Legacy Oaks of Sacramento.

Page 2 S2 explained that I got some training on Relias but did not receive floor training although it was not my responsibility, but they placed me on the floor to do care without training. Executive Director (ED), Donnabel told us to do the job, or you will be fired. S3 also confirmed the allegation and stated I observed a newly hired caregiver being placed on the floor and that the caregiver expressed frustration about short staffing and feeling overwhelmed. S3 did not recall the staff member's name. LPAs Jamaly and Christina Valerio interviewed Executive Director (ED) Donnabell Galicia, who has been hired a week before the complaint is filed. ED explained the hiring and training procedure and stated "newly hired staff, first get training on Relias, then depend on the position they go out on the floor and shadow, occasionally for few hours. For medication technicians, they get training on Relias then they shadow other med tech for 5 days then they get observed on the cart. LPAs asked if med techs doing care? ED stated they do 30 days care training before they do the med tech job. This is a way to get to know the residents. ED added that all staff including BS, med techs should be aware that they should do care in case of need. When asked if there were any new staff placed on the floor? There was a pause during the questions then stated only in emergencies they would be placed on the floor if we did not have enough people. On 5/4/2026 LPAs Jamaly and Christina Valerio interviewed Merylyn Otero who previously was working as Regional Manager and currently working as Regional Resident Services Director (RRSD). RRSD stated that there were some new hired staff that were hired by Resident Administrator/Financial (RD), and then we shifted to what we believe fits, for example S2 was hired as a med tech but we don't have position for it, and we only have caregiver position. RRSD acknowledged placing newly hired staff on the floor and stated " I caught them when RD put them on the floor. I noticed that they were on the floor, and I asked why they were on the floor and pulled them off the floor when I noticed that". During a separate interview with LPA Jamaly on 9/11/2026, RRSD reported that RD was hiring RD's family and friends without actual availability of positions at the facility, we had to shift those staff to different role. 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 Page 3 LPA reviewed Employment Applications of S2, S3, and S4. S2 position listed as caregiver, but during interview with LPA Jamaly, S2 denies being hired as caregiver and stated I was hired as BS, my signature on the form is forged. Per facility Weekly schedule for the month of April 2026 and first week of May 2026, S2 scheduled to shadow other staff on April 28, 29, 30 and May 1, 2026. Also, Per Relias record, S3 received only 7 hours of training. Based on interview conducted, document reviewed, facility placed newly hired staff on the floor without training So, this allegation is SUBSTANTIATED . A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Merylyn Otero and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility .

During the course of this investigation, this LPA reviewed the pet policy and interviewed 3 staff who were working at the time of the incident and 1 of the pet owners still residing at the facility. Out of the 4 individuals interviewed 3 stated that dogs were seen repeatedly off leash and that management did not address the issue. During this LPA's visit today, a dog was observed leaving a resident's room and walking toward the dining room. This was in direct violation of the Pet Policy which states under section 2: "Behavior and Supervision Requirements: Animals must be housebroken, socialized, and free from aggressive behavior(e.g. biting, growling). Pets must remain on a leash or in a carrier when outside a resident's private room and under direct adult supervision. Unsupervised animals are not permitted at any time." Section 1 Veterinary Clearance and Documentation states that, "All animals must present current vaccination records for rabies, distemper, and other regionally required immunization. Documentation must be submitted before the animal's entry and updated annually." The LPA and ED determined that a thorough review needed to be conducted to ensure that all pet documentation was up-to-date and copies were included in each resident's file. Based on interviews and observation, the facility has not been adhering to or enforcing its own pet policy. Animals have been in common areas of the facility off-leash, and the facility has not been ensuring that the animals living here are keeping their vaccinations current, therefore the Department found the allegation, "Staff did not ensure that pets in the facility received adequate care and supervision," SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Galicia.

