Gainsborough Oaks

Allegation investigated: Staff pushed resident resulting in injury Staff handles resident roughly

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegations. The purpose of this visit is to deliver findings for the above listed allegations. Upon arrival at 9:40 a.m., LPA Mosley was greeted by staff, Wilfredo Macandili who called the Administrator. The Administrator was unable to attend physically and designated staff to sign the report. The Administrator was available telephonically throughout the visit. On 08/06/2025 the Department received a complaint regarding the following allegations Staff pushed resident resulting in injury, and Staff handles resident roughly. To investigate this complaint on 08/07/2025 LPA Zabel Chochian conducted the unannounced initial 10-day complaint visit. LPA conducted interview with staff and Administrator, attempted to interview a resident and obtained copies of pertinent documents relevant to the investigation. Report continued on LIC 9099-C... Unsubstantiated (PAGE 2) Report continued from LIC 9099... On 08/14/2025 LPA Mosley conducted an unannounced subsequent complaint visit. Starting at 10:40 a.m. LPA and staff conducted a physical plant tour to ensure there are no immediate health and safety concerns, starting at 12:30 p.m. LPA conducted three (3) in-person interviews, one (1) resident and two (2) staff including the Licensee Representative /Administrator, conducted a file review and obtained copies of pertinent documents relevant to the investigation. On 08/26/2025 at 3:04 p.m. conducted a telephonic interview with a Power of Attorney of Resident #1 (POA R1). On 08/27/2025 at 3:37 p.m. attempted to conduct a telephonic interview with Resident #1 (R1). On 08/27/2025 at 4:04 p.m. attempted to conduct a telephonic interview with a Power of Attorney of Resident #2 (POA R2). On 09/03/2025 at 10:00 a.m. LPA conducted a collateral visit to a Skilled Nursing Facility (SNF) and interviewed R1 at 11:06 a.m. On 09/03/2025, the LPA conducted a subsequent visit at the facility. Starting at 1:25 p.m. LPA and staff conducted a brief physical plant tour to ensure there are no immediate health and safety concerns starting at 1:34 p.m. LPA conducted one (1) in-person resident interview and attempted to obtain copies of pertinent documents relevant to the investigation. On 09/03/2025 at 4:31 p.m. attempted to conduct a telephonic interview with Individual #1 (I1). On 09/03/2025 requested police report related to the incident from Ventura County Sherrif’s Department. On 09/04/2025 Received Police report from Ventura County Sherrif’s Department. On 09/04/2025 Subpoenaed hospital records for R1. On 9/04/2025 at 8:31 p.m. and 9:16 p.m. conducted a telephonic interview with Ventura County Sheriff’s Department responding Deputy (VCSD). On 09/04/2025 at 4:36 p.m. conducted a telephonic interview with Individual #2 (I2). On 09/04/2025 at 3:41 conducted a telephonic interview with I1. On 09/09/2025 received the incident report for R1 for an incident that occurred on 07/31/2025. The facility was cited on a different visit regarding reporting requirements. On 09/24/2025 at 1:28 p.m.,09/25/2025 at 8:45 a.m. and on 09/26/2025 at 3:37 p.m. the LPA attempted to conduct a telephonic interview with the POA for R2. On 09/26/2025 at 4:08 p.m. LPA attempted to conduct a telephonic interview with Responsible Person of former resident, Resident #3 (RPR3). On 09/29/2025 at 10:08 a.m and 4:38 p.m. LPA attempted to conduct a telephonic interview with RPR3. On 09/30/2025 received hospital records for R1. On 10/01/2025 at 11:46 a.m. and 4:42 p.m. and on 10/06/2025 at 10:22 a.m. LPA attempted to conduct a telephonic interview with RPR3. On 10/06/2025, LPA reviewed hospital records for R1. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099-C PAGE 2... During today’s visit, starting at 9:40 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns, and facility is in compliance with Title 22 Regulations. On the allegation Staff pushed resident resulting in injury, it is the concern of the reporting party (RP) that Staff #1(S1) pushed Resident #1 (R1) resulting in injury and hospitalization. To investigate the allegation, the LPA conducted interviews, file reviews, and obtain copies of pertinent documents relevant to the investigation. Interview with R1 revealed that on 07/31/2025 around 4:00 a.m. they were asleep and only remember being pulled from the bed with blood running down their forehead. R1 did not recall falling but remembers waking up injured, and a woman who suggested calling an ambulance, which was done before R1 requested it. R1 noted that no one ever witnessed S1 pushing them, however disclosed concerns to I1 and I2 about S1. R1 was afraid to disclose S1’s behavior to family in fear of retaliation. Record review revealed that R1 was admitted to the hospital on 07/31/2025 at 4:40 a.m. with multiple trauma tier two (2). It was noted that R1 is 93 years old, past medical history of diabetes hypertension and TIAs on Plavix who presents as a tier II activation. R1 is at baseline wheelchair bound but occasionally gets up to use the bathroom, on their own. R1 had a mechanical ground level fall and fell onto forehead. R1 reports generalized pain all throughout their body. No chest pain palpitations shortness of breath, no fevers, no chills, no nausea or vomiting. R1 had no acute findings in the chest, pelvis, bony abnormality, intracranial abnormalities. R1 had a large to moderate -size frontal scalp hematoma. On 08/02/2025 it was noted that R1’s pain appeared well controlled, with no current complaints of pain, field cervical collar removed, no acute fracture or cord signal abnormality. R1 was cleared for discharge from trauma standpoint. On 08/05/2025 R1 reported to POA R1 regarding abuse from S1. On 08/06/2025 hospital social worker was made aware of abuse. R1 was discharged from the hospital on 08/08/2025 at 4:50 p.m. to a Skilled Nursing Facility. Interviews with the facility staff, including S1 revealed that on 07/31/2025 at approx. 