Ventura Townehouse

Allegation investigated: . Staff did not assist resident with getting their needs met at a medical facility 2. Staff do no ensure residents have access to transportation from required medical appointments

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit to deliver the final findings of the allegation mentioned above. LPA met with Administrator Evan Granucci and informed him the reason of the visit. The following information was provided: Allegation #1: Staff did not assist the resident with getting their needs met at a medical facility. To investigate the allegation, on 09/18/2025, from 10:00 a.m. to 1:00 p.m., (LPA) interviewed three (3) staff members, Resident #1 (R1), and twelve (12) out of twelve (12) residents. LPA also obtained and reviewed facility and resident records. During today's subsequent visit, 08/20/2026, LPA conducted follow-up interviews with three (2) staff members and twelve (12) residents. According to the complaint, R1, was dropped off at medical appointments without assistance and was unsure whether prescribed medications were being taken, resulting in concerns that the facility was neglecting R1's medical needs....(Cont'd LIC9099C) - page 1 Unsubstantiated LPA interviewed R1, who acknowledged needing assistance at times but stated that R1 chooses to make personal decisions and that family members are actively involved in R1's care. Records confirmed that R1's family members serve as the responsible parties. Staff reported they assist and guide R1 as needed; however, R1's family schedules medical and personal appointments and arranges transportation. Physician records indicate that R1 is able to leave the facility unassisted. Although R1 has a documented cognitive disorder, R1 stated that medical decisions are made jointly by R1 and family members. Resident records further confirm that the facility manages and administers R1's medications, which are services being paid for by (R1). According to (R1s) admission agreement, “personal transportation and supervision” is an optional service for an additional charge for residents, which was declined by (R1). Residents interviewed reported using various transportation options for medical appointments, including the facility's transportation service and other transportation providers. None of the residents interviewed expressed concerns regarding the transportation assistance or medical support provided by the facility. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that facility staff failed to assist R1 in meeting medical needs during medical appointments. Therefore, the allegation is Unsubstantiated. Allegation #2: Staff do not ensure residents have access to transportation for required medical appointments. To investigate the allegation, on 09/18/2025, from 10:00 a.m. to 1:00 p.m., (LPA) interviewed three (3) staff members, Resident #1 (R1), and twelve (12) of twelve (12) residents. LPA also obtained and reviewed facility and resident records. During a subsequent visit, LPA conducted follow-up interviews with three (3) staff members and twelve (12) residents. According to the complaint, there were concerns that the facility did not provide transportation for R1’s medical appointments. Interviews with R1, other residents, and facility staff revealed that the facility provides transportation for residents’ appointments, including medical and personal appointments. Staff #1, the transportation supervisor, reported that the facility driver follows a set schedule for resident pick-ups and drop-offs throughout the week, with designated days for resident outings. (Cont'd LIC9099 - page 2) Regarding R1, interviews and records revealed that R1 also uses a personal driver arranged by R1 and R1’s family for personal and medical appointments. Facility staff reported that the facility has provided transportation for appointments scheduled by R1. Staff further reported that an escort service is available for residents who require assistance during appointments. The escort service is a paid service and was offered to R1; however, R1 and R1’s family declined the service. Based on interviews conducted and facility and resident records reviewed, there was insufficient evidence to support the allegation that staff do not ensure residents have access to transportation for required appointments. Therefore, the allegation is Unsubstantiated. Exit interview and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 31-AS-20250911105505

Allegation investigated: . Staff did not provide adequate supervision resulting in resident falling and sustaining an injury 2. Staff speak to resident in an inappropriate manner 3. Staff does not ensure resident is provided prescribed medication 4. Staff do not treat resident with dignity and respect

Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Evan Granucci to deliver the final findings of the investigation and allegations mentioned above. The following was determined: Allegation #1: Staff did not provide adequate supervision resulting in a resident fall and injury. To investigate the allegation, on 09/04/2025, from 10:30 a.m. to 12:30 p.m., LPA conducted an initial complaint visit, interviewed six (6) of six (6) staff, and reviewed resident and facility records. On 03/10/2026, from 10:30 a.m. to 2:00 p.m., LPA conducted a subsequent visit and interviewed twenty-one (21) of twenty-one (21) residents, including (R1). Records review indicated (R1) was admitted on 07/31/2024 and was independent, requiring only the use of a walker for balance support. On 07/30/2025, (R1) experienced an unwitnessed fall. (R1) reported not recalling the cause of the fall but believed it may have involved entanglement with the walker. (R1) activated (Cont'd LIC9099C) Unsubstantiated the emergency call system, staff responded promptly, and (R1) was transported to the hospital. (R1) was initially treated and returned to the facility; however, after reporting continued pain, (R1) was later diagnosed with a fractured humerus during a subsequent hospital visit. Following the second hospitalization, the facility reassessed (R1) and updated the service plan to include a higher level of care. Staff reported that prior to the fall, (R1) was independent and did not require supervision. After the incident, staff provided increased assistance, including regular checks and escorting. (R1) confirmed staff check on them periodically. Interviews by other residents identified as independent; not needing assistance from staff or using the emergency alarm. Based on interviews and records reviewed, LPA determined (R1) did not require supervision prior to the fall, and the facility implemented appropriate interventions following the injury. Therefore, there is insufficient evidence to support the allegation. The allegation is deemed Unsubstantiated. Allegation # 2: It was alleged that facility staff speak to residents in an inappropriate manner. To investigate the allegation, on 09/04/2025, from 10:30 a.m. to 12:30 p.m., during the initial complaint visit, LPA interviewed six (6) out of (6) staff. LPA also obtained and reviewed resident and facility documentation. On 03/10/2026, from 10:30 a.m. to 2:00 p.m., LPA conducted a subsequent visit and interviewed twenty-one (21) out of twenty-one (21) residents, including Resident #1 (R1). According to the complaint, the reporting party (RP) alleged that (R1) was being verbally belittled and humiliated by staff. However, during interviews conducted, including with R1, residents reported that staff are respectful and not rude. Residents further reported that staff are caring, provide appropriate care, and that they have not observed any instances of staff belittling or humiliating residents, including R1. Staff denied mistreating or humiliating residents and reported that they treat residents with respect and work diligently to provide quality care. LPA attempted to contact the reporting party (RP) and other potential witnesses on multiple occasions but was unsuccessful. Based on interviews conducted with R1, other residents, and staff, there is insufficient evidence to support the allegation that staff speak to residents in an inappropriate manner. Therefore, the allegation is determined to be Unsubstantiated at this time. (See LIC9099C Allegation #3: It was alleged that staff do not ensure residents are provided prescribed medication. To investigate the allegation, on 09/04/2025, from 10:30 a.m. to 12:30 p.m., during the initial complaint visit, LPA interviewed staff and six (6) out of six (6) residents. LPA also obtained and reviewed resident and facility documentation. On 03/10/2026, from 10:30 a.m. to 2:00 p.m., LPA conducted a subsequent visit and interviewed twenty-one (21) out of twenty-one (21) residents, and resident #1 (R1). LPA also audited and inspected residents’ medications and medication administration records (MARs), including those for R1. According to the complaint, it was alleged that R1 missed morning medication. However, records reviewed for R1 revealed that R1 was admitted to the facility on 07/31/2024, and medication management was not initially provided by the facility. Documentation indicated that R1 was authorized by their primary physician to store and self administer their own medication. The facility did not begin providing medication management services for R1 until September 2025. The alleged missed medication was not specifically identified or documented. Records reviewed after the facility began providing medication management indicate that medications were administered in accordance with physician’s orders. Interviews conducted with residents revealed that they have not missed medications administered by staff. Additionally, several residents reported that they independently store and self administer their own medications without staff assistance. R1 reported to LPA that they have not missed any medication administered by staff. Based on record review and interviews conducted, there is insufficient evidence to support the allegation that staff failed to ensure residents receive prescribed medication. Therefore, the allegation is determined to be Unsubstantiated at this time. Allegation #4: It was alleged that staff do not treat residents with dignity and respect. To investigate the allegation, on 09/04/2025, from 10:30 a.m. to 12:30 p.m., during the initial complaint visit, LPA interviewed six (6) out of six (6) staff. LPA also obtained and reviewed resident and facility documentation. On 03/10/2026, from 10:30 a.m. to 2:00 p.m., LPA conducted a subsequent visit and interviewed twenty-one (21) out of twenty-one (21) residents, and Resident #1 (R1). (See LIC9099C) According to the complaint, the reporting party (RP) alleged that R1 was not being treated with dignity and respect. Contrary to the allegation, during interviews conducted, including with R1, residents reported that staff are respectful and treat them with dignity. Residents further reported that staff are caring, provide appropriate care, and that they have not observed any instances of staff treating residents without dignity and respect, including R1. Staff denied the allegation and reported that they treat residents with respect and work diligently to provide quality care. LPA attempted to contact the reporting party (RP) and other potential witnesses on multiple occasions but was unsuccessful. Based on interviews conducted with R1, other residents, and staff, there is insufficient evidence to support the allegation that staff do not treat residents with dignity and respect. Therefore, the allegation is determined to be Unsubstantiated at this time. Exit interview conducted and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 31-AS-20250829153531

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Facility has insufficient staffing to meet the needs of residents in care

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit to deliver the final findings of the allegation mentioned above. LPA met with Administrator Evan Granucci and informed him the reason of the visit. The following was determined: To investigate the allegation, on 03/07/2025, from 10:00 a.m. to 1:00 p.m., Licensing Program Analyst (LPA) conducted an initial complaint visit, during which interviews were conducted with ten (10) out of ten (10) residents and three (3) staff members. LPA also obtained and reviewed resident and facility documentation. On 09/17/2025, from 2:30 p.m. to 4:30 p.m., LPA interviewed the reporting party and obtained additional information related to the complaint. On 01/15/2026, a subsequent visit was conducted and, from 10:00 a.m. to 1:00 p.m., LPA interviewed fourteen (14) out of fourteen (14) residents and four (4) staff members. (Con'td LIC9099C) Unsubstantiated According to the complaint, Resident #1 (R1) was paying for a higher level of care due to an injury requiring transfer assistance from staff. It was alleged that despite the increased level of care, staff response times did not improve. The complaint further alleged that staff frequently failed to respond in a timely manner, resulting in R1 attempting to transfer independently, sliding to the floor, and on one occasion remaining on the ground for approximately two (2) hours before receiving assistance. Overall, the complaint alleges that the facility is short staffed. To assess staffing sufficiency, LPA reviewed staff schedules and interviewed staff and residents. Staff schedules for the relevant time frames reflected staffing levels consistent with facility requirements for both day and evening shifts. Caregivers, medication technicians, and management staff were present and available to assist residents as needed. Staff reported that response times may vary depending on workload and resident needs at any given time; however, staff denied that R1 had been left on the floor for hours. Staff indicated they communicate frequently via walkie-talkies and are aware of residents requiring two person assistance, including R1. Residents interviewed reported that while there are occasional delays in assistance due to staff attending to other residents, staff ultimately respond and provide necessary support. Residents denied experiencing or witnessing wait times of several hours for assistance. Based on interviews conducted and records reviewed, the allegation may have occurred; however, there is insufficient evidence to determine that the facility had inadequate staffing or that R1 was left unattended for an extended period of time. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 31-AS-20250227131750

