Marymount Villa Retirement Center

Allegation: Staff are physically abusing resident in care. Finding: Unsubstantiated Based on the investigation, inter views with staff revealed that they have not witnessed or heard about any staff members physically or emotionally abusing any residents in care. Interviews with residents reveal that they have not experienced any staff members physically or emotionally harming them or others at the facility. Allegation: Staff are emotionally abusing resident in care. Finding: Unsubstantiated Based on interviews with residents, it was revealed that they have not experienced any staff members emotionally abusing them or witnessed any staff members emotionally abusing any residents. Interviews with staff revealed that they have not witnessed or heard about any staff members emotionally abusing residents in care. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted with Dolly Rizvi and a copy of this report provided.

On 5/12/2021 at 3:05PM, Licensing Program Analysts (LPAs) G. Luk and L. Hall arrived unannounced to conduct a case management inspection in regards to incident report received on 5/10/2021. LPAs met with Administrator, Dolly Rizvi. Incident report dated 5/10/2021 revealed that R1 AWOL and facility notified law enforcement and R1's responsible party. R1 was found by police a couple hours later and was escorted back to the facility. Interview with S1 revealed that R1 left the facility during morning shift change. S1 stated that facility staff looked for residents near BART and local shops, but unable to find R1. Facility staff called police and police was able to find R1 after a couple hours. S1 stated that R1 was given a different medication dosage when family member was caring for R1. S1 has changed noc/morning shift change procedures after incident to prevent future AWOLs. R1 has a new doctor's order for medications after consulting with R1's family. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty. Exit interview conducted with Dolly Rizvi. A copy of this report and appeal rights provided.

On 07/17/25 at 12:30 PM, while at the facility for another reason, LPAs Y. Brown and D. Panlilio conducted a case management visit to discuss administrator duties (must be present at the facility for a minimum of 20 hours per week) and reporting requirements with Executive Director (ED) Dolly Rizvi. LPAs also discussed the Emergency/ Disaster Plans with ED/ADM and requested updated reviewed copies with dates and signatures during visit. LPAs advised ED/ADM to conduct monthly staff meetings and discuss fire safety/emergency/disaster procedures and timely reporting requirements. ED/ADM confirmed with LPAs that no incident reports were submitted to CCLD for the emergency exit blockages on the 3 rd , 4 th and 5 th floors of the facility. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal Rights and a copy of this report Provided.

On 1/6/2026 at 12:45 PM, Licensing Program Analysts (LPAs) Y. Brown and A. Gomez arrived unannounced to conduct a Case Management visit in regards to an unusual incident report received 1/5/2026. LPAs met with Executive Director, Dolly Rizvi, and explained the purpose of the visit. It was reported that on 12/31/2025 resident (R1) eloped from the facility. At approximately 4:18 pm, the front desk received a call from R1's POA about R1 leaving the facility. R1 was located at a shopping center. Staff picked up R1 and brought R1 back to the facility. During visit LPAs reviewed R1's physicians report and care plan. LPAs also contacted R1's physicians that stated that R1 is not able to leave unassisted. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted with Dolly Rizvi appeal rights and a copy of this report provided.

Continued from LIC9099. Allegation: Licensee is financially abusing resident in care. Finding: Unsubstantiated Based on interviews with staff and W1 revealed that R1 receives monthly income from Supplemental Security Income (SSI) and the remaining income was provided by the family. Interview with complainant indicated that R1 was being charged private room rate when R1 did not request to be in a private room. There was a lack of evidence that licensee is financially abusing R1. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted with Dolly Rizvi and a copy of this report provided.

On 11/3/2021 at 11:00AM, Licensing Program Analyst (LPA) G. Luk conducted an unannounced Health & Safety inspection as a result of priority 2 complaints (15-AS-20211029160831 and 15-AS-20211026093939). LPA met with Executive Director (ED), Dolly Rizvi. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 106.6 degrees F in a resident's bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies twice a week. Refrigerator temperature was observed at 40 degrees F and freezer temperature was observed at -10 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 10/7/2021. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

On 11/7/2025, at 2:45 PM, Licensing Program Analysts (LPAs), Y. Brown and L. Hall arrived unannounced conduct a case management health and safety check. LPAs met with Bessy John, Care Coordinator. LPA toured the facility with the Bessy John, Care Coordinator, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. There are no imminent health/safety concerns on today's date. No deficiencies cited during the Health and Safety visit. Exit interview conducted and a copy of this report provided.