4:00 a.m. S1 heard R1 calling for help. Upon entering R1’s room S1 found R1 face down on the floor near their commode / portable toilet beside their bed. R1 stated they fell trying to use the toilet. S1 lifted R1 and S2 noticed a bump forming on R1 forehead and called 911. Report continued on LIC 9099-C PAGE 4... (PAGE 4) Report continued from LIC 9099-C PAGE 3... S1 had placed R1 in a wheelchair to make the paramedic transfer easier. Shortly after, the paramedics arrived and took R1 to the hospital where they were admitted. S1 had visited R1 in the hospital on 08/02/2025 around 1:30 p.m. where R1 was asleep. S1 visited for about twenty (20) minutes to speak with the doctor however unsuccessful and left. On 08/06/2025 around 5:00 p.m. attempted to visit R1, however, was told my nursing staff they were unpermitted and left. S1 stated they were confused as to why they were unpermitted, however respected R1’s wishes. S1 describes R1 as being generally independent however requires assistance with bowel movements or with accidents. Additionally, S1 states they have never pushed any resident including R1. S1 has never witnessed any of the facility staff push a resident including R1. S2 noted that they have never had any concerns with the way S1 treated R1. S1 and R1 got along well with each other. S2 has never witnessed S1 push R1. S2 has never heard of any resident being pushed, including R1 by any facility staff. Interview with POA R1 revealed that on 08/05/2025 R1 disclosed abuse including being pushed by S1 at the facility. Prior to 08/05/2025 POA R1 had no knowledge or suspicion of abuse from facility staff. Interviews with I1 and I2 revealed that R1 had raised concerns regarding S1, however, they never witnessed such acts. I1 and I2 reported that they noticed concerning behavior from S1 including verbal aggression and controlling actions when they were late. I1 revealed that R1 became withdrawn and quiet, which was unlike them. R1 had disclosed to I2 that S1 would poke them aggressively and was controlling, particularly at night. I2 noticed unexplained bruises on R1’s hands, which R1 attributed to falls, though they seemed uncertain. I1 and I2 never witnessed S1 push R1. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff pushed resident resulting in injury is deemed unsubstantiated at this time. On the allegation Staff handles resident roughly, it is the concern of the reporting party (RP) that Staff #1(S1) was very rough when handling R1’s care at the facility. To investigate the allegation, the LPA conducted interviews, file reviews, and obtain copies of pertinent documents relevant to the investigation. Report continued on LIC 9099-C PAGE 4... (PAGE 5) Report continued from LIC 9099-C PAGE 4... Interview with R1 revealed that they were primarily independent and required little to no assistance from the staff at the beginning of their stay, however as their condition declined S1 had to assist with toileting. R1 stated that S1 would become aggressive and rough detailing being pulled from the bed and being struck by S1 sixteen (16) times in total. R1 noted they would often apologize, believing they were hallucinating and speaking to imaginary people. R1 noted that no one ever witnessed S1 handling them roughly, however disclosed concerns to I1 and I2. R1 was afraid to disclose S1’s behavior to family in fear of retaliation. Interviews with staff including S1 revealed that R1 was occasionally provided caregiving support by the staff but was primarily independent, however declining as they became weak leading to their hospitalization. R1 had been hallucinating and reporting visions of people. There have been no reports or observations of rough handling by staff to R1 or any other residents. No disciplinary actions have ever been taken against any staff members, including S1. S1 stated they have never handled any resident roughly, including R1. Interviews with I1 and I2 revealed that R1 had raised concerns regarding S1, however, they never witnessed such acts. I1 and I2 reported that they noticed concerning behavior from S1 including verbal aggression and controlling actions when they were late. I1 revealed that R1 became withdrawn and quiet, which was unlike them. R1 had disclosed to I2 that S1 would poke them aggressively and was controlling, particularly at night. I2 noticed unexplained bruises on R1’s hands, which R1 attributed to falls, though they seemed uncertain. I1 and I2 never witnessed S1 handle R1 roughly. Interview with POA R1 revealed that on 08/05/2025 R1 disclosed abuse including being pushed by S1 at the facility. Prior to 08/05/2025 POA R1 had no knowledge or suspicion of abuse from facility staff. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff handles resident roughly is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 29-AS-20250806095002

