Cloisters of the Valley, LLC.

(Cont. from LIC 9099) Records review revealed pest control service invoices from February and March 2026 documenting treatment for crawling insects and rodents at the facility. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, is being cited on the attached LIC 9099D. A plan of correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents. 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 (Cont. from LIC 9099) LPA observed the facility to be clean, and free of pests, hazards or debris during the visit. LPA also observed housekeeping staff actively performing cleaning duties throughout common areas. A records review of the facility’s housekeeping logs for December 2025 showed detailed daily cleaning tasks, including routine cleaning of resident rooms and common areas. Although housekeeping documentation was later discontinued due to workload, available records support that structured cleaning practices were in place. Based on staff and resident interviews, direct observations, and records review, there is insufficient evidence to support that the facility is not kept clean. Therefore, the allegation is found to be unsubstantiated. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.

(Cont. from LIC 9099) Regarding staff not ensuring residents’ hygiene needs were met, interviews with residents and staff consistently reported that scheduled showers were frequently missed within the last month, largely due to ongoing staffing shortages and limited availability of caregivers to complete bathing tasks. Resident interviews reported going more than a week without receiving their scheduled showers. Staff interviews acknowledged that they were unable to provide showers when the facility was short-staffed or lacked necessary supplies. Staff further stated that the facility does not have a system in place to document missed showers, only refusals. Records review revealed that the facility maintained a standard shower schedule for all residents however, no documentation existed to show whether scheduled showers were completed or missed. Regarding the allegation that staff communicate in an inappropriate manner to residents in care, interviews with both residents and staff consistently reported that certain staff spoke to residents in a rude, harsh, or otherwise inappropriate manner. Resident interviews reported that some caregivers used unpleasant or short tones when interacting with them, and one resident stated they had personally observed disrespectful communication from management staff. Staff interviews further corroborated these accounts, with multiple caregivers confirming they had witnessed or were aware of staff raising their voices, speaking unpleasantly to residents, or making inappropriate comments. Management interviews also confirmed at least one prior incident involving an inappropriate comment made to a resident. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, is being cited on the attached LIC 9099D. An exit interview was conducted with Resident Service Director Marquette Corbett and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.

(Cont. from LIC 9099) Interviews and records review revealed that on 02/12/2026, R1 was sent out to the hospital and admitted for treatment of behaviors. R1 was medically cleared for discharge the next day, on 02/13/2026. Following R1’s clearance for discharge from the hospital, Staff 1 (S1) informed LPA that the facility needed to assess R1 prior to accepting R1 back into the facility. However, S1 stated that no staff were available to conduct the assessment. Review of R1’s progress notes dated 02/17/2026 revealed that the facility was actively seeking alternative placement for R1 rather than arranging for R1’s return at that time. Additional records review revealed that as of 03/02/2026, R1 had been transferred to a Skilled Nursing Facility and still had not returned to the facility, with interviews indicating that the transfer occurred because the facility would not accept R1 back. Licensee did not allow R1 to return to the facility or provide R1 with a 30 day written eviction. R1 was illegally evicted. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, is being cited on the attached LIC 9099D. A plan of correction was jointly developed with the licensee. An exit interview was conducted with Resident Services Director Marquette Corbett and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Case Management - Deficiencies visit. LPA identified herself and discussed the purpose of the visit with Executive Director Tia Suuronen-Goodwin. LPA was at the facility for a complaint investigation, when a violation was found after an interview with staff. LPA requested a records review of the incident report that occurred for R1, who was sent out to the hospital on 02/12/2026 for behaviors, however, interviews revealed that no incident report was written for R1. Records review revealed that R1's incident report was not reported to the department until 03/05/2026. The facility did not submit a written incident report to the department within the required seven (7) days of the occurrence. One deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). A previous citation was issued on 02/04/2026 for the same deficiency. Since the deficiency is a repeat violation within the last twelve (12) months, a Repeat Violation Civil Penalty of $250 was also assessed/charged to Licensee (refer to the LIC421-FC page). An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director Tia Suuronen-Goodwin whose signature below confirms receipt of these rights.