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Tuesday Cabiness and Jose Gary Tan and conducted an unannounced annual inspection. LPAs were greeted by the front receptionist who was informed the reason of the visit. Administrator Evan Granucci was contacted via telephone, who arrived shortly after. LPAs conducted a tour of the facility inside and out. The facility consists of one (1) main building which houses independent and assisted living residents, with (80) private villas also housed independent residents. The Memory Care has thirty (30) apartments, and the current was (30). The facility is fire cleared for five hundred sixty six (566) non-ambulatory residents, six (6) of which may be bedridden. The facility has a hospice waiver for twenty (20) residents. There are two (2) main entrances being utilized at the facility, the main entrance at the front of the main building for visitors and residents and the opposite entrance being used by residents living in the villas. The common areas such the front lobby, dining room lounge and dining room are on the first floor. The gym, salon, and game room are on the ground floor. Medication rooms on the first floor, as well administrative offices. The are laundry rooms on 2nd, 4th and 6th floors for residents use. A random selection of resident rooms were inspected in the Assisted Living Tower and resident rooms from the Garden Apartments. Resident rooms were observed to be furnished appropriately and restrooms had grab bars and non-skid mats as well as emergency alarms. Hot water temperature was measured in all rooms that were inspected; which temperatures ranged from 114.8 to 120.0 degree F. (continued to LIC 809-C) The physical plant tour in the memory care was also conducted, and the census at the time of the visit, was (30). The area is secured with a delayed egress system. The common areas of the memory care unit were observed and clean. Food is cooked in the main kitchen and transported to the memory care unit in hot boxes. Medications are centrally stored in the medication room. Personal accommodation in residents bedrooms and bathrooms were observed for safety, privacy, and comfort. The LPA Gary Tan toured the food service area. A sufficient supply of perishable and non-perishable food was observed and food was stored, and labeled in appropriate manner. Record Review with (10) residents and (10) staff files; all were inspected and reviewed to be complete with current training records. Medication records reviewed: No errors observed and doctor's orders were current and documented. No deficiencies were observed during today's inspection. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 17, 2026

Allegation investigated: Administrator Qualifications and duties

Licensng Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit to deliver the final findings of the allegation mentioned above. LPA met with Administrator Evan Granucci and informed him the reason of the visit. The following was determined: It was alleged that the Administrator was not available or reachable when attempts were made to contact him. To investigate the allegation, on 03/07/2025, from 10:00 a.m. to 1:00 p.m., during the initial complaint visit, (LPA) conducted interviews and obtained and reviewed resident and facility documentation. On 09/17/2025, from 2:30 p.m. to 4:30 p.m., LPA conducted additional interviews with witnesses related to the complaint. Interviews with staff revealed that there have been occasions when attempts to contact the Administrator were not immediately successful and that his work phone did not have voicemail capability. However, staff reported that the Administrator returned calls in a timely manner. Staff further stated that when the Administrator is unavailable, other administrative staff are accessible to address needs as necessary. In addition, residents indicated that the Administrator is seen at the facility daily and is available when needed. Unsubstantiated LPA has made multiple on-site visits to the facility for various purposes and observed the Administrator present and on duty. Additionally, LPA verified that the Administrator has an active and valid Administrator’s certificate on file. Although concerns were raised regarding the Administrator’s availability and performance of duties, based on interviews, observations, and document review, the LPA did not obtain sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time. Exit interview conducted and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 31-AS-20250227131750

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: . Staff behavior poses as a risk to a resident 2. Staff is answering a resident's phone 3. Staff made an unauthorized medical decision for a resident 4. Staff falsified documents regarding a resident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit, to deliver the final findings of the allegations mentioned above. LPA met with Executive Director Evan Granucci and informed him the reason of the visit. The following was determined: Allegation #1: It was alleged staff (S1 and S2) behavior posed as risk to resident # 1 (R1). To investigate the allegation, on 01/29/2025, from 1:00 p.m. to 2:00 p.m., Licensing Program Analysts (LPAs) Gary Tan and Angelica Segovia conducted the initial complaint visit and obtained documents related to the allegation. Multiple attempts were made to contact the complainant; however, the contact information provided was invalid or incorrect. During today’s visit, from 10:00am to 12:00 p.m., LPA T. Cabiness conducted additional interviews and re-reviewed documentation related to this allegation and a similar complaint involving R1. Prior to this visit, LPA Cabiness reviewed the facility’s complaint history and noted that concerns regarding staff behavior had already been addressed under complaint C31-AS-20250102144515, which remains under investigation. Unsubstantiated Interviews and facility record reviews revealed there are no staff currently employed at the facility identified as S1 or S2. Additionally, LPA was unable to obtain further clarification from the complainant to support or verify the details of the allegation. Based on interviews, facility records review, and the facility’s complaint history, the allegation may have happened; however, there is insufficient evidence to determine the validity of the complaint. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation # 2: Staff are answering a resident's phone. It was alleged staff were answering resident’s phone. To investigate the allegation, on 01/29/2025, from 1:00 p.m. to 2:00 p.m., Licensing Program Analysts (LPAs) Gary Tan and Angelica Segovia conducted the initial complaint visit and obtained documents related to the allegation. LPA attempted to contact the complainant multiple times; however, the contact information provided was invalid or incorrect. During today’s visit, from 10:00am to 12:00 p.m., LPA T. Cabiness conducted additional interviews and re-reviewed documentation related to the allegation and a similar complaint concerning Resident #1 (R1). The complainant alleged staff are answering (R1’s) phone. Prior to this visit, LPA Cabiness reviewed the facility’s complaint history and noted that concerns regarding staff behavior had already been addressed under complaint C31-AS-20250102144515, which remains under investigation. Interviews and facility record reviews revealed there are no staff currently employed at the facility identified as S1 or S2. Additionally, LPA was unable to obtain further clarification from the complainant to support or verify the details of the allegation. Based on interviews, and the facility’s complaint history, the allegation may have happened; however, there is insufficient evidence to determine the validity of the complaint. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation #3: Staff made an unauthorized medical decision for a resident. To investigate the allegation, on 01/29/2025, from 1:00 p.m. to 2:00 p.m., Licensing Program Analysts (LPAs) Gary Tan and Angelica Segovia conducted the initial complaint visit and obtained documents related to the allegation. LPA attempted to contact the complainant multiple times; however, the contact information provided was invalid or incorrect. During today’s visit, from 10:00am to 12:00 p.m., LPA T. Cabiness conducted additional interviews and re-reviewed documentation related to the allegation and a similar complaint concerning Resident #1 (R1). (Continued on LIC9099C The complainant alleged staff are answering (R1’s) phone. Prior to this visit, LPA Cabiness reviewed the facility’s complaint history and noted that concerns regarding staff behavior had already been addressed under complaint C31-AS-20250102144515, which remains under investigation. Interviews and facility record reviews revealed there are no staff currently employed at the facility identified as S1 or S2. Additionally, LPA was unable to obtain further clarification from the complainant to support or verify the details of the allegation. Based on interviews, and the facility’s complaint history, the allegation may have happened; however, there is insufficient evidence to determine the validity of the complaint. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation # 4: Staff falsified documents regarding a resident. To investigate the allegation, on 01/29/2025, from 1:00 p.m. to 2:00 p.m., Licensing Program Analysts (LPAs) Gary Tan and Angelica Segovia conducted the initial complaint visit and obtained documents related to the allegation. LPA attempted to contact the complainant multiple times; however, the contact information provided was invalid or incorrect. During today’s visit, from 10:00am to 12:00 p.m., LPA T. Cabiness conducted additional interviews and re-reviewed documentation related to the allegation and a similar complaint concerning Resident #1 (R1). The complainant alleged staff are answering (R1’s) phone. Prior to this visit, LPA Cabiness reviewed the facility’s complaint history and noted that concerns regarding staff behavior had already been addressed under complaint C31-AS-20250102144515, which remains under investigation. Interviews and facility record reviews revealed there are no staff currently employed at the facility identified as S1 or S2. Additionally, LPA was unable to obtain further clarification from the complainant to support or verify the details of the allegation. Based on interviews, and the facility’s complaint history, the allegation may have happened; however, there is insufficient evidence to determine the validity of the complaint. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided to Executive Director.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 31-AS-20250122114301

