Fillmore Country Club

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management – Incident visit for the purpose of investigating self-reported incident report. Upon arrival LPA and met with Administrator Connie Smiley and explained the reason for the visit. On 05/18/2026, the Regional Office reviewed the following Self-reported incident reports: On 05/12/2026, at approx 5:00 a.m., caregiver conducted routine round checks and found Resident #1 (R1) on the floor in front of their closet. R1 was assessed, 911 was called, then Paramedics arrived and R1 was admitted into a local hospital. Paramedics tested blood sugar and it was observed to be at 375. On 05/15/2026, the family / responsible party notified Administrator that R1 passed away while in the hospital. Hospital doctors informed the family / responsible party R1 had several brain bleeds. Administrator has not received the death certificate at this time. At approx 09:30 a.m. LPA conducted physical plant, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation. Based on interviews and records review no immediate or potential health and safety concerns were observed during the visit and no deficiencies cited at this time. LPA has determined should further investigation be warranted, LPA will return at a later date. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 22, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at approx 9:00 a.m. Upon arrival, LPAs were greeted by the front desk receptionist and explained the reason for the visit. LPA's met with Executive Director Connie Smiley shortly after. At approx 09:40 a.m. LPAs along with Executive Director Connie Smiley, 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. The following was observed: LPAs inspected the kitchen/food service area. Knives are stored and inaccessible to residents. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. A sufficient amount of emergency food was observed properly stored. The furniture in the common areas were observed to be clean and in good condition. The facility maintained a comfortable temperature. LPAs observed required postings throughout the common space. At approx 10:06 a.m LPA's observed that One (1) out of (3) Stairwells did not have an emergency evacuation chair. LPA's did not observe any obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. LPAs observed multiple randomly selected resident bedrooms on the first and second floor. All resident bedrooms were furnished appropriately and had sufficient lighting. All resident restrooms appeared to be clean, sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 109– 117 degrees Fahrenheit. Continued from 809 The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use. The facility maintained a comfortable temperature of 73 degrees. LPAs observed cameras throughout the common areas. LPA's requested to review live and recorded footage and observed that the audio components were disabled on each video. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA’s reviewed five (5) 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. All records were in order at this time. LPA's reviewed Personnel records, five (5) personnel files. File's were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. Medications review . All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medication appeared to be given as prescribed at the time of the visit. At approx 12:37 p.m. LPA's observed four (4) residents that had their medications stored in pre-poured cassettes stored for at least (2) weeks. Three (3) out of (4) of these residents did not have prescription orders on file for review. Infection Control Plan / Emergency Disaster Planning: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced 01/21/2025. Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on 12/06/2025. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. During today’s visit LPA obtained a copy of the facility’s LIC 500 and resident roster. Exit interview conducted, appeal rights discussed and copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 12, 2025

Allegation investigated: Due to neglect and/or abuse, resident sustained fractures in care

