The Village at Northridge

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Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced continuation of the annual inspection. LPA met with the Mary Rose Okahata- Assisted Living Director and disclosed the reason for the visit. LPA conducted file review for ten residents and seven staff members. During today's the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 17, 2026

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Mariana Agban and Licensing Program Manager (LPM) Mary Flores conducted an unannounced annual visit at the facility. The CARE inspection tool was not used due to technical issues. The domains were reviewed. LPA and LPM met with Mary Okahata Assisted Living Director and explained the reason for the visit. Facility is licensed to serve as an Elderly Residential Facility (RCFE) for 194 non- ambulatory adults 60 and over, of which 3 may be bedridden in rooms 138,140,141. Facility has an approved hospice waiver for 30 residents. Facility consists of a lobby, library, two Bristo areas, a dining room, commercial kitchen, wellness office, medication room, fitness room, craft rooms, game room, activity rooms, and other common areas in the 2nd and 3rd floors. It consists of 3 floors and a basement, 4th floor houses residents in independent living, the first floor consists of common areas, some assisted living, basement consists of staff lounge and storage. Department’s representative toured the facility with Maria Okahata the following domains were reviewed during this visit: Operational Requirements: Facility maintains a plan of operation, infection control plan created and last reviewed on 04/02/26, fire clearance. Facility is operating within the limitations of their license. They have 4 residents under hospice. A current liability insurance was observed. (CONTINUED ON LIC 809C) Physical Plant/Environmental Safety: During facility's tour all common areas were observed in good repair. A total of 17 random residents' rooms were observed, each room was furnished, with sufficient lighting, and bedding supplies. Water temperature was tested in each resident's bathroom and tested between 84.7 – 124.9 degrees F., which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars and skid mats. Medication is stored in medication rooms. Passageways, hallways, stairways are clear of debris and obstructions. Auditory signal/pendant buttons were tested for 4 residents and staff responded within less than 5 minutes. Facility has a fire sprinkler system throughout. Fire extinguishers were observed and last checked on 8/8/26. Elevators were observed working. Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted across activity room area. Food Services: The commercial kitchen and observed good quality/commercial food supplies for at least 2 days of perishables and 7 days of non-perishables. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. One person was listed with a modified diet by the dining room. Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication carts in each medication room. A review of medication for 10 residents was conducted. A log for PRN/Narcotics medication was observed. 5 out of 10 residents had medication listed that was not observed. Resident #2(R2) Atropine 1% eyedrops, Gentamicin 1%, Morphine Sulfate 100mg, Lorezapam 2mf, Hydrocodone-Apap 5-325mg per staff they have been discontinued. Resident #5(R5) Albuterol HFA 90mg, Iprat Albut .05, Dicoflinac gel. Resident #8(R8) Carisoprodol 250mg, Resident #9(R9) Albuterol HFA 90mg, Eszopidone 1mg, Promethazine 6.25mg, Resident #10(R10) Famotidine 10mg, Polyethylene Glycol 3350mg. Disaster Preparedness: LPAs reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 5/15/26. Evacuation chairs were observed in each staircase. Emergency drills are conducted monthly, last emergency drill was conducted on 09/05/26. Infection Control: Facility maintains a copy of infection control and was last reviewed on 04/26. Housekeeping staff were observed maintaining sanitizing procedures and Chef was observed doing proper hand washing. Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Sep 11, 2026

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) This requirement is not met as evidenced Based on observation, the licensee did not comply with the section cited above. Room#138 was 124.09 F, #270 was 99F, #273 was 84.7 and #208 was 121.6 F. This poses an immediate health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Executive Director agreed to provide proof of fixing the water temprature for the rooms menioned in the report. Proof will be emailed to the LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(6) · Plan of correction due date: Sep 17, 2026