On 12/29/2025 at 12:00PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct a case management visit. LPA met with Executive Director, Dolly Rizvi and explained the purpose for the visit. While LPAs were at the facility for a complaint investigation (#15-AS-20251215162420), the following deficiencies were observed. LPAs observed eviction notice issued to R1 on 11/13/2025 did not specify what care needs the facility was unable to provide to R1. LPAs observed facility did not provide 90 days written notice to R1 or R1's family regarding R1's increase rate. An email was sent on 11/26/2025 regarding R1's rate increase for December 2025. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct deficiencies may result in civil penalties. Exit interview conducted with Dolly Rizvi. A copy of this report and appeal rights provided.

CONTINUE FROM LIC9099 Allegation: Due to lack of supervision, a resident physically assaulted another resident resulting in injury and hospitalization Investigation Finding: Unsubstantiated The Department interviewed R1, R2, S2, S1, S3, S4, and S5. Staff reported that during lunch service, R1 was heard screaming from R1s room, and that Staff immediately responded. S4 stated seeing R2 leaving R1s room, then found R1 on the floor with blood and what appeared to be defensive wounds. Per Staff, R1 reported that R2 was in her room and in her closet when R1 attempted to stop R2, whereby both had struck the other. R1 had fallen backwards. R2 was unable to provide information related to the event. Review of a police report responding to the incident showed that there was no determination as to whether an assault had taken place or if R1 had an unwitnessed fall. R1 was immediately transferred to hospital where it was found that R1 had sustained a fracture, a cut above the eyebrow, and bruising. Hospital records indicate that R1 also had a back injury. It was indeterminate when that injury took place and it was noted that it could have been associated with R1s overall condition. A review of R1’s file did not indicate that R1 was a fall risk, and there was no record to indicate a history of falling at the facility. There was also no information to suggest that R1 had displayed a history of aggression. The Needs and Services Plan and the Physician’s report had no information to indicate that R1 needed additional supervision. A review of R2’s file indicated a history of aggression towards staff, but had no information to indicate known aggression towards other residents. There was no indication of R2 needing additional supervision, or a 1:1 caregiver. All staff interviewed stated having no knowledge of R2 having a behavior of aggression towards other residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. 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 CONTINUE FROM LIC 9099 Allegation: Resident In care was diagnosed with severe dehydration Investigation Finding: Unsubstantiated Interviews and record review (R1’s care notes) revealed that R1 was provided water, ensures, and juices. Charting shows that R1 was drinking the liquids that were provided to R1, however charting also revealed that R1 would on some occasions skip the ensure but would drink the water and juices provided. Interview with S1 revealed that R1 drank beverages on R1 own and was vocal about what drinks R1 wanted, and staff would provide and chart. Interview with S2 revealed that R1 loved coffee and would drink beverages on R1s own and that staff would measure intake. Interview with S3 revealed that R1 would drink beverages on R1s own and staff kept track of R1s intake. Interview with S4 revealed that R1 would drink beverages on R1s own and that staff would keep track on R1s intake. The Department obtained and reviewed R1s hospitalization report and there was no information to indicate that the resident had been dehydrated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated . 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 CONTINUE FROM LIC9099 Allegation: Staff did not assist resident with feeding Investigation Finding: Unsubstantiated Interviews and record review revealed that R1 is able to feed self. Review of R1’s physician report shows that R1 is able to feed self. Interview with S1 revealed that R1 ate on own. Staff would prepare the food and bring it to R1 but staff never assisted with feeding. S1 stated that R1 also liked extra snacks and food and would eat on R1’s own. Interview with S2 revealed that R1 ate on R1s own and no one had to assist R1 with feeding. S2 also stated that staff would ask R1 if R1 wanted snacks and R1 would eat them all. Interview with S3 revealed that R1 would feed R1 self and staff would keep track of how much R1 ate and drank and that R1 ate normal portions and would give snacks and R1 would eat them and loves coffee. Interview with S4 revealed that R1 would eat all food in R1s room on R1’s own and that the facility provided R1 with water, ensure, coffee and tea and R1 would eat and drink normal portions. S4 stated that staff has never fed R1, R1 and without assistance. A review of the Needs & Services plan and the Physician’s report indicated that R1 is capable of feeding self. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegations are UNSUBSTANTIATED. No deficiency was cited during this visit. Exit interview conducted and a copy of this report provided.

On 10/14/2025 at 12:00 pm, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 9/18/2025. LPA met with Dolly Rizvi, Administrator, and explained the purpose of the visit. The incident occurred on 9/16/2025. Incident report stated that R1 became non responsive. R1 was previously being seen at the facility by Home Health due to unstageable wounds. LPA reviewed R1's care plan and interviewed S1. Although R1 was seen by home health professionals who cared for the wounds, licensee failed to obtain exception request and have it approved prior to retaining R1 back to the facility. The documents that were obtained showed that R1 had unstageable wounds on 8/27/2025 and stage 4 wounds on 9/3/2025, while still residing at the facility. The document obtained from the hospital stated that R1 was discharged on 9/17/2025. S1 stated that R1 was placed on hospice on 9/24/2025. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal right provided.

