Vista at Simi Valley

Allegation investigated: Staff are not providing adequate care and supervision to residents in care. Licensee does not ensure that staff are adequately trained. Staff speak inappropriately in the presence of residents in care. Staff do not seek medical attention for resident(s) in a timely manner. Licensee does not ensure that residents are adequately assessed. Staff do not accord privacy to resident(s) in care. Licensee is accepting residents with higher level of care needs. Licensee is not adequately addressing bed bug infestation at the facility Staff are not following infection control protocols as needed.

Amended report. This report supersedes report issued on 08/13/2026. Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 02/24/2026 by LPAs M. Arroyo and B. Balisi. On today's visit, LPA Balisi met with Executive Director (ED), Brimen Vivar. Entrance interview conducted. During the initial visit on 02/24/2026, starting at approximately 09:45 a.m., the LPAs conducted a physical plant tour, interviewed nine (9) staff members and five (5) residents, conducted a resident file review, and obtained copies of pertinent documents. On 08/07/2026, LPA Balisi reviewed five (5) resident records. It was reported that "Staff are not providing adequate care and supervision to residents in care" as It was alleged that staff provided wound care to residents with pressure injuries, including cleaning, treating, and changing dressings. Interviews with nine (9) staff members revealed that no staff reported observing staff perform wound care for residents with pressure injuries. Unsubstantiated Continued from 9099 Staff stated that residents with wounds or pressure injuries are typically receiving hospice or home health services. According to staff, they provide personal care, monitor residents, and follow the hospice or home health care plan. If staff observe any concerns related to a wound, they report them to the med tech or Resident Care Coordinator, who then notifies the resident's hospice or home health provider. LPA interviewed the reporting party, who was unable to provide specific dates or times for the reported incidents. 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 providing adequate care and supervision to residents in care” is deemed Unsubstantiated at this time. It was also alleged that licensee does not ensure that staff are adequately trained. It was reported that staff assisting residents are inexperienced and inadequately trained. Record review of staff training records revealed that each staff member receives 40 hours of training during their initial year of employment. After completing their first year, each staff member completes at least 20 hours of continuing education annually. This training includes medication management, wound care, dementia care, activities of daily living (ADLs), fall prevention, and infection control. Interviews conducted with staff revealed that both caregivers and medication technicians (med techs) are provided wound care training yearly. However, the resident’s physician is responsible for diagnosing the condition and providing treatment recommendations, after which a licensed professional under home health or hospice provide wound care in accordance with the physician's care plan and instructions. Staff further stated that if they are ever uncomfortable managing blood exposure or treating a skin tear, they may request assistance from another trained staff member. Additionally, individualized one-on-one training is provided as needed, and staff are encouraged to seek guidance at any time. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “licensee does not ensure that staff are adequately trained”. Therefore, this allegation is deemed Unsubstantiated at this time. It was reported that "Staff speak inappropriately in the presence of residents in care" as it was alleged that staff make inappropriate comments around residents. Interviews conducted with nine (9) staff and (5) five residents reflected that all individuals interviewed have never observed any staff speak inappropriately or make inappropriate comments in the presence of residents. Continued from 9099-C LPA interviewed the reporting party, who was unable to provide specific dates or times for the reported incidents. 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 speak inappropriately in the presence of residents in care” is deemed Unsubstantiated at this time. It was reported that that "Staff do not seek medical attention for resident(s) in a timely manner" and “licensee does not ensure that residents are adequately assessed” as It was alleged that Resident #1 (R1) and Resident #2 (R2) sustained falls between 02/16 and 02/20 and did staff did not conduct assessments, instead they assisted residents off the floor. It was further alleged that staff were not properly assessing residents prior to admission. Interviews conducted and records reviewed reflected that R2 was admitted to the facility on 02/23/2026 after sustaining a fall at home. LPA found no documentation indicating that R1 sustained a fall during the alleged timeframe. LPA also reviewed incident reports submitted to the Regional Office (RO) and found no reports involving falls for either resident or other residents in care. LPA's interview with nine (9) staff members regarding the facility's protocol after a resident sustains a fall revealed that when a resident is found on the floor, staff do not move the resident immediately. Instead, they notify the med tech, who promptly conducts an assessment. The resident is evaluated for any visible injuries or bleeding, their ability to move is assessed, and staff determine whether the resident hit their head during the fall. If there is a head injury, 911 is contacted immediately. If the resident denies pain and there are no apparent injuries, the resident's family is notified to determine whether they would like the resident to receive further medical treatment. Additionally, residents are monitored for 72 hours following a fall to observe for pain or any changes in condition. Staff also stated that both the resident's family and primary care provider (PCP) are notified of the fall. Staff reported that they have not received any concerns or complaints regarding the facility's response to resident falls. Further interviews revealed that the Resident Care Director (RCD) completes a comprehensive assessment before accepting or admitting any resident into the facility. If a resident's condition changes after admission, staff report their concerns to the RCD, who reassesses the resident and discusses any necessary revisions to the care plan with the resident's family. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Continued from 9099-C2 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 do not seek medical attention for resident(s) in a timely manner” and “Licensee does not ensure that residents are adequately assessed” are deemed Unsubstantiated at this time. It was reported that "Staff do not accord privacy to resident(s) in care" as it was alleged that residents are not given privacy as confidential information is disclosed when medications are administered in common areas. LPA's interview with (10) ten staff and (5) residents reflected that medications are often administered in the dining room during scheduled medication passes. Staff stated that residents may receive their medications in the dining room or another location, depending on resident preference and the care plan. Staff and residents did not report that confidential medical information was disclosed or that residents were denied privacy during medication assistance. In addition, residents did not report any concerns of how medications were administered at this time. LPA interviewed the reporting party, who was unable to provide specific dates or times for the reported incidents. 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 do not accord privacy to resident(s) in care” is deemed Unsubstantiated at this time. It was reported that "Licensee is accepting residents with higher level of care needs" as It was alleged that Resident #3 (R3), Resident #4 (R4), Resident #5 (R5), Resident #6 (R6), and Resident #7 (R7) should not be retained at the facility because they require one-to-one care and have health conditions requiring a higher level of care. LPA reviewed the records for each resident and found no documentation of prohibited health conditions that would preclude admission or retention at the facility. Interviews with ten (10) staff members indicated that prospective residents are assessed before admission to determine whether the facility can meet their care needs. Staff stated they review each resident's care plan upon admission and before providing care and communicate directly with residents regarding their care preferences, including medication schedules and daily routines. Staff further stated that if a resident's care needs increase, they notify RCD for reassessment and to discuss any necessary changes in the resident's level of care with the family. All interviewed staff stated they had no concerns regarding the facility's ability to meet the care needs of residents currently in care. Continued from 9099-C3 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, “Licensee is accepting resident with higher level of care needs” is deemed Unsubstantiated at this time. It was also alleged that licensee is not adequately addressing bed bug infestation at the facility. It was reported that the facility has been infested with bed bugs many times with little to no effort to do anything about it until it got so bad that almost all rooms were affected and it wasn’t until then that a pest control company was called to treat the rooms, but the bug infestation came back again. A review of invoices from Orkin Pest Control revealed that Orkin began providing services to address bed bug concerns at the facility on 09/30/2025. According to the service report, Orkin inspected all areas of the facility for signs of bed bug infestation and treated one (1) apartment, as well as all common areas. During a follow-up visit on 10/13/2025, Orkin conducted another inspection and found no evidence of pest activity at the time of service; however, treatment was still administered in certain areas. On 10/16/2025, Orkin again inspected the facility and found no live bed bug activity but proceeded with treatment. During a subsequent follow-up visit on 10/302025, Orkin inspected all areas and observed no signs of bed bug activity, yet preventive treatment was again provided. Finally, on 11/10/2025, Orkin conducted an additional inspection and reported no evidence of pest activity at the time of service. Interviews conducted with staff revealed that Orkin conducts routine monthly inspections and utilizes a bed bug detection dog to inspect resident rooms and common areas. Staff reported that, although minor remnants of previous infestations had occasionally been identified, no further spread had been observed. Staff further stated that when a suspected bed bug is identified, management is immediately notified to take appropriate action. Furthermore, resident interviews indicated that bed bugs had been present in the past; however, residents reported that staff responded promptly to the issue and ensured that affected areas were treated accordingly. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “licensee is not adequately addressing bed bug infestation at the facility”. Therefore, this allegation is deemed Unsubstantiated at this time. Continued from 9099-C4 It was further alleged that staff are not following infection control protocols as needed. It was reported that staff were not wearing gloves when administering medications to residents. Interviews conducted with staff revealed that gloves are worn when providing personal care to residents or when there is potential exposure to bodily fluids. Staff stated that gloves must be changed between residents and between tasks, followed by proper hand hygiene after glove removal. They further explained that gloves are removed immediately after completing tasks that require their use and that proper hand hygiene is performed, as gloves should not be worn unnecessarily outside of care activities. Staff also stated that gloves are worn when preparing food and assisting residents with feeding. During the interviews, staff denied failing to follow infection control protocols and demonstrated knowledge of the infection control policies and procedures required by regulation. Additionally, staff reported that gloves are worn during medication administration when required. However, they explained that gloves are not necessary when assisting residents with the self-administration of medication, provided that proper hand hygiene is performed before and after assistance. Staff further stated that they had not observed other staff members failing to follow glove-use protocols and denied witnessing staff not wearing gloves when glove use was required. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff are not following infection control protocols as needed”. Therefore, this allegation is deemed Unsubstantiated at this time. No citations issued at this time. Exit interview conducted. Report was reviewed and copy provided.the state’s words, verbatim · CDSS document, Sep 18, 2026 · control 29-AS-20260220120321