Page 2 RP further stated that, the patient brought to hospital due to agitation on 3/17/2026 and then on 3/18/2026. Patient was tested for UTI and prescribed medication, and the resident didn't need 1:1 care after she we stabilized. I talked to them to accept the resident, follow the prescription order until you coordinate with responsible party or until another community care provider can be found, but they refused to accept her.” RP further stated that “you know it is hard to find a community care provider for residents who are on Medi-Cal. I wanted the resident to be accepted until another provider could be located and while coordinating with the responsible party and processing the eviction policy. I emphasized that the patient doesn't need 1:1 care and could be taken back to the facility, but they refused to accept her. On 3/24/2026 at 12:28 PM, LPA Christina Valerio received a telephone call from the facility's former Acting Administrator, Rosalie. Rosalie stated that R1 could not be accepted back from the hospital because R1 was not stabilized and the facility could not meet R1's needs at that time. Rosalie stated that R1 had been sent to the hospital after hitting staff members and was not at R1's baseline. Rosalie stated that she had requested documentation from the hospital but had not received the requested progress notes. Rosalie also stated that she had assessed R1 at the hospital and observed that R1 required a one-to-one sitter. Rosalie stated that the facility could not safely provide one-to-one staffing for R1. Rosalie further stated that she had spoken with the Long-Term Care Ombudsman (LTCO) regarding R1's situation. Rosalie stated that she wanted R1 to receive appropriate treatment and that the facility would accept R1 back if R1 returned at an assisted-living level of care that the facility could safely support. On 7/16/2026, LPA Jamaly interviewed the LTCO Sacramento Supervisor regarding the conversation described above. The LTCO Supervisor stated that he did not recall the specific conversation at that time and would review his records. He further stated that he was not in a position to agree or disagree with the facility regarding whether R1 could safely return to the facility. On 7/16/2026, LPA Jamaly interviewed staff 1 (S1). S1 stated that Resident 1 (R1) was so aggressive, ending up in hospital three times a week. I think R1 should not be admitted here because R1 was hitting care staff, another residents, refusing medication, and was eloping. We changed R1 room to prevent hitting other residents, but it did not work. 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 page 3 S1 added that on 3/18/2026 I witnessed R1 hit paramedic in the head with a vase when Alpha one trying to transport her to ER and in another incident R1 eloped and was found near Target store. S1 does not remember the exact date of R1 eloping. LPA Jamaly interviewed Executive Director (ED) Donnabell. ED stated that she was not employed at the facility at the time of the incident. However, based on discussions with facility staff, ED understood that R1 had not been formally evicted but was not accepted back because the facility determined that it could not meet R1's needs, specifically the need for continuous one-to-one staffing. On 8/10/2026, LPA Jamaly interviewed Responsible Party 1 (RP1) regarding the allegations. RP1 stated that the facility did not notify RP1 regarding R1's eviction or the facility's decision not to accept R1 back. RP1 stated that RP1 learned about the situation through Kaiser Permanente Hospital. RP1 stated that R1 had resided at the facility for approximately five years and had become increasingly combative after not receiving prescribed medications. RP1 also stated that the facility had failed to properly submit R1's paperwork to Social Security and Medi-Cal, which resulted in the loss of benefits. RP1 stated that RP1 eventually assisted R1 in reinstating the benefits. RP1 stated that Kaiser Permanente assisted in locating another facility for R1, where R1 is currently receiving medications and doing well. RP1 denied that R1 lacked adequate clothing and stated that RP1 had purchased multiple sets of clothing and other personal belongings for R1. RP1 stated that, after R1 left the facility, the facility did not return R1's clothing and personal belongings. Regarding the allegation that the facility did not accept R1 back, RP1 stated that the allegation was true. RP1 stated that the facility repeatedly sent R1 to Kaiser Permanente due to aggressive behavior, including one occasion when R1 remained hospitalized for approximately two months. RP1 also reported frequent changes in facility management and staff and stated that the facility did not provide appropriate care or adequately manage R1's paperwork. LPA Jamaly reviewed incident reports documenting multiple incidents involving R1's aggressive behavior and refusal of medications. 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 page 4 LPA Jamaly reviewed R1's Medication Administration Records (MARs). The records indicate that R1 refused multiple scheduled medications during March 2026, including morning and afternoon medications on numerous dates. The records also document that R1 was transported to Kaiser Permanente on 3/16/2026, 3/17/2026, and 3/18/2026 due to agitation and aggressive behavior. An Incident Report documented that on 3/18/2026, R1 became aggressive and hit a care staff member. Alpha One was called to assist, and R1 subsequently struck a paramedic in the head with a vase. The report stated that Alpha One personnel restrained R1 and transported R1 to Kaiser Permanente Emergency Room for evaluation. LPA Jamaly reviewed R1's LIC 602A. The document indicates that R1 had diagnoses including schizophrenia, insomnia, constipation, muscle weakness, and dementia, with ongoing agitation and aggressive behaviors. LPA Jamaly reviewed R1's Admission Agreement. The agreement states that the facility may terminate the admission upon 30 days' written notice when, following reassessment, it is determined that the facility is no longer appropriate for the resident. LPA Jamaly did not locate documentation showing that a 30-day written notice was provided to R1 or RP1 regarding the facility's decision not to accept R1 back. Additionally, based on interviews conducted during the investigation, the facility did not notify RP1 regarding its decision not to accept R1 back to the facility. LPA Jamaly reviewed R1's Preplacement Appraisal Information, LIC 603. The document indicates that R1 was unable to follow signals and required assistance with toileting, medication, and health and medical care. Based on interviews, records reviewed, the preponderance of evidence establishes that the facility did not accept R1 back from the hospital and did not provide evidence that the required eviction/discharge process had been properly followed or that RP1 had been provided the required notice. Therefore, this allegation is Substantiated. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Executive Direct Donnabell Galicia and a copy this report and appeal rights 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 Page 2 RP acknowledged that R1 had been diagnosed with a UTI but stated that RP was not alleging that the UTI resulted from inadequate care. On 8/10/2026, LPA Jamaly conducted phone interview with S2 and asked whether R1's toileting, grooming, and hygiene needs were adequately met. S2 stated that, generally, caregivers were responsible for meeting R1's needs despite significant staff turnover. S2 also stated that R1 frequently refused care, attempted to elope, and became aggressive when caregivers attempted to assist R1 with hygiene needs. S2 stated that R1 would sometimes slam the door and become aggressive toward staff. LPA asked S2 whether S2 observed any changes in R1's urine or other signs of a UTI. S2 stated that S2 did not observe changes in R1's urine and did not observe signs of a UTI at that time. LPA asked how frequently R1 was expected to be toileted or have briefs changed. S2 stated that R1 was expected to receive assistance approximately every two hours. When asked whether inadequate care resulted in R1 developing a UTI, S2 stated that S2 did not believe the UTI was caused by staff negligence. On 8/10/2026, LPA Jamaly interviewed S3. LPA asked whether R1's grooming and toileting needs were met. S3 stated that S3 was unsure because R1 was frequently aggressive, and other staff were sometimes reluctant to provide care. S3 stated that R1 was more receptive to assistance from S3 and that S3 assisted R1 with changing briefs, showering, and other personal care needs. S3 also stated that management requested S3's assistance when R1 eloped. S3 stated that R1 frequently refused care. When asked what management did when R1 refused services, S3 stated that management considered refusal of services to be R1's right. LPA asked S3 whether S3 believed inadequate care resulted in R1 developing a UTI. S3 stated that S3 was unsure. S3 reported observing messes in R1's room when attempting to provide care and stated that R1 was not receptive to assistance from other staff. S3 also stated that R1's personal hygiene declined over time. S3 reported observing that R1 sometimes went several days without changing clothes and believed that R1 may not have had sufficient clothing available. LPA reviewed R1's LIC 602A, dated 9/24/2025. The document indicates that R1 was unable to independently meet toileting needs but was not bowel or bladder incontinent. 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 Page 3 LPA reviewed R1's Care Plan, dated 2/3/2026. The

On 07/10/2026, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director (ED). LPA met with Donnabell Galicia and a brief interview followed. LPA arrived at this facility at 8:40 AM prior to management arriving. LPA observed one of the 2 Medication Technicians administering medications to residents in Assisted Living (AL). The Director of Memory Care arrived and provided this LPA a private room to prepare for delivering the findings to complaint investigation # 27-AS-20251103152307. Prior to meeting with the ED, this LPA took an independent tour of the facility. When the LPA arrived in Memory Care (MC) it was approximately 10:00 AM. LPA observed a Med Tech (M1) administering medications. LPA could see the screen and the resident they were administering medications to was supposed to have their medications at 8:00 AM. LPA noticed that MC was quieter than usual and the MedTech explained that many of the residents were taken to the Assisted Living area for a "Coffee Hour." M1 went on the say that they would go there after finishing up in MC to ensure that everyone got their morning medications. LPA requested the EMAR for 3 residents in MC (R1-R3). Upon record review R1 was administered their 6 different 8:00 AM medications at 10:20 AM. R2 was administered their 8:00 AM medication at 10:01 AM. R3 was not administered their 5 different 8:00 AM medications at all. The report presented for review was printed at 3:30 PM today. 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 This LPA shared this information with the ED. This deficiency has been cited on the LIC 809D page. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit a copy of this report was provide along with APPEAL RIGHTS and an exit interview was conducted with Galicia.

On 07/08/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management meeting. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director. LPA met with Donnabell Galicia and a brief interview followed. During the course of the investigation into complaint # 27-AS-20250915145921, this LPA learned that a resident, (R1) was administered PRN medications (prescription medications on an as needed basis). Facility staff logged that the medications were administered, however this LPA observed that the effectiveness of R1’s PRN medication, OXYCODONE-ACET 10MG-325MG TABLET, was not documented once on 08/10/25, twice on 08/29/25 and once on 08/30/25. Staff also did not record the effectiveness of a dose of ALBUTEROL SULF 25’S (BX) on 08/10/25. This deficiency was cited on the LIC 809D page. There were no other deficiencies cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Galicia.