(Cont. from LIC 9099) Interviews with staff corroborated the allegation, as staff reported the facility does not have sufficient staffing to meet resident care needs. Staff reported frequent shifts with only two caregivers responsible for more than sixty (60) residents, including multiple residents requiring two-person assistance. Staff also stated that the Resident Services Director and other non-direct care staff would frequently cover caregiver shifts due to shortages. Management acknowledged the use of external staffing agencies to compensate for staffing shortages. Resident interviews further corroborated staffing concerns, with residents reporting long wait times for assistance, delayed responses to call pendants, and challenges receiving timely incontinence care throughout their residence at the facility. Residents interviewed have resided at the facility for over three years and indicated that these delays have been an ongoing issue throughout their stay. A facility records review of staffing schedules confirmed an average of approximately two to three caregivers per shift who were able to provide lifting or physical assistance to over sixty (60) residents. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. 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 (Cont. from LIC-9099A) Regarding the allegation that the facility is in financial distress, specifically related to maintaining hygiene supplies and sufficient food, during unannounced visits, LPA observed an adequate supply of hygiene products as well as sufficient food observed in the dining area. Resident and staff interviews consistently stated that hygiene supplies are regularly provided and accessible. Records review of food supply invoices showed ongoing and consistent purchases across all food groups. Review of invoices for incontinence and hygiene products showed consistent and sufficient purchases of hygiene and incontinence supplies. Regarding the allegation that the facility did not provide residents with sufficient food, residents consistently reported that they receive enough food for their meals. Regarding the allegation that the facility did not have sufficient hygiene items, interviews reported that some staff prefer using briefs over pull-up products because they find them easier to manage, however, pull-up incontinence products were available at the facility. Regarding the allegation that the facility is malodorous, interviews with staff and residents consistently stated that they have not observed any foul or persistent odors in the facility and reported that housekeeping staff clean the facility daily. During multiple unannounced visits, LPA did not observe any malodors in the facility. The Department has investigated the above-mentioned allegations and based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.

(Cont. from LIC 9099) Regarding the allegation that staff did not provide a written incident report to the resident's responsible person within seven days, interviews with staff corroborated the allegation. By admission, staff reported that they called Resident 1 (R1)'s responsible party the day R1's incident occurred on 01/10/2026, however they had not sent a written report within seven days. Staff reported that R1's responsible party requested the written incident report and received it on 01/29/2026. Regarding the allegation that staff did not dispense medications as prescribed, interviews with staff corroborated the allegation. Staff #2 (S2) reported that they attempted to administer an as-needed pain medication in a method that was not consistent with the prescribed method, due to R1's condition. S2 stated that hospice staff came to the facility to demonstrate the correct administration technique for R1. By admission, staff also reported that they administered a discontinued medication to R1 on 01/23/2026. R1's Medication Administration Record revealed that the administered medication was placed on hold on 01/23/2026. Records review of R1's discharge paperwork dated 01/22/2026, revealed a discontinuation of three (3) medications, one of which was given to R1 on 01/23/2026. Based on interviews and record 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 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Service Director Marquette Corbett, whose signature below confirms receipt of these rights.

(Cont. from LIC 9099) During the investigation the Department established the following sequence of events. On January 25, 2025, facility staff reported to family and responsible parties, the facility was having an Influenza A outbreak within its staff and residents. According to an outside source interview, on January 26, 2025, R1 was noticed to have a cough, and such was reported to Staff 1 (S1). Interview with S1 revealed that R1’s Primary Care Provider (PCP) was faxed with details of the symptoms and S1 was later contacted by the PCP via telephone stating that they were unable to provide care to R1 and to contact another provider. Records and interviews collected revealed that on January 27, 2025, an outside sourced medical provider (OS1) visited R1 for other services and noted that R1 was having a cough, OS1 proceeded to report such to S1, S1 informed OS1 that this had already been reported to the medical provider. On January 28, 2025, R1’s responsible party contacted the facility and was informed R1 had not received medical care for symptoms. Responsible party proceeded to contact a medical provider and schedule a video visit with R1 for the next morning, January 29, 2025. During the video appointment, the medical provider advised the responsible party and facility staff to contact emergency medical care immediately. Medical records collected established that after being admitted to the hospital, R1 was diagnosed with Influenza A and acute hypoxic respiratory failure. Further interviews revealed that no staff communicated with the resident, or responsible party regarding response from the first medical provider and did not provide additional medical care to R1 between January 26, 2025, until January 29, 2025, therefore medical care was delayed. Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation. Therefore, the allegation is substantiated. A deficiency is cited per the Health and Safety Code (refer to the attached LIC 9099-D). The Department has determined this violation resulted in hospitalization to resident in care. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. Currently, according to Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058) were provided to Executive Director Tia Suuronen-Goodwin, signature on this form confirms receipt of documents.