Page 2 Allegation: Staff refused to accept resident (R1) back to the facility after an emergency (ER) visit. The reporting party (RP) stated that the facility administrator (ED) refused to accept R1 back to the facility due to a bed issue. The RP stated that R1’s semi electric bed which was brought to the facility from R1’s home was broken and unless R1 is provided with a replacement bed, either a hospital bed or another semi electric bed, ED won’t admit R1 back, and that ED said R1 has not eaten in 24 hours and has become agitated because of the bed being broken. ED denied the allegation that she refused to admit R1 back. ED stated the staff reported to her on 7/17/22 that the remote control of R1’s bed was broken and that R1’s daughters (FM1 and FM2) came to the facility on 7/18/22 and R1 was agitated because of the bed being broken and would not eat. R1 can feed self but would not want the staff put pillow to elevate/raise her head and was refusing to eat that day. ED also stated that she told the hospital several times to arrange the rental bed which will take only one hour, and that they can send the bill to the facility and the facility will get paid by the responsible party. ED further stated she told FM1 and FM2 they can rent a hospital bed temporarily, but the daughters were saying the insurance would not cover 100% of the cost. FM1 and FM2 told them to call 9-1-1 so R1 was sent out. R1 may also have UTI because R1 was very agitated that day. R1 was discharged back to the facility on 7/19/ 22. R1 stated not remembering what happened to her bed. LPA observed R1’s bed was working on 7/27/22. LPA tried to reach to FM1 and FM2 to obtain information, but they did not return LPA’s call. S1 and S4 confirmed ED’s statement that the remote control of R1’s bed was broken and that R1 was agitated and refusing to eat. S1 stated R1’s bed was broken on and off and the issue reported to R1’s daughters. S1 also stated that R1 was sent out on 7/18/22 and discharged back on 7/19/22. Hospital After Visit Summary showed R1 was admitted on 7/18/22 for feeding and behavior problems and discharged on 7/19/22. Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated. ....continued on 9099C (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 Page 3 Allegation: Staff did not ensure that resident's (R1) bed was in working condition. S1 stated R1's bed has been on and off broken and R1’s daughters were informed and aware. Prior to the last time the bed was broken on 7/17/22, the daughter sent a motor to the facility and the motor of the bed was replaced. The bed was not a hospital bed, but part of the bed can be raised with a remote control. S4 confirmed that the remote control of R1’s bed was broken. During interview on 7/27/22, R1 was not able to provide information about her bed but stated she’s happy. LPA observed R1’s bed was working that day. LPA tried to reach to FM1 and FM2 to obtain information, but they did not return LPA’s call. Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated. Allegation: Staff did not ensure that resident (R1) was adequately fed. S2 stated she fed residents during her shift and if residents refused to eat, she reported to her supervisor and facility nurse who gave her instructions what to do and she followed the instructions. S2 further stated they cannot force feed the residents, and that residents have right to refuse, but she came back and offer food 2 or 3x. She documented if resident still refused. S4 stated the caregivers were feeding R1. S4 also stated that R1 knew that R1 has medications that needed to be taken with food. S4 further stated that she does not remember any incident where caregivers refused and/or didn't feed R1. R1 stated she likes to eat dinner at 5:00 p.m. and dinner is already prepared at that time but was not able to provide information if caregivers refused to give her food. ....continued on 9099C (page 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 Page 4 Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

