Non-compliance follow-up·May 28, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell and Health Services Director (HSD) Jocelyne Bailon Saloche. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas, and the courtyard. There were 9 staff members total on schedule during the PM shift in Prom, Plaza, and Garden House. 9 out of 9 staff members are fingerprint cleared and associated to the facility. In Garden House, LPA randomly entered into rooms 101A, 102A, 103, 110, and 115 with the Garden House Director and HSD. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care. In Plaza, LPA randomly entered into rooms 207, 210, 211, 212, and 203 with the HSD and GM. No issues were noted. Residents who store their own chemicals, disinfectants, and medications are able to store these items per their physician's report/records. Page 1 of 2. LPA observed all training topics stated on the non-compliance plan was completed on July 18, 2024. The training topics includes resident rights, mandated reporting, changes of condition, toxic substances and sharp objects. Staff were also provided in-service training on personal rights in December 2024 and toxic chemical storage in February 2025. The training document contains the topic, date, name and signatures of the participants. LPA advised the GM to ensure all staff (including new staff members) are provided annual training on these specific topics per the non-compliance plan. 5 random resident files were reviewed. 5 resident files reviewed contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. Page 2 of 2.