On 6/30/2026 at 9:30 AM, Licensing Program Analysts (LPAs) Reza Jamaly and Christina Valerio conducted an unannounced visit to the facility to continue the investigating a complaint. Upon arrival, LPAs met with Executive Director (ED) Donnabell Galicia and explained the purpose of the visit. During the complaint investigation process, LPAs reviewed file for Resident 1 (R1) and noticed that there is no LIC 602 for R1 on file. LPA interviewed with ED Dannoabell Galicia on 6/11/2026, she stated that she was recently hired as the facility's Executive Director and had limited knowledge regarding resident records and facility operations that occurred before her employment. LPA Reza Jamaly sent an email to Memory Care Director Shareetika on 5/21/2026 and followed up on 6/29/2026 asking for updated LIC 602, however the facility failed to provide an updated LIC 602 for R1. In an interview with Memory Care director Shareetika, she state that we requested updated LIC 602 from R1's PCP via email and fax but received no response yet. Based on interviews, and file receive, facility failed to maintain an LIC 602 in R1 file. A deficiency is cited under California Code of Regulations, Title 22, Division 6, Chapter 8, 87506 (a) . An exit interview was held with Administrator Donnabell Galicia, and a copy of report was left at the facility. Appeal rights were provided.

page 2 At the time of the review, the facility was unable to provide a physician's order authorizing this medication change. LPAs requested R1's current physician's report during the investigation. On 3/24/2026, the facility provided a LIC 602 dated 11/10/2023. Since the document was not current, LPA Jamaly requested an updated physician's report, along with any physician's orders or supporting documentation authorizing the medication change, via email on 5/21/2026 and sent follow up email on 6/29/2026 to ED Donnabel Galicia and Memory Care Director, Shareetika Chand.  As of the date of this report, the facility had not provided a physician's order or other documentation authorizing the medication change reflected on the MAR. LPA Christina attempted to contact the Reporting Party (RP) via telephone on 3/24/2026 and on 5/21/2026 Reza Jamaly attempted again and also sent an email on 5/21/2025 requesting clarification and supporting information, however, no response was received from RP by conclusion of the investigation. LPAs also reviewed R1's Individual Service Plan, annual appraisal dated 2/5/2025, and Admission Agreement dated 12/2/2023. These records documented that R1 required assistance with medication administration and that facility staff were responsible for assisting R1 with taking medications as prescribed. Based on interviews, record reviews, and the facility's failure to provide documentation supporting the medication change, the Department has determined, by a preponderance of the evidence, that the allegation is SUBSTANTIATED. A deficiency is cited under California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(e), Incidental Medical and Dental Care. An exit interview was held with Administrator Donnabell Galicia, and a copy of report was left at the facility. Appeal rights were provided.

The following deficiency, 87465(e) (1-4) is cited per California Code of Regulations, TITLE 22, DIVISION 6, CHAPTER 8 Article 8. Exit interview was conducted with the licensee. Appeal Rights were issued, and a copy of this report was left at the facility.

A resident was sent out for evaluation on 6/17/26 due to multiple episodes of vomiting and diarrhea. On 06/18/26, 12 more residents reported similar symptoms. The Executive Director, Donnabell Galicia, reported the outbreak to Public Health and to Community Care Licensing. She stated that roughly 21 residents came down with these symptoms in total. When asked what steps she took to mitigate the spread of the virus, she stated that they closed the dining room and began providing room service to all residents. She stated she made sure that staff were wearing and had extra PPE and reviewed donning and doffing procedures. Galicia also stated that she communicated with housekeeping and staff the need to sanitize surfaces. LPA asked how information was communicated to residents about the situation. Galicia stated that she explained the situation to the medication technicians and carestaff. LPA asked if there were any emails, signs, or phone calls to residents or their responsible parties about the outbreak and she stated that regular communications took place if the resident was experiencing symptoms or was sent out for evaluation. LPA spoke to Resident Council President about the outbreak and he stated that residents did not know what was going on. He said, "Some residents thought it was a food borne illness since they closed the dining room. We weren't told anything. There was no mass communication to all residents and family members." LPA asked what guidance Public Health provided. Galicia stated that they just sent the spreadsheet for tracking purposes. LPA contacted the nurse (N1) at the Sacramento Public Health Office that Galicia had contacted. N1 forwarded the email that was sent to Galicia. There was a spreadsheet attached for tracking purposes, but there was also a 3 page document with infection control protocols that were not followed. The guide stated that, "For ILL Residents – a. Confine symptomatic residents to their rooms until 48 hours after symptoms cease." It also stated that the facility should "Cancel or postpone group activities until at least 48 hours after the last identified case." Family and visitors were not notified about the outbreak and some continued to visit. The standard for the preponderance of evidence has been met and the allegation, "Staff are not preventing diarrhea outbreak" has been SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. According to the California Code of Regulations, Title 22, no other deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was provided along with APPEAL RIGHTS. 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 with R1 and learned what their specific preferences were for bacon and there have been no more issues regarding the food service at the facility. The department found the allegation, "Staff do not provide adequate food service, " UNSUBSTANTIATED. A finding of unsubstantiated does not mean that the allegation did not happen or was untrue, it means that there was not a preponderance of evidence to show that the event was true. According to the California Code of Regulations, Title 22, no were cited during this visit. An exit interview was conducted, and a copy of this report was provided along with APPEAL RIGHTS.

On 06/25/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility conduct a case management visit following an observation made during a tour of the facility. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Executive Director (ED) Donnabell Galacia. The two met and a brief interviewed followed. During her walkthrough today, LPA observed an exit door that was off its hinges and propped into the door frame. LPA took a photo for documentation purposes. The resident (R1) with this LPA at the time said that they went to exit the building one day and the door just felll out if its frame. R1 stated that they were amazed that the glass did not shatter. This deficiency was cited on the LIC 809D page. According to the California Code of Regulations, Title 22, not other deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was provided along with APPEAL RIGHTS.

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit. LPA Valerio toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed all doors leading into the middle courtyard to be open, which allows hot air to come into the facility. LPA Valerio closed all the doors due to the facility warming up while the air conditioning was on. According to administrator Donnabell, they are advising all staff to close the doors if they see it open. The facility testing a new system to determine if it helps the situation. The new system would be installing automatic mechanisms on all the doors in order for the doors to automatically close if it is opened. Currently, they have it installed on one door. LPA Valerio observed thermostat monitors missing in the memory care area. LPA Valerio observed two (2) swamp coolers and two (2) fans. The thermostat located in the MC hallway was set to 68 degrees, but the temperature showed a reading of 74 degrees. LPA Valerio checked the thermostat in the kitchen/dinning hall and the thermostat showed 78 degrees at 1:49 PM. At 2:55 PM, the thermostat read 80 degrees F. LPA Valerio observed one a/c unit set to 67 degree and three fans in the dinning hall. In the kitchen area where staff prepare meals, there were two fans. At 4:24PM, the thermostat read a temperature of 83 degrees. However, LPA Valerio used state issued room thermometer which stated the temperature inside the dinning hall was 77 to 80 degrees F depending on where LPA and Administrator was standing. Continues 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 Continued from LIC 809 It was reported that the dinning hall was too hot during dinner time on 05/21/2026; therefore, residents were directed not to eat there and eat in their room or other areas of the facility. The thermostat read at 83 degrees. According to resident interviews, residents expressed that the dinning hall was hot and the rooms are hot, so they would rather eat in the dinning hall. It was reported to LPA Valerio on 05/21/2026 that staff do not have wipes to use to change residents and a watered pad are used instead. On 05/21/2026, LPA Valerio observed a staff grabbing wipes from the management office. On 05/22/2026, LPA Valerio observed two (2) boxes of nine (9) pack of wipes located in the management office. LPA Valerio observed one pack of wipes located in the back business office, which is also locked with a code. According to Administrator Donnabell, management staff provide a couple pack of wipes to staff upon request. If they need additional packs, they can ask management. LPA Valerio provided a Technical Violation to ensure staff are made aware of the process and a plan is put in place to have wipe packs accessible when management if not present in the facility. Per California Code of Regulations (CCR) - Title 22 - a technical violation and a citation was issued during today's visit. Appeal rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held, and a copy of this report was provided.