(f) Basic services shall at a minimum include:(6) Arrangements to meet health needs. This requirement is not met as evidenced. Based on observations, the licensee did not comply with the section cited above. Medications logs for R2, R4, R5, R8, R9, R10 listed medications that were not available for the residents. This poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Executive Director agreed to audit medications list for all the residents mentioned. Proof of audit will be emailed to the LPA by the POC date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced Case Management–Incident visit to follow up on the Self-Reported Report of Suspected Dependent Adult/Elder Abuse (SOC 341) and the Unusual Incident Report (LIC 624) received by Community Care Licensing (CCL) on June 9, 2026.LPA arrived at the facility, was greeted by the receptionist, and met with the Executive Director. The purpose of the visit was explained.According to the reports received, Staff #1 (S1) allegedly financially abused Resident #1 (R1). It was reported that on June 4, 2026, R1 wrote a check payable to S1 in the amount of twenty dollars ($20.00) as a tip. It was further reported that S1 altered the check amount from twenty dollars ($20.00) to two hundred dollars ($200.00).Upon becoming aware of the incident, the Executive Director initiated an internal investigation on June 10,2026. As a result of the investigation, S1 was immediately suspended from employment and subsequently resigned on June 10,2026. During today's visit, LPA requested and obtained copies of pertinent records, including, but not limited to, the resident roster, S1's personnel file, and R1's resident file.At this time, LPA is unable to conclude the investigation. Additional information and documentation are needed before a final determination can be made. Executive Director was advised and a copy of this report given.the state’s words, verbatim · CDSS document, Jul 1, 2026

Allegation investigated: Staff did not ensure food was free of contamination resulting in multiple illness to residents in care

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegation. LPA arrived, was greeted by the receptionist, and met with the Assisted Living Director, Mary Okhata, explaining the reason for the visit. LPA requested copies of pertinent information, including the Staff Roster, Resident Roster, Discharge Notes for R1, R2, R3, and R4, and other documents pertinent to the investigation. Today's investigation consisted of interviews with ten residents and four staff members. . Regarding the allegation: Staff did not ensure food was free of contamination resulting in multiple illness to residents in care. It was alleged that several residents contracted food poisoning due to food served at the facility on 04/02/2026.LPA conducted interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4), none of whom were able to confirm the allegation. (Continue on 9099C) Unsubstantiated S1 reported that the California Department of Public Health and Community Care Licensing Division were notified on 04/02/2026, and that the facility implemented appropriate measures to prevent the spread of illness. Interviews were with eight out of ten residents were unable to confirm whether the symptoms were related to food contamination or a viral illness. S2 reported that the facility implemented several infection control measures, including temporarily closing the dining and activity areas, requiring residents to remain in their rooms during meals, and conducting enhanced cleaning and sanitization of the kitchen, dining areas, and all common areas. S2 further stated that kitchen staff received additional training regarding foodborne illness prevention and proper food handling practices. At 10:15 AM, the LPA conducted a physical plant tour and did not observe any immediate health and safety concerns. Based on observations, interviews, and records reviewed, there is insufficient evidence to support the allegation of Staff did not ensure food was free of contamination resulting in multiple illness to residents in care. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 31-AS-20260414111909

Allegation investigated: Staff did not ensure food was free of contamination resulting in multiple illness to residents in care

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegation. LPA arrived, was greeted by the receptionist, and met with the Assisted Living Director, Mary Okhata, explaining the reason for the visit. LPA requested copies of pertinent information, including the Staff Roster, Resident Roster, Discharge Notes for R1, R2, R3, and R4, and other documents pertinent to the investigation. Today's investigation consisted of interviews with ten residents and four staff members. . Regarding the allegation: Staff did not ensure food was free of contamination resulting in multiple illness to residents in care. It was alleged that several residents contracted food poisoning due to food served at the facility on 04/02/2026.LPA conducted interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4), none of whom were able to confirm the allegation. (Continue on 9099C) Unsubstantiated S1 reported that the California Department of Public Health and Community Care Licensing Division were notified on 04/02/2026, and that the facility implemented appropriate measures to prevent the spread of illness. Interviews were with eight out of ten residents were unable to confirm whether the symptoms were related to food contamination or a viral illness. S2 reported that the facility implemented several infection control measures, including temporarily closing the dining and activity areas, requiring residents to remain in their rooms during meals, and conducting enhanced cleaning and sanitization of the kitchen, dining areas, and all common areas. S2 further stated that kitchen staff received additional training regarding foodborne illness prevention and proper food handling practices. At 10:15 AM, the LPA conducted a physical plant tour and did not observe any immediate health and safety concerns. Based on observations, interviews, and records reviewed, there is insufficient evidence to support the allegation of Staff did not ensure food was free of contamination resulting in multiple illness to residents in care. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 31-AS-20260414111909

