Activcare at 4s Ranch.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Denise Notter. Community Care Licensing received an Incident Report on 11/26/25 in which it was reported that on 11/22/25, Resident #1 (R1), had displayed a change in condition. Responding staff had called emergency services and R1 was taken to the hospital where a closed head injury was discovered, however the injury was unable to be categorized as new or old. The report notes that per R1's responsible party, R1 had a history of this type of diagnosis. Resident returned to the facility next day with no new orders. The report notes that three (3) hours before, R1 was found to be sitting on the floor on a landing mat, which alerted staff. R1 was noted to be alert and verbally responsive, and denied any pain. During today's visit, LPA conducted interviews and file review. A health and safety visit with R1 could not be completed as R1 had passed away shortly after the incident from their hospice diagnosis. Per file review and interviews, R1 was a high fall risk and their needs & services plan highlighted various measures in place to mitigate risk. At this time, LPA observed no health and/or safety concerns and no deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Notter to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Front Desk Staff Ahdiyeh Dargahi. Executive Director Denise Notter arrived later during the visit. The facility's license shows a maximum capacity of sixty (60) residents, fifteen (15) of which may be bedridden. The facility is approved for delayed egress and secured perimeter, and additionally has a hospice waiver for twenty (20). During today’s inspection there were forty-nine (49) residents in care. LPA and Executive Director Notter toured the interior and exterior of the facility and inspected a number of resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink in one resident unit was 108F. Extra linens and hygiene supplies were present, as well as multiple stores of Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents. [Continued on LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients.  Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Notter, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Most recent emergency drill was conducted on 1/26/25. Required licensing postings were observed in visible areas of the facility. LPA interviewed one (1) staff and one (2) residents, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Notter to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and discussed the purpose of the visit with Executive Director Denise Notter. The facility was licensed for a capacity of sixty (60) non-ambulatory residents, of which fifteen (15) may be bedridden. The facility was also approved for delayed egress, secured perimeter, a hospice waiver for twenty (20), a waiver for a locked perimeter gate, and a waiver for non-physicians to prescribe medications. The LPA toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in a locked area. No pools, nor bodies of water on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide detectors, fire extinguisher(s), and first aid kit were present . Required licensing postings were observed in a visible area of the facility. The LPA interviewed staff and reviewed multiple staff and client records. No deficiencies were observed, nor cited during today's annual inspection. An exit interview was conducted with Executive Director Notter, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided.

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Licensee Mark Alsop, after identifying herself and stating the purpose of the inspection. The facility serves 60 non-ambulatory residents, age 60 and above, of which 15 may be bedridden, and currently has 56 residents in care. There is an approved Hospice Waiver for 20 residents. This is a one-story complex, comprised of four (4) wings and equipped with delayed egress and secured perimeters. LPA was accompanied by the Licensee Mark Alsop during a tour of the facility. Tour was conducted inside and out and included a sample of 10 resident units, the dining area, recreation rooms, and food storage areas. Signal system are in place and operational. The last disaster drill was conducted in September 2023. No bodies of water are on premises. Passageways were free from obstructions. According to Licensee, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident unit and were tested for functionality. Delayed Egress and secured perimeter doors were also tested for functionality. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in locked hall closet. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars, and nonskid strips were present in residents’ showers. Hot water temperature in residents’ bathrooms were compliant. continued on 809C 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 809 Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked cabinet. The medication room is secured and has a locked medication cart, emergency supplies, and medications were labeled and kept in compliance with label instructions. Staff records review verified that all staff have a current First Aid certificate and at least one staff member, per shift, has a First Aide/CPR certificate, Criminal Record Clearance, Personnel Record, TB clearance, and Health Screening Report, and required training. Resident records reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. Conducted a thorough review of In-service training procedures. Transportation procedures were reviewed and complaint. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted, this report was discussed with Licensee Mark Alsop copy along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to the Licensee Mark Alsop.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Case management visit. The LPA identified himself, and explained the purpose of the visit to Executive Director, Mark Alsop. During today's visit, the LPA secured report signatures and delivered an amended report. An exit interview was conducted with Alsop, to whom a copy of this report and the licensee appeal rights (LIC9058) were provided.