Although concerns were raised regarding administrative practices and documentation, the investigation did not yield sufficient evidence showing that the Administrator acted outside the scope of administrative qualifications at the time of this report. The evidence does not meet the preponderance of evidence standard required to substantiate the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview done and copy of report printed for administrator.

Page 3 of 9099-A-C

The alleged improper fee increase was tied to the facility’s attempt to implement 1:1 care. This was discussed between the administrator and CCL on 2/23/26, and the Administrator was reminded that the facility cannot require 1:1 care without first completing a revised care plan and re-assessment. The facility was also reminded that it must accept the resident back and provide all required care and supervision pursuant to the needs identified through assessment. The admission agreement does reference the possibility of additional fees based on increased care needs; however, proper notification, assessment, and documentation must occur prior to charging additional fees. While the facility may ultimately implement and bill for 1:1 care if justified, the necessary procedural steps were not followed. The facility did follow CCL instructions and did not implement 1:1 care requirements or additional fees.

CCL also reviewed the facility’s prior citation related to an inaccurate incident report regarding a resident elopement. This previous violation does indicate a need for improved administrative oversight and reporting accuracy. However, because it was previously cited under reporting requirements, it does not independently demonstrate a failure to meet administrative qualifications for the current allegation.

The allegations further assert that the Administrator required at least three residents to wear Wanderguard devices despite their objections and despite the devices causing resident distress. CCL is aware of one confirmed case in which the facility relied on inconsistent information in the Physician’s Report (LIC 602A), despite repeated requests from the resident and their responsible party to have the device removed. Concerns regarding assessment accuracy and resident rights were discussed with the Administrator.

Continued on 9099-C

Page 2 of 9099-A-C

On 2/24/26, CCL, Long Term Care Ombudsman (LTCO), and the administrator discussed the incidents. CCL reminded the administrator of the eviction regulations and requested the resident be allowed to return. During this discussion, the administrator acknowledged that no unusual incident report had been submitted or called in, and no written eviction notice was provided to the family. CCL confirmed the administrator had not reached R1’s family to explain they could return to the facility without a 1:1, per the previous day’s conversation with CCL. Administrator stated they were hesitant for R1 to come back to the facility, citing safety concerns. However, CCL was informed R1’s family had obtained a physician’s note indicating R1 was not suicidal and did not pose a risk. CCL confirmed again that requiring R1’s family to pick them up at night with no notice was considered an illegal eviction, as was refusing to let R1 back into the facility. Administrator was again reminded after R1 was brought back to the facility, the facility was within their rights to obtain updated physician’s reports and conduct reappraisals of R1 to determine if an increased level of care or 1:1 supervision was needed. Administrator was reminded that proper justifications for care increases are required per regulation, and no documentation had been provided. Administrator was reminded in the meantime; they are responsible to ensure proper care and supervision is provided to all residents. Administrator agreed to let R1 back in the facility without a 1:1 caregiver. At approximately 2:30 p.m. on 2/24/26, CCL confirmed R1 returned to the facility without 1:1 care in place.

During interviews with LPA Rankin on 2/26/26 and 4/1/26, the administrator stated they told the family that R1 needed to go to a doctor and asked the family to pick R1 up, and that they would call the sheriff if the resident could not be calmed or appropriate assistance could not be obtained. The administrator stated this was not a threat, but rather an explanation of possible next steps. The administrator reported the goal was to obtain medical intervention to address R1’s extreme behaviors. Per administrator's understanding the sheriff's department is the local resource to assist with suicidal ideations.

Continue 9099-C

pg 3.

Based on facility documentation dated 2/20/26 at 4:52 pm; it was documented that R1’s family was informed they needed to pick up R1, and that R1 could come back “once [they are] properly medicated to manage [their] aggressive tendencies and any suicidal ideations.” In this same note was an update made by the administrator on 2/24/26 at 11:12 a.m. which states “…informed [family] that [they] needed to pick up [R1] and get [R1] to a physician…” and that “if [family] cannot get [R1] to a physician we would call the Sheriff for assistance…”.

Facility records included a “Medication Release (For Home Visits, Outings, and Other Reasons)” dated and signed by a Medication Technician and the family on 2/20/26. The form listed R1’s medications and the quantities released, which appear to constitute a full medication release. The quantities documented were “30 caplets, 88 caplets, 44 caps, 59 caps.”

On 2/23/26, prior to 4:00 p.m., Community Care Licensing (CCL) was informed about the facility’s statements that R1 could not return until certain conditions were met. At approximately 4:04 p.m., LPA Haner-Tomasko contacted the administrator, who confirmed the incidents described above and reported that 911 EMS was contacted but would not transport R1. During this call the administrator also confirmed to LPA Haner-Tomasko that they contacted R1’s family to take R1 to be seen by a physician due to a change in condition. It is against the facilities policy to transfer residents themselves for emergency services. LPA Haner-Tomasko documented that neither law enforcement nor the local crisis unit were contacted. The administrator was informed by CCL it was an illegal eviction to refuse to let R1 back into the facility. The administrator stated they would only let R1 return to the facility with 1:1 supervision. CCL explained increases in level of care could be discussed through the proper procedures, but the facility needed to allow R1 back into their home. Administrator indicated he understood. Continued on 9099-C

pg 2

During the 4/1/26 visit, interviews with two directors corroborated the above-stated events. During record review, LPA observed documentation of the facility’s attempts to obtain physician guidance regarding increased agitation, behaviors, and exit-seeking.

CCL received no written eviction notice for R1, and R1’s POA confirmed they did not receive any written eviction notice. While the facility made attempts to obtain medical support for R1, the facility did not comply with eviction procedures and did not permit R1 to return to the facility from the evening of 2/20/26 through the early afternoon of 2/24/26.

Based on interviews and record review, no written eviction notice was provided to CCL or to R1’s representative. Therefore, the allegation of Illegal Eviction is SUBSTANTIATED.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

pg4