Rancho Vista Senior Living.

On May 19, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Case Management Other, and met with the Administrator, Brian Taube. LPA Mixson introduced herself and explained the purpose of the visit. LPA Mixson toured the facility, along with the Administrator and made observations. There were enough staff present to attend to the residents at the time of this case management visit. There are no imminent health and/or safety concerns observed at the time of visit. The LPA requested and received pertinent documentation pertaining to the facility informing residents of the rent increase. LPA Mixson did not observe any health and/or safety hazards inside or outside of the facility at the time of this visit. LPA observed the facility utilities to be operating without issue. LPA Mixson assessed the available food and observed there was a variety of food types available for the residents in care. The food supply meets the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. The medications were found to be in sufficient supply, locked, and inaccessible to the residents in care. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. No deficiencies were observed or cited during today's visit. An exit interview was conducted, and a copy of this report was provided to the Administrator, Brian Taube.

On February 25, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Annual Inspection and met with the Administrator, Brian Taube. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 170 Elderly Adult residents and is currently operating at the capacity of 70 Elderly Adult residents. For a (740) facility type. LPA Mixson toured the facility along with the Administrator, Brian Taube, and made observations pertaining to the required annual visit. LPA inspected the facility inside and outside. There were no obstructions or debris to the indoor or outdoor passageways observed. Additionally, there were no bodies of water seen on the premises at the tie of this visit. The facility is a multi-story building located at 760 East Bobier Drive Vista, Ca. 92084. Physical Plant: The facility phone number is (760) 941-1480, and it is operable. LPA Mixson observed a sample of the residents’ bedrooms, and each was furnished as Regulations and Title 22. LPA Mixson inspected the facility bathrooms, and the hot water temperature tested within regulations, and was logged. The bathrooms were clean, and appliances were operating appropriately currently. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the LTCO poster. The cleaning supplies and sharp items were locked and inaccessible to the residents in care presently. There was designated storage spaces for the residents’ and staff’s files, and this office was locked and inaccessible to residents in care at present. There elevators were clean and operable at the time of this visit. Medications : Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. There were no documented errors observed on the centrally stored medication forms, and medications were stored in their original containers at the time of this visit. Food Service& furniture: The non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents at this time. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. The kitchen is an industrial style kitchen adjacent to a dining hall where meals are served in a restaurant style setting. 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 Care & Supervision / Administration: There were adequate staff present for the supervision of residents in care. The floor plans, telephone numbers and personal rights were found posted in the facility. The listed Administrator, Brian Taube holds a current administrator’s certificate, and it is posted in the facility. The overall facility is clean; the furniture is in good condition and arranged in a manner which provides space for residents to move safely. The facility cooling system and other appliances were operable at present. Licensee informed LPA there were safety lights for night throughout the facility. There is a receptionist and desk at the front lobby entrance. Records Reviewed and Resident/Staff Files: LPA Mixson reviewed the staff files and the facility's staff schedule. The staff files reviewed had the criminal clearances, updated training's, along with current First Aid certifications. The resident files reviewed possessed the required paperwork as per Regulations at the present, including current TB tests. Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as the disaster training binder. LPA observed the last fire drill met the Department standards and was conducted as required per standards. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to conduct regular cleaning of the facility. LPA reviewed the facility's infection control plan and found required infection control measures met the Department requirements. An exit interview was conducted. A copy of this report was reviewed and given to the Administrator, Brian Taube.

On February 25, 2026 Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a case management health and safety visit, and met with the Administrator, Brian Taube. LPA Mixson introduced herself and explained the purpose of the visit. LPA Mixson toured the facility, along with the Administrator and made observations. There were enough staff present to attend to the residents at the time of this case management visit. There are no imminent health and/or safety concerns observed at the time of visit. The LPA requested and received pertinent documentation pertaining to the facility locks on the residents doors in the memory care department. LPA Mixson did not observed any health and/or safety hazards inside or outside of the facility at the time of this visit. LPA observed the facility utilities to be operating without issue. LPA Mixson assessed the available food and observed there was a variety of food types available for the residents in care. The food supply meets the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. The medications were found to be in sufficient supply, locked, and inaccessible to the residents in care. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. No deficiencies were observed or cited during today's visit. An exit interview was conducted and a copy of this report was provided to the Administrator, Brian Taube.

