Legacy Oaks of Sacramento.

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.

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.

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.

The medication was not packed and sent out with the 5:00 PM medications. LPA requested the "Resident Leaves Report" which indicated that the resident left the building at 2:00 PM and returned at 11:10 PM. Even though the M3 was typically given at 8:00 PM, the doctor's instructions were, "TAKE ONE TABLET BY MOUTH AT BEDTIME." R1 retuned to the facility to go to bed and arrangements should have been made by the medication technician to ensure that R1 got their medication. This deficiency has been cited on the LIC 9099 D 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.

open. LPA closed the door and provided technical assistance to staff regarding the need to keep doors without screens closed to ensure the facility was kept free from insects and pests. When this LPA entered the memory care community, she checked the rear exit and it was not alarmed and the door opened freely to the back parking lot. This deficiency will be cited during a follow-up case management visit. LPA also observed residents' artwork (painted canvases) posted on the walls in the hallways of the community. There were 11 residents in the dining room enjoying a morning snack and 4 residents relaxing on furniture in the adjacent hallway supervised by staff. Upon returning to the assisted living area of the community, LPA observed an unlocked laundry room with detergent present and accessible to residents in care. This deficiency will be cited during the future case management. LPA also observed 10 residents playing Bingo led by the activities assistant. 4 other residents were on an outing to botanical gardens supervised by 2 staff. When LPA returned to the lobby area of the facility, LPA noted that the door to the Medication Room was open and that the keys were in the medication cart and the cart was unlocked. There were no medication technicians in the room at this time. LPA interviewed 3 staff members (S1, S2, and S3) who stated that they were instructed to leave the door open so that residents would be able to find them more readily when they were in the med room and not in the community. LPA reminded them that there was no one present in the room at the time the LPA walked in; the door should have been closed and locked so that all medications were inaccessible to residents in care. This deficiency will be cited in the follow-up case management visit. Regarding the allegation: Room used for behavioral interventions is malodorous. Legacy Oaks launched a program where they utilized staff trained on behavioral intervention techniques to assist and redirect residents having behavioral expressions. Residents from both the assisted living and the memory care communities were brought to room 37 where they could get away from triggers, play a game, watch a movie, and behaviors could be de-escalated. LPA visited room 37 which was designed to be a resident room, and observed the following: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The window was open and a fan was seated on the floor on one side of the room and blowing the decorations on the wall opposite. There was a diffuser on the counter. LPA observed shelves with games and activities along with a table in the center of the room surrounded by folding chairs. There was a sofa and other furnishings and decorations. LPA observed that the brown carpet was stained in several places, the largest being in front of the sofa area and another extending toward the kitchenette. LPA also observed that the baseboard molding adjacent to the carpet was warped and falling down in places. By the sink, it was completely detached and on the floor. LPA took pictures for documentation purposes. LPA then observed a small bookcase slightly in front of the bathroom door. LPA and a staff person moved the bookcase and this LPA entered the bathroom. LPA observed a broken toilet. The tank had been removed and was in the bathtub. The toilet had dirty brown standing water and toilet paper in it. The vanity was missing the door to the cabinet under the sink and Clorox and other toxic cleaning supplies were observed underneath. The tub/shower unit also had a metal shelving unit in it along with 2 buckets. One of the buckets approximately (3-5 gallons) had standing water in it. LPA took pictures for documentation purposes. A staff member, S1 walked in while this LPA was recording observations. LPA interviewed S1 and asked about the condition of the room. S1 stated they were told the room smelled badly because of the carpet and that was why they were constantly cleaning and brought in the air diffuser. LPA observed that her own eyes were irritated upon entering the room. When Designee Ashley Sylve arrived, LPA requested that the diffuser and fan be shut off and the window closed to see if she could assess what the room smelled like without them. LPA returned later with Sylve and found the room to be malodorous. LPA also observed that maintenance had begun removing all the furniture. Sylve stated that the room was being emptied out in preparation for maintenance to conduct all necessary repairs. While the room was used for behavioral interventions, it was not being used for the purpose that was stated in the facility's plan of operation and facility sketch. This violation will be cited in the follow-up case management visit along with the others motioned previously. Sylve stated they would conduct their Residential Habitation (RH) program in the activities rooms going forward. Room 37 room would be prepared for resident occupancy in order to return to compliance. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The allegation: Room used for behavioral interventions is malodorous. Based on observations and interviews with S2, S3, and S4, room 37 was found to be malodorous and unsanitary when this LPA observed the stained carpet, baseboard molding in disrepair, and the dirty brown standing water and toilet paper in the broken toilet in the bathroom. Prior to closing this report, this LPA also observed that the Business Office door was open with no staff present, and resident files with confidential financial information were left accessible to anyone walking by. One of the filing cabinet drawers was left open and in plain site. According to the California Code of Regulations, Title 22, due to time constraints, the other deficiencies noted in this report will be cited in a follow-up case management visit. A copy of this report was provided along with APPEAL RIGHTS and and exit interview was conducted.