The Reserve at Thousand Oaks

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 1:06 p.m., LPA met with the Executive Director (ED), Elizabeth Spencer and explained the reason for the visit. On 08/23/2023, the facility submitted a Report of Suspected Dependent Adult/Elder Abuse, where it was alleged that Resident #1 (R1) had engaged in a sexual relationship with Staff #1 (S1). An interview was conducted with the ED at 1:12 p.m. At 1:34 p.m., the LPA obtained copies of pertinent documents. At 2:45 p.m., the LPA along with the ED conducted a brief physical plant tour. No immediate health and safety concerns were observed during today's inspection. Further investigation is needed. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 31, 2023

Allegation investigated: Staff do not ensure the safety of food served to residents. Staff do not maintain food service equipment.

Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint visit for the above allegations. Upon arrival, the LPA met with Executive Director (ED), Elizabeth Spencer and the reason for the visit was explained. Entrance interview conducted. During today’s visit, the LPA conducted a physical plant tour to ensure there are no health and safety concerns at 1:10 p.m., a kitchen/food and dining area tour at 1:15 p.m., conducted interviews with the ED, four staff, and nine residents between 1:20 p.m. and 2:19 p.m., and obtained and reviewed documents pertinent to the investigation at 3:00 p.m. (Report Continued on LIC 9099C...) Unsubstantiated (Report Continued from LIC 9099...) It was alleged that staff do not ensure the safety of food served to residents. It was reported that residents are constantly getting sick even after eating the food served. While conducting the walkthrough, the refrigerator, freezer, and pantry were observed to have sufficient food from all different food groups. Food labels were inspected and checked for dates and expiration dates. Food labels had expiration date clearly marked. Interviews conducted with staff revealed food is typically arriving at the facility every other day and food is checked for quality at the same time as it is being received. Interviews conducted with residents revealed they had no concern with the food being served by the facility; and 9 out of 9 residents interviewed reported no issues with the quality of food and denied getting sick due to the food at any time while living at the facility. Based off the information obtained during the investigation, the Department does not have sufficient evidence to support the allegation of “Staff do not ensure the safety of food served to residents.” Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff do not maintain food service equipment. It was reported that mold has been previously reported on the food service equipment. While conducting the walkthrough, the coffee, soda, and food service machines were observed and checked for cleanliness. Review of documents revealed the facility had a third-party company come out to the facility in the last 30 days to service the fountain drink machine. Additionally, the service ticket states the third-party company inspected the ice machine and had valve adjusted; however, the service ticket did not report any mold on the machine at the time the service was done. Interviews conducted with kitchen staff revealed the cleaning of the food service machines is done every night. Staff maintain the machines clean everyday and stated they clean the nozzles and certain parts inside on a daily basis to ensure no bacteria grows inside. Based on LPA observation, record review, and interviews, the Department does not have sufficient evidence to support the allegation of “staff do not maintain food service equipment”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued at this time. Report was reviewed and a copy was issued.the state’s words, verbatim · CDSS document, Jul 27, 2023 · control 29-AS-20230724105236

Allegation investigated: Staff did not respond to resident's call for assistance in a timely manner Staff are verbally and psychologically abusing resident Rate increased without a valid reason

