Ivy Park at Sabre Springs.

(Continued from LIC9099 p.1) Outside source interviews revealed that for subsequent calls, R1 was informed of the calls and the outside source was able to speak to R1 via phone. Records review corroborated staff statements regarding the initial instruction for staff not to inform the outside source that R1 lived at the facility. Records additionally reflected the subsequent changes made by the facility regarding R1 being allowed to make the decision to receive or reject incoming phone calls. R1 was interviewed during an unannounced facility visit. Due to cognition, R1 was observed to have partial orientation. R1 informed that if they received a phone call from the outside source they would accept it. 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 Rob Daynes, 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 (Continued from LIC9099 p.1) During an unannounced facility visit LPA directly observed a posted visitation sign in the main hallway that stated the facility's visitation policy. The visitation policy stated that residents can receive visitors at any time, provided that the visitors respect the rights of residents and staff and abide by visitation policies during the visit. R1 was interviewed during an unannounced facility visit. Due to cognition, R1 was observed to have partial orientation. R1 informed that they have received visits from outside parties at the facility but was not able to recall specific information or dates. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(Continued from LIC9099 p.1) Staff interviews corroborated this allegation, as staff who had observed this issue informed witnessing specific caregivers exhibiting impatience with memory care residents by raising their voices or stating they would not help them. Staff interviews additionally revealed observations of a staff member hitting the hands of a resident during care when the resident was resisting, forcing a resident's hands from a bed rail and moving faster than the resident wanted to go, ignoring their protests. Additional staff observations included a staff member mocking a resident and responding to a resident in a way that escalated the resident's behavior instead of attempting to calm the resident down, a staff member using inappropriate supplies to clean a resident, improper protocols while changing a resident that did not maintain their dignity, and a group of staff not being respectful of a resident's change in condition. During interviews staff were asked if the situations were elevated, which some staff affirmed that they had notified management when the incidents occurred. Staff additionally mentioned that the incidents occurred during times where no management, families, or agency visitors were present. One incident was noted regarding an accusation against a staff member that had been previously investigated by the Department through case management and found to be unsubstantiated. Facility records were not found to show that the incidents named by staff were documented in staff files or that the staff were reprimanded for the incidents named. Outside sources were interviewed regarding the allegation. No outside sources had observed dignity issues by staff toward residents. Regarding the allegation, "Staff did not respond to residents' call buttons in a timely manner", it was alleged that residents experienced long wait times for staff assistance when they pushed their pendants. Staff interviews provided differing expectations of facility policy wait times, ranging from 7 to 20 minutes. Five (5) staff stated that the response times were reasonable and/or between 7-15 minutes. Five (5) staff stated that the response times were too long, observing wait times in excess of 30, 40, 60, 90 minutes, and three (3) hours. Staff stated that the that the response delays occurred on certain floors or during certain times of day. (Continued on LIC9099 p.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 LIC9099 p.2) Staff informed that some of the reasons for the wait times had to do with the pendant technology, the phones not working to know that a resident had paged, or not having a magnet to clear the phone. Other staff interviews revealed that some residents over-utilized their pendants, did not understand how to use them/pushed them in error, misplaced them, or would not allow staff to clear it. Staff who informed long wait times informed that there was no reasonable explanation for the delayed responses they witnessed, and that the staff members observed were on their personal phone instead of attending resident calls. Staff stated that while not every call was legitimately missed, the overall response time was too long and that management was aware. Staff additionally stated that the response times and assistance from management has recently improved with the new Memory Care Director. Review of facility pendant logs for the month of May 2025 revealed that a pattern of extended wait times did exist, corroborating the allegation and staff interviews. Excluding outliers, the pendant log showed that approximately 126 (one hundred twenty six) calls had response times greater than 20 (twenty) minutes. Outside source interviews were mixed regarding the allegation, as some sources informed that their respective residents were not cognizant to utilize their pendant, other sources stated that their residents did express to them that the response times were slow, and further sources informed not being concerned about response times or not having observed the response times. Resident interviews confirmed the wait times, as resident stated that they had waited 20 minutes or greater, or pushed their pendant and no staff responded to their call. Regarding the allegation, "Staff did