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. Upon arrival LPA met with Executive Director Maddison Lewis and explained the reason for the visit. LPA focused today’s visit on ensuring there are no health and safety hazards, resident records review and the facility is in compliance with Title 22 Regulations. At approx 11:35 a.m. LPA conducted a walk through of the facility. LPA inspected (5) randomly selected resident bedrooms. Resident rooms were observed to be furnished appropriately along with sufficient lighting. Resident bathrooms were sufficiently stocked with supplies and paper towels. No obstructions or hazards were observed inside or out. Records review, seven (7) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were observed to be in order at this time . No deficiencies issued. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, Aug 13, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. Upon arrival LPA met with Executiver Director Maddison Lewis and explained the reason for the visit. LPA focused today’s visit on ensuring there are no health and safety hazards, staff records review and the facility is in compliance with Title 22 Regulations. At approx 01:05 p.m. LPA conducted a walk through of the facility. LPA inspected (4) randomly selected resident bedrooms. Resident rooms were observed to be furnished appropriately along with sufficient lighting. Resident bathrooms were sufficiently stocked with supplies and paper towels. No obstructions or hazards were observed inside or out. LPA's reviewed Personnel records, eight (8) personnel files and the Executive Directors 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. No deficiencies issued. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with Resident Care Coordinator (RCC) Mariana Corrales and explained the reason for the visit. Executive Director Maddison Lewis was able to onsite during the visit. LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At approx 11:30am LPA conducted a walk through of the facility. LPA inspected (4) randomly selected resident bedrooms. Resident rooms were observed to be furnished appropriately with sufficient lighting. Resident bathrooms were sufficiently stocked with supplies and paper towels. Fire extinguishers were observed fully charged and last serviced on 08/04/2025. No obstructions or hazards were observed inside or out. LPA reviewed Resident Records. Eight (8) 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. No deficiencies issued. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, Feb 12, 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 9:40 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 shortly after. At approx 10:00am LPAs along with Resident Care Director Brimen Vivar, 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 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. Stairwells were 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. LPAs observed multiple randomly selected resident bedrooms in memory care and assisted living. 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 105– 112.1 degrees Fahrenheit. Continued from 9099 LPAs observed operational fountain located in the assisted living courtyard. The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use in both assisted living and memory care courtyards. 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. At approx 11:00 a.m. LPA observed residents participating in activities in the activity room. LPA’s reviewed Ten(10) 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, Ten (10) 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. 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. 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 08/14/2025. Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on------ LPAs conducted interviews with staff and residents during the inspection. LPA's 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, Nov 12, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with staff and explained the reason for the visit. Executive Director Madison Lewis arrived shortly after. LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At approx 10:40am LPA conducted a walk through of the facility. LPA observed multiple residents participating in an activity in the activities room. 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 space. Stairwells were 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 randomly selected resident bedrooms in assisted living as well as memory care. 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 105 - 120 degrees Fahrenheit. No obstructions or hazards were observed inside or out. At approx 11:00am, LPA conducted medication review. There are two medication rooms. 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 11:45am, Five (5) resident files were reviewed for, but not limited to, the following: current medical assessments with TB results and current needs and services plan. All records were observed to be in order at this time. No immediate health and safety concerns observed during the visit. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Aug 12, 2025

Type of visit: Case Management - Other

Licensing Program Analyst, Zabel Chochian arrived on 06/13/2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with Madison Lewis. On February 21, 2024, the Department concluded a complaint investigation regarding the following allegations: Questionable Death – The death of the resident was due to neglect and lack of supervision; and Neglect/Lack of Care and Supervision – The facility failed to respond to the resident in a timely manner. The licensee was cited for California Code of Regulations (CCR) 87464(f)(1)(5) Basic Services and CCR 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. At the time of the complaint visit on February 21, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the facility not providing proper care and supervision, which resulted in death due to intracranial hemorrhage from a fall. Today, 06/13/2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on February 21, 2024, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jun 13, 2025