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Elizabeth Spencer and explained the reason for the visit. On 1/30/2023, the LPA conducted staff interviews from 9:45 a.m. – 12:00 p.m., and collected pertinent documents. On 7/10/2023, the LPA conducted staff and resident interviews from 10:00 a.m. – 3:15 p.m. Additional resident interviews took place on 07/12/2023 from 10:00 a.m. – 11:15 a.m., and additional staff interviews took place on 7/13/2023 at 11:50 a.m. and 12:12 p.m. On 7/14/2023, the LPA interviewed Resident #1 (R1) at 1:37 p.m., and interviewed three (3) staff at 10:04 a.m., 10:40 a.m., and 11:20 a.m. Unsubstantiated Page 2 Regarding the allegation: Staff are verbally and psychologically abusing resident. It was alleged that staff were making inappropriate comments to Resident #1 (R1) in the form of threats, such as telling R1 they will be kicked out, telling R1 not to use the pendant, and berating R1 for requiring assistance. Although staff denied claims that they had been verbally abusive towards R1, some indicated that R1 had been verbally abusive towards them. The LPA obtained a letter issued to R1 from the Executive Director dated 01/23/2023, which noted that R1 was in violation of the Resident Handbook, as it was alleged that R1 used inappropriate language and behavior towards the staff. A review of the Resident Handbook that was signed by R1 indicated that ‘reported incidents of improper behavior, either toward other residents or employees, can result in eviction from the Community’. Per regulation, a licensee may evict a resident for one or more reasons, which can include ‘failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together, and must be made part of the admission agreement.’ An interview with R1 revealed that R1 enjoyed residing at the community and denied claims that staff had been rude or disrespectful. R1 admitted that they had had a ‘couple disagreements’ with staff but indicated that everything had been worked out. In addition, it was alleged that staff had made inappropriate comments towards R1. Staff commented that R1 would use their pendant often to receive care assistance with toileting and repositioning, but R1 had regularly used their pendant for assistance with retrieving their remote, obtaining a tissue, and so on. Staff commented that they would attempt to keep things within reach of R1 as they understand that R1 requires care assistance, but some staff admitted that they had informed R1 that it was best to use the pendant for care assistance or for emergencies only. Staff indicated that they were re-enforcing the use of the pendant to ensure that all residents in the community received prompt and adequate care. Lastly, there was an incident where a staff member was providing care to R1, in which the staff commented that R1 was ‘heavy’. A review of the video footage and interviews indicated that the staff member’s tone was more so matter of fact, and not in an accusatory tone in alluding that they were making an inappropriate comment about R1’s weight or appearance. The video footage further indicated that the staff tried to explain the reason as to why they referred to R1 as heavy by stating that R1 should assist during a one-person transfer, as the staff did not want to get hurt when assisting R1. Page 3 Based on the investigation, there is insufficient evidence to support the claim that staff are verbally and psychologically abusing resident. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff did not respond to resident's call for assistance in a timely manner It was alleged that there were instances when R1 waited for over thirty (30) minutes to receive care. Staff indicated that when a resident presses their pendant, a staff member must ‘acknowledge’ the pendant on the facility pager (which is time stamped), but it is not until the staff physically see the resident that they can reset the resident’s pendant, which then indicates that they have ‘responded’ to it. In addition, the staff who acknowledges the pendant isn’t always the staff that responds to the pendant in person. The LPA reviewed R1’s pendant logs from 1/29/2023 – 2/26/2023 and noted that R1 pressed their pendant an average of 16.8 times a day during that time period. The LPA reviewed pendant logs from 06/15/2023 – 07/10/2023 and uncovered that generally, staff respond to resident pendant calls within 4-8 minutes. As it refers to R1’s pendant logs, a review of response times indicated that staff responded to R1’s pendant calls on average within eight (8) minutes. Whereas there were some response times that went between 10-15 minutes, it was not most of the calls and represented sporadic occurrences. Staff claimed that it may take time to respond to a call light if they are assisting another resident with changing, toileting, or a shower. However, staff also noted that they will communicate with other caregivers if they are unable to respond to a resident pendant to ensure that someone is available to reach the resident in a timely fashion. R1 stated in their interview that staff were responsive in meeting their care needs and believed staff responded to their pendant press timely. Based on the information, there is insufficient evidence to support the claim that staff did not respond to resident's call for assistance in a timely manner. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Rate increased without a valid reason It was alleged that the R1’s monthly rate was increased without a valid reason. Interviews and records review supported claims that on 3/8/2022, R1 experienced a change of condition. As a result, R1’s care level increased from Level 1 to Level 4. There was also further discussion regarding care needs of R1’s dog, as R1’s service plan indicated that staff would walk R1’s dog four times a day. Page 4 On 4/21/2022, R1’s care plan changed from Level 4 to Level 5. This care plan was signed and dated by R1’s responsible party on 4/21/2022. However, on 4/22/2022, records reflected that R1’s care plan changed back from Level 5 to Level 4. The care plan for 4/22/2022 was not signed by R1’s responsible party until 5/31/2022. Staff noted that this change took place after a care plan meeting with R1’s family. Staff claimed that due to the level of care that R1 required, staff were unable to adjust care services as it related to transfer assistance, toileting, and status checks. However, staff stated that they adjusted the number of times that R1’s dog was walked from four times a day to three times a day. Records from 4/21/2022 displayed the ‘points’ for walking the dog at four times a day at 30 points, yet the 4/22/2022 record then reflected 17 points for walking the dog four times a day. Staff indicated that this was a typing error and brought out invoices to support claims that the dog walking was decreased to 17 points and that R1’s dog was only to be walked three (3) times a day, which brought R1’s care back down to a Level 4. Staff admitted that the document should have been re-issued to R1’s responsible party. As previously stated, R1 was deemed a Level 5 as of 4/21/2022, and this document was signed by R1’s responsible party. Staff stated they are unable to make a financial change unless there is a signature on a service plan or email confirmation of the change. Even though R1’s care was changed to a Level 4 on 4/22/2022, a signature was not obtained by R1’s responsible party for this document until 5/31/2022. As a result, R1 was charged at the Level 5 rate for the remainder of April 2022 through the end of May 2022. Once the signature was obtained to confirm R1’s care as a Level 4 on 5/31/2022, R1 received the difference in cost between the Level 4 and Level 5 rate in the form of a credit on their account for the time period of 4/22/2022 – 5/31/2022. Lastly, staff and records indicated that R1’s care plan had remained at a Level 4 and had not increased since the beginning of 2023, despite suffering either unwitnessed or assisted falls. Based on the information obtained during the investigation, there is insufficient evidence to support the claim that R1 suffered a rate increase without a valid reason. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued. Regarding the allegation: Resident is not receiving timely medical care It was alleged that on occasion, R1 did not receive timely medical attention. Records review indicated that on 3/8/2022, R1 complained of chest pain. A review of charting notes for R1 and interviews with R1’s responsible party detailed that R1 was complaining of chest pain. As a result, staff took R1’s vitals and vitals appeared normal. Records indicated that staff called R1’s responsible party and for R1’s responsible party to take R1 to urgent care. R1 also alleged that they had wanted to go to the hospital, yet the facility made the determination to call R1’s responsible party to determine if R1’s responsible party wanted to take R1 to the emergency room. R1’s responsible party demanded that the facility called 9-1-1. Emergency services arrived and R1 was taken to the hospital. Medical records confirmed that R1 required a triple bypass surgery. R1 recovered at a skilled nursing facility and returned to the facility on 4/11/2022. Based on the information obtained in interview and record review, there is sufficient evidence to support the claim that R1 did not receive timely medical care. Rather than call 9-1-1 when R1 complained of chest pain, staff called R1’s responsible party and inquired as to whether they themselves wanted to contact emergency services. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jul 26, 2023 · control 29-AS-20230222152042