not provide adequate supervision to resident(s)", it was alleged that staff were observed sleeping on shift and there were times when residents were not being supervised. Staff interviews corroborated this allegation, as nine (9) staff informed of being aware and/or directly observing staff sleeping on shift or being on their phones in lieu of assisting residents. During interviews, clarification was made to confirm that these instances negatively affected resident supervision, or that there were no staff actively supervising the residents, which was affirmed. Staff informed that an internal policy existed restricting staff from being on their phones while working the care floors, however not all staff adhered to this rule. Staff offered specific observations such as entering a care floor and observing all caregivers sitting in the corner on their phones, a caregiver on their phone with earbuds in both ears while not on break, a caregiver falsely stating where they were on two occasions while 2-person assist residents were waiting for assistance, and staff sleeping on shift while not on break. (Continued on LIC9099 p.4) 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 LIC9099 p.4) Interview information showed that a pattern existed on certain resident floors during certain times of the day. Review of facility records revealed Disciplinary Action Notices for staff who were found sleeping on shift and staff who left their care floor either unattended or low staffed. These staff were given written warnings and/ or terminated due to this behavior. Additional records revealed staff members being questioned by management for going on break at the same time with no supervision of residents on the floor. Outside sources were interviewed regarding the allegation. No outside sources had observed inadequate supervision by staff, however, the outside sources confirmed during interview that they did not visit their respective residents during the timeframe in question. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are 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 Rob Daynes, 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 (Continued from LIC9099 p.1) Staff interviews did not corroborate this allegation, as staff consistently stated that R1's medical conditions made it very painful for them to be repositioned, resulting in R1 resisting and refusing care. Staff stated that they directly observed staff and R1's Hospice agency attempt to consistently reposition R1 to avoid pressure injuries, however R1's resistance prevented them from doing so each time. R1's Hospice agency corroborated staff statements, informing that staff consistently attempted to turn R1 at regular intervals and also assisted them with turning R1 during visits, however R1 experienced progressive agitation due to pain, preventing them from being turned. This outside source additionally stated that R1's physical condition combined with becoming bed bound made their pressure ulcers inevitable, and the sores did not exist prior to R1's end stage condition. R1's Responsible Person informed that staff repositioned R1 as much as R1 would tolerate and were not neglectful in attempting to turn R1. Interviews with outside source medical professionals for other residents revealed that staff consistently turned other residents who were also at risk for pressure sores. R1 was unable to be interviewed due to passing away. Records review revealed that R1 was receiving Hospice services. Shift reports, care notes, and shower skin sheets during the timeframe of complaint showed that staff tended to R1 regarding repositioning. Regarding the allegation, Staff did not ensure residents' incontinence needs were met", it was alleged that Memory Care residents were not being assisted with toileting. Staff interviews were mixed regarding this allegation, with a majority of staff informing that toileting assistance was consistent and timely. Staff informed that toileting protocol was to assist or ask residents to use the bathroom approximately every two (2) hours. Some staff stated that residents in wheelchairs were not toileted as often as ambulatory residents, and other staff stated that communication between shifts resulted in confusion on when residents were being changed. Additional staff stated that at times the timelines were slightly extended, however, ultimately all residents were changed. Staff additionally noted that some residents refused to be assisted with toileting every two hours or had a behavior of inappropriately toileting around the building. Outside sources interviewed did not express concerns regarding residents being assisted with incontinence care at the facility. One outside source noted that their respective resident tended to be combative when being given assistance. All outside sources informed of directly observing staff assist residents to the bathroom. (Continued on LIC 9099 p.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 LIC9099 p.2) During unannounced facility visits LPA directly observed caregivers assisting r

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Resident Care Coordinator Alexis Encinas and Executive Director Rob Daynes, to discuss the purpose of the visit. Today's visit is in response to the Self-reported incident of a staff member’s (S1) mishandling of resident care for (R1) 06/22/2025. The facility suspended the staff pending internal investigation and terminated S1 on 06/30/2025. LPA conducted a wellness check at the facility; no health or safety issues were identified. Deficiencies are 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 Rob Daynes, Executive Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. This is an amended report signed by Health Services Director Ellie Davis.