Allegation investigated: Staff did not prevent a resident from developing pressure injuries

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit with the purpose of delivering findings for the above listed allegation. Upon arrival, LPA was greeted by front desk staff. LPA met with Executive Director (ED) Madison Lewis at 02:40PM. Entrance interview conducted. During an initial complaint visit conducted on 09/13/2024 from 09:30AM to 02:00PM, LPA Brian Balisi conducted physical plant tour, interviewed staff and reviewed and obtained pertinent documentation relevant to the investigation. During a subsequent complaint visit on 05/02/2025, LPA Dulek interviewed 4 (four) facility staff between 10:34AM and 12:17PM. LPA also called, interviewed, and obtained additional documents from the Executive Director. Throughout the course of the investigation, LPA Dulek reviewed all documents obtained. The following was then determined: The complaint alleges that Resident #1 (R1) developed a stage 3 pressure injury due to R1 not receiving Continued on LIC 9099-C Unsubstantiated proper care at the facility. Record review revealed that R1 moved into the facility on 07/07/2023. At that time, R1’s service plan was at a level 0 care. Service plan indicated R1 was able to care for their own Activities of Daily Living (ADLs) and R1 was able to store and administer their own medications. Physician’s report dated 01/12/2024 indicated that R1 was admitted to hospice care, R1 “needs hands on assistance due to terminal decline” for ADLs including, but not limited to: bathing, dressing/grooming, toileting. At that time, R1 continued to store and administer their own medications. R1’s physician’s report indicates no history of skin condition or breakdown. ED stated that cost was a concern to R1’s family member and that R1 refused to allow an increase in care. ED communicated with both R1 and their family member, who began looking to move R1 to another facility. R1’s family member stated an outside provider would assist R1. Interview with facility staff revealed that R1 was very independent and R1 was able to care for their own ADL needs, even while receiving hospice care. Hospice assisted R1 with showers twice a week. Facility staff indicated that if a resident is bedridden or has a pressure sore, staff will assist with repositioning the resident every 2 (two) hours. However, staff stated that R1 was able to turn and reposition on their own and R1 was not bedridden until the last 2 (two) – 3 (three) weeks R1 resided at the facility. Staff interviewed did not recall R1 having any pressure injuries that they were made aware of. Hospice notes indicate R1 was regularly observed by their chosen hospice care provider, with regular visits in August and early September 2024. Notes reviewed leading up to R1’s hospitalization indicate “pts skin intact” on 09/03/2024. While hospice did document 2 (two) visits on 09/05/2024, documentation indicates R1 “declined further skin assessment, [R1] wanted to sleep.” Record review revealed that R1 did have a pressure injury on their left lower buttock noted “present upon admit” to the hospital. While records reviewed indicate R1 was admitted to the hospital on 09/05/2024 at 09:01PM, pressure injury was not assessed until 09/06/2024 at 12:45PM. Hospital records note “it appears this wound was bigger in the past,” however R1’s skin was noted to be intact during hospice assessment on 09/03/2024. It should also be noted that following R1’s hospitalization, R1’s family changed R1’s hospice provider. Plan of care and visit notes for the new provider do not indicate the presence of a pressure injury/wound. Facility staff interviewed were unaware of R1 ever having a pressure injury, and facility staff were not providing shower assistance or regular direct care to R1, so facility staff would not have been regularly observing R1’s skin for changes. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted and copy of report was provided.the state’s words, verbatim · CDSS document, May 12, 2025 · control 29-AS-20240912104318

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced visit at the facility in conjunction with an investigation of complaint control # 29-AS-20240912104318. During the investigation, LPA observed deficiencies unrelated to the complaint allegation. Review of Resident #1 (R1)’s documents revealed that R1 had moved into the facility on 07/07/2023, at which time R1 had a physician’s report and service plan. On 01/12/2024, R1’s physician filled out a new physician’s report and R1 was admitted to hospice care on this date. Although R1 had a change of condition as evidenced by qualification for hospice care, the facility did not complete a new service plan at that time. Additionally, R1 was hospitalized on 09/05/2024 and was released back to the facility 2 (two) days later, however, no new service plan was completed at that time either. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, May 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: May 27, 2025

