Correction check·March 10, 2026

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a POC case management visit and was greeted by concierge. LPA met with Administrator Sanjay Kabadi On 2/19/26 facility was issued a citation on substantiated complaint findings of deficiency of Health and Safety Code 1569.269 (complaint # 21-AS-20260109140715). The plan of correction required facility to: Facility to submit plan identifying why response times are delayed and the method of correction facility will implement in order to correct the delays in call button/pendant response time, by plan of correction due date. Additionally, facility to ensure that pendant/call button system is in good repair, fully operational, and staff is sufficient to timely answer pendant/call button calls, by plan of correction due date. Facility to submit paperwork of pendant/call button system implementation and log showing that pendant/call button system is in good repair and fully operational, by plan of correction due date. Plan of correction was due 3/5/26. On 3/4/26 LPA received from facility the plan identifying why response times are delayed and the method of correction facility will implement in order to correct the delays in call button/pendant response time. However, as of today, 3/10/26 CCL has not received paperwork of pendant/call button system implementation and log showing that pendant/call button system is in good repair and fully operational. Therefore, a civil penalty is being issued for failure to correct for the period of 3/6/26 through 3/10/26 at $100 per day for a total of $500. The $100 per day civil penalty will continue to accrue until the deficiency is cleared. Per Administrator, facility has decided the vendor with whom they will purchase the new pendant system but have yet to sign the contract and begin implementation. Administrator will advise LPA once implementation has been completed. Once implementation is complete, facility will immediately train staff on new system and submit log to CCL showing system is fully operational and responses are timely. Continued on 809C... Continued from 809... Additionally, LPA conducted a review of facility’s transportation policy outlined in facility’s Admission Agreement, Plan of Operation, and Emergency Disaster Plan (LIC610E). Page 6 item G in facility Admission Agreement states they will make transportation available to residents "to the nearest appropriate health facilities for medical and dental appointments, social services agencies, shopping, recreational facilities, and religious activities, as outlined in the Resident Handbook." LPA reviewed Resident Handbook. Page 31 of handbook does offer an outline of transportation services and days on which services will be available. LPA reviewed facility's Plan of Operation (POO), section VIII pertaining to transportation. This section specifies in greater detail the times and days on which transportation services will be provided. Additionally, per the Plan of Operation, all Assisted Living (AL) residents can book a ride with Lyft by contacting the concierge. The cost is paid for by the facility, initially, but then charged back to the residents on their monthly statement. LPA discussed with Administrator including in the Admissions Agreement, or the Resident Handbook, the details stated in the POO to provide residents with clarity on services and charges. LPA discussed with Administrator alternative appointment scenarios that could fall outside of the specified days and times and making transportation available. Facility has a van that is operated by staff (S1 and S2) that are licensed with a class B to drive facility van. LPA reviewed training record and driver's license class, both drivers possess class B license. Additionally, facility is in the process of getting a bus licensed for use that will be used in conjunction with the existing van. Upon LPA arrival, LPA observed van in operation. Driver was heading out, enroute to a resident medical appointment. LPA reviewed facility's Emergency Disaster Plan (LIC610E), plan does not state that drills will be conducted with residents. However, residents are provided a Resident Emergency Preparedness Guide along with their Resident Handbook. Topics covered are: Resident Preparedness, In the Event of a Fire, Wildfire, Power Outage, Earthquake, Preparedness checklist, and Contacts. Guide does not state drills will be conducted with residents. On page 6 of guide, under "Community Basics to Know/Staffing," it states that "we conduct fire drills on a monthly basis, elopement drills...on a quarterly basis, and larger fire drills on an annual basis. Continued on 809C(2)... Continued from 809C... During these drills residents should react as though the situation is real and respond by following the appropriate steps as laid out in this guide." One could infer that residents are to be a part of the drills, but the guide does not expressly state as such. LPA discussed with Admin adding clarification to guide to remove any ambiguity. On page 7 of guide under "Onsite Designated Evacuation Assembly Sites," the location of evacuation sites are listed. Per Scott Doherty, V.P. Senior District Operations Manager (DOM), facility is currently updating their emergency disaster plan via a consultant. DOM reported to LPA that the consultant is helping the facility organize a community wide evacuation drill. Per DOM, consultant will speak with the residents within the next two weeks. This consultant will also help the on site operations team to update the community emergency procedure manual and the consultant will be helping the operations team to organize a community wide evacuation drill. Per DOM, the community also has scheduled representatives from the local fire department to come to the community to speak with the residents next week. Per LPA review of these documents, LPA finds facility to be following their plan of operation and Admissions Agreement. However, there is room for clarity as discussed with Administrator. LPA observed Emergency Disaster Plan to need updating as previous Health and Wellness Director and previous Administrator are listed under assignments of duties. Administrator will submit updated plan no later than April 1, 2026. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties . Exit interview conducted with Administrator and a copy of this report was given.