Continued from LIC 9099 According to the Resident Council Meeting Notes, residents expressed concerns with call lights being answered timely. They specifically stated that response time to residents rooms is too slow, insufficient staffing levels at night, residents are not informed when new staff will be entering their rooms, and memory care staff observed sleeping, on phones, sitting idle during shifts According to the posted Response from management to the resident council meeting, management responded with the following: "Management has address response time expectation with staff. Ongoing communication, monitoring, and training are being conducted to improve response times. Staff have been instructed to monitoring call systems and call logs more frequently to improve responsiveness and resident assistance. Management has addressed these concerns directly with staff members. Resident are encouraged to continue reporting concerns to management so they can be addressed promptly." Based on interviews, records review and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the 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 05/21/2026: LPA Valerio observed housekeeping cleaning AL rooms 05/22/2026 LPA Valerio observed housekeeping cleaning - LPA Valerio saw 3 housekeeping; 2 in AL and 1 in MC. LPA observed and spoke to the person collecting the trash. Staff stated they come by every day to pick up the trash. There are only a few residents that say do not come to pick it up. Staff stated that residents can refuse trash pick or for staff to enter their room. LPA Valerio observed the rooms that have posted signs stating when they preferred trash pick up. Based on this information, the allegation is unfounded. A finding of unfounded means the allegation is false, could not have happened, or is without a reasonable basis. Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. An exit interview was held, and a copy of this report was provided.

Continued from LIC 9099 An interview with staff revealed that the facility did not have a plan in place to address R1’s substance abuse despite R1 having a history of drug abuse and being suspected of possessing drugs on two separate occasions. However, efforts were continuously made in conjunction with R1s Care Coordination Agency to find another facility better suited for R1, without success. According to an interview with staff, staff reported that they felt if management had not been checking on staff, staff would not follow resident's care plan. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the 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 Continued from LIC 9099 - A According to the Sacramento County Sheriff's Office (SCSO) Report, the responding officer was unable to identify the white crystal-like substance. The officer noted that there were no other paraphernalia or substances found in the room; and that facility staff also had access to R1's room. R1 was not present for questioning by the responding officer. The substance was never tested or identified prior to destruction. The department attempted to interview R1; however, R1 refused to provide a statement. According to staff interviews, staff suspected the white powder, found in R1's room, in a prescription bottle of Trazadone issued to R1 was an illegal substance but were unsure. Staff denied that R1 exhibited signs of being under the influence at any time. According to interviews with residents, residents did not report being aware of any illegal substance being present in the community or being used in the community. Allegation: Unqualified staff are providing nursing care to residents while in care. According to Staff 1 (S1), S1 reported having training prior to working on the floor. S1 completed online training over four days and another four days of shadowing staff as they performed caregiver duties.  According to an interview with Staff 2 (S2), S2 reported received six day of training in total including online and shadowing their duties. S2 was hired to be behavioral specialist but has been scheduled as a caregiver. According to an interview with Staff 3 (S3), S3 stated Medication Technicians need to complete 16-20 hours on Relias and then two days of shadowing.  S3 reported that a staff member can only be a Medication Technician if they have been trained. A caregiver who does not have medication training cannot pass medications. According to an interview with Staff 4 (S4), S4 is able to be a medication technician and a caregiver because S4 has been trained to do both. According to an interview with a resident, a resident reported that past medication technicians have expressed that they do not know their job. New medication technicians are allegedly teaching other new staff. This resident would not disclose names of the staff. Continues on LIC 9099-C, 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 LIC 9099- C, Page 2 According to an interview with Staff 5 (S5), there was a new employee put on the floor; however, when they were put on the floor, they were not alone and with another staff member. Allegation: Staff are being instructed to make false claims to CCLD. According to interviews with staff, four (4) out of four (4) interviews reported that management does not instruct staff to make false claims or hide information. According to interview with Resident 2 (R2), R2 stated staff encourage residents to voice their complaints so issues can be addressed. R2 reported that the facility has a Town Hall Meeting to report complaints to staff. Based on all the information collected by the Department,  although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore the allegations are UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report was left at the facility.

On 05/15/26, Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit related to complaint investigation number 27-AS-20250522140000.  LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Shreetika Chand Memory Care Director (MCD) and Regional Service Director (RSD) and this LPA reviewed the citations to be delivered today as a result of the above mentioned investigation.  A tour was also conducted during this visit. Through the course of the investigation into the death of a resident (R1), this LPA learned that the required 2 hour checks for 05/03/25 were not conducted as required.  This deficiency has been cited on the LIC 809D page. LPA reviewed R1s care plans dated 07/12/24, 8/27/24, 10/11/24, 11/08/24, and 03/05/25.  The first 4 care plans all state that R1 required 2 hour checks and was a fall risk, yet even after having falls as documented by incident reports, no changes were made to R1's care plan. There was a slight change to the care plan on 03/05/25 when it was noted on page 3 that R1, "returned from hospital visit from VA with seizure activity and a change in ambulation and locomotion," yet no changes were made to R1's care plan to address R1's propensity to fall.  This deficiency has been cited on the LIC 809D page. LPA reviewed incident reports for R1. In them, the facility reports that they ran out of R1’s medications.  On 10/18/24 R1 was not administered the following: "cranberry juice cap 425 mg (1&2), Finasteride (10/02/24, 10/11/24, 10/21/24) Flovent 120 mcg/inh (10/23/24 - 10/25/24), Fluticasone (10/15/24 -10/22/24) Folic Acid 1 mg (10/01/24 – 10/11/24) Lamotrigine 200mg (10/02/24, 10/11/24 -10/15/24), Propranolol 80 mg (10/07/24,10/11/24, 10/18/24), Tamsulosin 0.4mg (10/10/24 – 10/15/24), Thera vite max (25) Vitamin b12 500 mg (10/10-/24-10/14/24) for October." On 08/02/24, R1 was sent out for emergency medication refills. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 03/17/25 R1 the facility reported that the resident was not administered Acetaminophen that they were prescribed to take 3X daily.  All doses were missed on 3/16/25 and 3/27/25 because their medication was out of stock. On 05/03/25, R1 was not administered their morning dose of Lamotrigine Oral Tablet 150 MG because the facility did not ensure that they had a refill on hand . This deficiency has been cited on the LIC 809D page. According to the California Code of Regulations Title 22, no other deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview was conducted with Chand.