(Continued from Page 1) Regarding the allegation resulted in resident sustaining two head injuries and staff neglect resulted in resident sustaining multiple falls, it was reported that between December 28, 2023, through February 8, 2024, R1 had ten incidents that included falls. R1 was admitted as a fall risk and had an unsteady gait. It was recommended that R1 use a walker. Information obtained from interviews stated R1 did not like to use the walker, and it was also advised that R1 would wander through the facility at night without their walker. R1 had a total of five falls where R1 was found on the side of the bed on the fall mat or found sliding off own bed onto the fall mats, one fall in the dining room where R1 slid off own wheelchair, and the last fall witnessed by R1’s spouse coming out of the bathroom and observed R1 attempting to get up from wheelchair and fell forward. One incident, R1 was walking in the hallway without walker, and feet got crossed causing to trip and fall hitting head, staff assessed and immediately called 911 and another incident, staff witnessed R1 in the dining room where R1 was agitated and threw body forward on wheelchair causing head to hit the floor, staff assessed and immediately called 911. Hospice documents reviewed revealed a low ground hospital mattress, halo rails and fall matt were in placed along with a walker and a wheelchair, due to R1’s anxiety and agitation, medication were noted to be ineffective by hospice. Regarding the allegation staff did not assist resident with dental hygiene as needed, it was reported that R1 sustained a mouth infection due to staff not taking his partial out when brushing his teeth. Based on staff and resident interviews it was revealed residents are helped by staff according to their needs. A review of facility records, R1’s needs and services plan dated December 28, 2023, requested assistance with personal hygiene for dental care, in which it was provided by staff. Regarding the allegation staff did not provide a copy of written agreement to resident’s responsible person at admission, it was reported requested and just now provided. Based on staff and resident interviews it was revealed residents and their responsible parties are provided a copy of written agreements. A review of facility records did reveal R1’ responsibility party signed documents December 19, 2023. (Continued on 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 (Continued from Page 2) Regarding the allegation staff retained a resident beyond their scope of care, it was reported the facility neglected to meet R1’ needs as a fall risk. Based on staff and residents interviews it was revealed that the facility took all precautions to prevent falls risks. A review of facility records, R1 was on hospice and a care meeting involved R1’S responsible party, hospice agency and facility to assist R1 with additional services and there were many fall precautions and prevention strategies put in place for R1 during the time frame at the facility. Based on staff interviews, witness interview, hospital records, facility records, the allegation Neglect Lack of Care and supervision resulted in resident sustaining multiple falls and Neglect Lack of Supervision resulted in resident sustaining two head injuries, staff did not assist resident with dental hygiene as needed, staff did not provide a copy of written admission agreement to resident’s responsible person at admission, staff retained a resident beyond their scope of care is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Beatrice Pena and Diane Domingo by telephone and a copy of this report along with LIC811- Confidential Names list was provided.