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jul 28, 2023

87465(g) Incidental Medical and Dental Care. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including ... an apparent life-threatening medical crisis ... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff failed to call 9-1-1 when R1 was experiencing chest pains and instead called R1’s responsible party, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 26, 2023

Plan of correction: The Administrator agreed to do the following: Hold an in-service training with staff, discussing the protocol as it pertains to contacting emergency services. Training must begin by 7/28/2023 and must conclude no later than 8/4/2023.

Allegation investigated: Insufficient staffing Resident sustained injuries from a fall while in care Resident are left unattended for an extended amount of time Staff do not respond timely to the residents alerts

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Elizabeth Spencer and explained the reason for the visit. On1/30/2023, the LPA conducted staff interviews from 9:45 a.m. – 12:00 p.m., and collected pertinent documents. On 7/10/2023, the LPA conducted staff and resident interviews from 10:00 a.m. – 3:15 p.m. Additional resident interviews took place on 07/12/2023 from 10:00 a.m. – 11:15 a.m., and additional staff interviews took place on 7/13/2023 at 11:50 a.m. and 12:12 p.m. Today, the LPA conducted resident and staff interviews between 10:00 a.m. - 2:00 p.m. CONT on 9099-C Unsubstantiated PAGE 2 Regarding the allegation: Facility has insufficient staff for the residents while in care It was alleged that the facility was severely understaffed. Interviews and records indicated that fully staffed meant there were at least two medication technicians and three to four caregivers for the AM shift (6 a.m. – 2 p.m.) and PM shift (2 p.m. – 10 p.m.). At times, there is only one (1) medication technician in the PM shift. Staffing is also based on the needs of the current residents within the facility. Staff admitted that at times, if someone calls off, staff will need to supplement with agency staff, assign a medication technician to also conduct caregiving duties, or management staff will step in. Staff interviews confirmed that in January 2023, management staff had to step in and conduct caregiving duties for certain shifts due to staff calling off work. Although some staff indicated that additional staff members were needed, the majority of staff felt that there was sufficient coverage to manage resident care needs. Similarly, most residents interviewed indicated that care needs have not suffered or gone unmet due to staffing concerns. The LPA reviewed pendant logs from 06/15/2023 – 07/10/2023 and uncovered that generally, staff respond to resident pendant calls within 4-8 minutes. Whereas there were some response times that went between 10-15 minutes, it was not most of the pendant calls and represented sporadic occurrences. Based on the information obtained in interviews and record review, there is insufficient evidence to support the claim that facility has insufficient staff for residents while in care. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Resident sustained injuries from a fall while in care It was alleged that due to neglect, Resident #1 (R1) sustained injuries from a fall. Records indicated that on 01/26/2023, R1 suffered an unwitnessed fall in their room. Due to the fall, R1 had a large skin tear on their left hand. When 9-1-1 arrived and R1 was being assisted onto the gurney, records indicated R1 collapsed on the floor and suffered an additional skin tear on the right leg. R1’s needs and services plan indicated R1 was a fall risk, required escorting to meals and activities, needed reminders to use their cane and walker if observed ambulating without the device, and R1 required reminders to ask for assistance when ambulating. Regarding toileting, R1’s plan documented that staff had to assist R1 with changing their briefs when necessary. A review of charting notes for R1 documented that on 01/07/2023, R1 complained of pain and stated that they tried to go to the bathroom and had almost fallen. Due to weakness, R1 was sent to the hospital. R1 was discharged back to the facility on 01/11/2023, and it was documented that R1 reported that they would ‘press [the] pendant if [they] were not feeling well and when [R1] needed to use the restroom’. PAGE 3 Interview and record review noted that during R1's hospitalization from the 01/26/2023 incident, staff visited R1 in the hospital on 1/31/2023. Staff stated R1 reported pressing their pendant because they had to use the restroom, but R1 got up and attempted to the restroom despite having pressed the pendant and subsequently fell. R1 allegedly reported that they would wait until staff arrive when they press their pendant for assistance. R1’s charting notes did not reveal that R1 had regular incidents when they would fall while ambulating despite needing staff assistance Resident interviews noted that most residents felt staff were responsive when pressing their pendant. Residents indicated that even in times where they fell or required medical attention and pressed their pendant, residents claimed that staff had been timely in responding to the pendant. Residents also denied ever being left unattended or soiled for an extended period. Based on information obtained in interviews and records review, there is insufficient evidence to support the claim that due to neglect, R1 sustained injuries from a fall. Although R1 suffered injuries from a fall, R1 alleged they attempted to go to the restroom after pressing their pendant for assistance. R1 had been reminded to use the pendant for assistance, and per the needs and services plan, R1 required changing briefs ‘as needed’. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Regarding the allegation: Residents are left unattended for an extended period of time while in care It was alleged that due to neglect, Resident #1 (R1) fell and was left unattended for an extended period of time. Records indicated that on approximately 01/26/2023, R1 suffered an unwitnessed fall in their room. As a result of the fall, R1 suffered a large skin tear on their left hand. When 9-1-1 arrived and R1 was being assisted onto the gurney, records indicated that R1 collapsed on the floor and suffered an additional skin tear on the right leg. Staff indicated that when a resident presses their pendant, a staff member must ‘acknowledge’ the pendant on the facility pager (which is time stamped), but it is not until the staff physically see the resident that they can reset the resident’s pendant, which then indicates that they have ‘responded’ to it. In addition, the staff who acknowledges the pendant isn’t always the staff that responds to the pendant in person. Staff interviews and a review of R1’s pendant logs from 1/26/2023 indicated that R1 had pressed their pendant at 11:47 a.m. and although R1’s pendant had been acknowledged by staff within 1 minute and 35 seconds, staff were unable to respond to R1’s pendant for fifteen (15) minutes. PAGE 4 The LPA reviewed pendant response times from 01/26/2023 and noted that most of the response times were around eight (8) minutes. Further interview and record review noted that R1 was hospitalized, and staff visited R1 in the hospital on 1/31/2023. Staff stated R1 reported pressing their pendant because they had to use the restroom, but R1 got up and attempted to the restroom despite having pressed the pendant and subsequently fell. Additional resident interviews noted that most residents felt staff were responsive when pressing their pendant for assistance. Residents indicated even in times where they had fallen or required medical attention and pressed their pendant, staff had been timely in responding to the pendant. Residents also denied ever being left unattended or soiled for an extended period. Based on information from interviews and records review, there is insufficient evidence to support the claim that residents are left unattended for an extended period of time. Regarding the 01/26/2023 incident, there is no indication as to when R1 fell within the 15-minute time frame of pressing their pendant and receiving a response from staff. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Regarding the allegation: Staff do not respond timely to the resident alerts It was alleged that residents were waiting for an extended amount of time to receive assistance. Most residents indicated that staff were responsive when pressing their pendant for assistance. Residents indicated that even in times where they had fallen or required medical attention and pressed their pendant, residents claimed that staff had been timely in responding to the pendant. The LPA reviewed pendant logs from 06/15/2023 – 07/10/2023 and uncovered that generally, staff respond to resident pendant calls within 4-8 minutes. Whereas there were some times that went between 10-15 minutes, it was not most of the calls and represented sporadic occurrences. Staff claimed that it may take time to respond to a call if they are assisting another resident with changing, toileting, or a shower. However, staff noted that they communicate with other caregivers if they are unable to respond to a resident pendant to ensure that someone is available to reach the resident in a timely fashion. Based on information obtained in interviews and records review, there is insufficient evidence to support the claim that staff did not respond timely to the resident alerts. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 14, 2023 · control 29-AS-20230127104251

