California Mission Inn.

(continued on 9099C) Resident sustained dermatitis due to staff neglect. It is alleged that a resident (name not provided) obtained dermatitis due to not having hair washed. LPA interviewed four (4) staff, and all four (4) staff denied any resident having dermatitis. LPA interviewed five (5) residents and all five (5) could not corroborate the allegations. Several staff stated that no resident currently has dermatitis at the facility. There is insufficient evidence to support this allegation. Facility is operating out of ratio . It is alleged that facility is operating out of ratio because resident (name not provided) is not being assisted out of bed. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. The caregivers interviewed all stated they can meet the resident’s needs. LPA interviewed five (5) residents and all five (5) could not corroborate the allegations. Several residents stated there is enough staff to meet resident's needs. There is insufficient evidence to support this allegation. Staff do not provide residents with adequate clothing. It is alleged that facility is not providing residents with clothing due to resident (name not provided) being in the same clothes for five (5) straight days. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. All four (4) staff stated they have not seen any resident in the same clothes for 5 days. The caregivers interviewed all stated that facility has a donation closet that provides clients clothing for free if they are in need, LPA interviewed five (5) residents and all five (5) could not corroborate the allegation. There is insufficient evidence to support this allegation. Based upon records review, interviews conducted, and observations, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted, and copy of the report was provided.

Licensing Program Analyst (LPA) Alberto Lopez conducted the unannounced annual inspection on 01/06/25. LPA met with Administrator, Jared Green, and the reason for the visit was explained. The facility is licensed for 85 non-ambulatory residents, ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents. LPA toured the facility with Maria Roleda, Wellness Coordinator reviewed files and medications using the Compliance and Regulatory Enforcement (CARE) tool. The following were observed: The facility is a 2-story building that consists of residents’ bedrooms on both floors. Each floor also has common areas, activity rooms, and communal restrooms. The dining hall and kitchen are located on the first floor. There is a memory care unit on the 2nd floor. The memory care unit has an indoor and enclosed outdoor area for resident recreation activities. LPA selected random rooms to inspect in both memory care and assisted living side. There were no sharps or cleaning products in their rooms. Facility is free of odors from incontinence. LPA observed adequate food supplies of 2-day perishable and 7 days of non-perishable. The facility receives food supplies twice a week. The kitchen is free of rodents and insects. LPA reviewed six (6) resident files. Resident files have an admission agreement, physician's report, consent forms, resident appraisal, personal rights, and property and valuable form. LPA reviewed five (5) staff files. The administrator's certificate expires on 4/14/26. Staff files have the health assessment with TB test result, criminal background clearance letter, and personnel record. Staff are receiving ongoing training. Medications are centrally stored in the locked cart. The facility utilizes the electronic medication log to document when given. LPA checked the medications for 4 residents and did not observe any discrepancies. Some PRN did not have labels. Facility has an updated Emergency Disaster Plan and conducts quarterly disaster drills for each shift. Last drill was 08/29/25 No deficiencies were issued today. Technical advisories provided exit interview was held, and a copy of this report was given to the administrator.

