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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802260
Report Date: 02/27/2024
Date Signed: 02/27/2024 12:18:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20221228090447
FACILITY NAME:ANNA'S GARDENSFACILITY NUMBER:
405802260
ADMINISTRATOR:JOHN P SHEPPARDFACILITY TYPE:
740
ADDRESS:100 CARMELDE LANETELEPHONE:
(805) 481-2662
CITY:GROVER BEACHSTATE: CAZIP CODE:
93433
CAPACITY:0CENSUS: 0DATE:
02/27/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Deiverd by MailTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility staff left resident soiled for an extended period of time.
Facility staff did not meet resident's oral hygiene needs.
Facility staff did not give resident medication.
Resident suffered from dehydration while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jeffries delivered final findings via US mail. The facility closed 04/20/2023 due to the licensee’s request to no longer operate a licensed facility.

On 12/28/2022, the Department received a complaint alleging Neglect/Lack of Care and Supervision of Resident #1 (R1). It was reported that R1 was hospitalized on 12/24/2022 with a heavily soiled brief with multiple incontinence pads stacked upon each other and soaked through. R1’s clothing was soiled from back to knee. R1’s mouth was extremely dry with no oral care evident and suffered from dehydration. The Medication Assistance Record (MAR) showed no medications provided for 12/23/2022.

On 01/04/2023, from 10:45am to 1:00pm, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to conduct the initial complaint visit for the allegations above. LPA Jeffries met with the licensee/administrator John Sheppard and explained the reason for the visit. At 11:10am the LPA and licensee/
CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 29-AS-20221228090447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNA'S GARDENS
FACILITY NUMBER: 405802260
VISIT DATE: 02/27/2024
NARRATIVE
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administrator took a tour of the facility and R1's room. The LPA took photos of the room, food supplies and other supplies relevant to the investigation. The LPA requested copies of documents pertinent to the investigation including R1's complete file and Medication Administration Record (MAR). The licensee was instructed to submit the requested copies to the Department. The LPA determined further investigation was needed and informed the licensee that final findings would be issued at a later date.

On 01/03/2023, at 10:45am, LPA Jeffries conducted an interview with Witness #1 (W1); and on 01/04/2023, conducted interview with licensee/administrator. On 01/05/2023, LPA Rachael De Leon conducted an interview with R1’s resident representative and Witness #2 (W2). In addition, LPA De Leon contacted Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miguel Magana, reviewed TCRC progress notes, San Luis Obispo (SLO) County Emergency Services (EMS) reports, Long Term Care Ombudsman (LTCO) report, medical records from Arroyo Grande Community Hospital and Marian Regional Medical Center, and death certificate. Facility file documents related to R1 were requested numerous times, however, the licensee/administrator only provided a Special Incident Report (SIR) and a death report for R1.

A review of the SIR submitted by the licensee/administrator states on 12/24/2022, R1 was trying to get out of bed, stood up and slid to the floor. No injury was noted, and 911 was called. According to the EMS report, paramedics arrived at the facility on 12/24/2022 at 10:18am and found R1 sitting in a wheelchair. The caregiver reported that R1 had been generally weak and seemed altered. The caregiver stated they had been giving R1 all their medication, but documentation showed that R1 had not had their medication in two (2) days. The paramedics also noted urinary incontinence in their report.

A review of the Arroyo Grande Community Hospital records noted R1 was brought to the emergency room (ER) on 12/24/2022, at 10:41am, with a chief complaint of altered mental status. The records noted R1 had a history of cerebral palsy, hypertension, dehydration presented to ER with mild confusion, cough, and weakness. R1 was covered in urine and feces and had sacral wounds. Poor oral hygiene was also noted. R1 has not had their medications in at least one (1) to two (2) days. Notes indicated R1 was fully vaccinated. In the ER, R1 tested positive for COVID-19 and a urinary tract infection (UTI). Due to being COVID-19 positive, R1 was transferred and admitted to Marian Medical Regional Center for isolation and further treatment.