Licensing Program Analyst (LPA) Kimberly Viarella and Regional Manager (RM) Stephenie Doub made an unannounced visit to the facility on this day for the purpose of conducting a case management visit. LPA and RM met with Memory Care Director (MCD) Tika Chand and explained the reason for the visit. At approximately 11:40 AM, LPA and RM conducted a walk through the facility. LPA and RM entered the memory care area and observed residents eating lunch. There was one staff present in the dining room with sixteen residents. Upon entering the dining area, LPA and RM observed a resident requesting more juice to drink. Staff advised the resident that there was only enough juice for each resident to have one cup and only water was available, if they wanted an additional something to drink. RM Doub observed one resident not eating their food. The resident stated that they did not want the food and wanted a grilled cheese sandwich. RM Doub asked the staff present if there was a way for the resident to get something else to eat. The staff reported that they would need to wait until another staff member was present. It was approximately 20 minutes before another caregiver arrived. LPA followed up with dining services who reported that there was no request for any meal substitutions for memory care. LPA observed the bathroom faucet in RM 34 was not working. The resident who resides in that room stated that the faucet had not been working since they moved in two weeks ago. LPA and RM also observed the drawer in RM 30 to be off the hinge preventing the drawer from being able to open or close. At approximately 12:20 LPA and RM observed residents sitting in the courtyard smoking just outside of the building. Based on the information above the following deficiencies were cited per Title 22 regulations. An exit interview was conducted with and a copy of this report along with appeal rights was provided.

Continued from LIC 9099 There were no notes on the MAR to indicate the reason for the missed medication dose on the records provided to LPA Valerio. On October 1, 2025, R2 did not receive their dose of "Flucticasone Prop spray" due to the medication not being available in the community." R3 had an order for Alendronate sodium. The order is to take 1 Tab by mouth every week. According to the MAR, facility staff indicated that the medication was not available on October 23, 2025 and October 30, 2025. R3 also had an order for Vitamin D3, which was not given on October 5, 2025 because the facility did not have it available. On April 30, 2026, LPA Valerio received an Unusual Incident Report (UIR) for Resident 4 (R4). According to the UIR, R4 was provided a medication that was for another resident; however, the medication was not fully ingested. R4 was sent out and returned to the community the same day with a discharge diagnosis of "worried well". Allegation: Facility is in financial distress The solvency audit was conducted by Audit Investigator Banahene. According to the The September 2025 sample month Profit & Loss statement, the facility did not generate any revenues and had a net loss. The licensee did not provide any document to show that the facility’s rent or mortgage was paid and that the licensee has good control over the facility. The review of the six-month utility billings showed that the licensee made full payments for PG&E, Comcast, Waste Management, Pest Control, Consolidated Utilities. However, the licensee did not make any payment for SMUD in April 2025 and made only partial payments in May, August, September 2025 and carried unpaid balance as high as $25,708. Additionally, the records show that the licensee had a lot of significant monthly financial obligations (loans and credits cards), which creates some financial concern due to the facility not generating income or sufficient income to cover expenses. Additionally, a working capital analysis was performed and the licensee had a negative working capital for the Sample Month September 2025. A negative working capital indicates that the company doesn’t have enough current assets to cover its short-term obligations and may have trouble paying suppliers and creditors and difficulty raising fund. The bank statements provided showed positive balances, however, the positive balances were significantly below the estimated monthly expenses for the facility with 160 beds. Moreover, it appears the licensee does not have sufficient cash reserves to cover the operating cost. Continues on LIC 9099 - 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 Allegation: Staff inappropriately moved residents to other rooms for staff use of those rooms On 02/03/2026, LPA Valerio was told by previous Administrator Johnathan Aguilar that as far as he knew, the residents should have been informed. All residents were moved due to renovations and maintenance and would be moved back after it was done. On 02/03/2026 , Staff 1 (S1) informed LPA Valerio that residents were given notice. S1 remembers the paper and an email that was sent from management. LPA did not receive a copy of the notice that was provided to the residents. LPA Valerio reviewed resident council meeting notes dated October 2,2025. Resident Council Meeting notes are written by the residents and submitted the executive director for review. According to the meeting notes, residents wrote the following: "Confusion reigns! Everyone is confused about the abrupt changes with NO notification. Some people woke up on Monday being told they were moving that day. People were thrown together with no consideration about compatibility. We are repeatedly told that you work for us, but this is a prime example of that not being true. What is going on? Residents are upset over the way the changes were handled so abruptly without notification. Management says they posted flyers; but they were posted after the moving had begun; people don't go down the halls reading what's on the walls. It would have been better had they given notices to each resident effected. Prior to the flyers being posted, people were just moved to different areas without notice. It was upsetting." According to an interview with Resident 4 (R4), the previous management were moving people abruptly without notice. They posted it on the wall but we don’t look at wall. They said the room was a problem but they never did the work. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.

According to the Reporting Party (RP), the facility fired the staff conducting activities. During LPAs visit on April 13, 2026, LPAs observed the activities room doors to be closed with a sign stating a meeting was in progress. According to the activity schedule, Blackjack was the scheduled activity for 2:00 PM. The calendar indicated that there was nothing planned for 3:00 PM and had a letter "S" inputted on the time slot. LPAs observed residents watching television and writing for their leisure. There was not a staff led activity being held during this time. LPA Valerio and LPA Jamaly reviewed a Termination of Employment letter for Staff 2 (S2), which was the Transportation Driver. According to Interim Administrator Mery Lyn, they decided to terminate S2 because it was learned that S2 would cancel resident appointments and would not communicate with management regarding the missed appointments. LPA Valerio and LPA Jamaly reviewed resident council meeting notes dated April 2, 2026. Notes stated, "residents are not happy with transportation. There is a lack of communication and too many cancellations." According to an interview with Interim Administrator Mery Lyn, LPAs learned that S2 would show up to work late or leave work early, which caused residents to miss their appointments or scheduled outings. LPAs learned that the duties of a transportation driver include accommodating all resident appointments or outings. S2 would turn residents away if they wanted to go somewhere, such as Safeway, and did not have an appointment. LPAs learned that a new transportation driver was hired on April 13, 2026. Before this date, the facility utilized Lyft or Uber to transport residents to their appointment from April 7 - April 13, 2026. If there was an emergency, Alpha One was contacted. Per California Code of Regulations (CCR) - Title 22, deficiencies are being cited on the attached LIC 9099 - D page. Appeal rights were provided. An exit interview was held, and a copy of this report was provided.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Medication is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.

