Rowntree Gardens.

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit. Administrator (AD) Claudia Lusca was called and arrived a short time later and was present the remainder of the inspection. During the visit, random resident rooms were inspected, and hot water temperatures were measured. All resident rooms that were inspected were clean, well organized, and had all the necessary requirements: night stand, chair, lamps/lights and storage space. Resident bathrooms were clean and organized. All grab bars were tightly secured to the wall. Hot water temperatures were recorded in the range of 111.5 – 118.4 degrees Fahrenheit. The kitchen was clean and well organized. LPA Haley observed temperature logs on all the refrigerators. The facility has a two-day supply of perishable food items and seven-day supply of nonperishable food items. The exterior portion of the facility was clean, and well organized. LPA Haley observed plenty of shaded areas with tables and chairs. Walkways were clean, clear, and free of obstruction. No bodies of water were observed. The facility conducts various emergency evacuation drills, the last evacuation drill was conducted in May 2025, and a Fire evacuation drill was conducted in August 2025. During the tour fire extinguishers were observed mounted on the walls in different areas of the facility, and smoke detectors were observed in all the resident rooms that were randomly inspected. Continued 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 Tri Signal Integration INC conducts a quarterly Fire Alarm Life Safety System Inspection. The last inspection was conducted in October 2025. Annuals fees are paid. Facility contact information was reviewed and confirmed. 18 staff files were reviewed, and 15 resident files were reviewed during the visit. 10 resident medications were reviewed, no discrepancies were noted, and 3 resident interviews were conducted. No deficiencies are being cited during today’s visit. An exit interview was conducted, and a copy of the report was provided.

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Administrator (AD) Claudia Lusca was called and arrived at the reception desk, was present during the visit and lead the tour of the facility. The inspection began by inspecting random rooms in the Memory Care unit, Independent Living, and Assisted living. Random rooms were inspected while residents were having lunch. All resident rooms that were inspected were clean, well organized, and had all the necessary requirements: night stand, chair, lamps/lights and storage space. In the resident bathrooms, all grab bars were tightly secured to the wall. No hazardous items were observed in any of the resident bathrooms. Bathroom water temperatures were recorded in the range of 105.8 - 107 degrees Fahrenheit. The kitchen was clean and well organized. LPA Haley observed temperature logs on all the refrigerators, and a temperature logbook for all the cooked food. The facility has a two-day supply of perishable food items and seven-day supply of nonperishable food items. All canned food noted to be within expiration date. The exterior portion of the facility was clean, and well organized. LPA Haley observed plenty of shaded areas with tables and chairs. Walkways were clean, clear, and free of debris and tripping hazards. No bodies of water was observed. The facility conducts various emergency evacuation drills, the last evacuation drill was conducted August 23, 2024. Disaster drills are conducted quarterly, and the last fire drill was conducted July 29, 2024. Continued 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 During the inspection LPA Haley observed several fire extinguishers mounted on the walls in various places, and a few fire hoses were also observed. Tri Signal Integration INC conducts a quarterly Fire Alarm Life Safety System Inspection. The last inspection was conducted April 16, 2024. During the inspection, 9 staff files were reviewed, 5 resident files were reviewed, 5 resident medications were reviewed, and 3 resident interviews were conducted. No deficiencies are being cited during todays visit. An exit interview was conducted, and a copy of the report was provided to Administrator Claudia Lusca.

CONTINUED FROM LIC9099 Based on records reviewed and interviews conducted, it was determined that resident R1 was admitted to the facility on or around September 30, 2020. Per the physician report established upon admission, resident had an indication of dementia as well as a colostomy, was displaying confusion/disorientation and was not receiving hospice care at the time of admission. Due to an initial change in condition an updated physician report dated March 3, 2021 was established by R1's primary care physician to reflect the resident's incontinence status. Final updates were observed in August 2021 after R1 was admitted onto hospice care with a terminal diagnosis of hypertensive heart disease. The hospice admission agreement was also reviewed and indicates a date of admission of August 6, 2021. The progression of R1's condition was confirmed to have been well established and documented throughout their admission. Multiple fall episodes were confirmed to have occurred, however witness interviews established that appropriate preventative measures had increasingly been put into place, with the prescription of a hospital bed, fall pads, and culminating in the provision of a full-time one-on-one presence which was confirmed to be in effect at the time of the August fall incident. Therefore, even though multiple falls are confirmed to have occurred, evidence gathered does not corroborate the fact that they could be attributed to negligence or failure to provide care and supervision from facility staff. As a result, the allegation is found to be Unsubstantiated, meaning 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. An exit interview was conducted and a copy of this report was provided to a facility representative.