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced Case Mangement-Incident to follow up on the Death Report for Resident#1 (R1) on 11/20/25. LPA arrived, was greeted by the receptionist, and met with the Assisted Living Director, explaining the reason for the visit. LPA requested copies of pertinent information which includes and not limited to LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and are in compliance with Title 22 Regulations. Today's investigation consisted of interviews with 3 staff members, R1's family member, and record reviews. LPA is unable to close out the investigation at this time. Additional information needed prior to concluding investigation. Assisted Living Director was advised and a copy of this report given.the state’s words, verbatim · CDSS document, Dec 5, 2025

Allegation investigated: Staff did not properly address resident's multiple falls at facility.

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsequent complaint visit to include additional interviews for the Substantiated complaint report on 12/30/2024. LPA arrived and was greeted by the receptionist and met with the Assisted Living Director Mary Okahata, and explained the reason for the visit. LPA requested copies of pertinent information, which includes LIC 500 and the Resident Roster. LPA conducted a physical plan tour to ensure the health and safety of the residents are protected and are in compliance with Title 22 Regulations. During today's visit, LPA interviewed an additional 5 residents, 3 staff member, and the Executive Director. Based on information obtained, the allegation remains Substantiated at this time. Facility staff did not properly address multiple falls at the facility. Resident#1(R1) Service Plan acknowledges that R1 is a fall risk; however did not address actions taken to prevent future falls. R1 had 18 fall incidents at the facility from January to December 2024. Exit interview conducted, POC is cleared, copy of this report signed and delivered. Substantiatedthe state’s words, verbatim · CDSS document, Sep 26, 2025 · control 31-AS-20241213122323

Type of visit: Case Management - Deficiencies

In connection with Complaint No. 31-AS-20241213122323, Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced Case Management – Deficiency visit. LPA met with Mary Okhata Assisted Living Director. During the course of the investigation, LPA observed that Resident 1 (R1) had experienced multiple falls. LPA observed that there were two fall incidents for which no documentation or evidence of an unusual incident report was available. LPA advised the Assisted Living Director regarding the regulatory reporting requirements. An exit interview was conducted Assisted Living Director, citation was issued, appeal rights given and a copy of this report was signed and deliveredthe state’s words, verbatim · CDSS document, Sep 26, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 3, 2025

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.. (D)Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on record review, R1 had experienced multiple falls LPA observed that there were two fall incidents for which no documentation or evidence of an unusual incident report was available. This poses a potential health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: Assisted Living Director will conducted in service staff meeting and will provide a copy of the training material and attendees list.