Based on the departments observations and interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Citations issued on the following d-Page. A copy of the report was read to the administator and given to the administrator representative, with a copy of the appeal rights. exit interview was conducted with the current administrator. designated signatory is staff tammy

requested and law enforcement did not investigate. LPA reviewed 16 incident reports dated 12/21/24 – 05/04/25 sent to community care licensing. 5 of these reports described incidents where R1 told staff they fell and hit their head, or staff found the resident on the floor with a head wound. R1 was sent out for evaluation each time. 8 reports described R1 having a change of condition. An additional 3 reports, dated 08/02/24, 10/18/24 and 03/17/25, described medications that were not administered to R1. The report dated 08/02/24 stated that "the resident was experiencing a change of condition related to missing their medications. The MD appointment was not scheduled until September 2024; and there were no other satellite clinic appointments available. The resident was sent to the … hospital in attempt to get emergency refills for all medications to hold until the next in-person appointment in September." The report dated 10/18/24 described 10 medications that were missed for two or more days from October: 10/01/24 - 10/25/24 (25 days). The report dated 3/17/25 also stated that R1 missed doses on 2 days because the facility did not have them in stock. LPA will be following up with a case management to address R1’s repeated falls and head injuries. LPA will also address Licensee’s not ensuring that R1’s medications were in stock for administration. Regarding: Questionable death of a resident . The Department found the allegation, questionable death of a resident (R1) to be UNSUBSTANTIATED. A finding of unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. According to the California Code of Regulations, Title 22, no deficiencies were observed during today's visit. A copy of this report was provided and an exit interview was conducted with Aguilar. Another visit was conducted immediately following this one to address the other allegations that were a part of this complaint. 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 responsible party (RP) for the 11 residents listed and interviewed those for R2 - R8. This LPA learned the following: The RP for R2 stated R2 had been utilizing a home health agency that had their own hospice agency and transitioned to that when hospice services were required. They stated that they “had a positive experience with Legacy Oaks.” The RP for R3 stated that Legacy Oaks "didn't offer us any options - they put R3 on hospice with Medical One without telling any of us. They apologized and said they were wrong and that they should have notified us." There was no notice of a change of condition, discussion about a reappraisal, and additional hospice options were not provided. The RP for R4 stated that when it became clear that hospice services were needed, "Legacy Oaks said they had an agency and gave me their card. No other hospice options were provided. The RP for R4 stated, "A very nice young lady spent hours evaluating R4 but then they said R4 was not accepted to their program. Another agency called us the next day and they took R4." The RP for R5 stated that they received a phone call from a representative at Legacy Oaks. The RP stated that this representative called and told them. “R5 is now on Medical One Hospice, did you know that?” The RP stated that they were not notified of any change of condition that would require hospice services and they were not offered any other options. The RP for R6 stated that a staff person (S10) recommended Medical One, no other options were provided. The RP explained that R6 did not renew their medical insurance and was dropped by their carrier. Since they could not pay, Medical One discontinued providing services to R6. Another hospice agency picked R6 up. The new agency was the one listed on the document provided to this LPA as they were the agency actively serving this resident at the time of this complaint; however, they started with Medical One. Regarding: Staff are coercing residents into using the facility's hospice company. The RPs for 4 different residents stated that they were not provided options for hospice services other than Medical One. The preponderance of the evidence standard has been met and the department finds the above allegation SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. 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 Regarding: Staff are threatening residents. Regarding: Staff did not safeguard residents personal belongings. LPA learned through this investigation that resident 6, (R6) had snacks stored in their room that staff, (S9) would help themselves to during their shift. In an interview with S16, this LPA was told that R6 went to S16 crying and afraid because S9 told R6 that they would end up in Memory care. S16 asked why R9 thought they were going to memory care. R6 told them that “S9 told R6 to stop complaining to Management about them - no one was going to believe them and they were going to put R6 in memory care.” S16 brought this information to the ED who said that they would take over the investigation. The ED, Aguilar, stated that an investigation was conducted into the matter and said that they confirmed that S9 had been bullying R6 and taking their snacks. As a result of that investigation, combined with other previous offenses, S9 was terminated. This LPA also learned through interviews with S12, S16, and R6 that weeks went by before S9 was prevented from taking R6's personal property. LPA asked how long, R6 responded weeks, but I don't know how many. S12 stated that at the time there were a few employees suspected of stealing from residents. S9 was one of them. Another resident, (R8) told S12 that they woke up once and saw S9 going through their things when they had no reason to be in R8's room. S12 stated that they knew management had been informed of the situation by S16, but nothing was done about it for weeks. "It was even brought up in stand-up." LPA Viarella interviewed S6 and asked what happened when they went to management regarding S9 taking their food and threatening them. R6 said at first they said they would look into it, but nothing happened. S9 kept doing it. Then they reassigned S9 so they wouldn't even a reason to come to my room, but S9 still came and told me to stop complaining. Eventually it stopped but it took a while. LPA asked which members of management R6 spoke with and R6 said they didn't want to talk about it anymore, they were just glad it stopped. Regarding: Staff are threatening residents . Regarding: Staff did not safeguard residents personal belongings. The standard for the preponderance of evidence has been met and the department found the above allegations to be SUBSTANTIATED. These deficiencies have been cited on the LIC 9099D page. 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 Regarding: Staff are not adequately supervising residents at night. This LPA interviewed the Designated Facility Administrator / Executive Director (ED) Jonathan Aguilar, regarding company policy. Aguilar stated that staff were to be "awake during their shifts and at no time sleeping on the sofas throughout the building." LPA observed that the Plan of Operation had a section titled "Awake Night Staff: Staff members were scheduled to be alert and on-duty during overnight hours to monitor and support residents requiring nighttime supervision." This LPA conducted 5 interviews, 2 residents and 3 staff R4, R7, S3, S4 and S5. R4 stated they had seen staff sleeping on the sofas in the hallways of the assisted living area. LPA stated that this complaint was opened on 05/22/25 and asked if this was occurring back then as well. R4 said yes. "Some of the staff that used to do it a lot aren't here anymore, but it still happens sometimes, not as much as it used to, but I have seen it." R7 also stated that they had seen staff sleeping on the sofas during the overnight shift too. S5 stated they had seen staff sleeping on the sofas in both the assisted living area and memory care. S4 and S5 stated that S6 had 2 disciplinary warnings for sleeping while on duty. LPA asked the ED for a copy of S6's personnel file. The ED was unable to locate it; however, he was able to provide this LPA with a copy of the second warning dated 11/10/25. It stated, "The employee was observed sleeping during their scheduled shift." Regarding: Staff are not adequately supervising residents at night. 2 residents and 3 staff stated that staff have been seen sleeping during their shifts. The standard for the preponderance of evidence has been met and the department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. Regarding: Staff are not following residents care plans. When S5 was asked if care plans were being followed, S5 stated that, that "Residents are not getting the showers they are supposed to. S5 stated that when they get a refusal, they change their approach or do a change of face. Others don't bother. There are some refusals, but some caregivers are just lazy." While reviewing personnel files, this LPA observed that 4 staff members (S20-S24) received disciplinary warning notices on 10/24/25. The warnings were for not documenting “the resident’s refusal to participate in the scheduled shower on (dates listed were 10/24/25, 10/11/25, 09/06/25, 09/13/25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on a document review, MedTech, S7 did not complete any annual MedTech training in 2025 and only 2 hours of dementia care training. LPA reviewed the personnel file for S7 and found that on 10/12/25 S7 stated, “I was giving four people meds at the same time.” S7 gave a medicati