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Rose Gonzalez and explained the reason for the visit. On 11/20/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding injuries sustained by a resident at the Fillmore Country Club facility. It was reported that Resident #1 (R1) sustained multiple unexplained injuries while at the facility, including a fracture to the wrist. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Douglas. On 11/21/2024, from 1:25pm to 3:30pm, Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA Balisi met with assistant administrator Rose Gonzalez and explained the reason for the visit. At approximately 1:30pm, the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation. Unsubstantiated No immediate health and safety concerns were observed during the visit. The LPA determined further investigation was needed prior to issuing findings.On 12/04/2024, at approximately 4:40pm, Investigator Douglas conducted an interview with Kaiser Permanente Woodland Hills hospital staff; on 01/14/2025, at approximately 3:25pm, with R1’s resident representative; and on 02/27/2025, from approximately 12:45pm to 2:00pm, with assistant administrator, staff, and attempted to interview R1 (who was unable to articulate a statement or be interviewed). In addition, the investigator reviewed Kaiser Permanente Woodland Hills medical reports, and facility documents related to the investigation including incident reports, progress notes, and needs and services plan. Facility file documents reviewed revealed R1 was admitted to the facility on 06/25/2022. R1’s diagnosis included dementia, hypertension, hyperlipidemia and atherosclerosis of aorta. The facility progress notes reviewed did not indicate R1 sustained any falls. The progress notes indicated on 11/08/2024, staff found R1 pulling self near the bars (bed rail); on 11/13/2024, R1 was found two times pulling self in between bars; on 11/16/2024, staff noticed R1’s wrist a little swollen, R1 said it did not hurt, R1’s resident representative said they noticed it last night and R1 crying in pain. On 11/17/2024, staff moved R1 over in bed, R1 was “super close” to the bar; on 11/21/2024, staff put pillow in between bar and R1’s arm, R1 was grabbing on bar and pulling self to side. R1’s Needs and Services Plan, updated 06/10/2024, noted R1 had dementia, wheelchair bound, can self-propel in wheelchair, verbally communicates needs, max care, needs assistance with all activities of daily living, shower schedule twice per week, R1’s resident representative manages R1’s medications, laundry and housekeeping, caregivers will notify R1’s resident representative of any pain or symptoms R1 may be having and notify of any changes and MD if needed. The Department’s investigation revealed R1 sustained several significant injuries at the facility over the period of 11/07/2023 – 11/20/2024, which included a bruised clavicle, fractured shoulder, and fractured wrist. Copies of medical reports documented the injuries R1 sustained during this period. A review of the unusual incident reports for R1 revealed that the facility submitted reports on 11/08/2023, 01/03/2024, and 11/21/2024 for R1’s unexplained injuries. Per the Kaiser Permanente Woodland Hills medical reports reviewed, the following was revealed related to the incident reports. On 11/07/2023, it was noted that R1 was presented to urgent care by R1’s resident representative with neck pain they had been experiencing for the last six days. Bruising was observed on R1’s left clavicle area. It was determined R1 sustained a “bruised clavicle.” R1 disclosed that R1 experienced an unwitnessed fall at the facility resulting in the injury. However, staff members were unaware of any fall and stated they never discovered R1 on the floor prior to the discovery of R1’s injury. R1 also did not complain of pain. Staff interviewed noted R1 sometimes said they “fell” just prior to their family member visiting, but it was not true and R1 had not fallen. On 12/29/2023, it was then reported that R1 was again presented to the urgent care with left shoulder pain R1 claimed had been experiencing the last three days. It was discovered R1 had sustained a fracture to the right humeral head articular (shoulder). It was noted as a “probable fall.” However, staff members again disclosed they never observed R1 on the floor prior to that injury. R1 also did not complain of any pain. Staff members explained R1 is not mobile and would not be able to lift themselves up off the floor on their own. On 11/20/2024, R1 was again presented to urgent care (by R1’s resident representative), complaining of left wrist pain R1 estimated had been bothering R1 the last five days. Following X- rays, it was discovered R1 sustained a left wrist fracture. However, R1 did not disclose any recent falls. Staff members also claimed those five days prior, there was no report that R1 had experienced a fall at the facility. R1 also had not complained of any pain. It was noted by staff that, on 11/16/2024 (four days prior to R1’s injury), staff observed R1’s wrist was “a little swollen.” However, R1 did not complain of pain. When R1 was asked by staff what happened, R1 indicated it happened the previous night when R1 was dressing self. The Department’s interviews conducted revealed that R1’s resident representative did not believe Fillmore Country Club staff members were physically abusing R1. However, they believed the staff were aware of R1’s injuries and were simply not reporting them. Facility staff were interviewed and denied physically abusing R1 or witnessing any abuse. Staff explained they believed R1 may have sustained injuries as a result of consistently wedging themself between the bed and a bed rail attached to the mattress. Staff also explained R1 would bang on the wall next to their bed instead of using their pendant when they needed assistance. During the investigation, Investigator Douglas attempted to conduct an interview with R1, however, R1 was unable to articulate a statement. Based on all the information obtained during the course of the investigation, R1 sustained several significant unexplained injuries (bruised clavicle, fractured shoulder, and fractured wrist) at the facility, however the Department’s investigation did not provide sufficient evidence to determine neglect/lack of care and supervision or physical abuse. Therefore, the allegation of “Neglect/Lack of Care and Supervision Facility resident sustained significant unexplained injuries” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, May 29, 2025 · control 29-AS-20241120161811

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 10:10 a.m. Upon arrival LPA met with Administrator Connie Smiley and Assistant Administrator Rose Gonzalez and explained the reason for the visit. At approx 10:20am LPA along with Administrators , 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. The following was observed: At approx 10:22am The LPA inspected the kitchen/food service area. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. Between 10:22 a.m. - 11:30 a.m. the furniture in the common areas were observed to be clean and in good condition. The facility maintained a comfortable temperature. LPA observed required postings throughout the common areas. Each stairwell was observed to have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. LPA observed eight (8) randomly selected resident bedrooms. All resident bedrooms were furnished appropriately and had sufficient lighting. All resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 106.7 – 118 degrees Fahrenheit. LPA observed appropriate outdoor furniture, with a covered shaded area for resident use. Continued from 809 The facility maintained a comfortable temperature of 73 degrees. LPA observed five (5) cameras throughout the common areas and was observed to only record video footage at this time. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA reviewed Resident Records at 11:30 a.m. six (6) 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. All records were in order at this time. LPA reviewed Personnel records at approx. 12:00 p.m. Five (05) personnel files and the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order at this time Medications review began at approximately 01:30 p.m. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medication appeared to be given as prescribed at the time of the visit. Interviews conducted at approx. 02:00 p.m. Infection Control Plan / Emergency Disaster Planning: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced 10/07/2024. Emergency disaster drills conducted quarterly as per regulation; the last emergency drill was conducted on 10/25/2024. Carbon Monoxide / Smoke Alarms tested on 04/04/2024 and functioned properly. LPA obtained the following during inspection: Census, LIC 500, and copy of latest Limited Liability Insurance. Exit interview conducted and a copy of report issuedthe state’s words, verbatim · CDSS document, Dec 16, 2024

Allegation investigated: Staff is refusing to repair facility walls. Staff did not ensure facility A/C unit was properly installed. Staff did not replace bathroom filters. Staff did not keep facility free of vermin. Staff are not properly caring for residents in care.