Page 2 LPA conducted inspection on 10/14/21 and interviewed staff on 12/06/24 and 4/04/25. All three housekeepers interviewed stated that during peak of Covid-19 on 2020 and 2021, there were only about 3, 4, 5 housekeepers. Two out of this 3 housekeepers stated they were not able to clean all the residents' rooms. One of these 2 housekeepers stated that this housekeeper was also assigned to do the laundry. Therefore, the allegation is substantiated. A finding that a complaint is substantiated means that the allegation is valid because the preponderance of evidence standard is met. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED over the phone. ED authorized Ernesto Buendia to sign and receive this report. Exit interview conducted. Appeal Right, LIC9098 Proof of Correction form and copy of this report 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 Page 2 Allegation: Resident (R1) was severely dehydrated. - UNSUBSTANTIATED R1's family member (FM) stated that on 11/04/20, the facility called and told FM that R1 needed to go to the hospital due to the resident not eating for 2 weeks. R1's doctor told FM that R1 was severely dehydrated. The 2 caregivers interviewed stated they give water to residents. One of these caregivers stated giving water to residents 4 to 5 times during their shift. LPA reviewed the documents obtained from the facility and the Plan of Care showed R1 came back from the hospital after being treated for UTI. There was no hospital discharge document or other document indicating R1 was dehydrated. LPA tried to obtain records from FM but unsuccessful. Allegation: Staff did not notify responsible party of resident's (R1) change in health condition. - UNSUBSTANTIATED FM stated that the facility did not inform FM that R1 was not eating and positive of COVID-19. R1's doctor told FM on 11/04/20 that R1 was positive of COVID-19. LPA interviewed 4 staff (2 caregivers and 2 care coordinators) who all stated that when there's a change in resident's health condition, med-tech and facility nurse are informed who in-turn assess the resident. The med-tech or the facility nurse notifies the resident's family member. LPA also reviewed the copy of line list showing the names of residents who were tested positive of COVD-19 from 10/23/20 to 11/20/20 submitted by the facility to the Department of Public Health and provided to Community Care Licensing. R1 was not included on the list. Allegation: Facility did not ensure the COVID-19 positive residents were isolated. Six staff (2 caregivers, 2 housekeepers and 2 care coordinators) were interviewed who all stated that residents who tested positive of COVID-19 were isolated. Two of these staff stated that residents in Memory Care, because of dementia, came out of their rooms to the common area. One of these staff also stated that resident who's not positive of COVID-19 comes out to the common area. ....continued on 9099C (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 Allegation: Resident (R1) was missing teeth from dentures. - UNSUBSTANTIATED Six staff (2 caregivers, 2 housekeepers and 2 care coordinators) were interviewed who all stated they never heard or observed any resident missing teeth from dentures. Two of these staff stated that residents dentures may gone were missing but were found in the residents clothing. LPA was not able to interview R1 as R1 had passed away prior to the Department receiving the complaint. Allegation: Resident (R1) missing personal property. UNSUBSTANTIATED FM stated that R1's prescription glasses were missing. Six staff (2 caregivers, 2 housekeepers and 2 care coordinators) were interviewed who all stated they never heard any resident missing eyeglasses. One out of 2 residents interviewed stated not losing anything. The other resident stated not losing eyeglasses. LPA was not able to interview R1 as R1 had passed away prior to the Department receiving the complaint. R1's LIC621 Resident Personal Property And Valuables was reviewed which showed eyeglasses not listed. Based on records review and interviews, the 5 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there's not a preponderance of evidence to prove that violations occurred. No deficiency cited. The ED authorized Ernesto Buendia to sign and receive this report. Exit interview conducted and copy of this report provided.

On 1/28/2026, at 11:00 AM, Licensing Program Analysts (LPAs), Y. Brown and P. Manalo arrived unannounced conduct a case management health and safety check. LPAs met with Dolly Rizvi, Administrator. LPAs toured the facility with the care staff including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable food s. Continue on LIC809C. 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 LIC809. The Following Deficiencies were observed during visit: At 10:41 am, LPAs observed that the cabinet in the common area on level 3 is missing a handle, dresser and floor in room 315 is in disrepair. At 10:51 am, LPAs observed that there were disinfectants and cleaners like Lysol sprays, Petroleum Jelly, Razor, and A+D Ointment, in an unlocked cabinet in the common area. At 10:55 am, the water temperature was measured at 95.7 degrees Fahrenheit in a random sample of residents shared bathrooms Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Dolly Rizvi and a copy of the appeal rights and this report provided.

At 12:30 pm on this day, December 6, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) received by the Department from the facility on December 5, 2024. LPA met with Wellness Coordinator (WC) Kristinia Morgan and Care Coordinator (CC) Bessy John and informed the reason for visit. UIR indicated that on December 1, 2024, resident (R1) was out with R1's family when R1 was complained of pain in the left wrist. The family took R1 to the hospital where it was discovered that R1's wrist is broken.The UIR is missing last page (page 2) which LPA obtained from CC on this same day. LPA reviewed R1's records and obtained copies of the following documents: Face Sheet; LIC602A Physician's Report; facility notes; hospital's After Visit Summary. LPA conducted interviews. No deficiency cited on this day. WC has to leave the facility and gave permission to have CC sign and receive this report. Exit interview conducted and copy of this report provided.

On 11/19/24 at 2:35 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver an amended report from the visit that occurred on 10/01/24. LPA met with Administrator, Dolly Rizvi and explained the purpose of the visit. Amended report delivered. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

S1 stated that for the protection of the staff involved the staff was reassigned to another section of the facility and that the money R1 gave the staff was a fake $100 bill. This agency has investigated the above complaint. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

While at the facility for other reason and upon review of roster, Licensing Program Analyst (LPA) Delmundo learned that staff (S1) is not associated to this facility. LPA reviewed S1's file which showed S1 was fingerprinted and cleared, somehow, S1 was disassociated. LPA spoke over the phone with Executive Director (ED) Dolly Rizvi and discussed the above in the presence of Care Coordinator Bessy John. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and plan and proof of correction were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Bessy John.