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced Case Management – Other inspection at the facility today due to the closure of the licensed facility. Today, October 9th, 2025, at 9:40 a.m. LPA Mosley was greeted by Wilfredo Macandili who called the Administrator. The Administrator is unable to physically attend and designated her husband, Wilfredo Macandili to sign the report on their behalf. The Administrator was available telephonically throughout the visit. On September 19th, 2025, the Department was advised by Maria Macandili, Facility Administrator / Licensee Representative that after careful consideration and due to personal health reasons to close the facility and surrender their RCFE License. As of 9/11/2025 their last resident moved out. Today’s inspection is to ensure that there are no longer any elements of care or supervision of a licensed facility being provided at this location and to officially close the facility. At 9:45 a.m., LPA Mosley and Wilfredo Macandili conducted a brief tour of the home. During the inspection, the LPA found no evidence to support that the home is being operated as a licensed facility. The license was forfeited at the time of the visit. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Case Management - Deficiencies

At approximately 1:15 p.m. Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Deficiencies visit due to a deficiency observed during a complaint investigation. At 1:40 p.m. LPA requested to review former resident files that have resided at the facility within the last 3 years. LPA was informed telephonically by the Administrator that the files were not available however the Administrator could fax them to the LPA by the end of the day. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Sep 12, 2025