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegations liste above. Upon arrival LPA met with Assistant Administrator Rose Gonzalez and explained the reason for the visit. On 11/01/2024 between 10:15 a.m. - 03:00 p.m. LPA conducted the initial complaint investigation. LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of pertinent documentation relevant to the investigation. Today LPA conducted physical plant and interviewed staff. It was reported that "Staff is refusing to repair facility wall" as it was alleged that there are cracks in the walls between rooms 14 and 13 as well as between rooms 18 and 19. Interviews with seven (7) staff members and six (6) residents revealed that none of the (13) people interviewed reported seeing any cracks in the walls. During the physical plant, LPA also did not find any cracks in the interior or exterior walls of the building. Unsubstantiated Continued from 9099 Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff is refusing to repair facility wall” is deemed Unsubstantiated at this time. It was reported that "Staff did not ensure facility A/C unit was properly installed" as it was alleged that the facility air conditioner unit is not working properly in the hallway between 204 and 206. Interviews and records revealed that the air conditioning units in the main lobby and kitchen were replaced within the last three months, however there were no air conditioner units replaced on the 2nd floor in the past three months. Interviews with seven (7) staff members and six (6) residents revealed that all (13) people interviewed have observed the A/C to function properly at this time. During the inspection, the Licensing Program Analyst (LPA) noted that the indoor temperature was set at 74 degrees Fahrenheit, while the outdoor temperature was 69 degrees Fahrenheit. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not ensure facility A/C unit was properly installed” is deemed Unsubstantiated at this time. It was reported that "Staff did not replace bathroom filters" as it was alleged that filters in the two (2) public restrooms in the lobby are not functioning properly. During the inspection, the LPA did not find any filters in the bathrooms; however, there were exhaust fans present in each bathroom. The LPA inspected four (4) common area bathrooms and six (6) private bathrooms in randomly selected units and found that the exhaust fans were functioning properly at the time of the inspection Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not replace bathroom filter” is deemed Unsubstantiated at this time. Continued from 9099-C It was reported that "Staff did not keep facility free of vermin" as it was alleged that mice and termites were observed in the facility. Interviews with seven (7) staff members and six (6) residents indicated that none of the 13 people interviewed have seen any mice or termites in the facility. A review of pest control invoices from the past three months showed that the pest control company visits the facility once a month to treat common areas. Additionally, there were no notes regarding the presence of mice or termites during these inspections. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not keep facility free of vermin” is deemed Unsubstantiated at this time. It was reported that "Staff are not properly caring for residents in care," as it was alleged that residents are always complaining about staff. Interviews with six (6) residents in care indicated that none of them expressed any concerns about the level of care provided by the staff. Additionally, interviews with seven (7) staff showed that they were knowledgeable about residents' care needs, facility operations, and emergency procedures. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff are not properly caring for residents in care” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 29-AS-20241030125452

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 10:08 a.m. The LPA met with Administrator Luis Gonzalez and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The fire extinguishers were last inspected on 1/06/2023. The carbon monoxide detectors were tested and functioned properly. The smoke alarms and fire suppression system were last tested 9/21/2023 by AA Technology & Electric; all functioned properly. There are three (3) stairwells and all of them lacked evacuation chairs. KITCHEN: The commercial kitchen was clean and appliances all appeared operable. The facility has a sufficient supply of perishable and non-perishable food as well as an emergency supply of food and water. BEDROOMS: The LPA observed ten randomly chosen rooms. Rooms were appropriately furnished, clean and had sufficient lighting. The hot water temperature was tested in three residents' rooms and was over the regulatory limit of 120*F. The temperatures were measured as follows: room 108 was 121.8*F, room 121 was 128.5*F, and room 204 was 127.4*F. RESTROOMS: Restrooms inside the randomly chosen rooms were clean and sanitary and in operating condition. COMMON SPACES: The lobby, activity rooms, dining room, lounge areas, theater, gym, and hair salon were all appropriately furnished and in good condition. The LPA observed the required postings throughout the facility. The patio area was equipped with furniture for residents' use. (continued on 809-C) (continued from 809) INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID. RESIDENTS AND STAFF: LPA reviewed five residents' files and five staff files; all were complete. Medications were reviewed and appear to be given as prescribed. LPA interviewed three residents and three staff; no concerns were noted. 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. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted with Administrator Luis Gonzalez. Report was provided.the state’s words, verbatim · CDSS document, Dec 6, 2023