Allegation investigated: Facility staff do not treat resident with dignity and respect

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit, to deliver the final findings of the allegation mentioned above. LPA met with Executive Director Evan Granucci and informed him the reason of the visit. The following was determined: It was alleged that staff did not treat Resident #1 (R1) with dignity and respect. To investigate the allegation, on 01/04/2025, from 1:00 p.m. to 2:00 p.m., (LPA) interviewed witnesses identified in the complaint. On 01/09/2025, from 10:00 a.m. to 2:30 p.m., LPA conducted the initial complaint visit, obtained and reviewed resident records, and interviewed staff, R1, and 25 out of 250 residents. On 04/04/2025, from 10:00 a.m. to 10:45 a.m., LPA obtained additional information from witnesses regarding the allegation. According to the information obtained, facility staff attempted to have R1 sign documents without R1’s consent, and it was alleged their behavior toward R1 was rude and disrespectful. During interviews, R1 confirmed that staff attempted to have R1 sign documents but stated that this was an isolated incident involving R1’s daughter and a financial inheritance matter. R1 also stated that, Unsubstantiated overall, staff have consistently been respectful and kind. Interviews with other residents corroborated that staff treat residents respectfully and often go out of their way to assist when needed. Based on interviews with R1, staff, other residents, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided to ED. During the interview, R1 reported that staff took R1 in the facility’s medication room and tried to place a pen into R1’s hand. R1 also stated that staff attempted a couple more times to have R1 sign the same documents on two separate occasions following the initial incident. Although facility staff denied the allegation and other residents did not report concerns regarding harassment, based on R1’s consistent and detailed statements, supporting witness information, and review of R1’s Power of Attorney documentation, LPA determined the allegation is Substantiated. This poses a potential health and safety risk to residents in care. Citation issued, appeal rights, exit interview and copy of report given to Administrator.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 31-AS-20250102144515

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 8, 2025

87468.1 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: (3) To be free from punishment, humiliation, intimidation...This requirement was not met, evidenced by, during interviews from the investigation staff on several ocassions attempted to have R1 sign documents that R1 didn't want to sign. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Executive Director will hav in-service training with staff pertaining to resident rights and including conservator and Power of Attorney for residents.

Allegation investigated: . Staff do not keep the facility free from odor 2. Staff did not ensure that resident was provided comfortable living accomodations

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit to investigate the allegations mentioned above. LPA met with Executive Director Evan Granucci and informed him the reason of the visit. The following was determined: Allegation #1: It was alleged that staff do not keep the facility free from odor. To investigate the allegation, during today’s visit and on 06/13/2025, between various times ranging from 8:30 a.m. to 1:00 p.m., (LPA) conducted interviews and a physical plant inspection. Resident #1 (R1) expressed concern about an odor coming from the bathroom sink. According to the Executive Director (ED), the chief engineer, and R1, several visits and inspections of R1’s bathroom had been conducted, and staff did not detect any odor. R1 reported being the only person able to smell the alleged odor. LPA inspected R1’s bathroom sink and noted a faint smell coming from the sink. However, LPA also observed various personal hygiene products on the bathroom counter, making it difficult to distinguish whether the odor was from the sink or the products. Additionally, LPA interviewed R1’s neighbor, who reported no odor coming from their own bathroom. Unsubstantiated To accommodate R1, the ED offered to relocate R1 to another apartment; however, R1 declined the offer. To address the concern, R1, the ED, and the chief engineer agreed to have the facility’s contracted plumber inspect R1’s bathroom. R1 accepted this plan and stated to LPA that after the plumber’s inspection, they will either adjust to the odor or allow the facility to resolve the issue based on the plumber’s findings. Although it was alleged that the facility is not free from odor, based on interviews and observations, there is insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation # 2: It was alleged that staff did not ensure the resident was provided comfortable living accommodations. To investigate the allegation, during today’s visit and on 06/13/2025, between 8:30 a.m. and 2:00 p.m., (LPA) conducted interviews and a physical plant inspection. Resident #1 (R1) expressed concern about an odor coming from the bathroom sink. Although it was alleged that staff were not attempting to resolve the issue, R1 reported to LPA that the facility has been overly accommodating and has offered to relocate R1 to a different apartment. R1 declined the offer and stated a willingness to work with facility staff to address the concern. The (ED), chief engineer, and other maintenance personnel have conducted several inspections of R1’s apartment to identify the alleged odor. Staff have consistently reported that they were unable to detect any odor; R1 is the only individual who reports noticing it. To further address the issue, the ED has arranged for the facility’s contracted plumber to inspect R1’s bathroom and apartment. R1 informed LPA that they will either adjust to the odor or allow the facility to resolve the matter based on the plumber’s findings. Based on the information obtained through interviews and inspections, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided to the Business Office Director Daniel Adams.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 31-AS-20250610131209