Resident Records:Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by: Request for former residents files are not provided when requested... Administrator stated the files were not on site and can fax them over to LPA.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Licensee will ensure that all current and former resident's files are maintained for 3 yeas and made available to the Department for review. Provide the Department with a copy of ALL former resdients within the past 3 years to LPA Mosley by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:50 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator / Licensee Representative, Maria Macandili arrived at 11:14 a.m. and the reason for the visit was explained. Entrance interview. The LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: This includes the living room, dining room and open office area. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 12:07 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed expired dated 09/22/2023 which poses / posed an immediate health and safety risk to persons in care. LPA informed Administrator the importance and requirement of having an active fire extinguisher. The Administrator agreed to purchase new fire extinguisher today 08/14/2025. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill is unknown. LPA informed Administrator the importance and requirement of drills conducted quarterly. The Administrator agreed to conduct a drill this week. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C... BEDROOMS: There are six (6) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms and two (2) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: The facility contains three (3) total restrooms. Administrator indicated 1 (one) is for resident use and 2 (two) are for staff use. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in the resident restroom at 10:58 a.m. and measured 112.5 degrees Fahrenheit, within the required range. KITCHEN: The LPA inspected the kitchen/food service area at 11:03 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 118.6 degrees Fahrenheit at 11:07 a.m. Cleaning supplies and other chemicals are kept in the laundry room locked and inaccessible to residents in care. LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the resident restroom. Laundry room has a washer and dryer and locked cleaning supplies. BACKYARD: The entire property is fenced. The backyard has a covered patio area with shade, patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. The pathway used as an emergency exit was free of obstructions at the time of the visit. LPA observed a swimming pool that was gated and locked. The garage was locked and attached to the house. Report Continued on LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... RECORDS: Record review began at approx. 11:10 a.m. Resident Records :were reviewed beginning at 11:15 a.m. two (2) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Resident #1 had an incomplete appraisal and missing LIC 621, updated physician report, needs and service plan. During the visit LPA observed R1 to be on a Gastrostomy tube (G-tube). During record review LPA did not see any documentation of R1 having any documentation on the Prohibited Health Condition which poses an immediate health and safety risk to persons in care. LPA was informed by the Administrator that R1 will be placed on Hospice however it is still being discussed by the family. Resident #2 was missing paperwork however it was cited in a Case Management visit conducted on 08/07/2025. Personnel Records: were reviewed beginning at 11:50 a.m. two (2) Personnel files including the Administrator’s file were attempted to review including but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were missing. Administrator stated they did not have any of the staff files as they are currently reviewing them at an off site location which poses a potential health, safety or personal rights risk to persons in care. LPA informed Administrator the importance of having all files available. Administrator agreed to have files on site after self audit was completed. INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facilities emergency disaster plan. The facilities policies and procedures, as they pertain to emergency planning, are satisfactory. At the time of the visit the infection control plan was not available which poses a potential health, safety or personal rights risk to persons in care. LPA informed Administrator the importance of having all files and records available. Administrator agreed to email LPA the plan once completed. MEDICATIONS: Medication review began at approximately 12:05 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the dining room. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. Report Continued on LIC 809-C PAGE 4... (PAGE 4) Report Continued from LIC 809-C PAGE 3... DOCUMENTS: Documents obtained during the visit include: LPA did not collect any documents as Administrator stated they did not have their paperwork on site. LPA requested Administrator email their LIC 500 facility roster and LIC 9020A Resident roster and copy of the Limited Liability insurance. INTERVIEWS: Starting at 12:30 p.m. Two (2) staff and one (1) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. During the interview, R1 was unable to effectively communicate with the LPA. When prompted with questions, R1 did not provide verbal responses but instead made grunting sounds that could not be interpreted. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Case Management - Deficiencies

This Case management visit was conducted to address the deficiency noted during complaint investigation visit conducted on 08/07/2025. Resident files observed incomplete - for Resident #1 missing Appraisal/Needs and services plan, physician report and admission agreement. For Resident #2 - missing current physician report and Appraisal/needs and service plan. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted. Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Aug 14, 2025

Resident Records - (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out 2 resident records observed incompletet. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Administrator/Licensee will maintain complete copy of resident files in a centralized location in the facility moving forward. Provide missing records for both residents: Appraisal/Needs and services plan and physican report; admission agreement for Resident#1 only. Submit to CCLD by due date.