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Deficiencies visit. LPA identified herself and discussed the allegation mentioned above with Resident Service Director, Marquetta Corbett. LPA was at the facility for complaint investigation, when a violation was observed. Upon arrival, there were no staff present at the front desk but staff were observed walking around. The medication room was located near the front desk and opened/unlocked. Medications were made accessible to anyone walking by the medication room. LPA observed ambulatory residents walking around, near the medication room. LPA stood in front of the medication room, waiting for staff to return. A medication technician arrived carrying a pitcher of water. LPA explained the medication room should be locked when staff are not present. The medication technician stated they were aware the medications needed to be locked, and apologized. A deficiency was observed and cited on LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Service Director whose signature below confirms receipt of these rights.

The RSD explained on 12/05/25 their Maintenance Director was contacted to break open the medication cart, so they could dispense medications. The maintenance director was able to open the medication cart. However, it was not prior to resident’s first AM dose. Therefore, morning medications were not dispensed on 12/05/25. A review of facility Progress Notes dated 12/04/25 indicated the medication cart was locked and/or staff could not open the cart. The RSD explained once the lock was broken on the cart, the cart was stored in a locked room for safety. Medication technician explained Ron’s Pharmacy came out over the weekend and fixed the lock. The RSD explained the lock was not broken open initially on 12/04/25 to obtain the medications, as the facility did not want to damage Ron’s Pharmacy medication cart. Residents were interviewed and stated they were no adverse reactions to not receiving their medications. LPA was advised by staff that the Executive Director was out of the building today. However, The Executive Director was present but did not meet with LPA regarding the compliant investigation. Towards the end of the visit the Executive Director made LPA aware they were out sick when the incident occurred and it was the responsibility of staff to report the issue. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Service Director whose signature below confirms receipt of these rights. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Service Director whose signature below confirms receipt of these rights.

(Cont. from LIC 9099) R1s Plan of Care for 09/29/2023 stated staff is to assist with toileting activities and assist with peri-care. This information was verified by RSD who stated what this information means is when a resident calls or pushes their button to be taken to the bathroom the caregiver would have to wait outside the door or close it or have it opened but be there to assist. R1s Plan of Care wasn’t changed until 10/01/2024, which required staff to conduct two-hour rounds to offer and ask R1 if he/she needed to be changed and to assist getting to and from the bathroom. On the new Plan of Care, to mitigate future falls the facility had increased safety checks. The facility staff knew R1 was a risk for falls and what interventions were needed to prevent reoccurrences. The facility was responsible for the neglect/lack of care and supervision causing R1 to have serious bodily injury as the resident was left on the toilet with no supervision which resulted in R1 falling and sustaining a fracture to his/her left ankle. At the time of the complaint inspection on 11/10/2025, executive director was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. An immediate Civil Penalty is being charged and assessed as $500 on the LIC421IM. An exit interview was conducted with Executive Director Tia Surronen-Goodwin, and a Plan of Correction was jointly developed. A copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director Goodwin, signature on this form confirms receipt of documents. 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 (Cont. from LIC9099-A) For the allegation of staff did not adequately assist resident with incontinence care needs in a timely manner, RP alleged that many times R1 is left for hours in soiled diapers because the staff is "too busy" or "understaffed". R1 mentioned that there have been times where he/she sits for hours in soiled diapers and staff does not come and help. RP also said that R1 is not in soiled diapers. On a follow up interview, RP did state that R1 had a dirty brief and a caregiver took a few minutes, before caregiver was able to help. Regarding the allegation of staff did not assist in resident with grooming needs, R1 rarely gets his/her teeth and hair brushed, as well as washing face. R1 said will sit for hours, and no one comes and checks, they don’t brush R1s hair or offer a washcloth. At the same time while the interview was being conducted, a caregiver came in with a washcloth and cleaned R1s face. For the allegation of staff did not assist resident with mobility needs, RP alleged that there isn't always qualified staff members on hand that can get R1 in and out of bed and to the restroom. RSD mentioned that caregivers monitor R1, conduct hourly rounds to ensure R1s safety, and give assistance as needed. Another staff member, S3 mentioned that when he/she takes care of R1, S3 will change R1s diaper every two hours while R1 is in bed, if R1 needs to use the toilet S3 will help R1 to R1s wheelchair take R1 to the restroom. S3 also added that R1 has never gotten out of bed on R1s own, R1 usually uses the pull cord when he/she needs assistance. (Cont. on LIC9099-C pg.2) 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 (Cont. from LIC9099-C pg.1) Regarding the allegation of Staff did not provide assistance for resident to participate in facility activities, RP stated that R1 is left limited to the bed and deprived fresh air or going outside. R1 doesn't get much interaction with other residents or participating in any activities. According to ADM, R1 refuses to join activities. Every morning, the activities team go to rooms and ask residents to join activities. RP shared that R1 doesn’t want to get out of bed and gets anxiety if R1 leaves the room, R1 would rather be on the computer. Based on interviews, observations and records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Tia Surronen-Goodwin, and a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director Goodwin, signature on this form confirms receipt of documents.