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. The LPA met with Executive Director Elizabeth Spencer and informed them of the reason for the visit. At 9:55 a.m., the LPA and the Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Common Areas: The facility is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors. In addition, there are additional resident units in six (6) stand-alone buildings. Common spaces on the first floor include the theater, salon, secured pool, and spa. The second floor includes the reception area/lobby, library, activity rooms, fitness room, and physical therapy room. The third floor includes the kitchen/dining services, and activity rooms. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 8/2022. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair. Kitchen: Dining is located on the third floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was posted, and the facility offers daily specials and a standard selection at every meal. Snacks and beverages are available for residents in the Bistro area on the 2nd floor. Resident Units: The LPA and Executive Director toured thirteen (13) randomly selected resident units throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Smoke detectors observed in resident units were operational at the time of the visit. Restrooms: The LPA and Executive Director observed restrooms in thirteen (13) resident units. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces in the bathing unit. Water temperature was tested throughout the visit, and water measured between 110 – 120 degrees Fahrenheit. Outside areas: The LPA and Executive Director toured the outside areas and courtyards. There was appropriate outdoor furniture, with a covered shaded area for residents observed in several facility courtyards. There is a locked pool for resident usage with appropriate fencing and it was locked inaccessible. For residents to use the pool, residents must check out a key from the front desk. Parking is available for residents and visitors. Files: Residents records review began at 11:50 a.m. Six (6) records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. Resident records were in order. Six (6) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training. Out of the six (6) files reviewed, three (3) require valid first aid certification (Staff #1, Staff #2, Staff #3). Otherwise, records were in order. Facility conducts emergency drills regularly. Training records were reviewed, and no discrepancies were observed at the time of the visit. Medications: Medications review began at 2:30 p.m., Medications are centrally stored and locked in the Wellness Center on the third floor. For one resident (R1), the pill count was off for two medications (Xarelto, Escitalopram) by one pill, specifically for 7/10/2023. Staff checked R1's medical record (MAR) but it was indicated as administered on 7/10/2023. Not all medications were documented on the centrally stored medications and destruction record (CSMDR) for 4 out of 5 residents (R1, R2, R3, R4). However, staff re-requested the CSMDR forms from the pharmacy during today's visit. Technical violation issued. Documentation: The LPA obtained a copy of the liability insurance, Infection Control Plan, resident roster, and staff roster. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jul 12, 2023