Type of visit: Case Management - Deficiencies

In conjunction to the complaint 31-AS-20250721161857 LPA Mariana Agban conducted case management- Deficiencies visit. During the physical plan tour, LPA observed R1's room to be dirty. LPA observed stained carpet, unclean bedsheets on the floor, the toilet was unclean as well and a lot of clutter in the kitchen area. Exit interview conducted, citation issued and a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jul 31, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 5, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on the observations the licensee did not comply with the section cited above. LPA observed R1's room dirty with stained carpert, storage boxes, unclean toilet and unclean bedsheets on the floor. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Assisted Living Director will ensure that R1's room is clean and will email pictures of clean room by the POC date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced continuation of the annual inspection. LPA met with the Mary Rose Okahata- Assisted Living Director and disclosed the reason for the visit. LPA conducted file review for 7 residents. Due to time constraints, LPA was unable to complete the annual inspection during today's visit. Assisted Living Director was informed that a follow up visit will be conducted. During today's the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mariana Agban arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff at the front desk. LPA later met with Director of Assisted Living Mary Rose Okahata, and the purpose of the visit was explained. LPA conducted a physical tour at 11:30 AM. LPA observed the following: Common Areas: These include the living rooms, dining areas, activity rooms, and other shared spaces. All common areas were observed to be cleaned and properly furnished. The facility maintains a comfortable temperature of 75.0°F. Bathrooms in the common area were observed to have trash cans with lids and infection control prevention signs posted. Hot water temperature was measured from a bathroom sink at 105.1 degrees Fahrenheit. No cleaning supplies or hazardous items were present in common bathrooms during the inspection. Laundry Area: LPA toured the laundry area. No deficiencies observed. Medication Room: The Facility has a designated medication room where medications are kept inaccessible to residents. Fire Alarms are located throughout the facility and are functional. The last fire drill was conducted on 05/17/25. Fire extinguishers are also located throughout the facility with a service date of 07/12/2025. Carbon Monoxide: Alarms are located throughout the facility and are operable. The kitchen area was toured, and LPA observed there to be sufficient one-week non-perishable foods and two days' perishable food for all residents. Bedrooms were randomly selected to tour and were observed to have appropriate furniture and sufficient lighting. Bathrooms were observed to have grab bars and non-skid mats. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with various shaded areas for residents. There is a swimming pool that is fenced all around it's parameters. The fence was at least five foot high with a gate, that is also five foot high. The pool door automatically locks after each entry. (Continue 809 C) Resident Files: LPA conducted a file review of two (2) out of 166 residents to ensure compliance with licensing forms. Due to time constraints, LPA was unable to complete the annual inspection during today's visit. The Assisted Living Director was informed that a follow-up visit will be conducted. Today's the facility complies with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 16, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced case management visit to this facility. LPA arrived, was greeted by the receptionist, and met with the Assisted Living Director, explaining the reason for the visit. On May 15, 2025, Community Care Licensing (CCL) received a Special Incident Report (SIR) regarding Resident#1(R1) being AWOL. On May 13,2025, R1's roommate informed Staff#1 (S1) that R1 was missing and needed assistance in locating R1's whereabouts. After 15 minutes of searching the facility, S1 was unable to find R1. S1 then reported to Staff#2 (S2) and the Assisted Living Director. Facility staff successfully located R1 outside the facility across the street. The Assisted Living Director called 911 and notified R1's responsible party. Paramedics and the facility nurse confirmed that R1 had no injuries and did not require a transfer to the hospital. During today's visit, LPA conducted three staff interviews and record reviews. According to R1's physician's report, R1 is not allowed to leave the community unsupervised due to dementia or cognitive decline. The Assisted Living Director updated R1's service plan to meet R1's current needs and safety requirements. Currently, a private care attendant is present 24/7 to ensure R1's health and safety. Based on the information obtained, the licensee did not ensure that R1 has an auditory device to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement. Exit interview conducted, citation issued, appeal right given and copy of this report delivered.the state’s words, verbatim · CDSS document, May 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(e) · Plan of correction due date: May 22, 2025

The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement,, This requirement is not met as evidenced by: Based on interviews and record reviews, R1 left the facility unsupervised. The licensee did not ensure that R1 has an auditory device to monitor exits on exterior doors and perimeter fence gates. This poses an immediate risk to the health, safety, or personal rights of those in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: The Assisted Living Director will provide R1 wander guard device by the POC date. The Assisted Living Director has updated the service care plan, and currently, R1 has a 24/7 care attendant to ensure R1's safety.

Allegation investigated: Staff did not make resident records available to resident's authorized representative

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegation. LPA arrived and was greeted by the receptionist and met with Executive Director Thomas Rekowski and explained the reason for the visit. LPA requested copies of pertinent information which includes LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and are in compliance with Title 22 Regulations. Today's investigation consisted of interviews with 15 out of 160 residents, 1 staff members and record review. Allegation: Staff did not make resident records available to resident's authorized representative It was alleged that staff did not make Resident#1's (R1) records available to R1's authorized representative. Per the complainant, the written request was sent on 02/24/25, however, there was no response from facility staff until 03/25/25. Interview with Staff#1(S1) revealed that there was a delay due to technical issues. Records review revealed that S1 had received the records request from R1's authorized representative on 02/21/25. (Continue on 9099C) Substantiated Nevertheless, S1 responded to R1's authorized representative on 04/03/25. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview conducted, citation issued, appeal rights given and copy of this report delivered.the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 31-AS-20250325133704

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Apr 11, 2025

(19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days..This requirement is not met as evidenced by; Based on interviews, the S1 did not provide the requested documents promptly to authorized representativethe state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: S1 will provide proof of sending requested documents by the POC date.