(Continued from Page 1) LPA was able to interview Resident #1 (R1) to obtain pertinent information due to R1’s current cognitive impairment, R1’s interview could not corroborate allegations. Regarding the allegation lack of supervision that resulted in resident sustaining an injury that caused hospitalization, R1 was found on the floor by staff and was immediately assessed and 911 was called and was taken to the hospital and discharged to a Skilled Nursing Facility for two and half months and returned to Pacifica November 8, 2023. On December 13, 2023, R1 had a lumbar procedure outpatient and from the procedure was weak in recovery and activities started to decease. R1 was at the facility for seven weeks due to R1’s multiple hospitalization's, procedures and rehabilitations and early removal from the facility. Regarding the allegation staff did not ensure resident was provided fluids resulting in dehydration, based on staff interviews, staff would provide R1 with water, juice, or smoothies and at times R1 would refuse to drink liquids that were offered, a review of R1’s assessment dated 11/08/2023 stated R1 was independent in feeding self. Regarding the allegation staff did not give resident’s medication as prescribed, based on staff interviews, R1 was on medication management and staff would take R1’s medication to R1 to take and R1 would refuse to take medications sometimes, staff would give R1 some time and would return with the medication to take, a review of R1’s facility records, an assessment and Physician’s Report revealed R1 needed prompting assistance with medication management. Regarding the allegation staff did not ensure resident was nourished, based on staff interviews, R1 was prepare meals and sometimes meals were brought to R1 at bedside if R1 did not want to go to the dining area and R1 at times would not eat the food and did not want to be bothered at times, R1 was always provided meals and snacks. A review of facility records, an assessment stated that R1 was able to eat independently. (Continued on 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 (Continued from Page 2) Regarding the allegation staff did not assist resident with CPAP machine, based on staff interviews, R1 did have a CPAP machine, and staff was aware of R1 having to use CPAP machine at night and at times R1 would refuse assistance from staff with wearing the machine and sometimes would be found during checks not wearing the machine. A review of facilities records for R1, a needs and services plan stated resident uses a CPAP machine at night. Regarding the allegation resident did not have a call assistance button, based on staff, resident and witnesses interviews it was revealed resident rooms are equipped with emergency call system and pendants are available to residents if they choose. A review of facility records did not reveal on R1’ admission agreement that a pendant was requested or issued to R1. Regarding the allegation staff left resident in wet briefs for an extended period resulting in sores, based on staff and witnesses interviews, any resident who needs assistance with incontinence care will be check, assessed and changed, it was revealed at times that R1 would not want assistance from staff, R1 would become verbally aggressive with staff, staff would give R1 some time and return to do the assistance with R1’s toileting needs. A review of facility records revealed R1’s assessment stated that R1 needed assistance with toileting and no corroborating documentation of R1 resulting in sores. Regarding the allegation facility’s screen door was in disrepair, based on staff, residents, and witnesses’ interviews, it was revealed there are sliding glass doors with sliding screen doors that designed to open to 6 inches as a safety precaution for residents in the building. LPA corroborated sliding glass doors and sliding screen doors opening to 6 inches for rooms. (Continued on 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 (Continued from Page 3) Based on staff interviews, witness interview, facility records, the allegation that Neglect Lack of Care and Supervision for resident’s unwitnessed fall and sustained a fracture that required hospitalization and Neglect Lack of Care and Supervision for staff failing to seek timely medical, Staff did not ensure resident was provided fluids resulting in dehydration, staff did not give resident’s medication as prescribed, staff did not ensure resident was nourished, staff did not assist resident with CPAP machine, resident did have a call assistance button or pendant, staff left resident in wet briefs for an extended period of time resulting in sores, facility’s screen door was in disrepair is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Diane Domingo and a copy of this report along with LIC811- Confidential Names list was provided.

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility with LPA identification and business card. Resident record review began- Ten (10) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Employee records review began- Six (6) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and renewed on 2/26/2025 and still processing. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The buildings are maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 110.0 degrees F. Laundry is done in the designated laundry room located on the 2 nd floor of building B. There is a locked closet for storing laundry soap and other chemicals in the housekeeper’s closet on the 2 nd floor All outdoor and indoor passageways are free of obstruction. (Continued on next page) 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 on from Page 1) There is a location for sharps in the kitchen. LPA verified there is a telephone working at this location. There are no firearms stored and no bodies of water observed. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors are tested quarterly 2/12/2025 for ten (10) buildings and LPA observed report from Dialcom Systems Group Inc. were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 1/6/2025. The facility is conducting emergency disaster drills monthly. The last disaster drill was conducted on 03/28/2025. Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with Diane Domingo and a copy provided at the time of the exit interview.