874763 Reappraisals (a) The pre-admission appraisal...Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary...to note significant changes in condition...and to keep the appraisal accurate...reappraisal. This requirement is not met as evidenced by: The licensee did not comply with the above cited section, as R1 was admitted to hospice care, a new physician's report indicates R1 required additional care, however, no reappraisal was completed, which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: Executive Director (ED) agreed to conduct a training with facility nurse to ensure nurse is aware of Title 22 regulation related to reappraisals. ED will also conduct training with all care staff on repositioning. Proof of training completion will be sent to CCLD by POC due date.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with staff and explained the reason for the visit. Executive Director Madison Lewis arrived shortly after. LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At approx 09:45am LPA conducted a walk through of the facility. LPA observed multiple residents participating in an activity in the activities room. 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 space. Stairwells were 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. LPAs observed randomly selected resident bedrooms in assisted living as well as the common areas of memory care. 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 105 - 120 degrees Fahrenheit. No obstructions or hazards were observed inside or out. LPA reviewed Resident Records at 02:00 p.m. Five (5) resident files were reviewed for, but not limited to, the following: current medical assessments with TB results and current needs and services plan. Five (5) personnel files 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 observed to be in order at this time. No immediate health and safety concerns observed during the visit. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, May 6, 2025

Allegation investigated: Staff do not re-order incontinent supplies timely resulting in residents not having incontinent supplies Due to lack of staff, residents are developing pressure injuries

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with staff and explained the reason for the visit. Executive Director Madion Lewis arrived shortly after. On 02/18/2025, the initial complaint visit was conducted by LPA between approximately 10:10 a.m. - 03:30 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. Today LPA interviewed residents, staff and families / responsible parties of residents in care. It was reported that "Staff do not re-order incontinent supplies timely resulting in residents not having incontinent supplies", as it was alleged that there is insufficient supply of incontinent products. Interviews conducted with eight (8) staff revealed that seven (7) out of eight (8) have always seen a sufficient supply of incontinence products available. One (1) out of the (8) staff interviewed stated they have observed some incontinent supplies to be low approximately once or twice in the last year , but each time supplies were ordered and arrived to the facility in a timely manner. Unsubstantiated In addition, all staff interviewed stated that when they observe any supplies to be low they inform either the med techs or management. All staff indicated that they have observed supplies to be ordered in a timely manner at this time. During a physical plant, the LPA found a proper supply of these products in seven (7) resident rooms in assisted living and four (4) randomly selected bedrooms in memory care, as well as in a supply closet next to the med room and a storage room on the 2nd floor. Interviews with four (4) families / responsible parties of residents in care revealed that they did not express any immediate or potential concerns for lack of supplies for residents at this time. 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 do not re-order incontinent supplies timely resulting in residents not having incontinent supplies” is deemed Unsubstantiated at this time. It was reported that "Due to lack of staff, residents are developing pressure injuries" as it was alleged that that there have been multiple shifts with only one (1) caregiver to assist all the residents. Interviews with eight (8) staff members indicated that seven (7) have never observed a shift with only one (1) caregiver. One (1) staff member reported that, on one occasion in the past year, they worked a shift with no other caregiver for approximately two (2) hours due to staff calling out. However, during this time, they received assistance from medication technicians and at least two (2) staff members from management until additional staff were called in. LPA's review of staff schedules showed that, typically, there are at least three (3) caregivers scheduled per shift, and on heavy shower days, four (4) caregivers are scheduled. During the NOC (night) shift, there are (3) caregivers on the floor, along with a med tech and a nurse on call. Additionally, interviews and records review revealed, that five (5) residents have been observed with pressure injuries since November 2024, but all were seen by home health or hospice care at least twice a week. Furthermore all staff indicated depending on care plan residents are repositioned or placed with proper support at least every hour. Interviews with four (4) families or responsible parties of residents in care revealed that none expressed any immediate or potential concerns about staffing or response times at this time. 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, “Due to lack of staff, residents are developing pressure injuries” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 29-AS-20250212142729

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with Administrator Madison Lewis and explained the reason for the visit. LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At approx 01:30pm LPA conducted a walk through of the facility. 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 space. Stairwells were 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. LPAs observed four (4) randomly selected resident bedrooms in memory care and assisted living. 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 105 - 120 degrees Fahrenheit. Fire extinguishers were observed fully charged and last serviced on August 13, 2024. The facility has a sufficient supply of perishable and non-perishable food. No obstructions or hazards were observed inside or out. LPA reviewed Resident Records at 02:00 p.m. 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 observed in order at this time. No immediate health and safety concerns observed during the visit. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jan 23, 2025

Allegation investigated: Sexual abuse – staff sexually abused resident. Staff caused injury to resident. Staff handled resident in a rough manner. Staff left residents in soiled diapers resulting in a rash. Staff disturbs resident’s sleep.

