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13 | On 03/16/26 Licensing program Analyst (LPA) M. Garza arrived at the facility for an unannounced complaint visit. LPA met with Executive Director, Sheree Addison, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in rooms in common areas and in kitchenetts getting ready for lunch.
During visits for this complaint, LPA completed tours of the facility, completed interviews and requested documentation (medical assessments, staff schedules, needs and services plans, charting notes, staff and resident rosters and reviewed video). LPA observed meal service on 4 of 4 dates (8/6/25, 8/26/25, 11/24/25 and 2/24/26) and observed residents in their rooms that required assistance. R1 was observed on 8/6/25, 11/24/25 and 2/24/26 with an empty water cup on top of their beside table. Interviews conducted disclosed that each visit staff had recently checked on R1 (15 minutes or less) without filling up their water cup. R1 is bedridden and relies on others for assistance with their needs.
4 of 4 interviews conducted disclosed that R2 was found with a knife that had to be removed by staff. The location R2 found the item is unknown. LPA observed video of R2 with a knife that was removed from their hands by staff. Review of records (medical assessment dated 02/27/24) and needs and services plan) disclosed that R2 is aggressive and should not have access to sharp items.
The allegations listed above have met the preponderance of evidence standard per California Code of Regulations, Title 22. Deficiencies cited on 9099D. The allegations listed above are SUBSTANTIATED. If not corrected, the deficiencies poses a direct impact to residents in care.
Exit interview completed with ED, Sheree. A plan of correction was developed by ED and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. |
| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
03/17/2026
Section Cited
CCR
87309(a) | 1
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7 | 87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
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7 | ED stated they will provide a plan of correction in writing by POC date, to include all staff training on resident safety. In-service sign in sheet and training material will be provided to CCL as proof of correction. |
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14 | This requirement was not met as evidence by: LPA observation and interviews conducted. The licensee did not comply with the section cited above in that interviews conducted disclosed that R2 had a knife in their possession. LPA reviewed video of R2 having a knife in their possession and staff attempting to remove it from them. This poses an immediate health safety and or personal rights risk to residents in care. | 8
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Type B
03/27/2026
Section Cited
CCR
87633(6)(A) | 1
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7 | 87633 Hospice Care of Terminally Ill Residents (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan. (A) The training shall include but not be limited to typical needs of hospice patients, such as turning and incontinence care to prevent skin breakdown, hydration, and infection control. | 1
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7 | ED stated they will complete all staff training to include basic services that should be provided to all residents in care. In-service sign in sheet and training material will be provided to CCL by POC date as proof of correction. |
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14 | This requirement was not met as evidence by LPA observation, review of records and interviews conducted. The licensee did not comply with the section cited above in that in R1's water cup was observed empty on 8/6/25, 11/24/25 and 2/24/26. Interviews with staff on schedule at the time stated R1 was recently (15 minutes or less) been checked on. Hospice file reviewed indicated training was completed but does not have an in-service sign in sheet or what was covered in this training. This poses a potential health safety and or personal rights risk to residents in care. | 8
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