T he Business Office Director (BOD) explained they suggested the responsible party donate the balance to the facility but it was not required. The BOD stated the facility's policy was to refund the resident or Power of Attorney (POA). R1's responsible party was not the POA. Therefore, they did not refund R1's resident's responsible party. The BOD stated in August of 2025 the facility changed their policy and is now refunding residents responsible party's if even if they are not the POA. The BOD stated they do not have anything in writing stating they can only refund the resident or the Power of Attorney. A review of R1's file reflected a credit statement owed as of 08/01/25 in the amount of $2649.64. A review of R1's Admission Agreement dated 05/03/22, indicated under the Refund Policy that if the agreement is terminated, the resident must vacate and remove their property. R1's agreement was terminated and R1's belongings were removed on 07/16/24, and no refund was issued. The BOD also stated the refund check was approved today and awaiting corporate signatures. The Executive Director (ED) was interviewed but unable to provide facility policy details and referred LPA to the BOD. The ED was unable to provide any details regarding why R1 was not refunded once R1's belongings were removed from the facility. Based on and interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tia Suuronen-Goodwin whose signature below confirms receipt of these rights.

Records review revealed that the facility staff self-reported the hot water outage to residents and residents’ representatives via email communications. Interviews with internal sources revealed that there was an issue with the water heater’s valve and it took a few days to obtain a repair. During the hot water outage, staff were transporting residents to a sister facility to obtain showers, and the facility bought a portable shower. Interviews with internal and external sources and records reviewed corroborated that the facility was without hot water for multiple consecutive days. Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. 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 According to the allegations received, staff were seen being physically inappropriate with a wheelchair bound resident by doing wheelies with their wheelchair while the resident was present. It was alleged that staff were unprofessional in the way they spoke to residents and had made a joke about a resident’s incontinence management. It was alleged that Resident #1 (R1)’s pre-operation instructions were not followed by staff and that a physician on-site at the facility tried to enter a resident’s bedroom without permission. It was also alleged that a staff member went through a resident’s purse without permission and that a health insurance program was billed for Resident #2 (R2)’s physician visits at the facility while R2 was not present at the facility. Interviews with internal sources revealed that some wheelchairs bound residents have difficulty raising their feet doing ambulation assistance from staff. Therefore, in the process of aiding residents’ staff may lift the front wheels off of the ground slightly to back up the resident and aid them with foot placements. Interviews with internal and external sources did not reveal a concern for staff being physically abusive nor handling residents inappropriately. Interviews with internal and external sources also did not reveal a concern for unprofessional or verbally abusive staff. Interviews did not reveal a scenario where staff made jokes about a resident’s incontinence management. Per record review, R1 was scheduled for surgery on January 22, 2025, and per the pre-operation instructions, R1 was instructed to receive a hot shower. Interviews and records reviewed revealed that during that time period, the water heater was broken, and the facility did not have hot water. R1 was transferred to a different location by their representative and was provided with a caregiver to shower R1 as instructed. Records reviewed revealed that R1’s representative was compensated by the facility in order to follow the physician’s instructions. Interviews with internal and external sources did not reveal that a physician entered R1’s room without knocking and announcing themselves prior to entering. Interviews revealed that if staff do not get a response from a resident, they will enter to check on the well-being of the residents. [Continued on LIC9099-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 Review of R1’s progress notes dated December 28, 2024 revealed that R1 exhibited an aggressive behavior after stating they did not receive their bedtime medications. Interviews and records reviewed revealed that R1 was asked to check their purse for the bedtime medications, and when the medications were not located, R1 brought the purse over to staff to have them check. Interviews and records reviewed did not reveal that R1’s purse was looked through without R1’s consent. Interviews and records review did not reveal that the licensee is billing for services not provided. Interviews revealed that the physicians that come to the facility are contracted and not employees of the facility. Thus, the billing between the health insurance program and the physician’s visit is not billed through the licensee. Based on interviews and record review, the investigation did not yield a preponderance of evidence to conclude that staff are physically and verbally abusing residents, staff did not follow physician instructions for resident, staff did not accord resident privacy, staff did not safeguard resident’s personal belongings, and the licensee is billing for services not provided. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted Executive Director Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management Visit to cite a deficiency which was identified during a separate complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Business Director Suzie Dizon . On today's date, LPA Strong reviewed Resident 1 (R1) Admissions Agreement and found that the Assisted Living Waiver Addendum to Residency Agreement was not signed by R1 or Responsible Party. Based on records reviewed a deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). An exit interview was conducted with Business Director Suzie Dizon. A copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to her during today’s visit.