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi conducted a subsequent complaint visit to deliver findings for the above allegations. LPAs met with the Executive Director, Madison Lewis and explained the reason for the visit. Entrance interview. On 05/07/2024, the Department received a complaint regarding an allegation of Sexual Abuse – Staff sexually abused resident. It was alleged that Staff #1 (S1) was inappropriately touching Resident #1 (R1). The initial 10-day complaint visit was conducted on 05/08/2024, and a subsequent visit was conducted on 10/01/2024 by LPA M. Arroyo. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... . On 05/08/2024, LPA Arroyo conducted an interview with the Interim Executive Director (IED) at 3:25 p.m., and conducted a resident file review and obtained copies of pertinent documents at approximately 4:05 p.m. On 10/01/2024, LPA Arroyo conducted interviews with the Executive Director (ED), three (3) staff members, eight (8) residents, and one (1) family member between 11:50 a.m. and 2:40 p.m., and conducted a file review and obtained copies of pertinent documents at approximately 12:00 p.m. Police report was also obtained and reviewed. Information obtained and reviewed revealed R1 was admitted to the facility on 07/29/2021. Per R1’s physician report, dated 01/18/2024, revealed that R1’s primary diagnosis is cerebrovascular disease with a secondary diagnosis of mild cognitive impairment and hyperlipidemia. Per report, R1 is identified as being confused/disoriented yet able to follow instruction and communicate their needs. The report also indicates R1 is not able to bathe, dress/groom, or take care of their toileting needs. Interviews conducted with staff revealed that they have not had any resident report or claim that they have been sexually abused by S1 or any other staff member at the facility. Additionally, during interviews conducted with R1, R1 denied any sexual abuse by S1 or anyone else in the facility. Similarly, interviews conducted with residents revealed that residents did not report any problems, complaints, or abuse by anyone working at the facility. Furthermore, per police report, dated 05/15/2024, when R1 was asked by law enforcement if they had been a victim of abuse, R1 stated they were not a victim of abuse, nor had they witnessed any of the staff abusing the other residents. Additionally, law enforcement deemed this case as “unfounded/no evidence of abuse”. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the allegation of “Sexual Abuse - staff sexually abused resident”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff handled resident in a rough manner and staff caused injury to resident. It was reported that S1 was handling one resident in a rough manner while changing their diaper and another resident was observed with bruises on both their forearms. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Interviews conducted with staff revealed that residents undergo a body check every morning to monitor for any cuts or bruises, ensuring that any necessary follow-up care can be provided. Staff members stated that no residents have reported any injuries caused by other staff or expressed concerns about staff being too aggressive during assistance. Additionally, staff noted that residents are vocal when they disapprove of any actions taken by staff. An interview with a family member confirmed that staff assist the residents and treat them well. Interviews with residents revealed that they have never experienced rough or inappropriate handling during assistance. Residents expressed that they are treated well by staff and reported no concerns about their living conditions at the facility. Based on interviews conducted with staff, residents, and family member, the Department does not have sufficient evidence to support the allegations of “staff handled resident in a rough manner” and “staff caused injury to resident”. Therefore, these allegations are deemed Unsubstantiated at this time. It was also alleged that staff left residents in soiled diapers resulting in rash. It was reported that S1 leaves multiple residents ‘soaking wet’ in their diapers resulting in resident’s sustaining rashes. Interviews conducted with staff revealed that residents who are incontinent are changed every two hours, depending on their individual needs. Staff members noted that diapers are checked and changed every two hours, unless they observe the resident needing a change sooner. An interview with a family member confirmed that staff assist the resident promptly and feel that the facility is meeting the resident's needs. Interviews with residents indicated that staff frequently check on them throughout the day. Furthermore, residents reported that staff are responsive to their requests for help and expressed no concerns about their care or living conditions at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff left residents in soiled diapers resulting in rash”. Therefore, this allegation is deemed Unsubstantiated at this time. It was further alleged that staff disturbs resident’s sleep. It was reported that staff disturb residents sleep when waking the residents up in the mornings. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Interviews conducted with staff revealed that residents are typically in their beds and ready to sleep between 8:00 p.m. and 8:30 p.m., and they wake up around 6:30 a.m. to 7:00 a.m. In the mornings, staff begin making their rounds to prepare residents to go to the dining room for breakfast. Staff stated that most residents are usually awake by the time they enter their rooms, but on occasion, a resident may request more time to get up. In such cases, staff will move on to the next resident and return later. During interviews with residents, none reported any concerns with the morning staff. Residents expressed that staff were helpful and attentive. Additionally, residents shared that they enjoyed living at the facility and reported no concerns. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff disturbs resident’s sleep”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy issued.the state’s words, verbatim · CDSS document, Nov 20, 2024 · control 29-AS-20240507143936