(continued from 9099) The investigation revealed regarding allegation that Staff verbally abused a resident in care. It is alleged that a staff member harassed and verbally abused a resident in care. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. All six (6) staff stated they have never witnessed any staff being verbally abusive or harassing any residents. S6 denied being verbally abusive to resident and stated S6 goes out of way to accommodate resident. LPA interviewed six (6) residents and five (5) of five (6) residents were not able to corroborate the allegation. R1 stated there are no witnesses regarding verbal abuse. There is insufficient evidence to support this allegation. Allegation: Staff are spraying chemicals in a resident's room . It is alleged that staff are spraying chemicals in the resident’s room, and it can be smelled on resident's clothing. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. LPA interviewed six (6) residents and five (5) of six (6) residents were not able to corroborate the allegation. LPA toured resident’s room and room was not malodorous or smell like chemicals. Some staff stated that resident had requested that no chemicals be used in resident’s room, only water to clean and disinfect. R1 stated that R1 did mention to staff to only use water to clean and disinfect. LPA toured common areas and there was no chemical odor anywhere in the facility or in resident's room. R1 stated that it is R1 decision to not have any caregiver come into R1 room and not the staff at facility. There is insufficient evidence to support this allegation. Allegation: Staff are serving food that is not of quality to a resident in care . It is alleged that the food is not of good quality and may have poison. LPA interviewed six (6) residents and four (4) of six (6) residents were not able to corroborate the allegation. One (1) resident stated she loved the food and especially the deserts. One resident stated that the food has too much salt, sugar and oil. One staff member stated that residents are provided with a menu checklist to choose alternate food items that fit their taste and/or diets. LPA toured the dining room during lunch hour, and the food was observed to be in good presentation and nutritious. LPA observed other residents with alternate meal items that they pre-selected in the early morning hours. All the residents observed in the dining room had finished their food during the visit. There is no evidence to support the allegation. Based upon records review, interviews conducted, and observations, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Hayden Petrovick, Marketing Director . A copy of the report was issued.

Staff explained that Resident #1 resides in the cottages that is considered independent living and has a separate address. Staff do not provide care or supervision to the individuals in the cottages. However, since the housing is on the premises, the rent increase had applied to the cottages as well. Allegation – Facility has plumbing issues. Staff indicated that if they find anything in disrepair, they will put in a work order. Maintenance staff indicated they try to fix the issues right away when they receive a work order. Per staff, R1 resides in the cottages which is considered independent living and has a separate address. However, maintenance will assist with any items in disrepair if they are notified. LPA spoke to R1 who stated the plumbing issue has been resolved. Based on information gathered, R1 has a separate address from the facility and is not receiving any care or supervision from staff. The facility roster does not contain R1’s name as part of their resident roster. Interviews with staff indicated that R1 is independent and resides in the cottages which care is not provided. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Staff H. Cummings. A copy of this report along with the appeal rights was provided.

Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 9/24/24. LPA met with Administrator, Jared Green, and the reason for the visit was explained. The facility is licensed for 85 non-ambulatory residents, ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents. LPA toured the facility, reviewed files and medications using the Compliance and Regulatory Enforcement (CARE) tool. The following were observed: The facility is a 2-story building that consists of resident bedrooms on both floors. Each floor also has common areas, activity rooms, and communal restrooms. The dining hall and kitchen is located on the first floor. There is a memory care unit on the 2nd floor. The memory care unit has an indoor and enclosed outdoor area for resident recreation activities. LPA selected random rooms to inspect in both memory care and assisted living side. There were no sharps or cleaning products in their rooms. Facility is free of odors from incontinence. LPA observed adequate food supplies of 2 day perishable and a week of non-perishable. The facility receives food supplies twice a week. The kitchen is free of rodents and insects. LPA reviewed 5 resident files. Resident files have the admission agreement, physician's report, consent forms, resident appraisal, personal rights, and property and valuable form. LPA reviewed 5 staff files. The administrator's certificate expires on 4/14/26. Staff files have the health assessment with TB test result, criminal background clearance letter, and personnel record. Staff are receiving ongoing training. However, LPA provided a technical assistance to ensure staff are receiving the required number of hours on dementia care. Medications are centrally stored in the locked cart. The facility utilizes the electronic medication log to document when given. LPA checked the medications for 5 residents and did not observe any discrepancies. Facility has the updated Emergency Disaster Plan and conducting quarterly disaster drills for each shift. No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.