Allegation investigated: . Facility was not kept free from pests 2. Facility has expired food in the kitchen. 3. Staff do not follow proper food and general sanitation practices

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit, and met with Executive Director Evan Granucci to explain the reason of the visit. The following information was delivered and determined: Allegation #1: It was alleged facility not kept free from pests. To investigate this allegation, (LPA) conducted an unannounced visit to the facility from 10:00 AM to 4:30 PM. During the visit, LPA conducted interviews with staff and residents, reviewed facility documents, and performed a physical plant inspection. Based on the information obtained, the facility recently experienced a pest control issue in the kitchen area and received treatment to address the problem. While the facility contracts with a licensed pest control company for ongoing pest management and preventive measures, the issue had been present and required intervention. Documentation reviewed during the visit confirmed that the exterminator conducted a scheduled treatment on 02/11/2025. Therefore, based on interviews and documentation reviewed, the allegation is Substantiated. The Plan of Correction (POC) was cleared during the visit, as the facility received pest control services on 02/11/2025. Substantiated Allegation #2: It was alleged facility has expired food in the kitchen. To investigate this allegation, Licensing Program Analyst (LPA) conducted interviews and a physical plant inspection of the kitchen from 11:30 AM to 12:30 PM to assess the facility’s perishable and non-perishable food supply. During the inspection, LPA observed expired canned food items stored on the shelves, mixed with unexpired items. Additionally, LPA identified dented canned goods that should have been discarded. This is a health and safety risk to residents in care. Therefore, based on interviews and observations, the allegation is Substantiated. Allegation # 3: It was alleged staff do not follow proper food and general sanitation practices. To investigate this allegation, (LPA) conducted a physical plant inspection of the kitchen and observed staff handling food from 11:30 AM to 12:30 PM. During the inspection, LPA observed staff preparing desserts without wearing gloves. According to reports received, staff are required to wear gloves when handling food. Failure to follow proper food safety protocols presents a health and safety risk to residents in care. Therefore, based on interviews and observations, the allegation is Substantiated. Citations issued, appeal rights, exit interview, and copy of report provided to ED.the state’s words, verbatim · CDSS document, Feb 11, 2025 · control 31-AS-20250210113144

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(5) · Plan of correction due date: Feb 12, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (5) To be served food of the quality...necessary to meet their nutritional needs. This requirement was not met, evidenced by, during today's physical plant inspection, LPA LPA observed expired non-perishable canned goods stored on the shelves in the kitchen. LPA also observed several cans to be dented, which should have been discarded. This is health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: POC is cleared during visit, expired and dented cans were discarded. Per the ED, moving forward, items will be discarded prior to the expiration.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(15) · Plan of correction due date: Feb 26, 2025

87555 General Food Service Requirements: (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. This requirement was not met, evidenced by during today's observations, LPA observed staff preparing desserts without gloves. Interviews by staff reported, they are required to wear gloves. This is a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Bryan Gross, Director of Dining Services reported to ED, that he spoke to staff that gloves are to be worn during the preparation of all food. Training will be conducted with staff, and proof of training document to be submitted to LPA by POC date 02/26/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(27) · Plan of correction due date: Feb 18, 2025

87555 General Food Service Requirements: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met, evidenced by, during todays visit it was reported the facility recently experienced a pest control issue in the kitchen area and received treatment to to address the problem. Documentation reviewed during the visit confirmed that the exterminator conducted a scheduled treatment on 02/11/2025. This poses as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: POC cleared during the visit. Facility received treatment for pest control issues in the kitchen area today.

Allegation investigated: Staff do not ensure residents are spoken to in an appropriate manner

On 1/29/25 at approximately 10:00 AM, Licensing Program Analysts (LPAs) Angelica Segovia and Gary Tan conducted an unannounced subsequent complaint visit to this facility to investigate the above allegation(s). LPAs were greeted by Executive Director Evan Granucci. LPAs stated the reason for their visit. It was alleged that staff are being verbally abusive towards residents. To investigate the allegation LPAs asked for census, staff, and resident Rosters. LPAs requested pertinent documents at approximately 10:30 AM. LPAs conducted physical plant tour around 11:00 AM. LPAs conducted interviews between 11:30 AM to 12:30 PM. LPAs interviewed 5 (5) residents and nine (9) memory staff members. Interview with Executive Director (ED) on 12-9-24 revealed that they have not witnessed staff members being verbally abusive towards residents. ED revealed that they conduct their mandated annual training as well as staff member training for their on-boarding with topics on “respect, dignity, and resident’s rights”. LIC809C-continued Unsubstantiated Interview with Reporting Party (RP) revealed that they witnessed Staff #1, 2, and 3 (S1, S2, S3) call residents “fat” and they smell like “urine”. LPA Segovia’s interview on 12-9-24 revealed that staff #4 (S4) was made aware of allegations from other staff regarding staff members treating residents without dignity and respect. S4 stated that they were made aware of a few incidents where staff #3 (S3) allegedly called residents “fat” and that they “smelled like urine”. S4 then revealed after conducting their own separate investigation, S3 was called “fat” by a resident 1 (R1) and not the other way around. LPA Segovia interviews with nine (9) residents revealed that nine (9) out of nine (9) staff members stated they have not witnessed any staff members being verbally abusive towards residents and they have not treated residents disrespectfully. Interviews with three (3) aware memory care residents out of five (5) memory care residents interviewed revealed that they are happy with how the staff members treat them and have not witnessed any staff members being disrespectful and/or spoke inappropriately to any resident. Two (2) out of five (5) residents interviewed were not able to respond to LPA’s interview. Based on observation and interviews there is not enough evidence to state that staff members have been disrespectful to residents. This allegation is deemed UNSUBSTANTIATED at this time. No other immediate Health and Safety issues observed. Exist interview conducted. A copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 31-AS-20241205091235