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility staff are not replacing or reimbursing residents for lost items.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced 10-day initial complaint visit to this facility. At 9:55 a.m., the LPA met with staff and explained the reason for the visit. At 10:03 a.m., the LPA met with the Executive Director, Elizabeth Spencer. At 10:05 a.m., the LPA conducted an interview with the Executive Director. At 10:07 a.m., the LPA conducted an interview with Associate Executive Director. Between 10:49 a.m. and 11:27 a.m., the LPA along with the Executive Director and Associate Executive Director, conducted a brief physical plant tour. Between 10:52 a.m. and 11:21 a.m., the LPA also interviewed six (6) out of one hundred twenty-four (124) residents. At 10:27 a.m., the LPA reviewed records and obtained copies of pertinent documents. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Facility staff are not replacing or reimbursing residents for lost items. On 05/08/2023, the Department received a complaint in which it was alleged that the facility does not follow the regulations regarding Theft & Loss. The complainant did not specifically state an incident of the facility not replacing or reimbursing a resident for a lost item. Interview conducted with the Executive Director at 10:05 a.m., explained that the Reserve at Thousand Oak’s Theft and Loss procedures and information is included in both the resident handbook and the admission agreement. The Executive Director explained that prior to admission, the Executive Director holds a meeting with the future resident or resident’s representative to review documents and policies, which includes the Theft and Loss policy. The facilities’ Theft and Loss information and procedures is mentioned three (3) times throughout the resident handbook and admission agreement. The Executive Director provided copies of the handbook and the admission agreement to the LPA. At 10:27 a.m., the LPA reviewed the resident handbook and admission agreement and confirmed that the Theft and Loss policy is in both. The admission agreement has an “Appendix B” that states the California Health & Safety Code sections 1569.152 and 1569.153 and is signed by the resident or the resident representative during the meeting with the Executive Director. The Executive Director also stated that upon admission, the move in documents and paperwork also includes the Client/Resident Personal Property & Valuables (LIC 621). At 10:07 a.m., the LPA also conducted an interview with the Associate Executive Director. The Associate Executive Director explained that upon admission, it is also communicated with the future resident or resident representative of the option of a safe box for the residents’ personal belongings. The Executive Director explained that if a resident reports a personal belonging missing, the resident reports it to staff and the Executive Director or the Associate Executive Director. From there the Executive Director or Associate Executive Director meet with the resident and fill out the Resident Theft and Loss Record (LIC 9060). Once it’s filled out and if the item is over the value of $100 dollars, they report it to law enforcement. The facility also reports said incidents to Licensing. The Executive Director, and Associate Executive Director or staff also help the resident look for the missing item. The Executive Director explained that the facility does document all efforts in the LIC 9060. Furthermore, the resident handbook states that if a resident has a lost or damaged items that it should be reported to the Front Desk. The admission agreement also states that the facility will be responsible for the loss of any personal property belonging to the resident only if the loss or damage was caused by the negligence of the facility or of the facilities employees. Continued on LIC 9099-C. Additionally, interviews conducted with residents did not mention concerns regarding their personal belongings. Per California Health & Safety Code sections 1569.152, if the facility fails to make reasonable efforts to safeguard resident property, then the facility shall reimburse a resident for or replace stolen or lost resident property at its then current value. Based on record review and interviews, the facility does make reasonable efforts to safeguard resident’s property. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 11, 2023 · control 29-AS-20230508162415

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management - Incident visit, to conclude the findings from an investigation that began on 5/26/2022. The LPA met with Executive Director Elizabeth Spencer and explained the reason for the visit. On 5/25/2022, the facility submitted a Report of Suspected Dependent Adult/Elder Abuse and a Special Incident Report, where it was alleged that Resident #1 (R1) had engaged in a sexual relationship with Staff #1 (S1). This incident was referred to the Community Care Licensing Division’s Investigation’s Branch and assigned to Investigator Hector to investigate. Investigator Hector interviewed R1 on 6/7/2022 at 3:30 p.m. and interviewed S1 on 7/22/2022 at 12:28 p.m. Additional staff interviews took place on 6/7/2022 4:50 p.m., and additional resident interviews happened on 7/25/2022 at 1:13 p.m., 1:42 p.m., 1:58 p.m., 2:13 p.m., 2:18 p.m., and 2:38 p.m. A police report regarding the case was requested and reviewed on 6/23/2022. The investigation revealed that during S1’s tenure at the facility, residents described S1 as hard-working, dedicated, and helpful. Residents whom had consistent interactions with S1 denied claims that they had observed S1 interacting with R1 or other residents inappropriately. Interviews affirmed that S1 engaged with residents in a professional manner. Yet R1 claimed that R1 and S1 had a romantic relationship, in which R1 alleged that they engaged in sexual contact with S1. However, R1 was unable to identify, confirm or deny the presence of tattoos or other modifications on S1’s body, nor was R1 able to recall specific details of their sexual encounters with S1. Per the information obtained from a police report, it was indicated that they were unable to establish that a crime had occurred. According to interviews with facility residents, R1 was known amongst the residents as being overly affectionate and had been known to kiss residents on the lips in a ‘friendly manner’. Yet S1 denied all claims that they had engaged with R1 in a sexual manner. Yet, S1 admitted to hugging R1 and to kissing R1 on the forehead. S1 also admitted to engaging in this behavior with another resident at the facility. As many regarded S1 as kind and hardworking, S1 admitted to receiving gratuity gifts from residents ranging from cash, gift cards, and a laptop. S1 also admitted that they knew of the facility policy which prohibited the acceptance of any forms of gratuity from residents. The investigation revealed that as a result of the accusation, S1 was placed on administrative leave. Interviews with S1 revealed that S1 has since resigned. S1 has not returned to the facility. Whereas there is insufficient evidence to support the allegation of sexual abuse, there is sufficient evidence to support the claim that S1 had inappropriate contact (i.e. hugging and kissing residents on the forehead) with facility residents and accepted gifts from residents. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Aug 23, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 30, 2022