Type of visit: Required - 1 Year

At 11:06AM Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff Willfredo Macandili and informed them of the reason for the visit. Administrator Maria Macandili arrived at 11:25AM. Entrance interview conducted. At 11:40AM, the LPA, along with Administrator, conducted a tour of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Facility fire extinguisher was fully charged and recently purchased on 09/22/2023. All hardwired smoke alarms were tested at 01:57PM and carbon monoxide detectors were tested at 02:10PM and all functioned properly. The LPA observed all required postings throughout the facility. Bathrooms: The facility contains 3 (three) bathrooms. Administrator indicated 1 (one) is for resident use and 2 (two) are for staff use. LPA observed the resident bathroom, which was properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats. The hot water was measured in the shared bathroom during the physical plant tour. Hot water measured at 116.0 degrees Fahrenheit, which is within the required range. Bedrooms: The facility contains 6 (six) total bedrooms; 4 (four) are designated for resident use and 2 (two) are designated for staff use. The resident bedrooms were properly furnished and sufficient lighting. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Staff rooms were observed to be locked. Resident #1 (R1) was observed to have full bedrails. Administrator indicated that R1 had been on hospice and staff stated they had requested half rails for R1 from the vendor, but had yet to receive them. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked cabinet. Report continued on LIC 809-C Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature throughout the visit. The LPA observed the fireplace in the living room adequately screened. There were no obstructions and/or tripping hazards throughout the facility. Cleaning supplies were stored in a locked cabinet inside the laundry room. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture and a swimming pool that was gated and locked. The garage was locked and attached to the house. Record Review: Beginning at 11:53AM, LPA reviewed staff and resident files. The LPA reviewed two (2) out of two (2) Resident Files for items including but not limited to: physician's reports, needs and service appraisal, personal rights. The LPA reviewed two (2) out of two (2) staff files for items including but not limited to: staff training, health screening, TB test results. All files reviewed contained all documents. Emergency Disaster Plan/Infection Control Plan: During today's visit, LPA reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. The LPA inquired about the facility's infection control plan. The facility does have a COVID Mitigation Plan and is following basic infection control practices, however did not have a written Infection Control Plan. LPA provided Administrator with the LIC 9282 form during the visit. Medications: At 01:35PM, a medication review was initiated. Medications are centrally stored and locked in a cabinet in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Interviews: Throughout today's visit, LPA interviewed 2 (two) staff and attempted to interview 2 (two) residents. During Administrator interview, it was identified that the Licensee corporation is suspended. Administrator agreed to contact the suspending agency and keep LPA updated with an action plan to get back into good standing. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted with Administrator. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 6, 2024

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are storing expired foods at the facility. Facility does not have an emergency evacuation plan in place. Staff did not ensure residents are provided nutritional meals. Staff did not ensure facility is maintained clean. Staff are not trained