Allegation investigated: Staff did not properly address resident's multiple falls at facility.

Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted an unannounced subsequent complaint visit for the above allegation. LPAs arrived and were greeted by the receptionist and met with the Assisted Living Director and explained the reason for the visit. LPAs requested copies of pertinent information which includes LIC 500 and Resident Roster. LPAs conducted a physical plan tour to ensure the resident's health and safety were protected and in compliance with Title 22 Regulations. On today's visit, LPAs conducted additional resident and staff interviews and obtained additional documentation relevant to the investigation. Allegation: Staff did not properly address resident's multiple falls at facility. It was alleged that staff failed to properly address Resident#1(R1) multiple falls at the facility. Interview with Staff#1(S1) revealed that R1 is a fall risk and sustained multiple falls causing wounds and skin tears. LPAs conducted a file review and observed that R1's Service plan confirms that R1 is a fall risk and has an unsteady gait. File review also revealed that from Nov 1, 2024, to Dec 17, 2024, R1 had multiple falls at the facility. Substantiated Furthermore, a review of R1's care plan was insufficient when addressing R1 as a fall risk. Based on the information obtained, the allegation is substantiated. Citation issued on the 9099D. Exit interview conducted, appeal rights given, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 30, 2024 · control 31-AS-20241213122323

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Jan 6, 2025

Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal, Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by: During file review, it was revealed that R1 is a fall risk. Facility's care plan was not sufficient in addressing R1 as being a fall risk, which poses a potential threat to a resident in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: As POC, the licensee will re-assess R1 and make updates on R1's care plan to better address R1's falls. Copy of this care plan is due to the licensing agency by January 6, 2025

Allegation investigated: Facility staff yelled at resident in care Facility staff did not treat residents with dignity and respect.

Licensing Program Analyst (LPA) Mariana Agban conducted unannounced subsequent complaint visit to include additional interviews for the Substantiated complaint report on 8/15/24. LPA arrived and was greeted by the receptionist and met with Executive Director and explained the reason for the visit. LPA requested copies of pertinent information which include LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and is in compliance with Title 22 Regulations. During today's visit, LPA interviewed 15 out of 150 residents. The allegations remain Substantiated. POC is cleared as of 08/19/24. Exit interview conducted and a copy of this report delivered. Substantiatedthe state’s words, verbatim · CDSS document, Oct 3, 2024 · control 31-AS-20240809162409

Allegation investigated: Facility not clean, safe, sanitary and in good repair

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegation. LPA arrived and was greeted by the receptionist and met with Assisted Living Director and explained the reason for the visit. LPA requested copies of pertinent information which includes LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and are in compliance with Title 22 Regulations. Allegation: Facility not clean, safe, sanitary and in good repair It was alleged that the facility has mold and leak issues in different areas, including residents' rooms on the third floor, the basement ceiling, Staff break room, and staff restrooms. LPA toured residents rooms on the third and second floors and observed no mold or leak issues. LPA also toured the basement, staff breakroom, and restrooms and observed no leak or mold issues. LPA interviewed the Assisted Living Director and 10 staff members and 15 out of 153 residents. Interview with residents and 9 out of 11 staff members denied the allegation. (continue on 9099C) Unsubstantiated Interview with the Assistant living Director revealed that when staff or residents notice any disrepair in the facility a maintenance work order will be placed immediately and maintenance staff will work on the issue promptly. Based on observations and interviews the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 11, 2024 · control 31-AS-20240905092917

