Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
02/23/2026
Section Cited
CCR
87211(a)(1)(D) | 1
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3
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5
6
7 | 87211(a)(1)(D) Reporting Requirements – “The licensee shall report by telephone to the licensing agency, local law enforcement, and the responsible person any suspected physical abuse … immediately, or within 24 hours.”
The following requirement has not been met as evidenced by:
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5
6
7 | The licensee shall ensure that all suspected physical or sexual abuse is reported immediately, or within 24 hours, to the licensing agency, local law enforcement, and the resident’s responsible party, as required by Title 22 CCR §87211. The licensee shall review and revise its abuse reporting procedures to ensure immediate notification occurs. All staff shall receive training on mandated reporting requirements and timelines. Documentation of reports shall be maintained in resident files and submitted to LPA by POC date of 02/23/2026. |
 | 8
9
10
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12
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14 | Based on record review, the facility failed to immediately notify law enforcement when Resident #1 disclosed possible sexual abuse on 03/09/22. Law enforcement was not contacted until 03/10/22. This posed an immediate health and safety risk to all residents in care.
| 8
9
10
11
12
13
14 | |
Type B
03/08/2026
Section Cited
CCR
87463(a) | 1
2
3
4
5
6
7 | 87463 Reappraisals – “The licensee shall arrange a meeting with the resident and/or representative when a significant change occurs in the resident’s condition to determine if the facility can continue to meet the resident’s needs.”
The following requirement has not been met as evidenced by:
| 1
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3
4
5
6
7 | The licensee shall ensure a reappraisal is conducted whenever a significant change occurs in a resident’s physical, mental, or functional condition. The licensee shall review procedures to ensure residents and/or their responsible representatives are included in the reappraisal process. Staff responsible for assessments shall be trained on identifying significant changes in condition and completing timely reappraisals. The licensee shall implement ongoing monitoring to ensure residents are placed and maintained at the appropriate level of care based on current reappraisals and send proof to LPA by POC date of 03/08/2026. |
| 8
9
10
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12
13
14 | Based on file review, residents with dementia and wandering behavior were moved from memory care into assisted living without evidence of reappraisal, while continuing to require memory care services. This resulted in residents not being placed at the appropriate level of care, which poses a potential, health, safety, or personal rights risk to residents in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/08/2026
Section Cited
CCR
87411(a) | 1
2
3
4
5
6
7 | 87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The following requirement has not been met as evidenced by:
| 1
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5
6
7 | The licensee shall ensure sufficient staff are scheduled at all times to meet residents’ care and supervision needs. The licensee shall review staffing patterns in relation to resident acuity and adjust staffing as necessary. Staff shall be trained to provide care consistent with residents’ assessed needs. The licensee shall implement ongoing oversight to ensure residents receive timely assistance and send proof to LPA by POC date of 03/08/2026.
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| 8
9
10
11
12
13
14 | Based on record review, residents reported not receiving assistance consistent with their care needs. This poses a potential, health and safety risk to residents in care. | 8
9
10
11
12
13
14 | |
Type B
03/08/2026
Section Cited
CCR
87468.2(a)(4) | 1
2
3
4
5
6
7 | 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The following requirement has not been met as evidenced by: | 1
2
3
4
5
6
7 | The licensee shall ensure residents are treated with dignity and are not left seated for prolonged periods without appropriate repositioning, assistance, or activity consistent with their assessed needs. Staff shall be trained on residents’ personal rights and mobility assistance requirements. The licensee shall review resident care plans to ensure mobility and repositioning needs are clearly identified and implemented, and send proof to LPA by POC date of 03/08/2026.
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| 8
9
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14 | Based on record review, residents reported being left in wheelchairs all day. This poses a potential, health and safety risk to residents in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/08/2026
Section Cited
CCR
87507 | 1
2
3
4
5
6
7 | 87507 Admission Agreement – “All basic and optional services, rates, and charges shall be specified in the admission agreement. The licensee shall not charge for services that are not provided.”
The following requirement has not been met as evidenced by: | 1
2
3
4
5
6
7 | The licensee shall ensure residents are charged only for services that are specified in the admission agreement and actually provided. The licensee shall review all current admission agreements and billing records to verify accuracy. Any billing discrepancies shall be corrected. Administrative staff responsible for billing shall be trained on admission agreement requirements and appropriate billing practices. The licensee shall implement ongoing monitoring of billing records to ensure continued compliance and submit proof to LPA by POC date of 03/08/2026. |
| 8
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10
11
12
13
14 | Based on documentation, residents were charged for memory care services and the “Circle of Friends” program despite not receiving or attending such services. This violates the admission agreement and created a financial burden on residents, which poses a potential, health, safety, or personal rights risk to residents in care. | 8
9
10
11
12
13
14 | |
Type B
03/09/2026
Section Cited
CCR
87464(a)(2) | 1
2
3
4
5
6
7 | 87464(a)(2) Basic Services – Personal Care and Supervision – “Basic services shall at a minimum include: (2) Personal assistance and care as needed by the resident … including assistance with bathing, grooming, dressing, mobility, and other personal needs.”
The following requirement has not been met as evidenced by: | 1
2
3
4
5
6
7 | The licensee shall ensure residents receive personal care assistance, including assistance with bathing and hygiene, as needed. Staff shall be re-trained on providing and documenting personal care services in accordance with residents’ assessed needs. The licensee shall review resident care plans to ensure required personal care services are identified and implemented. Ongoing supervision and periodic audits shall be conducted to ensure residents’ personal care needs are consistently met. and proof submitted to LPA by POC date of 03/09/2026.
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| 8
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14 | Based on record review, residents reported not being assisted with showers. This poses a potential, health and safety risk to residents in care. | 8
9
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14 | |
NARRATIVE |
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32 | Regarding the allegation staff are not assessing residents for change in level of care. Collateral notes reflect multiple residents with dementia or wandering behaviors were moved from memory care into assisted living, while continuing to be billed for memory care or for “Circle of Friends” services they did not attend. Residents with ongoing needs had access to unsecured patios and were redirected after wandering off facility grounds. Based on interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Regarding the allegation: Staff are not meeting residents’ needs. Residents reported being left in wheelchairs all day, refusing showers for extended periods, and not receiving appropriate dementia care. Documentation indicates these concerns were known but not consistently addressed. Based on information reviewed, staff did not consistently meet residents’ basic care needs. Based on interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Regarding the allegation: Staff left resident in wheelchair for extended period of time. Resident reports indicate a lack of transfer to recliner and being left in a wheelchair throughout the day. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Regarding the allegation: Facility is charging residents for services not used. Residents were billed for memory care or for “Circle of Friends” programming despite not receiving or attending these services. The documentation reviewed identifies several residents impacted. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Regarding the allegation Staff are not meeting residents’ showering needs. Records indicate a facility resident had not been showered in one month. This is consistent with concerns of resident care needs not being met. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
The following deficiencies are being cited Per Ttile 22 Regulations. Exit Interview conducted with Executive Director Wes Lavender, and a copy of this report provided. |