During the investigation LPAs interviewed and reviewed documents between S1 and R1 social worker via email exchange. The documents stated S1 did not denial R1 back to the facility after R1 gets discharge, but due to R1 health concerned R1 was sent to a SNIFF after the hospital discharged R1, therefore this allegation is unsubstantiated. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided .

Page 2 Allegation: Resident (R1) sustained fractured finger while in care. On 11/02/21, LPA Delmundo interviewed S1, S2, S4, S6, and R1. S2 stated having observed R1 had purplish discoloration at one of the small fingers that on 10/24/21, and that R1 yelled out when it was touched. S2 then had R1 transferred to hospital for evaluation. All other staff interviewed was not able to provide information as to how the injury occurred. S6 stated having observed a fresh wound at R1’s right elbow but had no knowledge of how it happened. S2 and S7 were not aware of the subject incident. S1 reported being aware that the facility’s LVN observed that R1 had swelling on one of R1’s finger. S4 only stated having knowledge that R1 was transferred to hospital due to a swollen finger. R1 reported not remembering how the wound happened and did not state that there was any staff involvement. On 8/13/24, LPA Delmundo interviewed FM, who reported being aware that R1 was sent to hospital for the finger injury; and that R1 can be combative and “out of control” and “could see” R1 causing self-injury due to the behaviors. On 11/2/21, LPA Delmundo reviewed R1’s file and observed the Physician’s report indicating a diagnosis of Dementia with Behavioral Disturbance. Based on all information gathered, the allegation is closed as unsubstantiated. A finding that the complaint 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 violations occurred. Allegation: Facility staff hit resident (R1). During complaint intake, the reporting party (RP) stated that R1 informed the RP that R1 is beaten by facility staff. The RP further stated that RP had spoken to FM, who reported being aware that R1 needed transfer to the hospital for an injury. FM further stated that R1 is “manipulative,” “delusional,” and “paranoid”; and did not believe that staff had hurt R1, but that due to aggressive behavior R1 has hurt the staff; and that R1 showed no caution for self-safety. RP stated R1 was sent to hospital via ambulance and diagnosed with right finger fracture. ....continued on 9099C (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 Page 3 All 5 staff (S1-S5) interviewed denied hitting residents and stated not observing any staff hitting residents. S4 stated there was an incident when R1 twisted a spoon and scratched S4. S1 confirmed R1 was sent out on 10/2021. S2 stated R1 asked S2 to check R1’s finger and S2 observed discoloration on the left pinkie and R1 was transferred to hospital; however, R1 was discharged back to the facility without the After Visit Summary. Facility’s Internal Incident Report matched S2’s statement. R1 was not able to provide information regarding the subject incident and indicated that staff are “good.” R3 and R4 declined to be interviewed. R2 and R5 stated having no knowledge of or having been aware of staff abusing any resident. Review of R1’s records showed R1 has dementia, aggressive behavior, and behavior disturbance. LPA interviewed R1’s family member (FM) who confirmed RP and staff’s statements that R1 has agitation and behavior issues. FM stated R1 was combative and hurt herself. Based on all information gathered, the allegation is closed as unsubstantiated. A finding that the complaint 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 violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

On 11/18/2024 at 9:15 AM, Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Dolly Rizvi, and explained the purpose of the visit. The facility’s fire clearance was approved for ninety nine (99) non-ambulatory residents, of which nine (9) may be bedridden and approved for eighteen (18) hospice. LPA toured the facility with Wellness Coordinator Kristinia Morgan, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in visitor bathroom was measured at 110.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher all around the facility was last serviced on 10/15/2024. At 10:02 am LPA reviewed 9 residents records. At 10:45 am, LPA reviewed 4 staff records and 4 of 4 were fingerprint cleared and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Allegation: Staff handled resident roughly Unsubstantiated. During the course of investigation, LPAs interviewed residents (R), staff (S), and resident family members (W). R1, R2, R3, R4, and R5, stated that they have not witness any staff rough handle any residents at the facility nor heard any of the staff rough handle any residents. S1, S2, S3 and W1 stated they have not witness nor heard any of the facility staff rough handle any residents. All individuals interviewed stated that they have not witnessed any resident's falling, any resident being rough handled or any resident being dropped on the ground. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

It was alleged facility did not observe resident's changes in condition resulting in infections. Based on interview with 3 staff, body checks are conducted during showers and staff will inform med-tech or nurse on duty if staff observes any unusual marks on residents body. R1 had a history of cellulitis and during record review, LPA observed a history of communication with R1's podiatrist. It was alleged facility did not safeguard resident's dentures. LPA reviewed R1's property and valuables, and LPA did not observe R1's denture listed on LIC 621. However, S1 stated that R1 tends to remove her denture because the fitting was tight and uncomfortable. S1 stated when R1's family member found the denture in R1's pocket, R1's family member removed it from facility. LPA was unable to prove or disprove allegation. Although the allegations may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Executive Director.