On 01/14/26, Licensing Program Analyst (LPA) Kimberly Viarella made unannounced visit to this facility to conduct a case management visit regarding an SOC 341 that was reported to Community Care Licensing. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Jonathan Aguilar and a brief meeting followed. Community Care Licensing received an SOC 341 on 1/13/26 for an incident involving 2 residents in memory care on 01/05/26. This was a violation of reporting requirements as the report should have been submitted within 24 hours. Upon review of personnel records, not all of the staff working in memory care at the time of the incident had all of the required dementia care training. LPA reviewed training materials for S1 who did not have any of their annual training completed for 2025. These 2 deficiencies were cited on the LIC809D page. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Aguilar.

Two residents stated that they occasionally experience delays in receiving assistance with their daily needs but noted that the situation has been improving. The remaining three residents reported that they seldom experience any issues.A facility staff member reported that there are six caregivers and two medication technicians assigned to both the AM and PM shifts, and a total of five staff members assigned to the NOC shift. A review of the facility’s staffing schedules corroborated this information. Based on the information gathered, there is not sufficient evidence to prove that due to lack of staff the facility cannot meet the residents needs. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation 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. An exit interview was conducted, and a copy of this report was provided to the facility at the end of this visit. 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 During a facility visit by the Department on 11/13/2025, it was observed that the main hallway in the memory care building also had lifted flooring and was in disrepair. Staff confirmed that these areas required repair. Additional observations were made by LPA Pascua. LPA Pascua and FDA Aguilar toured 10 resident bedrooms and common areas, including the living area, activity area, and main hallways. The majority of the 10 resident bedrooms had significant flooring lift. In addition, some ceiling tiles had been removed or were missing. Furthermore, LPA Pascua observed a large portion of the facility’s roofing that showed visible wear and tear and contained an opening. Based on the information gathered through observation and record reviewed, the preponderance of evidence was met, therefore the above allegations noted were SUBSTANTIATED. One deficiency was cited An exit interview was conducted with FDA Aguilar and a copy of the reports were provided at the end of the visit.

On 10/23/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a follow up a case management visit regarding the deficiencies observed during a complaint investigation (# 27-AS-20250804095207) visit on 08/06/25. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director (ED). LPA met with ED Jonathan Aguilar and Ashley Sylve the Quality Assurance/Performance Improvement Director (RQAPID).  A brief meeting followed. During this LPA's tour of the facility on 08/06/25, this LPA observed the following: LPA observed an unlocked laundry room with toxic chemicals accessible to residents in care. LPA also observed Clorox bathroom cleaner and Crest mouth wash under the sink in room (#37). These were violations of the California Code of Regulation (CCR) 87309,  "Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage." This LPA also observed the door to the Medication Room in Assisted Living was open and the keys to the medication cart were in its lock.  No staff were present in the medication room or the room that was being used as an office attached to it. This was a violation of CCR 87465 "Incidental Medical and Dental, "(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication." 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 When this LPA toured the facility and tested the rear delay egress door in the Memory Care Community, the door opened without delay and the alarm did not sound. This was a violation under Health and Safety Code, "1569.699(a) Exit doors; egress-control devices of time-delay type; fences.  H&S 15699(a) states, "(a) When approved by the person responsible for enforcement, as described in Section 13146, exit doors in facilities classified as Group R, Division 2 facilities under the California Building Standards Code, licensed as residential care facilities for the elderly, and housing clients with Alzheimer’s disease or major neurocognitive disorder, may be equipped with approved listed special egress-control devices of the time-delay type, provided the building is protected throughout by an approved automatic sprinkler system and an approved automatic smoke-detection system. The devices shall conform to all of the following requirements:…" LPA observed that both the entrance door to the Business Office, and its interior door to the smaller office within, were open and a file drawer was left open leaving residents confidential financial information accessible. This was a violation under Additional Personal Rights of Residents in Privately Operated Facilities CCR, 87468.2 "(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law." These deficiencies were cited on the attached LIC 809D pages. LPA also observed during today's visit that an Activities Director/Life Enrichment Coordinator has not been hired yet. The previous person was laid off in September. LPA asked the ED what plans were in motion to fill the position. LPA provided technical assistance and referred to CCR Planned Activities 87219 (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: (1) Socialization to promote or enhance personal relationships. Activities may include, but are not limited, to: (A) Group discussion and conversation. (B) Reminiscence activities, such as looking at photos, letters, or greeting cards. (C) Cultural and/or religious activities, such as holiday celebrations and cultural traditions. (D) Other social activities such as arts, crafts, games, gardening, pet care, and other recreational activities promoting social interaction. 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 (2) Daily living skills/activities which foster and maintain independent functioning. (3) Cognitive and mental stimulation activities such as reading, writing, movies, crossword puzzles, board and card games, and using the computer. (4) Sensory stimulation, such as music therapy and aromatherapy, or tactile activities, such as pet therapy. (5) Leisure time activities cultivating personal interests and pursuits, and encouraging leisure-time activities with other residents. (6) Physical activities that maintain physical health including games, sports, exercises, and other similar activities that promote balance, strength, coordination, flexibility, and range of motion. (7) Education, achieved through special classes or activities. (8) Provision for free time so residents may engage in activities of their own choosing. (b) Residents served shall be encouraged to contribute to the planning, preparation, conduct, clean-up and critique of the planned activities. (c) The licensee shall arrange for utilization of available community resources through contact with organizations and volunteers to promote resident participation in community-centered activities which may include: (1) Attendance at the place of worship of the resident's choice. (2) Service activities for the community. (3) Community events such as concerts, tours and plays. (4) Participation in community organized group activities, such as senior citizen groups, sports leagues and service clubs. (d) In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies. Copies shall be retained for at least six (6) months. (e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. This person shall have had at least six (6) months experience in providing planned activities or have completed or be enrolled in an appropriate education or training program. (f) In facilities licensed for fifty (50) persons or more, one staff me mber shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made 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 available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers. LPA requested a plan be submitted to Community Care Licensing for how/when the facility will fill the full-time 40 hour, on site, position ensuring that the candidate meets all of the qualifications required in Title 22. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS, and an exit interview was conducted with Aguilar and Sylve.