The investigation revealed: Allegation: Staff do not provide resident with activities. It is alleged that resident is not included or encouraged to participate in activities. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. LPA interviewed two (2) residents and one (1) of two (2) could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. R1 reported that staff never ask R1 to join in activities. S4 reported that S4 always encourages R1 at least 3 times for each daily activity to join in the activities but refuses. LPA observed S4 encouraging R1 to join in activities and R1 refused which is R1 right. LPA observed many residents participating in different activities during different times of visit. There is insufficient evidence to prove the alleged allegation. Allegation: Staff isolates resident while in care. It is alleged that resident is isolated by staff. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. R1 stated R1 likes to be alone and enjoys staying in R1 room listening to music. Staff reported that they encourage resident to leave room several times daily but refuses. There is insufficient evidence to prove the alleged allegation. Allegation: Resident is left in soiled diapers for an extended period of time. It is alleged that resident is left in soil diapers. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. Staff provided a task log to LPA that documents when diapers are changed and it is consistent with care plan. Staff stated that they will deviate from scheduled diaper change and provide service earlier than scheduled if needed. LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. LPA toured all the rooms in memory care and no room or common area had foul odors or evidence that residents are left in soil diapers. There is insufficient evidence to prove the alleged allegation. Allegation: Staff are not meeting resident's toileting needs. It is alleged that resident is not being assisted in toileting needs. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. Staff provided a task log to LPA that documents when personal care is provided and it is consistent with care plan. (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 LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. There is insufficient evidence to prove the alleged allegation. Allegation: Staff do not ensure that resident has clean linens. LPA interviewed six (6) staff and 6 of 6 staff denied the allegations. LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. S3 reported that S3 is responsible to change the linens in all the resident's rooms once per week. S3 stated S3 will change the linens more frequently if they get soiled before the scheduled day. S3 stated that someone changed R1 linens today and S3 does not know who. LPA asked S3 to show LPA R1 linen that had just been changed and LPA observed it to be clean and dry. There is insufficient evidence to prove the alleged allegation. Based upon records review, interviews conducted, and observations made the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Executive Director Rhon Hipolito. A copy of the report was issued.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent Annual Required 1-year Visit on 10/30/2023 at 10:23 am. Initial Annual Required 1- year visit was conducted on 10/19/23. LPA was met by Wellness Director, Ruby Racca-Magao and explained the purpose of the visit. The facility is licensed for 85 non-ambulatory adults, ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents. There are currently 14 residents in memory care and 34 in assisted living. LPA Ramirez reviewed ten (10) personnel records and ten (10) resident records and received a copy of facility liability insurance. Three (3) out of the ten (10) personnel records reviewed are care givers in the facility memory care unit. LPA Ramirez observed an Administrator's Certificate for Dwight Dunagan which expires 07/11/2024. LPA Ramirez did not observe and deficiencies during today's visit. Exit interview was conducted with Administrator Dunagan. A copy of this report and appeals rights was provided.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 10/19/2023 at 11:03 am. LPA was met by Wellness Director, Ruby Racca-Magao and explained the purpose of the visit. The facility is licensed for 85 non-ambulatory adults, ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents. There are currently 14 residents in memory care and 34 in assisted living. The facility consists of 2 floors and a memory care unit on the 2nd floor. There are resident rooms on both floors, along with common areas, and communal bathrooms. There is a chapel room in which it is utilized by both California Mission Inn and California Mission Inn Rose Manor facilities. * Signage are posted throughout the facility. They consist of proper wearing of the masks, sneezing etiquettes, and COVID-19 symptoms checks. * Sufficient amount of PPE supplies of at least 30 days were observed in the storage area located in the first floor. Disinfectants and cleaning supplies are stored and locked in the housekeeping area. * Sufficient food supplies of 2 day perishable and a week of non-perishable items are observed. Food items are restocked every Tuesday and Friday. Water temperature in kitchen sink was measured at 136 degrees F. LPA Ramirez will issue Technical Violation. * LPA Ramirez selected the following rooms at random to inspect: 128, 130, 154, 155, 254, 257, and 276. All resident rooms contained required linens, lighting and furniture. * Dining room area was observed to be clean and contained multiple tables with plenty of seating. * LPA observed medication room to be locked and inaccessible to residents in care. Due to time constraints, LPA will return to complete annual inspection. No deficiencies were issued today. An exit interview was held. A copy of this report, LIC 9102 and appeal rights were given to the Wellness Director.