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced continuation of the annual inspection. LPA met with the Executive Director (ED) and disclosed the reason for the visit. LPA reviewed resident and personnel files and conducted interviews. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mariana Agban arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff at the front desk. LPA later met with Director of Assisted Living Mary Rose Okahata and the purpose of the visit was explained. LPA conducted a physical tour at 12:05 PM. LPA observed the following: Common Areas: These include the living rooms, dining areas, activity rooms, and other shared spaces. All common areas were observed to be cleaned and properly furnished. Facility maintains a comfortable temperature of 77.0 F. Bathrooms :in the common area were observed to have trash cans with lids and infection control prevention signs posted. Laundry Area: LPA toured laundry area. No deficiencies observed. Medication Room: Facility has a designated medication room where medications are kept inaccessible to residents. Fire Alarms: are located throughout the facility. LPA was informed that Reg 4 testing will be conduced on Sept 4, 2024. Fire extinguishers are also located through the facility with service date 07/16/2024. Carbon Monoxide: alarms are located throughout the facility and are operable. Kitchen area was toured, and LPA observed there to be sufficient one-week non-perishable foods and two days perishable food for all residents. Bedrooms: were randomly selected to tour and were observed to have appropriate furniture. Bathrooms were observed to have grab bars and non-skid mats. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with various shaded areas for residents. There is a pool with a fence located outside that is designated for the independent living community. The pool door automatically locks after each entry. (Continue 809 C) Due to time constraints, LPA was unable to complete the annual inspection during today's visit. Administrator was informed that a follow up visit will be conducted. During today's the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 28, 2024

Allegation investigated: Facility staff yelled at resident in care Facility staff did not treat residents with dignity and respect.

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegations. LPA arrived and was greeted by the receptionist and met with Director Assisted Living and explained the reason for the visit. LPA requested copies of pertinent information which include LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and is in compliance with Title 22 Regulations. Allegation: Facility staff yelled at resident in care It was alleged that facility staff yelled at R1 about R1's pet. Interview with S1 denied the allegation. S1 stated that they were trying to explain the situation to R1 and their voice might have elevated from frustration. Interview with staff revealed that S1 and R1 were in the medication room where S1 was asking staff to witness R1's pet urinating in the facility hallways and on the walls. Six (6) out of 10 staff members confirmed that S1 yelled at the R1. Based on information obtained the allegation deemed Substantiated. (Continue on 9099C) Substantiated Allegation: Facility staff did not treat residents with dignity and respect. It was alleged that facility staff had humiliated R1 in front of others. Interview with S1 denied the allegation. S1 stated that R1 was following S1 to the medication room where S1 had asked staff to raise their hand if they had witnessed R1's pet urinating in the hallways and common areas. Interviews with six 6 out of 10 staff members confirmed that R1 was humiliated in front of staff members by arguing and looking for witnesses. Based on the information obtained the allegation deemed Substantiated.the state’s words, verbatim · CDSS document, Aug 15, 2024 · control 31-AS-20240809162409

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(1) · Plan of correction due date: Aug 22, 2024

80072(a)(1) Personal Rights (a)...each client shall have personal rights which include,...(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by: Based on interviwes R1 was subjected to infliction of humiliation by facility staff. This poses a potential health and safety risk to the resident inthe state’s words, verbatim · CDSS document, Aug 15, 2024

Plan of correction: Executive Director agreed to email LPA a statement of understanding this cited section by the POC date.

Allegation investigated: Staff made financial decisions on behalf of resident without proper authorization Staff turned off resident's telephone service Staff turned off resident's Wi-Fi service

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegations. LPA arrived and was greeted by the receptionist and requested the Administrator. The Nursing Director Represnantive greeted and assisted LPA until Executive Director arrived. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and is in compliance with Title 22 Regulations. LPA requested copies of pertinent information which include LIC 500 and Resident Roster. Interview with Executive Director and records review revealed that R1 lives in the independent living community part of the facility and not the Assisted living section which is licensed by Community Care Licensing. The department does not have jurisdiction in the Independent Living section of the facility. LPA obtained copies of R1's Residency and Service Agreement. Based on the information LPA gathered LPA determined that the allegation is unfounded. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. (Continue on 9099C) Unfounded This agency has investigated the complaint alleging (Staff made financial decisions on behalf of resident without proper authorization, Staff turned off resident's telephone service, Staff turned off resident's Wi-Fi service). We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.” Exit interview conducted and copy of report delivered.the state’s words, verbatim · CDSS document, May 23, 2024 · control 31-AS-20240517081647