On 8/25/25 the outdoor temperature was 105 degrees F* and the facility interiors (bedrooms and common areas) were not 30 degrees below outdoor temp (75 degrees). The use of the Infrared thermometer gun, wall thermostats, and observations were used to determine temperatures. Staff interviews, resident interviews, and observations determined that at least two thermostats in the hallway and three resident bedrooms were not functioning properly. Residents and staff confirmed staff are verbally notified if their room is not cooling, in which a maintenance ticket is created and the maintenance worker offers to install a standing/portable AC units and /or fans. Staff have placed standing/portable AC units in resident rooms when the central AC is not cooling all rooms properly, in which portable cooling units or switching rooms were offered to residents. Staff reported that historically the AC has not operated as it should, especially in the summertime and have put standing AC/portable AC units and/or fans in resident bedrooms as needed as a temporary solution. Staff admitted the AC unit is not always in working in good condition and there is an ongoing issues with the AC unit in the building. On 8/21/25, the DFA stated the facility was in the process of obtaining bids to install a more permanent solution in the server room and hallway area in which there is lack of ventilation as well as possibly some swap coolers. During this visit, on 10/3/25, DFA stated the facility is actively working to resolve the AC unit issue and there is improvement on this matter. DFA also stated the facility started to routinely change out air filters as of 9/15/25. DFA stated that changing out air filters has helped the AC unit function properly, as it is not working as hard. The facility is able to maintain an average between 75-80 degrees in the past month. Residents in rooms 36-71 have been relocated as the rooms are undergoing renovation to ensure all furnishings are operating properly, including the air conditioner and plumbing. Based on observations, record review, and interviews, the allegation that staff did not ensure that facility A/C is operable SUBSTANTIATED. Based on the information gathered through observation and record reviewed, the preponderance of evidence was met, therefore the above allegations noted were SUBSTANTIATED. one deficiency was cited (See LIC809D). An exit interview was conducted with DFA and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the 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 On 08/13/25, Licensing Program Analyst (LPA) Kimberly Viarella substantiated an allegation that staff are mismanaging resident's medications. Additionally, LPA Viarella is working with the facility to address issues around the facility not submitting timely reporting requirements. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred at this time. Based on observations, record review, and interviews, the allegation that staff are administering the incorrect medication to residents in care is UNSUBSTANTIATED but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code Regulation, TITLE 22 regarding this allegation. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

An incident report submitted to CCLD regarding the circumstances of R1's death indicated that first responders estimated R1's time of death as some time "earlier that morning" based on R1's body temperature and the rigor mortis present in R1's body. LPA Moleski reviewed R1's care plan, dated 1/6/25. R1 was required to have checks every two hours, per the care plan. R1's appraisal, dated 1/6/25, indicated that R1 required special observation and/or night supervision. The appraisal was signed by Sylve on 1/6/25. LPA Moleski reviewed witness statements taken by facility staff regarding R1's death. Staff members who observed R1 on the evening of 1/28/25 indicated that R1 appeared normal, and was observed sitting up. An overnight caregiver on duty assigned to R1's care (S10) said in a statement that they had given water to R1 around 11 p.m. on 1/28/29, and passed by R1's room again around 2 a.m. and saw R1 asleep. Witness statements do not indicate that any additional contact was made with R1 until R1 was found unresponsive by housekeeping staff in the morning. In a statement, one staff member who alerted first responders to R1's condition (S11) said EMTs estimated R1 had died "during the overnight hours based on [R1's] physical state." LPA Moleski reviewed R1's call button responses and observed R1's last call for assistance was just before 11 p.m., presumably when S10 provided R1 with water. In an interview, Sylve said that, based on witness statements, the last time R1 was checked on was at 2 a.m. The department has determined the following as it relates to the allegation that facility staff are not checking on residents during their shifts: Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87466. An exit interview was held with Sylve. A copy of this report and appeal rights were left with Sylve. 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 Although R1's death was reported to the local coroner's office, no autopsy or biopsy were performed, and R1's death certificate did not indicate the death was suspicious. LPA Moleski reviewed witness statements taken by facility staff regarding R1's death. Staff members who observed R1 on the evening of 1/28/25 indicated that R1 appeared normal, and was observed sitting up. An overnight caregiver on duty assigned to R1's care (S10) said in a statement that they had given water to R1 around 11 p.m. on 1/28/29, and passed by R1's room again around 2 a.m. and saw R1 asleep. Witness statements do not indicate that any additional contact was made with R1 until R1 was found unresponsive by housekeeping staff in the morning. The department has determined the following as it relates to the allegation of a questionable death: Based on record review, the above allegation is UNSUBSTANTIATED, which 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 regarding the above allegation. An exit interview was held and a copy of this report was left with Sylve.

On 09/25/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to conduct a case management as a follow-up on complaint number 27-AS-20250424084313 closed earlier today. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with Ashley Sylve, the Quality Assurance/Performance Improvement Director (RQAPID)/Designee. LPA met with Sylve and a brief meeting followed. During the course of that investigation, this LPA learned the following. Based on a review of the pendant call alert, there were days when either R1 did not have a pendant (both the family and facility staff commented that it had been lost and replaced). This LPA learned the following from a review of the call logs. From 05/01/25 though 05/14/25, R1 activated their pendant 66 times, out of that number, 11 of these calls for assistance took longer than 15 minutes to respond to. On 05/01/25, It took staff 2 hours and 26 minutes to address R1's call. On 05/02/25, it took 1 hour and 2 minutes. On 05/06/25, it took another 1 hour and 2 minutes. On 05/08/25, it took 31 minutes, and on 05/09/25, it took 1 hours and 20 minutes. According to the California Code of Regulations (CCR) Title 22, the Licensee did not ensure that CCR 87411(a) was followed. This regulation requires the Licensee to provide "care and supervision as necessary to meet the residents' needs." This deficiency was cited on the LIC 809 D page. There were no other deficiencies cited during today's visit. A copy of this report was provided along with APPEAL Rights and an exit interview was conducted with Sylve.

In order to ensure services were provided, resident checks have been increased to once ever 2 hours or once every hour if the resident required it. Staff have been stationed in the hallways so that they may hear residents call for assistance. Bells and whistles have also be purchased to assist residents in alerting staff. In addition, residents have been moved from one side of the building to the other. This was done for multiple reasons: so that repairs and remodels may be completed, to increase the efficiency of the air conditioning units during extreme heat, and to decrease the response time of carestaff. Flyers were put up announcing the move on or about 09/05/25 and the move began on Monday, 09/08/25. LPA and Ombudsman provided technical assistance on the importance of communicating with the residents and their responsible parties regarding resident moves and facility repairs. The ED stated that a formal notice regarding the above information will be mailed out by the close of business on 9/16/25. According to the California Code of Regulations, Title 22, the following regulation was violated: 87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. This deficiency has been cited on the LIC 9099D page. The ED stated that in the interim, they will relocate the alert system so that it may be physically monitored by staff and functional. The monitor will use walkie-talkies to communicate alerts to carestaff until the system is fully automated and functioning at 100%. No other deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Ashley Sylve.

The department has determined the following as it relates to the allegation that facility staff are not following infection control guidelines: Based on interviews, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87470(a)(1)(B)(5). An exit interview was held with Sylve. A copy of this report and appeal rights were left with Sylve.