CONTINUED on LIC9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 29-AS-20221228090447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNA'S GARDENS
FACILITY NUMBER: 405802260
VISIT DATE: 02/27/2024
NARRATIVE
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A review of the Marian Medical Regional Center records revealed R1 was admitted 12/24/2022 with the chief complaint of generalized weakness. The records noted concern of care of R1 upon arrival to the ER. The records noted “R1 was living in substandard conditions”, “found to be living in squalor”, “found in unlivable conditions”. Due to the poor living situation, Adult Protective Services (APS) was contacted to find a new board and care facility placement. Due to R1 being COVID-19 positive R1 needed to stay 10-days before they could be placed. The assessment noted COVID-19, mild gingivitis, allergies, depression, iron deficiency anemia, hyperlipidemia, neuropathy, hypertension, and cerebral palsy. The records further noted R1 “appears unkempt, poor oral hygiene, hair matted and R1 smells of body odor; emaciated. Recent weight loss without trying. Needs one (1) person assist with all activities of daily living”. Dr. Khalsa made a note about R1’s low blood pressure and a possible connection to missed medications. On 12/31/2022, while at the hospital, R1 began having respiratory difficulty, suffered cardiac arrest, and passed away. The cause of death was listed as Cardiopulmonary Arrest, Covid-19, and Cerebral Palsy.

The licensee/administrator denied the allegations and submitted a written statement that they “changed R1 every four (4) hours during the day and in the morning after awakening. Waking R1 in the night to change R1 caused problems with schizophrenia. R1 wore two (2) depends, and two (2) pads at night for incontinence. R1 was fed large amounts of food daily and R1’s weight loss was discussed with the doctor. Assisted R1 with tooth brushing twice a day. Medications were given as directed. R1 drank a full 64-ounce container of water daily in addition to coffee, orange juice and milk”.

TCRC listed R1’s diagnoses as high cholesterol, hypertension, chronic periodontitis, anxiety, and mild intellectual disability. According to the TCRC progress notes, dated January 2022 to September 2022, nighttime was worse for R1, episodes of incontinence and yelling. R1 was eating well, but losing weight, skin picks. There were no documents reviewed that indicated R1 was diagnosed with schizophrenia.

On the allegation: Facility staff left resident soiled for an extended period. R1 was brought to the ER on 12/24/2022 covered with urine and feces. R1 had four (4) layers of incontinence briefs/pad completely soaked through. The licensee/administrator admitted they did not change R1 during the nighttime. Therefore, the allegation is deemed Substantiated at this time.

CONTINUED on LIC9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20221228090447

FACILITY NAME:ANNA'S GARDENSFACILITY NUMBER:
405802260
ADMINISTRATOR:JOHN P SHEPPARDFACILITY TYPE:
740
ADDRESS:100 CARMELDE LANETELEPHONE:
(805) 481-2662
CITY:GROVER BEACHSTATE: CAZIP CODE:
93433
CAPACITY:0CENSUS: 0DATE:
02/27/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Deiverd by MailTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility staff did not prevent resident from sustaining pressure injuries while in care.
Facility staff did not ensure that resident was fed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jeffries delivered final findings via US mail. The facility closed 04/20/2023 due to the licensee’s request to no longer operate a licensed facility. The facility closed 04/20/2023 due to the licensee’s request to no longer operate a licensed facility.

On 12/28/2022, the Department received a complaint alleging Neglect/Lack of Care and Supervision of Resident #1 (R1). It was reported that R1 was hospitalized on 12/24/2022 with pressure wounds observed to R1’s spine and buttocks. In addition, it was reported that R1 did not eat for two (2) days.