Allegation: Unexplained rapid weight loss of resident (R1) LPA interviewed the ED who stated residents are weigh once a month and weights are recorded. The ED indicated that residents sometimes refuse to be weigh. This ED's statement was confirmed by 4 staff interviewed. Review of records showed residents were weighed once a month. R1 refused to be weigh on one of the month on the record. Record also showed no drastic change on R1's weight. Allegation: Staff not responding to resident's calls for help It was alleged that when R1 calls for help, R1 is ignored by staff. All staff interviewed indicated that if resident calls for help, they come and check the resident within 5 minutes or less. If resident need to be assessed, med-tech or the facility nurse is called. Four out of 6 residents interviewed stated caregivers attend to them whenever they call for help. One of the resident indicated he uses call button to call for help and if no one shows up right away, he uses walkie talkie. LPA was unable to obtain information from R1. Alegation: Failure to call 911 It was alleged that when resident asked staff to call 911, staff refused. LPA interviewed 4 staff who all indicated they call 911 is when needed. All four staff indicated that R1 has behavior of wanting to call 911. R1's family member (FM) was interviewed who stated that when R1 was living in R1's home, R1 calls 911 every 2, 3 days which R1 does when R1 moved to the facility. FM further stated that the facility nurse keep a close contact and inform FM. Review of records showed R1 has dementia, somatic delusional disorder and anxiety. B ased on all information gather, the 3 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

LPA discovered during a review of R1's incident report that S1 applied ice pack on R1 and resident refused to go to the hospital. R1 was monitored closely by care staff and once staff observed swelling, S2 contacted non-emergency transportation. S2 contacted R1's responsible party and informed of wait time so S2 was instructed to call 9-1-1 by R1's responsible party instead. It was alleged staff did not inform resident's authorized representative of injury in a timely manner. However, during record review of R1's incident report on 4/6/23, both R1's conservator and family member were both notified by S2 of the incident that occurred on 4/25/22. S3 stated S2 left a voicemail for R1's conservator then notified R1's family member. 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 allegatio ns are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Executive Director.

Facility staff are not ensuring that resident is following a prescribed diet R1's plan of care dated 6/21/2021 stated that R1 was on a renal and diabetic diet. Interview with staff revealed that diabetic diet limit carbs, more vegetables, less salt, and diabetic dessert. However, LPA observed R1's blood sugar log for October 2021 was in the high 300s with one day in the 500s. S4 stated that R1 does not keep to the diet and R1's doctor has been notified. After reviewing R1's file, LPA did not observed correspondence to doctor regarding R1 not adhering to renal and diabetic diet. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights 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 Facility staff are not arranging transportation for resident's medical appointment. Interview with staff revealed that front desk was arranging transportation for R1. Transportation information indicated that facility was arranging transportation for R1 three days a week. Care notes indicated an incident where the car did not show up, but facility called another transportation service for R1 at a later time. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.

On the allegation Staff are not preforming ADLs. Based on record review and interviews the facility is conducting the ADL's of each resident and evaluating each resident on what assistance they need. The facility also has a schedule for the residents ADL's and logs for showers given to the residents. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.

It was alleged staff did not notify responsible party of residents change in health. However, during record review, LPAs observed an email communication between S5 and S6 indicating that they are communicating any concern regarding R1 with R1’s responsible party. In addition, record review of internal incident report revealed that the facility notified R1’s responsible party on 12/27/2020 of R1’s fall. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

LPA observed resident's complete file included records for 2021. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.

On this day at approximately 10:40 am, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct case management visit to follow up on six residents that needed immediate transfer from Montgomery Springs Manor. LPA met with Administrator Dolly Rizvi. LPA explained to Rizvi the purpose of visit. During the visit, LPA interviewed Residents 1-6. Based on interviews conducted, there are no immediate health and safety concerns noted. A copy of this report was provided to Administrator.

On 10/31/2022 at 1:15 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Administrator, Dolly Rizvi and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility with Dolly including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and patio. Facility has a sufficient two day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, Covid questionnaires, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. Fire extinguisher was observed serviced. LPA observed facility passages inside and out free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Allegation: Facility mismanaged resident's medication-Unsubstantiated The Department has investigated this allegation and per interviews and records review found that inaccurate count medications was not noticed by staff S6 and S7, and no additional information regarding miscounted medication was found. Based on R1’s Medication Administration Records (MAR), most of medications were given to R1 except Haldol 2mg/ml when R1 was discharged. S6 stated that Haldol was finished and required to be refiled. W1, W2 and W4 stated that refilling medications was responsible by resident’s POA or conservator. Allegation: Facility failed to provide adequate assistance with dressing-Unsubstantiated The Department has investigated this allegation and per interviews and records review found that staff S4 and S5 who were R1’s caregivers denied not to provide adequate assistance with dressing. Both caregivers stated that R1 knew what clothes R1 liked to wear and what type of hair R1 liked to be made. R1 always had her dressing including bra, compress socks, and shoes on outings. No other witness and additional information of alleged violation occurred in subject time period was found. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit interview conducted the care coordinator, and a copy of this report provided.