persuaded R1 to release S1’s wrist. Despite this, R1 continued to display aggressive behavior, swinging their arms, and hitting their hand against the arm rest of the wheelchair. According to hospice records from Salus Hospice, dated April 26, 2024, to May 07, 2024, R1 refused to let the hospice nurse assess or provide care, which led to further combative behavior. A review of R1’s records indicate a history of agitation and combativeness towards staff during activities of daily living (ADLs), resistance to care, and inappropriate behaviors associated with dementia, such as kicking, swinging, and attempts to strike during ADL care. The only record describing R1’s injuries are hospice visit notes for May 07, 2024, indicating patient’s left arm observed with bruising from elbow to hand due to patient banging their hand and arm on the arm rest of wheelchair. Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. This report was reviewed with facility representative, and a copy was furnished to the facility.

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following on a self-reported incident report received in the Orange County Regional Office (OCRO) on 11/03/23 regarding Resident #1 (R1). LPA met with Administrator (AD) Claudia Lusca-Borcsa and discussed the purpose of the inspection. During the inspection, LPA toured the facility with AD, conducted a health and safety check on R1, observed the facility to be clean and organized, and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food, the electricity and water were running, the facility had soap and paper towels, and the medications and sharps were properly stored. LPA interviewed AD, inspected R1’s medications, and requested and reviewed copies of the resident roster, staff roster, and R1’s resident file. There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

Office visit to discuss Stipulation and compliance requirements with Randy Brown and Allison Nakatomi. · CDSS reviewed the proposed disclosure language and is working with CFH’s attorney, Pam Kaufmann, on required revisions. · CFH is required to submit the escrow reports quarterly. · CFH is required to include a signed attestation that there were no life care contracts entered for each reporting period. · CFH is required to submit its Financial Plan (Plan) (1793.13(a)(2). CDSS expects to receive the Plan no later than 60 days of the date. · CFH will be required to continue submitted financial statements and occupancy reports. These are required to be submitted quarterly (based on CFH’s fiscal year). CFH’s action taken to comply with Stipulation: · CDSS approves Gary Johnson to serve on CFH’s Board. · CDSS approves the change naming Ann Hablitzel as the Board Chair to separate the roles and ensure and there are no overlapping responsibilities do with the Chief Executive Officer (Randy Brown). · CDSS approves the proposed financial consultant, MHS Consulting (Jeremy Kauffman), to identify implementable strategies to improve the CFH’s performance and provide quarterly reports to CFH and the Department regarding CFH’s financial operations. · CFH has submitted a proposed Continuing Care Contract (Type B/ 36-Month Amortization) to the Department for its review and approval. The Department has reviewed this contract and found that it does not conflict with the Continuing Care Statutes. · CFH has submitted a revised Escrow Agreement to the Department for its review and approval. The Department has reviewed this agreement and found that it complies with the terms in the Stipulation.

R1 was admitted to the facility September 5, 2023 and there was a plan in place to get the resident acclimated to the community and new surroundings. There was a staff member present in the memory care unit to redirect the resident if needed, hourly visual checks were conducted, and eventually 1 on 1 care is required if necessary. On September 5, 2023 facility staff contacted R1's physician because R1 refused to take medication and R1's son was called as well. The residents son came to the facility (9.5.23) because R1 was having a hard time adjusting. September 6, 2023, Rowntree staff contacted R1's physician regarding medication for anxiety and restlessness. Staff also requested recommendations to deal with the residents anxiety and restlessness during the call to the physician. September 7, 2023, Rowntree staff left another message with R1's physician to request assistance because none of the previous calls were returned. On the same day (9.7.23) about 7PM, R1 was able to open an emergency exit in the memory care unit and exit the building. Alarms went off and staff followed right behind the R1 and redirected the resident back to memory care. As a result of this attempted elopement, it was determined R1 would need 1 on 1 care. R1's son was informed of this decision, and Rowntree Gardens covered the cost of the 1 on 1 care for the first day and was willing work with 1 on 1 care providers of the son's choice. September 8, 2023, a care plan meeting was held with R1's son and it was determined the facility would not be able to meet R1's needs. Based on the information gathered during the investigation through interviews and document review, the allegation mentioned above is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.

A review of the two combined police reports, do not reveal any break in or burglary to the resident’s room, and no video surveillance was available to be reviewed. Further, document review and interviews reveal, it’s not exactly clear when the items were lost or stolen from the resident. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation: Jewelry was stolen from resident, occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.