On 01/04/2023, from 10:45am to 1:00pm, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to conduct the initial complaint visit for the allegations above. LPA Jeffries met with the licensee John Sheppard and explained the reason for the visit. At 11:10am the LPA and licensee took a tour of the facility and R1's room. The LPA took photos of the room, food supplies and other supplies relevant to the
CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 29-AS-20221228090447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNA'S GARDENS
FACILITY NUMBER: 405802260
VISIT DATE: 02/27/2024
NARRATIVE
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 investigation. The LPA requested copies of documents pertinent to the investigation including R1's complete file and Medication Administration Record (MAR). The licensee was instructed to submit the requested copies to the Department. The LPA determined further investigation was needed and informed the licensee that final findings would be issued at a later date.

On 01/03/2023, at 10:45am, LPA Jeffries conducted an interview with Witness #1 (W1); and on 01/04/2023, conducted interview with licensee/administrator. On 01/05/2023, LPA Rachael De Leon conducted an interview with R1’s resident representative and Witness #2 (W2). In addition, LPA De Leon contacted Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miguel Magana, reviewed TCRC progress notes, San Luis Obispo (SLO) County Emergency Services (EMS) reports, Long Term Care Ombudsman (LTCO) report, medical records from Arroyo Grande Community Hospital and Marian Regional Medical Center, and death certificate. Facility file documents related to R1 were requested numerous times, however, the licensee/administrator only provided a Special Incident Report (SIR) and a death report for R1.

A review of the SIR submitted by the licensee/administrator states on 12/24/2022, R1 was trying to get out of bed, stood up and slid to the floor. No injury was noted, and 911 was called.

According to the EMS report, paramedics arrived at the facility on 12/24/2022 at 10:18am and found R1 sitting in a wheelchair. The caregiver reported that R1 had been generally weak and seemed altered. The caregiver stated they had been giving R1 all their medication, but documentation showed that R1 had not had their medication in two (2) days. The paramedics also noted urinary incontinence in their report.

A review of the Arroyo Grande Community Hospital records noted R1 was brought to the emergency room (ER) on 12/24/2022, at 10:41am, with a chief complaint of altered mental status. The records noted R1 had a history of cerebral palsy, hypertension, dehydration presented to ER with mild confusion, cough, and weakness. The records also document sacral wounds but did not list a description of size or staging. During the visit, R1 stated they were hungry because they did not have lunch. Notes indicated R1 was fully vaccinated. In the ER, R1 tested positive for COVID-19. Due to being COVID-19 positive, R1 was transferred and admitted to Marian Medical Regional Center for isolation and further treatment.