87468.1(a)(1) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as S1 admitted to hugging and kissing R1 on the forehead, as well as accepted gifts from residents, which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 23, 2022

Plan of correction: The Administrator agreed to do the following: 1. S1 was placed on leave as of 5/24/2022 and has since resigned. 2. Facility staff will review Regulation 87468 and the internal policy regarding accepting gratuities. Proof of completion provided no later than 8/30/2022.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Executive Director Elizabeth Spencer and informed them of the reason for the visit. The LPA and the Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Common Areas: The facility is a three-story building. There are resident rooms on all three floors. Upon entry to the facility, there is a central entry point for symptom screening and temperature checks for residents, staff, and visitors. Staff were observed wearing appropriate face coverings throughout the visit. In addition, the LPA observed hands-free hand sanitizer interspersed throughout the common grounds. There were no obstructions or tripping hazards throughout the facility. The facility maintains a comfortable temperature at 73 degrees. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair. Outside areas: The LPA toured the outside area of the facility and the courtyard. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a pool for resident usage with appropriate fencing and it was locked at the time of the visit.. Parking is available for residents and visitors. Area is maintained clean. Kitchen: Dining is located on the third floor and was observed to be clean and sanitary at the time of the visit. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. The menu was posted and the facility offers an alternate menu. Facility uses Sysco Foods for food deliveries, and delivery takes place twice a week. Snacks and beverages are available for residents in the Bistro area on the 2nd floor. Common Restrooms: The LPA observed common restrooms on all three floors. The LPA informed the Executive Director that signs promoting good hand hygiene should be placed in all common restrooms in the facility. However, all restrooms were fully stocked with soap and paper towels. Infection Control: During today’s visit, the LPA spoke with the Executive Director regarding the community's infection control practices. The LPA encouraged the Executive Director to create a centralized location with COVID-19 signage that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. However, the community previously had the appropriate signs posted for resident review prior to the cosmetic changes made on the second floor. The community has an adequate supply of Personal Protection Equipment (PPE) and is able to obtain additional supplies. The community's cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. If needed, the facility has the capacity to designate isolation zones or can isolate persons in their room if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The Infection Control Plan was submitted timely. The community's policies and procedures pertaining to infection control were adequate. No deficiencies observed at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 24, 2022

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Due to neglect, resident's pressure injury progressed to a stage 3 pressure injury while in care