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness and Licensing Program Manager Troy Agard conducted an unannounced annual inspection. LPA and LPM met with Administrator Evan Granucci and informed him the reason of the visit. The facility consists of one (1) main building which houses independent and assisted living residents, with (80) private villas also housed independent residents. The Memory Care has thirty (30) apartments, and the current was (25). The common areas such the front lobby, dining room lounge and dining room are on the first floor. The gym, salon, and game room are on the ground floor. Medication rooms on the first floor, as well administrative offices. The are laundry rooms on 2nd, 4th and 6th floors for residents use. At 10:00 AM, the LPA began the physical plant tour, and LPM started resident and staff record review. A random selection of resident rooms were inspected in the Assisted Living Tower and resident rooms from the Garden Apartments. Resident rooms were observed to be furnished appropriately and restrooms had grab bars and non-skid mats as well as emergency alarms. Hot water temperature was measured in all rooms that were inspected; which temperatures ranged from 114.8 to 120.0 degree F. The physical plant tour in the memory care was also conducted, and the census at the time of the visit, was (25). The area is secured with a delayed egress system. The common areas of the memory care unit were observed and clean. The LPA observed residents preparing to eat for lunch. Food is cooked in the main kitchen and transported to the memory care unit in hot boxes. Medications are centrally stored in the medication room. Personal accommodation in residents bedrooms and bathrooms were observed for safety, privacy, and comfort. The facility maintains a comfortable temperature at 75°F. The facility's smoke alarms are hard wired and interconnected and back up and tests are done in house on a quarterly basis. The facility is equipped with sprinkler system. Fire Drill was last conducted on September 2024. The LPA met with the Food Service Director Bryan Gross, at 10:55 AM and toured the food service area. A sufficient supply of perishable and non-perishable food was observed and food was stored at the appropriate temperature. LPM Troy Agard conducted record review with (10) residents and (10) staff files; all were inspected and reviewed to be complete. No deficiencies were observed during today's inspection. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 29, 2024

Allegation investigated: Staff do not ensure resident is allowed to visit with other residents

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an intial complaint visit, and met with Executive Director Evan Granucci, who was explained the reason of the visit. The following was determined: It was alleged that staff do not ensure resident is allowed to visit with other residents. During today's visit, from 10am to 145pm, LPA conducted a physical plant inspection, reviewed facility documents, and conducted interviews. It was reported to LPA, that facility was not allowing resident # 1 (R1) to visit resident # 2 (R2). From the information obtained, (R2) is under a conservatorship, and at this time, the family is not allowing visitors due to (R2s) medical condition. The facility is following the direction of the family member who is the conservator, therefore, based on interviews and documents reviewed, the allegation is Unsubstaniated. Exit interview and copy of report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 27, 2024 · control 31-AS-20240822153539

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a (24) hour case management, due to a death of a resident. LPA received an email on 08/19/2024 from the Administrator, that resident # 1 (R1) had committed suicide at the facility. LPA reviewed the email on 08/20/204, and conducted the visit. LPA obtained resident records, interviewed staff and the Administrator. LPA also received the death report pertaining to( R1). According to the report that was received and reviewed by LPA, here is a summary: "On 08/17/2024 at approximate 945pm, the concierge notified the medication room that (R1) had called 911. The med-tech went to the villa while the paramedics was assessing the (R1). (R1) expressed feeling unwell and took Tylenol PM. After evaluation, the paramedics did not transport (R1) to the hospital and (R1) returned to sleep. On 08/18/2024 at approximate 1040pm, (R1) went to the med-room to report not feeling well. Med-tech took (R1's) blood pressure, which was high, and 911 was called to transport (R1) to the hospital. 911 diagnosed (R1) with high blood pressure and during assessment, resident stated that if they did not transport (R1) to the hospital '(R1) would commit suicide'. Resident was sent to CMH (Community Memorial Hospital) for evaluation. On 08/19/2024 at approximate 4am, resident was discharged back to the community. On 08/19/2024, resident had breakfast at 715am, and lunch at 12pm in the main dining room with staff served resident. Resident also attended the 1030am music event in the front lobby. Med tech went to resident’s villa at 130pm to check on resident and obtain hospital discharge paperwork, Staff found resident hanging by a rope around the neck which was tied to (R1's) kitchen divider shelving. 911 was immediately called and upon arrival CPR was performed and resident was pronounced deceased". According to the Administrator, the police interviewed staff; there was no police report number provided or identification of names by the officers who came to the facility. From all the information obtained during the visit, at this time, there is no further action to be done; unless LPA receives more information from the facility or the police department. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Aug 20, 2024

Allegation investigated: Facility staff did not provide 60 days written notice for rate increase Facility staff are charging for services not identified in the admission agreement

Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director Evan Granucci and informed him the reason of the visit, which is to discuss the allegation above. The following information was provided during the investigation: Allegation # 1: It was alleged facility staff did not provide (60) days written notice for rate increase. During today's visit, from 10am to 4pm, LPA conducted interviews with staff, and residents. LPA also interviewed the complainant. It was reported to LPA, that the facility installed an in-house high speed internet service for all residents at the facility. According to the interviews, the residents and some of the family representatives received notification of the new service and the rate increase. Documenatation received and reviewed, the facility did not provide proper notification, which according to regulations, is a (60) day written notice. Therefore, based on interviews and documentation, the allegation is Substantiated. Substantiated Allegation # 2: It was alleged facility staff are charging for services not identified in the admission agreement. During today's visit, from 10am to 4pm, LPA conducted interviews with staff, and residents. LPA also interviewed the complainant. It was reported to LPA, that the facility installed an in-house high speed internet for residents, with an additional $55.00 a month fee for the service. According to interviews, and documentation reviewed, the internet service and rate increase was not included in the admission agreement as a basic service. According to regulations, the facility cannot create expenses from residents' personal cash resources for any basic services identified in the admission agreement. Therefore, based on interviews and documentation, the allegation is Substantiated at this time. Both allegations are a poses a potential health and safety risk to residents in care. Exit interview, citations issued, appeal documents, and copy of report provided.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 31-AS-20240708161314