CONTINUED on LIC9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 29-AS-20221228090447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNA'S GARDENS
FACILITY NUMBER: 405802260
VISIT DATE: 02/27/2024
NARRATIVE
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A review of the Marian Medical Regional Center records revealed R1 was admitted 12/24/2022 with the chief complaint of generalized weakness. The records noted concern of care of R1 upon arrival to the ER. The records noted “R1 was living in substandard conditions”, “found to be living in squalor”, “found in unlivable conditions”. Due to the poor living situation, Adult Protective Services (APS) was contacted to find a new board and care facility placement. Due to R1 being COVID -19 positive R1 needed to stay 10-days before they could be placed. The assessment noted Covid-19, mild gingivitis, sacral decubitus (wound care following), allergies, depression, iron deficiency anemia, hyperlipidemia, neuropathy, hypertension, and cerebral palsy. The records further noted R1 “appears unkempt, poor oral hygiene, hair matted and R1 smells of body odor; emaciated. Recent weight loss without trying. Needs one (1) person assist with all activities of daily living. The wound consult notes document wounds were present on admission to coccyx with thick scaly dry skin with surrounding tissue of mild blanchable redness. The left foot was noted to have an abrasion with thin red scabs with surrounding tissue of mild blanchable redness. Both heels noted to have red to purple blanchable boggy tissue. There were no real open wounds noted. Contractures and very poor skin conditions were reported. However, there were no dimensions measured and no diagnosis of pressure injuries of any stage documented.
The licensee/administrator denied the allegations and stated in writing that they “there was never any broken skin – used ointment” and R1 was “fed large amounts of food daily, discussed weight loss with doctor”. TCRC listed R1’s diagnoses as high cholesterol, hypertension, chronic periodontitis, anxiety, and mild intellectual disability. According to the TCRC progress notes, dated January 2022 to September 2022, nighttime was worse for R1, episodes of incontinence and yelling, and R1 was eating well, but losing weight.
On the allegation: Facility staff did not prevent resident from sustaining pressure injuries while in care. The medical records reviewed indicated R1 had sacral wounds with no open wounds noted. There were no dimensions measured and no diagnosis of pressure injuries of any stage documented. The licensee/administrator stated there was never any broken skin and they used ointment. R1’s resident representative was interviewed and did not have concerns and felt the placement was appropriate for R1. Therefore, the allegation is Unsubstantiated at this time.
On the allegation: Facility staff did not ensure that resident was fed. TCRC notes indicated R1 was eating well but losing weight. The hospital records indicated R1 was emaciated and had a recent weight loss without trying. The licensee/administrator stated R1 was fed large amounts of food daily and the weight loss was discussed with the doctor. Therefore, the allegation is Unsubstantiated at this time.
Exit interview, copy of report mailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 29-AS-20221228090447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANNA'S GARDENS
FACILITY NUMBER: 405802260
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/27/2024
Section Cited
CCR
87625(b)
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87625 Managed Incontinence
(b) In addition to Section 87611…the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. (3) Ensuring that
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Facility closed effective 04/20/2023.
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incontinent residents are kept clean and dry…free of odors from incontinence. This requirement is not met as evidenced by:Based on interviews and records review, the licensee did not comply with the section cited above.Facility staff failed to
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ensure R1 was checked on and changed during the night, which posed an immediate health and safety risk to residents in care.
Type A
02/27/2024
Section Cited
CCR
87464(f)(1)(4)
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87464 (f)(1)(4) Basic Services
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (4) Personal assistance and care as needed by the resident and as indicated in the
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Facility closed effective 04/20/2023.
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 pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement is not met as evidenced by:
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Based on records review, the licensee did not comply with the section cited above. Facility staff failed to ensure R1 was provided sufficient oral hygiene and hydration, which posed an immediate health and safety risk to residents in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 29-AS-20221228090447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANNA'S GARDENS
FACILITY NUMBER: 405802260
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/27/2024
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide assistance in obtaining such care, by compliance with the following:
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Facility closed effective 04/20/2023.
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 (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:Based on records review, the licensee did not comply with the section cited above. Facility staff failed to ensure R1
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received medications for two (2) days, which posed an immediate health and safety risk to residents in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 29-AS-20221228090447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNA'S GARDENS
FACILITY NUMBER: 405802260
VISIT DATE: 02/27/2024
NARRATIVE
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On the allegation: Facility staff did not meet resident's oral hygiene needs. Medical records noted poor oral hygiene with a diagnosis of mild gingivitis. There was not sufficient evidence that R1’s teeth had been brushed twice a day as stated by the licensee/administrator. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: Facility staff did not give resident medication. When the EMS arrived at the facility on 10/24/2022, documentation showed that R1 had not had their medication in two (2) days. Further, Dr. Khalsa made a note about R1’s low blood pressure and a possible connection to missed medications. The licensee/administrator stated they gave R1 medications as directed, however, did not provide the MAR documentation to the LPA when requested. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: Resident suffered from dehydration while in care. Medical records noted a history of dehydration, R1 presented with dry mouth, dehydration and diagnosed with a UTI. The licensee/administrator stated R1 drank 64-ounces of fluid daily but did not provide any documentation. Based on the medical records, and the medical diagnosis, the allegation is therefore deemed substantiated at this time.


Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).



Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9