Licensing Program Analyst (LPA) Zabel Chochian conducted complaint visit to the facility. Upon arrival LPA met with staff #1 and reason for the visit was stated. Administrator arrived at facility approximately 3:40 p.m. Reason for visit was explained and allegations were discussed. On 05/29/2024, Community Care Licensing Division (CCLD) received a complaint with the above allegations. Investigation was initiated by Licensing Program Analyst (LPA) Zabel Chochian. LPA Chochian toured the facility with staff from approximately 2:45 p.m. – 3:00 p.m. Interview was conducted with staff from 3pm-3:30 p.m. Following is a summary of the investigation findings: Regarding allegation, “Staff are storing expired foods at the facility” – The reporting party alleged that facility is storing expired canned foods. LPA conducted a tour of the kitchen and observed canned food items in the kitchen. A credible witness also provided information that facility is storing expired canned food items. Staff reported that they are checking all canned food items now and will dispose all expired cans. Based on observation of the expired canned food items in the kitchen and interviews, the allegation “Staff are storing expired foods at the facility” is deemed Substantiated at this time. (Continue to LIC 9099c). Substantiated Regarding allegation, “Facility does not have an emergency evacuation plan in place”. Information was provided that staff #1 was not able to provide facility emergency evacuation plan. Interview with staff #1 conducted during todays visit revealed that there is not a written evacuation plan or that he is not aware of any written plan. Administrator reported that she is working on completing one for the facility. Based on observation of the expired canned food items in the kitchen and interviews, the allegation “Facility does not have an emergency plan in place” is deemed Substantiated at this time. Regarding allegation, “Staff did not ensure residents are provided nutritional meals”. Information was reported that staff do not plan meals a head and therefore do not provide resident quality food. It was reported that residents were served pasta and nothing else. LPA conducted interview with staff today and asked staff what residents had for lunch and staff stated “pasta”. LPA asked staff what’s for dinner and staff stated he doesn’t know yet. Interview with this staff confirmed that staff do not plan meals and serve resident meals not of good quality. LPA observed a piece of salmon in a container that was confirmed to be sitting out for over an hour. According to staff he was defrosting the salmon to cook for a resident. Based on observation of the facility food supply, and interview with staff, the allegation “Staff did not ensure residents are provided nutritional meals” is deemed Substantiated at this time. Regarding allegation, “Staff did not ensure facility is maintained clean”. Information was received that facility is not maintained clean. LPA conducted a tour with staff and following was observed: kitchen cabinets stained/dirty; messy rooms with clothing and other belongings on the floor (photos taken); cob webs hanging from ceiling in rooms and hallway area; resident room ceiling stained (maybe due to leakage); resident door has blinds and are in disrepair (photo taken). Based on today’s observation, the allegation “Staff did not ensure facility is maintained clean” is deemed Substantiated at this time. Regarding allegation, “Staff are not trained”. Information was received that staff #1 is unqualified to care for residents needs. LPA conducted interview with staff #1. Staff was able to communicate however when asked a certain question about the facility and training staff has received Staff #1 would refer to his wife (administrator). Staff #1 was unable to state what training he has completed; was not able to state facility evacuation/emergency plan. Staff said that they would just evacuate to the front. Administrator stated that she does not have training did not have any training records for staff #1. Based on interviews, the allegation “Staff are not trained” is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, May 30, 2024 · control 29-AS-20240529164940

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jun 3, 2024

The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. This requirement is not met as evidenced by: Based on observation and interviews it was revealed resident are not provided with a nutritious meals. This poses a potiential health and safety hazard to resident in care.the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: Licensee/Administrator shall develop a menu for resident meals to be served which are good quality and nutritional. Also provide in-service from outside vendor for training regarding General food service requirements. Submit planned menu and scheduled training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 10, 2024

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation facility observed with cobwebs; dusty and disrepair; resident rooms observed dusty; ceiling observed stained (water damage) kitchen cabinet dirty;the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: Licensee/Administrator agreed to make repairs and maintain facility clean at all times. Administrator shall provide photos of the facility kitchen (cabinets) cleaned ; common areas and each bedroom cleaned and organized.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87212(a) · Plan of correction due date: May 31, 2024

87212 Emergency Disaster Plan (a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. This requirement is not met as evidenced by: Based on interview with administrtor and staff it was revealed that Licensee/administrator has not yet completed an emergency disaster plan.the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: Licensee/Administrator agreed to develop and submit the emergency disaster plan by 5/31/24.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.625(a)b(c) · Plan of correction due date: May 31, 2024

(a) The Legislature finds that the quality of services provided to residents of residential care facilities for the elderly is dependent upon the training and skills of staff. It is the intent of the Legislature in enacting this section to ensure that direct-care staff have the knowledge... (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: Licensee/Administrator agreed to hire a vendor to provide training to staff #1 according to Health and Safety code 1569.625(a)b(c). Locate and provide proof of trainer and schedule of training dates and times to be provided to staff #1. Also submit copy of certificates issued by vendor. Based on interview with staff and Licensee it was revealed that staff #1 has not completed the required training.