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.655(a) · Plan of correction due date: Jul 26, 2024

Health and Safety Code section 1569.655:(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than (60) days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase...This requirement was not met, evidenced by, based on interviews and documentation, the facility did not provide proper notice for the new installation of the internet service. This poses as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: The Executive Director (ED) has AGREED to submit to a LPA a formal written letter, that regulations have been read, and any admission agreement changes must have proper approval from Licensing before issued to residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(f) · Plan of correction due date: Jul 26, 2024

Safeguards for Resident Cash, Personal Property, and Valuables: (f)No licensee or employee of a facility shall make expenditures from residents' cash resources for any basic service specified in this Chapter. or any basic services...This requirement was not met, evidenced by; based on documentation and interviews, the facility are charging residents an additional $55.00 a month for internet service, that was not previously identified in the admission agreement. This poses as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: The ED will issue a credit for the additional internet service fee to all residents. ED submitted to LPA the new admission agreement with the additional internet fee. Licensing will review the document to verify if the new agreement with the fee is granted based on Licensing regulations. Once it's been reviewed, if the facility cannot bill residents for the additional fee, the ED has AGREED to cease billing and credit residents.

Allegation investigated: Staff did not follow residents care plan Facility did not seek medical treatment for resident after fall Staff are not ensuring residents receive three meals a day Staff are not managing residents' incontinence needs Residents rooms are not being cleaned as needed Staff did not receive adequate training

On 05/21/24, at 8:03am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Deserae Navarro, Front Desk Staff. Deserae Navarro called Executive Director, Evan Granucci via telephone and arrived about an hour later. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather additional information, gather documentation, conduct additional interviews and deliver findings for this complaint. On 07/28/2021, LPA JoAnn Rosales initiated the complaint investigation. On 07/28/2021, LPA JoAnn Rosales interviewed staff and residents and obtained documents. On 05/21/24, LPA Saucedo conducted a subsequent visit that consisted of obtaining the census, resident, and staff roster. LPA Saucedo conducted the physical tour at 8:25am. During this tour, LPA Saucedo conducted additional staff and resident interviews and obtained additional documentation. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not follow residents care plan. It is being alleged that some residents need a higher level of care and/or need assistance from caregiving staff that are not getting help. It was confirmed that four (4) out of four (4) caregivers help residents with any type of assistance that they can provide to the resident. In addition, the Resident Care Director and Housekeeping Director confirmed that there are different care plans for different residents. There is Assisted Living Care and Memory Care at the above facility. There is Home Health and Hospice also being provided to different residents. Twenty (20) out of twenty-four (24) residents confirmed that their needs are being met. Twenty (20) out of twenty-four (24) residents also confirmed that staff treat them well. Therefore, based on the LPA's record reviews, staff and resident’s interviews the above allegation(s) above is unsubstantiated at this time. Regarding the allegation: Facility did not seek medical treatment for resident after fall. It is being alleged that the facility did not seek medical treatment for residents after falling. There is documentation that shows residents are taken to the hospital when an incident happens. LPA Rosales obtained Unusual Incident/Injury Reports from residents that were sent to the hospital after incidents occurred. LPA Rosales also obtained information on the medical treatment that some residents received after being sent to the doctor. It is confirmed that twenty (20) out of twenty-four (24) residents get medical treatment if something does happen to them or/and if they feel sick. It was confirmed that ten (10) out ten (10) staff know the process of seeking medical treatment for residents if they need help. Therefore, based on the LPA's record reviews, staff and resident’s interviews the above allegation(s) above is unsubstantiated at this time. Regarding the allegation: Staff are not ensuring residents receive three (3) meals a day. It is being alleged that some residents do not receive breakfast because they move to slow and then must wait for lunch time. Twenty (20) out of twenty-four (24) residents confirmed that they receive all three (3) meals. Some residents can order their food over the phone, and it is delivered to their room if they wish not to come to the dining area. It was confirmed that ten (10) out of ten (10) staff ensure that residents do receive their three (3) meals area. Therefore, based on the LPA's staff and resident interviews the above allegation(s) above is unsubstantiated at this time. LIC 9099C-continued Regarding the allegation: Staff are not managing resident’s incontinence needs. It is being alleged that there are not enough caregivers to provide help with incontinence needs. It was confirmed that four (4) out of four (4) caregivers do provide incontinence needs to the residents. It was confirmed that there is a list of residents that need incontinence needs. LPA obtained the list of the residents that need incontinence care. Twenty (20) out of twenty-four (24) residents confirmed that their incontinence needs are being met. Therefore, based LPA’s record reviews, staff, and resident’s interviews the above allegation(s) above is unsubstantiated at this time. Regarding the allegation: Residents rooms are not being cleaned as needed. It is being alleged that the housekeepers and caregivers only clean once a week. It was confirmed that twenty (20) out of twenty-four (24) residents understand that housekeeping is only done once a week which was included and signed in their Residence and Care agreement. The residents also have an understanding that if they want additional cleaning services it will be provided based on the additional housekeeping services that charges a fee under Appendix A of the Residence and Care agreement. It is also confirmed that ten (10) out of ten (10) staff understand the different housekeeping services. LPA obtained the Residence and Care agreement and Appendix A from the Executive Director. Therefore, based on the LPA's record reviews, staff and resident’s interviews the above allegation(s) above is unsubstantiated at this time. Regarding the allegation: Staff did not receive adequate training. It is being alleged that the housekeeping staff do not get an orientation, do not know how to mix chemicals properly and do not know how to care for memory care residents. Ten (10) out of ten (10) staff confirmed that they do get adequate training in different areas depending on their job title. It was confirmed that they get different types of training annually such as online/video training, Accident Prevention, Infection Control and Hand Washing. The Housekeeping Director did confirm that there is no mixture of chemicals at the above facility. There is a chemical machine that dispenses the different types of chemicals, and the bottles of chemicals have their individual labels according to their chemical type. LPA was able to observe the training records of the staff which is provided by a company named, Assisted Living Education. Therefore, based on the LPA's record reviews and staff interviews the above allegation(s) above is unsubstantiated at this time. An exit interview was conducted, no citations were issued for above allegation(s), and a copy of this report was given to the executive director.the state’s words, verbatim · CDSS document, May 21, 2024 · control 31-AS-20210721160917