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 10:30 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 shortly after. At approx 11:11am LPAs along with Resident Care Director Brima , 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 11:12am The LPAs 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 11:11 a.m. - 12:00 p.m. 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. Stairwells were 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. LPAs observed eleven (11) randomly selected resident bedrooms in memory care and assisted living. 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 110.4 – 119.6 degrees Fahrenheit. Continued from 809 LPAs observed operational fountain located in the assisted living courtyard. The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use in both assisted living and memory care courtyards. The facility maintained a comfortable temperature of 73 degrees. LPAs observed three (3) 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’s reviewed Resident Records at 12:15 p.m. Ten (10) 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 at approx. 01:40 p.m. Ten (10) 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. 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. 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 12/17/2023. Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on 10/10/2024. LPAs conducted interviews with staff and residents during the inspection. LPA's 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, Nov 20, 2024

Allegation investigated: Staff did not address resident's change in health condition Staff did not take precautions to prevent a scabies outbreak

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation finding. Upon arrival LPA met with Madison Lewis, Managing Director and explained the reason for the visit. Allegation finding were discussed. On 02/13/2024, Community Care Licensing Division received the above complaint allegations. Investigation into the allegations consist of records review, interview with staff, and random residents on 02/16/2024, from approximately 4pm-6pm. Other potential witnesses were contacted on 8/19/2024. Following is a summary of the allegations and investigation finding: Allegations) “Staff did not address resident’s change in condition and Staff did not take precautions to prevent a scabies outbreak”: It was reported that the facility did not address resident #1 (R1) excessive skin dryness and did not take precautions to prevent a scabies outbreak. It was also reported that R1 was tested positive for scabies. (Continue to LIC9099c). Unsubstantiated It is alleged that the resident has had scabies for some time and was highly contagious. Interviews conducted with facility staff and records reviewed revealed that on 02/03/2024, ambulance was called for R1 due to an unusual, altered status and distress. Staff interviewed and records reviewed confirmed that R1 was evaluated by a physician on 01/17/2024 for the skin dryness and was not noted as scabies. Staff reported that they did not have any other resident with any skin issues. Staff interviewed reported that R1 was in the hospital for a week and was discharged on 02/07/2024 to a rehab-facility and was cleared to return to the facility on 03/16/2024. Staff denied having any scabies outbreak at the facility and reported that R1 was regularly observed, and any changes were communicated to the family and doctor timely. Seven (7) out of seven residents interviewed including R1 did not report any care issues at this time. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation that “Staff did not address resident's change in health condition and Staff did not take precautions to prevent a scabies outbreak”. Therefore, the allegations is deemed UNSUBSTANTIATED at this time. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 29-AS-20240213083220

Allegation investigated: Unknown individual in the facility drugged resident in care Unknown individual in the facility raped resident in care

Licensing Program Analyst (LPA) Zabel Chochian initiated a subsequent complaint visit to issue findings for the above allegations. Upon arrival LPA with Madison Lewis, Managing Director and reason for the visit was explained. Also the allegation finding was discussed. . On 02/15/2024, the Department received a complaint which alleged that an unknown individual in the facility drugged and raped Resident #1 (R1). The time frame of the abuse is unknown but is believed to have occurred in the recent past. It is believed that R1 has dementia. It was also reported that the police are in the process of interviewing R1, staff and other potential witnesses. Community Care Licensing Division’s Investigations Branch (IB) was assigned to obtain police report. On 02/16/2024, the LPA conducted the initial visit, interviewed staff at approximately 4 p.m. and reviewed documents; completed a physical plant tour and conducted interviews with random residents and R1 from approximately 5 p.m. to 6 p.m.. (Continue to LIC9099c). Unsubstantiated A review of records, including but not limited to preplacement appraisal, medical assessment, and centrally stored medication record. R1 was admitted to the facility on 11/20/2023. Preplacement appraisal dated 11/13/2023 noted history of short-term memory loss, confusion, agitation, and hallucinations. Medical assessment dated 11/15/2023 noted that R1 has mild cognitive impairment, is able to manage all daily activities with minimal assistance. Staff interviews revealed that R1 has beginning Alzheimer’s disease and noted to have a history of hallucinations. R1’s responsible person also confirmed that R1 does have bouts of hallucinogenic episodes and memory issues. R1 was interviewed by an Officer from the Simi Valley Police Department on 02/12/2024 at approximately 1 pm. R1 did not disclose abuse of any nature. Police report was not generated. Random resident interviews expressed that they are treated well and felt safe in the facility. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Unknown individual in the facility raped resident in care and Unknown individual in the facility drugged resident in care” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 29-AS-20240215143207

