met with facility Business Office Manager, Danielle Twitchell and explained the purpose of the visit. LPA was screened by facility staff upon entry. R1’s AWOL Incident- The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 09/05/23 regarding resident (R1) leaving the facility unattended on 09/02/23 , at approximately 6am. Per incident report, R1 was found outside the facility unassisted by facility staff . R1 was brought back to the facility uninjured by facility staff. LPA followed up with facility after this incident and gathered information for R1 including LIC602. Facility notified R1s doctor and family regarding this AWOL incident. R1's physician's report dated 06/08/23 indicates that resident has diagnosis of dementia and cannot leave the facility unassisted. Resident has not tried to leave facility again and has been communicating better with the staff if R1 needs something. The facility has been continuously implementing measures to prevent the AWOL incidents from occurring in the future to ensure the health and safety of residents in care. No citations were issued at this time and only Technical Advisory has been issued to the facility. Exit interview conducted. Copy of report provided to facility.

On 08/08/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 07/18/23. LPA met with Administrator, Stephen MacDonald and explained reason for visit. Special Incident Report (LIC 624) and Abuse Report (SOC341) was submitted by facility on 07/18/23 to CCL stated that R1 alleged that R1 was sexually violated at the facility on 07/18/23. Incident report indicated on 07/18/23, R1s family informed the Executive Director, Stephen MacDonald that R1 was sexually violated. R1 was unable to verbally communicate (due to R1s medical condition). Per R1s family, R1 told the family regarding the incident and family notified facility immediately. Facility notified R1s physician, law enforcement and responsible party on 07/18/23 regarding this incident. Facility called 9-1-1 and law enforcement arrived and investigated. It was advised to family that resident be seen in ER. R1 was seen by their physician on 07/19/23 and blood test and other lab tests have been conducted. Results came as ‘unremarkable’. Lab results indicated that ‘No antibodies to HCV detected; a nonreactive result does not exclude the possibility of exposure to HCV’ for R1. Per facility, R1 was back to their baseline and doing well for now. R1 has been living at the facility since 07/05/21. Based on this information, no citations were observed or cited during this visit. Exit interview was conducted and copy of the report has been provided.