The investigation revealed the following: Allegation: Facility does not have sufficient staff to meet the care needs of residents. It is being alleged that facility does not have sufficient staff to operate the facility transport vehicle. On 03/29/25 between 1pm-3pm LPA conducted Interviews with S1-S7 regarding the allegation above, 5 of 7 staff interviewed denied the allegation above, 2 of 7 staff interviewed reported being unaware of transportation procedures or schedules. On 03/29/25 between 3pm-3:25pm LPA conducted interviews with resident R1-R5, 4 of 5 residents interviewed denied the allegation above, 1 of 5 residents interviewed confirmed the allegation above and stated resident has been unable to obtain the care needed due to transportation. On 03/30/25 LPA conducted a review of LIC 500 dated 03/18/25, LPA observe facility driver to be scheduled 5 days a week from 8:30am-5pm. On 03/30/25 LPA conducted a review of appointment calendar and appointment book, LPA observed R1 to be scheduled for transportation between 2-4 times a month. Allegation: Staff does not ensure facility has sufficient quantity of food for residents in care. It is being alleged that the facility has ran out of food 3 times during dinner service. On 03/29/25 LPA conducted a tour of the facility kitchen and observed the dry pantry, refrigerator, and freezer to be fully stocked and labeled with expiration dates. On 03/29/25 during kitchen tour LPA also observed food delivery taking place. On 03/29/25 between 1pm-3pm LPA conducted Interviews with S1-S7 regarding the allegation above, 7 of 7 staff interviewed denied the allegation above and reported residents can obtain additional food upon request, 2 of 7 staff interviewed also added that the kitchen receives food deliveries 2 times per week. On 03/29/25 between 3pm-3:25pm LPA conducted interviews with resident R1-R5, 4 of 5 residents interviewed denied the allegation above, 1 of 5 residents interviewed confirmed the allegation above and stated resident has gone 3 days without obtaining food. On 03/29/25 LPA conducted a review of R1's narrative charting dated February 2024-March 2024 that R1 refuses meal service completely or resident consumes very little to no food from tray. Allegation: Staff do not ensure proper sanitary practices are followed while providing bathing services to residents in care. It is being alleged that residents who require bathing assistance in their bed get their face washed using the same water that was used in the bowl for the rest of their body. On 03/29/25 between 1pm-3pm LPA 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 conducted Interviews with S1-S7 regarding the allegation, 5 of 7 staff interviewed denied the allegation above and reported bed baths are conducted by hospice nurses, 2 of 7 staff interviewed reporting having no knowledge of bathing procedures. On 03/29/25 between 3pm-3:25pm LPA conducted interviews with resident R1-R5 regarding the allegation above, 4 of 5 residents interviewed denied the allegation above and reported not needing shower assistance and having no concerns with the water used for hygiene purposes. 1 of 5 residents interviewed confirmed the allegation above and reported not having a shower for over 3 days. On 03/30/25 LPA conducted a review of hospice notes from October 2024- March 2025 for R1, LPA observed documentation reporting R1 has received 2-3 bed bathes from hospice nurse upon agreement as it is also documented that R1 has refused hospice nurse assistance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.

(Continuation of LIC9099) They were aware any evictions would need to be individualized. Staff #1 (S1) said that they are aware that only the notice was sent out. The facility did not evict any residents when the notice was sent out. They worked with the families to find alternatives for their medications. The facility was removing its nursing staff and injections would not be a part of the Medication Technicians job description as they were not medical professionals. Most residents transitioned into oral medications or had outside agencies oversee their insulin medications. S1 mentioned few residents opted to move to other facilities. An interview with the Long-Term Care Ombudsman (LTCO) reviewed former notes which showed LTCO made a site visit on February 7, 2022, with no remarkable notes. LTCO received information regarding a notification sent to families for persons who need assistance with insulin care, but no additional information was entered. A letter from Pacifica Senior Living, dated February 9, 2022, said “Effective 4/09/2022 Pacifica Vista will be discontinuing our Diabetic Management program due to the Nationwide Nursing shortage.” The letter had information to contact Michael McCoy or their Regional Director of Operations with questions or concerns. According to R1s Admission Agreement, dated February 13, 2019, the facility assisted with medication management. According to R1s medication administration record, dated February 2022, it demonstrated that the primary care physician’s order indicated the units to be increased or decreased to be used depending on R1s sugar levels at bedtime. R1 was provided with their routine insulin pen to be used before meals. Physician’s Report (LIC602) dated March 10, 2021, R1 was diagnosed with cognitive impairment and was deemed unable to manage their own medications. According to the R1s assessment, dated July 15, 2020, and September 15, 2021, they were categorized as level 5 and required total medication assistance. R1 Needs and Service Plan, dated September 15, 2021, and July 15, 2020, showed R1 had a diabetic diet and needed total assistance with medications. Additional records revealed that R1s LIC 602, dated May 12, 2023, was updated to include their medications and their orders. R1s MAR, dated August 2022, said that they were taking their blood sugar medication orally. According to the Facility’s Death Report, R1 passed at the facility on September 18, 2023, where R1 received hospice services. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Angeles Frasier, Resident Service Coordinator. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to Resident Service Coordinator Frasier at the conclusion of the visit. The signature below confirms the documents were received.