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Executive Director Elizabeth Spencer and explained the reason for the visit. On 02/18/2022, the Department received a complaint, alleging that due to neglect, Resident #1’s (R1) pressure injury progressed to a stage 3 pressure injury while in care. On 02/22/2022, the LPA conducted the initial visit and interviewed ten (10) staff from 10:00 a.m. - 3:10 p.m. and obtained pertinent documents. In addition, the LPA interviewed a medical professional whom provided care for Resident #1 (R1) on 02/24/2022 at 3:22 p.m. Lastly, the LPA requested medical records on 03/03/2022 and received the records on 03/25/2022. CONT 9099-C Unsubstantiated The investigation revealed that Resident #1 (R1) was admitted to this facility on 11/12/2021. Interviews and records review revealed that R1 was discharged from a skilled nursing facility, in which R1 had recently had a stroke and was diagnosed with a stage two pressure injury. However, the pressure injury had healed. R1 was admitted to this facility with home health services for speech, occupational, and physical therapy. Interviews revealed that on 1/12/2022, R1 was visited by home health and R1 was observed with a wound on the coccyx. The wound was diagnosed as a stage two pressure injury. As such, home health requested an order for an air mattress and on 1/13/2022, home health requested an order for staff to reposition R1 every two hours. Home health requested an additional wound evaluation, yet R1’s primary care physician noted that R1 needed to be seen by their provider to determine appropriate treatment. Thereafter, the frequency of home health visits increased to approximately three times a week due to the progression of the wound. Prior to this, medical records confirmed that facility staff communicated to R1’s primary care physician that if R1’s wound was staged above a stage two, the facility would be unable to retain R1 in this facility. Thus, R1 had an appointment with their primary care physician on 1/19/2022. Interviews confirmed that staff were not immediately notified regarding the staging of R1’s pressure injury after the 1/19/2022 physician’s visit. In fact, medical records review confirmed that on 1/21/2022, facility staff sent a note to R1’s physician, requesting information regarding the staging of the wound. Thereafter, R1’s physician sent over documentation, confirming that the wound was evaluated as a ‘stage three-four pressure injury’. After receiving the documentation, the facility recognized that R1 needed a higher level of care, and R1 was sent to the emergency room on 1/21/2022. R1 was admitted to the hospital and was discharged to a skilled nursing facility on 1/22/2022 for wound care. R1 did not return to the facility. Staff claimed to have regularly repositioned R1, yet it was communicated by the majority of staff that R1 was resistant to repositioning and would oftentimes ‘return’ to an original position after being repositioned. An interview with home health confirmed that home health had no concerns regarding the care that R1 received at the facility and believed there was insufficient evidence to claim that staff failed to reposition R1, as wounds can rapidly progress within hours. CONT 9099-C Records review and interviews further confirmed that R1’s wound was regularly observed and treated by home health, and home health did not stage R1’s wound above a stage two throughout the duration of R1 residing at this facility. Once the facility received documentation that the wound had progressed to a stage three pressure injury, the facility noted that R1 needed a higher level of care and R1 was sent to the emergency room. Based on the information provided, there is insufficient evidence to support the claim that due to neglect, R1’s stage two pressure injury progressed to a stage three pressure injury while in care. R1’s pressure injury was regularly observed and assessed by an appropriately skilled professional while residing at this facility. The investigation did not reveal any suspicion of neglect or lack of care from home health or hospital staff. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued. Regarding the allegation, it was alleged that the facility failed to safeguard R1’s personal belongings, as an air mattress was ordered for R1 and R1 did not receive it in a timely manner. Interviews and records review revealed that due to R1’s stage two pressure injury, home health requested an order for an air mattress for R1 on 1/14/2022. Interviews revealed that it was delivered the evening of 1/14/2022 and that facility staff signed off for the air mattress. However, interviews revealed that although staff claimed to have signed for the mattress, staff were unable to locate the mattress after it was delivered on 1/14/2022. As a result, R1’s responsible party had to order a new air mattress for R1, and it was delivered on 1/18/2022. Upon arrival of the new mattress, the original mattress that was delivered on 1/14/2022 was found in R1’s room. Staff were unaware as to whether R1’s original mattress was always in R1’s room, or if the mattress was discovered after the 1/14/2022 and placed in R1’s room thereafter. Staff speculated that R1’s mattress was overlooked, as it was ‘rolled up’ like a sleeping bag when it was initially discovered. However, the use of the air mattress was to offset pressure on R1’s coccyx pressure injury, and due to staff oversight, R1 was without the air mattress from 1/14/2022 – 1/18/2022. Based on the information obtained, there is sufficient evidence to support the claim that staff failed to safeguard R1’s personal belongings. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jun 1, 2022 · control 29-AS-20220218085027

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jun 10, 2022

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above as it related to R1's air mattress, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 1, 2022

Plan of correction: The Administrator has agreed to do the following: 1. Submit a Plan of Action, detailing how the facility will ensure that resident personal property is safeguarded. Submit plan to CCLD no later than POC due date of 6/10/2022.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management - Incident visit. The LPA met with Assisted Living Director Prisila Bustos and explained the reason for the visit. Executive Director Elizabeth Spencer was out of the community at the time of the visit. On 5/25/2022, the facility submitted a Report of Suspected Dependent Adult/Elder Abuse and a Special Incident Report regarding an alleged violation of personal rights against Resident #1 (R1). This incident was also cross reported to the local ombudsman office and the local police department. During today's visit, the LPA obtained documents. It is noted that this incident was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Edward Hector. Further investigation is required before findings are delivered. No health and safety hazards noted at this time, and no citations were issued. Exit interview conducted. A copy of the report was issued. A copy of the signed report was emailed to Executive Director Elizabeth Spencer.the state’s words, verbatim · CDSS document, May 26, 2022