(CONTINUED FROM LIC9099) 2024, a care conference was held regarding R1. The interviews revealed that facility staff informed an outside source that R1 was no longer eligible for a private room at the rate they were paying. Staff informed the source that the facility would be transferring R1 to a shared room. All interviews consistently reported that no date was given by the facility as to when R1’s room transfer would occur. Per interviews, no minutes were taken of this meeting. Interviews revealed that R1 was transferred to a shared room on July 22, 2024. When interviewed, staff said they did not present R1’s representative with a 30-day written notice of transfer. When interviewed, staff said they thought the May 16th care conference was all that was necessary. As a result of this investigation, staff expressed an understanding that they should have provided written notice of the transfer as per the resident’s admission agreement. A review of R1’s Residence and Care Agreement reads as follows, “We will provide you with thirty (30) days' written notice before substituting your Apartment.” Based on interviews with residents, staff and outside sources and record reviews, the Department’s investigation yielded sufficient evidence to confirm the allegation that staff did not notify the responsible party of a resident's change in care. The Preponderance of Evidence standard has been met. Therefore, the allegation is Substantiated. California code of Regulations, Title 22, Division 6 & Chapter 1 is being cited on the attached LIC 9099D. LPA investigated a secondary element of this complaint regarding a resident’s payment obligation to the facility. Interviews and record reviews revealed that changes had occurred with the resident’s supplemental funding agency. A review of records and interviews revealed that the issue does not fall within the jurisdiction of CCLD. No additional investigation was conducted into this portion of the complaint nor was a finding made. LPA advised all pertinent parties. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058 01/16) were provided to Director, Suzie Dizon, whose signature below confirms receipt of these rights.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Business Office Director Susie Dizon. LPA also spoke with Executive Director Disha Hall via phone during the visit. Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/24/2023), involving Resident #1 (R1) and Staff #1 (S1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check. LPA reviewed and collected copies of pertinent facility personnel and care records, and reviewed police correspondence. LPA also interviewed relevant facility staff. By the date of LPA’s site visit, R1 had since moved out of the facility, and they could not be reached for interview. However, per R1’s latest LIC602 Physician’s Report (dated 04/28/2022): R1 had no cognitive impairment diagnosis and their doctor determined they were not confused/disoriented, able to follow instructions, able to communicate needs, and able to manage their own cash and economic resources. The LIC603 Preplacement Appraisal (dated 05/10/2022) and the Care Plan (dated 09/15/2022) which licensee performed also showed R1 was able to express themselves and communicate verbally “without difficulty.” Interview of the facility administrator corroborated that R1 was “alert and oriented X4.” [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] Records and interviews showed: During July 2023, while R1 resided at the facility, R1 had privately given S1 permission to drive/operate their automobile outside of work for the purpose of finding an alternate residence for R1. On 07/20/2023, R1 first reported to facility management that they had earlier loaned their car to S1, and since lost phone contact with S1 over multiple days, causing R1 distress. Upon learning of the incident, facility management timely suspended R1’s employment, commenced an internal investigation, and reported the incident to the San Diego Police Department (SDPD) and CCLD. On 07/21/2023, R1’s automobile was returned to them (via the care of their responsible person). While SDPD did not pursue criminal charges, Licensee’s internal investigation concluded that S1 had engaged in “misappropriation of resident property.” S1’s employment administratively ended on 08/09/2023. A preponderance of evidence exists to show that during the incident in question, licensee’s staff (S1) used R1’s automobile beyond the scope of their consent/permission, resulting in R1’s temporary loss of control of property, and causing R1 distress. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Dizon. A copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Dizon and Hall during the visit.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Activities Director Jerome Landers. LPA then met and discussed the purpose of the visit with Executive Director Disha Hall. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/26/2023). According to the LIC624: on 10/25/2023, Resident #1 (R1) and Resident #2 (R2) both eloped together from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.] Police located R1 and R2 on 10/26/2023, and they were subsequently returned to the facility. During today’s visit, LPA performed a facility tour and welfare check on R1 and R2. LPA also collected copies of pertinent care and hospital records and interviewed multiple relevant staff. According to their latest LIC602 Physician’s Report (dated 03/01/2023), R1 was diagnosed with Dementia and Cerebral Atherosclerosis, and their doctor determined that they were not able to safely leave the facility unassisted. According to their latest LIC602 Physician’s Report (dated 10/03/2023), R2 was diagnosed with Dementia and Alzheimer’s Disease, and their doctor determined that they were not able to safely leave the facility unassisted. Staff interviews, corroborated by date and time stamped records, showed: Between 11:00 AM and 12:05 PM on 10/25/2023, multiple facility staff saw both R1 and R2 present on the facility premises. Camera footage showed that around 12:08 PM, R1 and R2 exited the facility via a perimeter courtyard gate door. This gate door was unlocked but was alarmed to alert staff whenever it was opened. During today’s visit, LPA observed that the alarm on this gate was working and loudly audible. [CONTINUED ON LIC 809-C, 1 of 2] 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] During the incident, multiple staff heard the alarm and responded on foot to the gate, but when they arrived, R1 and R2 were not in sight. Staff reset the gate alarm without looking for the person(s) who set off the alarm and without performing an accounting of residents in care. Around 4:10 PM on 10/25/2023, staff first recognized that R1 and R2 were missing. Facility staff performed an unsuccessful search of the facility and surrounding neighborhood, then notified law enforcement and the residents’ respective responsible persons, consistent with timelines described in the facility’s Elopement Policy (i.e., Absentee Notification Plan). The next day, on 10/26/2023, police located R1 by 9:00 AM and located R2 by 11:53 AM. Both residents were transported to the hospital for evaluation, before being returned to the facility. Staff interviews, corroborated by hospital and facility records, showed: While away from the facility, R1 suffered a left distal radius (i.e., left wrist) fracture of unknown origin, and arrived at the hospital with “dehydration,” a urinary tract infection, and an “acute kidney injury.” Due to language barriers and their baseline memory loss, it could not be determined from R1 how their wrist fracture occurred. LPA observed that R1’s left wrist was indeed wrapped/splinted. While away at the facility, R2 suffered blisters to the bottoms of both of their feet. Due to their baseline memory loss, R2 was not able to be qualified as a reliable historian about the incident, but R2 confirmed they suffered feet blisters during the time that they were away from the facility. A preponderance of evidence exists to show that during the incident in question, Licensee’s staff were not trained to competently respond after the above-mentioned gate alarm had sounded. This resulted in staff not timely recognizing that R1 and R2 had exited the facility premises. A preponderance of evidence also exists to show that four (4) full hours had elapsed without Licensee’s staff visually checking on R1 and R2, despite both residents requiring supervision due to their Dementia diagnoses. [CONTINUED ON LIC 809-C, 2 of 2] 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-C, 1 of 2] Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). The incident resulted in serious bodily injury to R1, and non-serious bodily injury to R2. Therefore, an immediate civil penalty of $500.00 was assessed (refer to the LIC 421-IM). Since one of the deficiencies is a repeat violation within a 12-month period of time, a civil penalty of $250.00 was also assessed (refer to the LIC 421-FC). Plans of Correction were jointly developed with the licensee. An exit interview was conducted with Hall, to whom a copy of this report, the LIC809-D, the LIC421-IM, LIC421-FC, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.