On 09/06/22 at 10:30AM, Licensing Program Analysts (LPAs) D Panlilio and M. Malik arrived unannounced to conduct a case management health & safety check and met with Executive Director (ED) and explained the purpose of the visit. LPAs were screened at the front entrance with routine COVID-19 symptom checks done by staff. LPAs toured the facility with ED. LPAs observed facility had sufficient food supplies in the kitchen. During visit, LPAs observed 14 staff wearing face masks assisting 33 residents with various activities such as having late breakfast, singing in the activities rooms in the 1st, 2nd and 3rd floors and assisting some residents go back to their bedrooms. LPAs observed freezer temperatures were at 0 deg F and refrigerator temperatures were at 40 deg F. LPAs observed sufficient food supplies (2 day perishables and 7 day non perishables) in the kitchen area . LPAs also observed adequate supply of PPEs stored in a cabinet on the 1st floor. Medications were observed stored in the medication room which is always staffed and locked. Toxic chemicals were observed stored and locked in the 3rd floor Wellness Room cabinets. Pathways and hallways were observed free of obstruction and fire hazards. Sufficient staffing was observed during visit. Facility is maintained at a comfortable temperature of 74 deg F for residents in care. LPAs observed residents at the common area appeared to be well groomed, neat and comfortable. Facility appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during inspection. Exit interview conducted and a copy of this report provided.

On 07/21/2022 at 10:20AM, Licensing Program Analysts (LPA) C. Fowler and L. Hall arrived and conducted an unannounced case management health & safety check and met with Dolly Rizvi, Executive Director (ED) and explained the purpose of the visit. LPAs was screened at the front entrance with routine COVID-19 symptom checks done by staff. LPAs toured the facility with ED. LPAs observed facility had sufficient food supplies in the kitchen. Food supplies are ordered & delivered weekly on Monday and Thursday. LPAs also observed adequate supply of PPE in storage room located on the 1st floor. Sufficient staffing was observed during visit. Staff was observed wearing surgical masks. Pathways and hallways were observed free of obstruction and fire hazards. Facility is maintained at a comfortable temperature for the residents in care. LPAs observed residents at the common area appeared to be well groomed, neat and comfortable. Facility appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during inspection. Exit interview conducted and a copy of this report provided.

This is an amendment to the original 809 issued on 7/13/2022. On 07/13/2022 at 9:50 AM Licensing Program Analysts (LPAs) C. Fowler and L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 07/10/2022. LPA met with Administrator Dolly Rizvi and explained the purpose of the visit. Incident report dated 7/10/2022 revealed Resident 1 (R1) jumped from the 3rd floor of the facility. During visit LPAs interviewed ED Dolly Rizvi, S2. S3, collected and reviewed documents, and toured four (4) rooms in memory care. During interview ED Dolly Rizvi stated she conducted an over-the-phone assessment with Kaiser prior to R1 being admitted into the facility on 07/08/2022. ED Dolly Rizvi stated she was not aware that R1 had suicidal ideations. Further investigation needed. Exit interview conducted and a copy of this report was provided.

Facility has insufficient staffing. Interview with witnesses revealed that there's not enough staff at the facility. Interview with staff revealed that facility is short staff at times. Interview with residents revealed staff during NOC shift takes longer time or not at all when responding to pendent call. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations is found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights 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 Facility staff is not allowing the daughter to visit the resident. Interview with residents revealed that visitors were allowed to visit residents. Interview with witnesses revealed that they can visit residents, but would need to follow facility's visitation policy. Record review indicated that visitors are screened prior to visit and facility limits the number of visitors in one location. Due to the pandemic, facility has new visitation policy to reduce the spread of COVID-19 which limits the number of persons per visit and the time of visitation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.