Allegation investigated: Insufficient staffing during meal time Facility is in disrepair

On 05/07/24, at 9:50am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administrator Evan Granucci. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather additional information, conduct additional interviews and deliver findings for this complaint. On 11/17/2021, LPA JoAnn Rosales initiated the complaint investigation. On 11/17/2021, during LPA JoAnn Rosales' visit, eleven (11) staff were interviewed. On 03/27/23 there was a subsequent visit by LPA Tuesday Cabiness. On 05/07/24, LPA Saucedo conducted a subsequent visit that consisted of obtaining the census, resident, and staff roster. The Administrator Evan Granucci met with LPA Saucedo to conduct the physical tour at 10:20am. During this tour, LPA Saucedo conducted additional interviews, obtained documentation and delivered findings. LIC9099C-continued Substantiated Regarding the allegation: Insufficient staffing during mealtime. It is being alleged that there is understaffing during mealtimes; thus, creating unreasonable delays for residents during mealtimes. On 11/17/21, LPA Rosales interviewed eleven (11) out of eleven (11) staff whom confirmed that there were understaffed and sometimes the wait time for residents to receive their food ranged from twenty (20) to forty (40) minutes. During LPA Saucedo's interview with the administrator, they did state that this was during COVID-19. On 05/07/24, LPA Saucedo interviewed 22 (twenty-two) out of 25 (twenty-five) residents that confirmed there is currently no issue with the staffing during mealtimes and the mealtime wait is reasonable depending on what they are ordering at the time. Based on LPA’s observations, staff, and resident interviews the above allegation(s) is found to be SUBSTANTIATED. Regarding the allegation: Facility is in disrepair. It is being alleged that the roof was leaking. On 11/17/21, LPA Rosales interviewed seven (7) out of eleven (11) staff whom confirmed that the roof was leaking. On 05/07/24, LPA Saucedo obtained documentation that there were repairs being conducted prior to the time of the allegation and the repairs started July of 2021. On 05/07/24, LPA Saucedo interviewed 22 (twenty-two) out of 25 (twenty-five) residents that confirmed there was no roof leakage to any of their rooms and the common areas of the facility. On 05/07/24, LPA Saucedo, also obtained a picture of the dining hall ceiling area that has now been repaired. Based on LPA’s observations, staff, and resident interviews the above allegation(s) is found to be SUBSTANTIATED. This is an amended copy of the report previously issued on 05/07/2024. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same. Regarding the allegation: Facility menu is not meeting food service requirements. It is being alleged that the food quality is poor not providing soup, salad or any type of desert. On, 11/17/21, LPA Rosales interviewed eleven (11) out of eleven (11) staff confirmed that the menu does show all the different foods that will be provided at breakfast, lunch, and dinner. On 11/17/21, LPA Rosales was able to observe and obtain different menus which list the type of soup, salad and desert that will be provided. On 05/07/24, LPA Saucedo interviewed 22 (twenty-two) out of 25 (twenty-five) residents that confirmed there is no issue with the facility menu. Based on LPA’s observations, record reviews, staff, and resident interviews the above allegation(s) is found to be UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, May 7, 2024 · control 31-AS-20211109121157

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 7, 2024

87411(a)Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment, and grounds.This requirement is not met as Based on the LPAs interviews the staff did not ensure proper staffing inregards to the meeting the needs of the residents in a tinely manner which poses an immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, May 7, 2024

Plan of correction: The administrator/Licensee shall ensure there is enough staffing at all times to reduce wait times for mealtimes. On 05/07/24, LPA Saucedo did make lunch observations which showed there was no wait time for the residents and resident interviews confimred there is now no wait times for mealtimes. POC 05/07/24 and Cleared 05/07/24

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: May 7, 2024

87303 (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 the LPA observation and interviews the licensee/administrator did not ensure the roof area/ceiling of the dining room area of the facility to be in repair at all times which poses an Immeidate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, May 7, 2024

Plan of correction: The licensee/admnistrator shall ensure that the roof area/ceiling of the dining hall is repaired at all times. POC 05/07/24 Cleared POC 05/07/24,The licensee/administrator provided documentation of roof repair and LPA took a picture of the roof repair.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a (24) hour case management visit, pertaining to a Special Incident Report (SIR) notification of a resident's death. On 11/20/2023, Administrator Evan Granucci contacted Licensing and spoke to LPA Angela P. who reported: "At 3:26pm, LPA (OD) received a phone call from the Administrator, Evan Granucci, and was informed that on 11/20/23 around 11:30am, resident # 1 (R1) went up to the 7th floor, which is a common area with an outdoor veranda, moved a chair close to the fence, R1 got over the fence and jumped. The body was discovered by another resident, who later reported to the concierge. LPA was informed that the resident was receiving Hospice Services and lived in an Assisted Living (independent) area. Due to the nature of the death 911 was called and police report filed. LPA was informed that the Death and Police report will be submitted promptly". During today's visit, LPA interviewed the Administrator and obtained R1's facility records. According to the Administrator, a hour prior to the incident, R1 was seen by staff, and there were no signs of distress. R1 does not have a history of depression, or suicidal ideation; but was recently admitted to hospice 10/11/2023, for coronary artery disease . Staff found R1 outside on the ground unresponsive with no pulse. 911 was called and R1 was pronounced deceased. The Ventura County police department were contacted; who visited the facility, the same day of the incident and reviewed facility surveillance. It was observed R1 used a facility chair and climbed over the railing from the 7th floor. The police deemed the incident as a suicide and no foul play. It was also reported that there were no witnesses by staff or residents of R1 falling from the 7th floor. Based on today's interview and documentation received, LPA has determined, no further action is needed at this time, and due to the police deeming no foul play. Police report # 23-75173 Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Nov 21, 2023