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one-hundred and eight (108) clients live at this facility. There was twenty-eight (28) staff members present. The Business Office Manager, Jhonalyn Libunao and The Resident Services Director, Esmeralda Reyes conducted the facility tour. The Executive Director, Mike McCoy completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration : LPA reviewed employee records. Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Michael D McCoy’s Administrator’s certificate expiration date is 08/08/2024. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen. 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 Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 107.0 degrees F. Laundry is done in the designated laundry room located on the 2 nd floor of building B. There is a locked closet for storing laundry soap and other chemicals in the housekeeper’s closet on the 2 nd floor. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are no fireplaces at this facility. There are no pools at the facility. LPA observed emergency supplies and first aid kits. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed ten (10) random residents’ medication logs and observed that they were logged and dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed smoke detectors and carbon monoxide detectors throughout the facility. The facility alarms are hardwired throughout the facility and monitored by Dialcom System Group, 24 hours a day. The City of Vista Fire Department granted Pacifica Senior Living a fire department permit on 06/19/2023. There were fifty-four (54) fire extinguishers on site, last recharged date 01/08/2024. 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 Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Executive Director, Mike McCoy.

According to the former Executive Director, R1 was able to receive their phone calls in the reception area. Callers would need to call the facility and they transfer the call to the area where the resident resides. In review of the resident’s records R1 does get confused and forgetful. According to the facility’s basic services the facility does not provide a phone to the resident but when requested the Community would make reasonable access to a telephone for local calls. In review of R1’s Admission Agreement, families/residents are responsible for the telephone and the connection to their preferred company. During a visit on 09/08/2021, LPA observed that the resident had a cell phone charger plugged in to the wall and a note with the cell phone number and said the property belonged to the R1s friend and to return the property to R1. Although the charger was present the cell phone was nowhere in sight. According to an interview with R1 their POA had removed their cell phone device. Based on the information obtained there is insufficient evidence to support the allegation. It was alleged that the facility is not allowing Resident #1 (R1) to receive their visitors. During an interview with the former Executive Director, they mentioned that R1’s power of attorney (POA) had requested R1 not to have visitors as they wanted R1 to adjust to their new surroundings. ED said that visitors had contacted a lawyer to sue their POA but R1 was unaware that they were doing so. Interviews with staff confirmed that they did refuse R1 to have their visitors enter into the community to visit with them. Staff confirmed that they proceeded with the refusal of visitors at the direction of R1’s POA. According to staff interviews there were a total of three visitors who were refused visits with R1. Interview with R1 confirmed that they recognized who two of three visitors were. In review of a self-reported incident report (IR) submitted to the San Diego Regional Office (SDRO), it said that one of R1s visitors was making R1 upset for issues that were beyond R1s control. This caused R1 to want to leave the facility and staff were unable to redirect R1. The visitor raised their voice to R1 and then told R1 that they should “bust through the doors.” Staff were able to contact R1s POA who reassured R1 everything was fine. At this time, the staff was able to redirect R1 and management requested to speak with R1s visitor outside. Staff were able to contact local law enforcement who recommended that staff not allow visitor to return to the community. If the visitor returned, they recommended the facility to call law enforcement again. According to the Physician’s Report, R1 is unable to leave the facility unassisted and is cognitively impaired. Records show that R1 does have an assigned power of attorney (POA) who is able to make their decisions for them. Based on the letters from R1’s primary care physicians which said that R1 met the criteria for neurocognitive disorder and lacked the capacity to make decisions, as such court orders had assigned R1 POA’s. Due to R1s cognitive state of mind, visits could be set-up during times when R1s family was at the facility. Based on the information obtained there is not sufficient evidence to support the allegation. (Continuation 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 (Continuation of LIC9099-C) Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside source interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Michael McCoy and Memory Care Director Starsha Clark. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to Executive Director Michael McCoy at the conclusion of the visit. The signature below confirms the documents were received.