Resident sustained pressure injuries while in care. - UNSUBSTANTIATED LPA Luisa Fontanilla interviewed Executive Director, one nurse, one Receptionist and 4 caregivers. LVN and caregivers interviewed state they do not recall R1 developing pressure injuries while at the facility. Staff state they were applying barrier cream on R1’s buttock, putting pillow under R1’s legs to get them elevated, check and change diaper/reposition every one-two hours. A review of R1’s Physician’s Report and medical records indicate R1 has a history of ulcer of right heel and ulcer of buttock. On 9/17/2019, R1 had an office visit with Podiatry Doctor for Ulcer of Right Heel. R1 moved to the facility on 10/28/2019. Facility not following physician's medical orders. – UNSUBSTANTIATED Reporting Party alleged staff were not following R1’s doctor order to change R1 every two hours instead of every 4 hours. On 4/12/2022, LPA L. Fontanilla interviewed caregivers and nurse. Staff interviewed state that they reposition, check/change R1’s diaper if needed at least every 1-2 hours. And that staff apply skin barrier ointment on R1’s buttocks to prevent pressure sores. Facility not observing changes in resident's health. - UNSUBSTANTIATED RP alleged that during RP’s last visit with R1 prior to lockdown, RP observed R1 shaking due to problem urinating and had to instruct staff to send R1 to the hospital. However, RP does not remember the date of the incident. Based on records reviewed, R1 complained of pain with urine on 7/31/2020. Facility notified the doctor and R1 was prescribed antibiotic for 5 days. Treatment ended on 8/10/2020. On 8/21/2020, R1 complained of burning to touch and with urination. R1’s doctor was notified and urinalysis was ordered. R1’s Physician’s Report indicate R1 is able to communicate needs. Staff not treating resident with dignity. - UNSUBSTANTIATED RP alleged that staff throw away left over foods brought for R1 by family. Based on caregiver notes dated 8/20/2020, R1 was served left over foods brought by R1’s family. Based on records reviewed and interview conducted, the above allegations are unsubstantiated. 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. There is no deficiency noted. Exit interview was conducted and a copy of this report was provided to Executive Director.

According to facility care notes, R1 was given sandwiches, yogurt, and diabetic juice at various meal/snack times. Facility's diabetic diet plan from nutritionist states meals should included 1/2 cup of carbohydrates, more meat and veggies, diabetic drink, and diabetic desserts (cake or fruit). Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.

LPA interviewed staff (S1, S2, S3 and S4). S1 said R1 eats everything unless R1 is not in good mood. S1 stated R1 likes hot dog, hamburger and fries. S2 said R1 likes hot dog a lot and if R1 does not like the meal for the day, R1 is given hot dogs. All 4 staff indicated if residents do not like the meal for the day, they are given options which LPA confirmed with resident (R3). S5 stated that there's daily menu on paper and residents can also ask for substitute. S5 indicated that the chef orders food supplies every Thursday and items like egg sandwich, cheeseburgers, turkey or ham sandwich, and hot dogs are normally fully stocked. If item is not available, the front desk person is asked to change the menu day prior which LPA confirmed with the front desk person. On November 2, 2021, LPA Delmundo tried to interview R1 and R1 declined. LPA tried to interview R2 and R4 but unsuccessful. On April 1, 2022, LPA L. Holmes tried to interview R1 but was unable to obtain relevant information regarding menu and food R1 likes. Residents (R5 and R6) stated if they don't like the menu for the day, they are given substitute. R7 and R8 have no complaint while R9 is not satisfied with the food. Based on all the information gathered and LPAs unable to obtain information from R1, the allegation is closed as unsubstantiated. A finding is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Exit interview conducted and copy of this report provided to Lydia Olson.

While conducting an investigation of a complaint (Control # 15-AS-20211026093939), resident (R1) showed to Licensing Program Analyst (LPA) Delmundo a wound on R1’s right elbow while LPA was interviewing R1. The wound was about 2 inches x 1 1/2 inches with fresh blood, skin scraped and part of flesh exposed. LPA interviewed the staff (S6) who was assigned to R1 that day. S6 stated she observed R1's wound on the right elbow that day and that the blood was fresh. She attended to other residents and forgot to put bandage on R1's wound nor report to the facility nurse (LVN). S6 further stated does not know what happened and that it could be that R1 hit the bed rails. LPA called LVN who confirmed it was not reported to her. LVN attended to R1 after LPA spoke with her. On this day, September 27, 2024, LPA conducted a case management resulting from the above. LPA met with Wellness Coordinator (WC), and informed the reason for visit. LPA also spoke over the phone with Executive Director (ED) Dolly Rizvi. The ED gave permission to WC to sign and receive this report. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED over the phone in the presence of WC. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Based on information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. Exit interview conducted. A copy of report and appeal rights 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 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.

On 06/08/22 at 1:30PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of a Death Report dated on 06/02/22 submitted to CCLD regarding unknown cause of death. LPA explained the purpose of the visit with administrator Dolly Rizvi. Administrator stated to LPA that subject resident has a history of acute posthemorrhagic anemia and had been in baseline until passed. LPA obtained resident's preplacement appraisal, appraisal/needs and services plan, physical therapy notes, care notes, and staff schedule to review. LPA also interviewed 2 staff (S1 & S2) during visit. Both staff stated that they have not noticed resident's health condition has been changed while in care. Return to facility for further information maybe needed. Exit interview conducted with Administrator and a copy of this report provided.