Clearwater at Sonoma Hills

87463(g)(j) Reappraisals-The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements – General, to support each resident's physical, social, emotional, safety and health care needs, as identified in their current appraisal. Per review of records, R1 is not to be in the community/out of the facility unsupervised per medical assessment, and review of resident records. R1 exited and AWOL the facility without staff’s knowledge on 8/14/25, 8/2/25, 6/6/25, and 5/8/25. This is a risk to health & safety of resident in care.

87211(a)(1)-Reporting Requirements-Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case Per record review, The Department was not in receipt of R1’s AWOL incidents that occurred on 5/8/25 and 6/6/25. This is a risk to personal rights and/or health & safety of resident in care..

Based on LPA's staff record reviews, staff S1 and S4 lack required first aid certification, the licensee did not comply with the section cited above in [2] out of [6], which poses/posed a potential health, safety or personal rights risk to persons in care.

87465(a)(4) Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Per review of records, R1 received last dose of the medication 4/19/25. The medication assistant staff didn't refill the medication as required. Resident R1 was not provided the medication as prescribed from 4/20/25 through 5/24/25, per medication MAR review. The medication was refilled/obtained, and resident was provided the medication as ordered on 5/25/25; R1 missed a total of "35" days of the prescribed medication, per review of records and conducted interviews. This is a health & safety risk to the resident (s) in care.

LPA observed open commercial size boxes/bags of chocolate chips, pancake mix, walnuts, horchata drink mix, and jello pudding mix, open in the kitchen/pantry with no means to close the packages securely in order to prevent them from potential contamination. LPA obtained pictures for the file, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Based on file/record review, the licensee did not comply with the section cited above in 4 out of 6 direct care staff files/records missing required inital trainining documentation, including medication administration training for medication technicians, and 5 out of 6 staff files/records missing required annual training which poses an immediate health, safety or personal rights risk to persons in care.

87468.1(a)(1) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: LPA interviews identified that staff, S2, made an inappropriate comment during the meeting held to address a resident's (R1) care plan; In summary, the comment regarded the hygiene care plan, previously this type of plan was referred to as the "grandma and grandpa stinky club." This is a potential risk to residents' personal rights and/or risk to health and safety.

Based on the observed food found left uncovered on the kitchen counter and several instances of unsealed/uncovered food in the walk-in refrigerator and freezer as well as in the dried goods storage room in the main kitchen, the licensee did not comply with the section cited above in several instances which poses an immediate health, safety or personal rights risk to persons in care.

Based on file/record review, the licensee did not comply with the section cited above in 4 out of 4 medication technician staff files/records lacked required inital and/or annual medication administration trainining documentation, which poses an immediate health, safety or personal rights risk to persons in care.

87211(a)(1) Reporting Requirements-A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case, This requirement was not met as evidenced by: LPA's investigation finding that a resident's (R1) medication had not been centrally stored as required, and had been sent out of the community with another resident's medications during the discharge of R2. This is a potential risk to residents personal rights.

87465 (h)(2) Incidental Medical & Dental Care- Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: LPA's record reviews, and interviews, R1 had a prescription medication go out of the community with R2's medications who had moved out of the facility. R2's responsible party contacted the facility and returned R1's medication. The medication was not kept secured and inaccessible to all others that don't and/or shouldn't have access to the medications. This is an immediate risk to the health and safety of residents in care, and a risk to residents personal rights.

87468.2(a)(2) Additional Personal Rights of Residents in Privately Operated Facilities- To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by: R1 had a prescription medication go out of the community with another resident's, R2, medications who had moved out of the facility. R1's identification, their medication pills, name and medication information, was not kept confidential as required. This is an immediate risk to residents health and safety, and to resident's personal rights.

87468.1(a)(11) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by: Per interviews with staff, and review of records, staff were instructed that R1 was not to have private visiting in their room, and the resident's R1's room would need to be kept locked during their visit with a friend. R1 was denied a private visit with a friend. This is a risk to resident's personal rights.

87468.2(a)(4) Additional Personal Rights of Residents- In addition to the rights in Section 87468.1, Personal Rights of Residents: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. This requirement was not met as evidenced by: Per investigation, S4, has been wriiten up, on 7/11/23, by Administration staff for speaking inappropriately to a resident.The documentation was provided to the LPA. The LPA interviewed the above staff; including S4 who confirmed the incident, and confirmed having spoken to a resident inappriately at that time. This is a risk to residents personal rights and/or a risk to resident's health& safety.

Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff members did not have a current First Aid as required by Title 22 regulations. This poses an immediate health, safety or personal rights risk to persons in care

Based on observation, LPAs observed 1 cleaning cart containing cleaners/toxins/disinfectants not being locked and staff was inside a Resident unit and away from the cart. This poses a Immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 1 staff member was not associated to the facility. Furthermore, LPAs contacted the Santa Rosa Regional Office search the employee name and the employee was not found to be associated to Clearwater at Sonoma Hills. This poses an immediate health, safety or personal rights risk to residents in care.

87555 (b)(9) General Food Service-Requirements(b) The following food service requirements shall apply: (9)Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by: LPA reviewed incident report of meat that was undercooked being served to memory care residents. Residents did consume the food. This is a health and safety risk to residents in care.

Incidental Medical & Dental Care 87465(c)(2) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: LPA reviewed incident report on resident medication errors, and interviewed staff- Three(3) residents received medications in error, medications were not provided as ordered by the Physician. This is a risk to residents Health & Safety. Civil Penalty assessed in the amount of $1000.

87705(b)(2)Care of Persons with Dementia - Safety measures to address behaviors such as wandering. ***Based on incident report Resident R1 & R2 eleoped from facility without staff knowledge , the facility failed to take safety measures to address behaviors such as wandering for residents R1 & R2 which poses an immediate Health, Safety risk to residents in care. As per staff interviews and incident reports, residents left the facility w/out staff knowledge. In both cases they left facility & were alert by individuals that observed residents being at risk., one resident wandered away from the facility and the other resident wandered outside to the front of the assisted living facility.unsupervised.

LPA's review of resident incidents, R1 12/5, R2 11/20, R3 3/20/22, R4 11/20, & R5 10/12 & 10/13, residents had not received their medication as prescribed by the Physician. Based on LPA's record reviews on resident incident reports, the licensee did not comply with the section cited above in [5] out of [5] resident assistance with prescribed medications which poses an immediate health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care 87465(a)(5)The licensee shall assist residents with self-administered medications as needed. This requirement has not been met as evidence by: LPA's observations, review of records, and interviews with Administrator and Health Services Director regarding the incident reports submitted on medication errors by staff assisting residents, (R1through R5, with prescribed medications and failing to ensure medications are given as prescribed. This ia an immediate health and safety risk to residents in care.