If they were wet, they would be changed. According to a former staff member, they would be assigned approximately 20 to 30 residents, but they checked if changing was needed. They mentioned that there may have been times where other staff may not have changed all their residents, but they never witnessed, nor did they miss in changing their assigned residents. Staff and former staff did say that there were residents who would either refuse or give staff difficulties changing them. When this occurred, staff would switch resident checks to observe if another staff member would be able to assist with those who refused or had difficulties with. No staff reported issues with other shifts not keeping up with their checks. Former and current staff reported working well with their co-workers. In review of the facility documents, it was noted that the resident had a loss of cognitive functioning and needed one-person standby assistance for toileting needs. Documents show that the facility needed to assist the resident in the bathroom every two hours for toileting assistance. According to the facility service plan, it annotated that incontinence care or toileting service while resident is awake; if the resident refused, they would need to inform nurse on duty and or the RSD; also, if resident refused care to a care staff, they would try change of staff face technique. It was noted that the resident was able to shower self and noted that at times R1 refused to be showered by their third-party agency. The facility did have incontinence checks logs for R1 the months of August 2020 and September 2020 only. According to records, staff would change the R1 between 6:30 AM – 7:30 AM; with mainly staying within the range assisting the resident in the morning with incontinence care at about 7:00 AM. The facility staff incontinence checks ranged daily between 28 minutes to about 3 hours but staying within the range of checking R1 every 2 hours between the hours of around 7 AM until about 10 PM. Incontinence checks indicated if the resident needed to be changed or was dried at the time of the check. Based on the information obtained during interviews and records reviewed, there is insufficient evidence to support the allegation. It was specifically alleged that due to staff not changing R1 throughout the night, R1’s entire room was malodorous when they opened their door. Staff and former staff interviewed did not raise concerns regarding residents not being changed during their assigned shifts. If staff did not have issues with residents being changed, there would be no indication that there were residents who had a malodorous room due to staff not checking residents’ incontinence care. Based on the evidence obtained during the investigation, there is insufficient evidence to support the allegation. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside sources interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be 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 The report was discussed, and an exit interview was conducted with Executive Director McCoy, and Resident Service Director Reyes . A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to ED McCoy at the conclusion of the visit. The signature below confirms the documents were received.

Additional feedback provided during interviews with staff and residents revealed that caregivers make the residents’ bed and clean the residents’ room daily. Based on observation and interviews, there is no concerns that would prove that the facility is dirty or malodorous thus the allegations are UNSUBSTANTIATED. An allegation(s) finding of unsubstantiated means, although the allegations may have happened or are valid, there is not a preponderance of the evidence strand to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was provided to Starsha Clark.

On September 29, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to the facility to conduct a Health and Safety Visit and met with the Administrator Mike McCoy. LPA Mixson toured the facility along with the Administrator. LPA Mixson observed facility clean, neat, and well organized. The utilities were observed to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide assistance to the residents as needed. LPA Mixson assessed the available food supply and observed the supply exceeds the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. Medications were found to be in sufficient supply and locked on med carts and in the med room. There were no Health and/or Safety concerns observed while conducting the tour of the facility at this time. The facility had the required Regulation postings. The LPA observed an activities schedule, the resident council minutes and schedule of the next meetings. LPA Mixson observed the environment was positive and the residents were welcoming and greeting staff and visitor who arrived. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or the welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to the Administrator Mike McCoy.

Interviews with internal and external sources indicate that the hospice agency disseminated information to facility care staff, who followed the agency’s directions and R1’s Plan of Care. On 10/08/19, R1 was diagnosed with pressure injuries on their coccyx (Stage I and Stage II). A dressing was applied weekly to the affected areas. Records reflect that on 05/19/2020, one of R1’s pressure injuries transitioned to Stage III. Hospice and facility care staff increased position changes to provide perineal care every two hours. Records reveal that, on 06/02/20, one of R1’s pressure injuries degraded to Stage IV. Records and interviews with staff and outside sources reported that R1 was not compliant with repositioning and often removed protective pillows arranged to elevate the affected areas. It is noted that CCLD regulations permit residents with a terminal diagnosis and are receiving hospice care to remain at a facility if they develop prohibited conditions, such as a Stage IV pressure injury. Records also noted that R1 had an advance directive. The directive noted that the hospice agency and facility care staff would apply a cooperative and integrated plan of care and document the services provided by whom and at what frequency. The facility staff received training from the hospice agency regarding R1’s expected course of illness and symptoms of their impending death. Notes reflect that the hospice agency kept facility staff informed on the care and proper procedures of R1’s wound care and how to reposition R1 every two hours. A review of R1’s progress notes illustrated that facility and hospice staff documented R1’s repositioning. The Department has investigated the allegation that because of neglect/lack of supervision R1 was admitted to the hospital with an unstageable pressure injury. This investigation yielded no corroboration or evidence to show that facility staff failed to rotate or reposition R1 in a neglectful manner, causing the pressure injury to degrade to Stage IV. Therefore, the allegation of neglect/lack of supervision is Unsubstantiated. An exit interview was conducted with Director McCoy and a copy of this report was provided to Mr. McCoy, whose signature below confirms receipt of copies of this report and Licensee Rights (LIC 9058).