Allegation investigated: Questionable Death – The death of the resident was due to neglect and lack of supervision. Neglect/Lack of Care and Supervision – The facility failed to respond to the resident in a timely manner.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Brimen Vivar and Managing Director Madison Lewis and explained the reason for the visit. On 04/11/2023, the Department received a complaint regarding Neglect/Lack of Care and Supervision and the Questionable Death of Resident #1 (R1). It was alleged that the facility staff failed to respond to R1 in a timely manner and that there was a concern of questionable death due to neglect/lack of care and supervision. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Lorraine Patterson. On 04/14/2023, from 12:00 p.m. to 3:15 p.m., LPA Chochian conducted an unannounced complaint visit. During the visit, facility records were requested and reviewed. (continue to LIC9099c) Substantiated On 05/18/2023, at approximately 2:35 p.m., Investigator Patterson conducted an interview with R1’s resident representative; on 07/10/2023, from approximately 11:45 a.m. to 1:15 p.m., with the interim Executive Director, staff and residents; on 07/11/2023, at approximately 1:16 p.m., with the Ventura County Medical Examiner Coroner’s office Investigator; on July 13, 2023, from approximately 9:04 a.m. to 5:41 p.m., with staff; and on 07/20/2023, from approximately 2:43 p.m. to 3:52 p.m., with the interim Executive Director and staff. Additionally, Investigator Patterson reviewed Los Robles Hospital Medical Center records, County of Ventura Medical Examiner’s Office Investigative Report #1170-22, death certificate, photos, and facility file documents related to R1. Facility records reviewed revealed that since 09/07/2021, R1 stayed at the facility at different times on a temporary short-term respite basis. The Physician Report dated 07/22/2022, listed R1’s primary diagnosis as hypertension, hyperthyroid, BPH, and peripheral vascular disease. The secondary diagnosis was listed as Coronary Artery Disease (CAD), cataracts, osteoarthritis, a fall history, and previous head injury. R1 is ambulatory and independently transfers. R1 follows directions and communicates their needs. R1 has the capacity for self-care and medication management. The facility Assessment /Level of Care dated 07/18/2022, documented R1 is an early riser and receives two weeks of respite care. R1 has limited vision and no dietary restrictions, R1 is independent, and bed status is out of bed all day. R1 requires no status checks or assistance with Activities of Daily Living (ADL). R1 walks with a walker and requires grab bars in the bathroom. R1 bathes and performs ADLs and transfers independently. The facility reported no history of falls, and R1 does not require special care. A review of the facility concierge shift notes for 07/31/22, between 8:00 a.m. and 4:30 p.m., summarized that R1’s resident representative called the facility between breakfast and lunch. R1’s resident representative reported R1 is not answering their phone. The caregivers were paged to check on R1. It was further documented, "We only have two caregivers on the floor!!" "They were tending to other residents," and that a caregiver was sent to R1’s room but there was no answer. "We saw R1 at breakfast but not lunch," and that a caregiver was sent again, knocked and there was no answer, and that the caregiver did not have a key, so the facility had to get a caregiver with a key. At 2:00 p.m., the caregiver went to R1’s room to check on R1 because R1’s resident representative was very concerned that R1 was not answering their phone. The investigation further revealed that R1’s resident representative reported that on the morning and afternoon of 07/31/2022, they alerted the facility’s receptionist on at least two (2) occasions that they were concerned that they could not reach R1. (continue to LIC9099c) Photos of screen shots of R1’s cell phone showed that R1’s resident representative had attempted to call R1 at 7:27 a.m., 10:01 a.m., 10:39 a.m., and 12:24 p.m. R1 was not checked on until R1 was found in their room at approximately 2:15 p.m., unresponsive with a head injury. Los Robles Regional Medical center records reflected that on 07/31/2022 at 3:00 p.m., R1 was transported to the hospital via ambulance. Medical records further noted that the R1 was found down with obvious signs of trauma. Staff found R1 in the afternoon covered in feces, urine, and blood. R1 was not responsive, left pupil was larger than the right, abrasions over all four extremities. Moreover, Computed Tomography (CT) scan of the head reported a large left subdural hematoma measuring up to at least 2.1 cm with associated 1 cm of left to right midline shift. Large hematoma in the left frontal region measuring at least 3 cm, moderate bilateral subarachnoid hemorrhage with large amounts of blood. R1 was not intubated due to R1s DNR status. Due to the extensive hemorrhage, trauma surgeon determined that no surgical intervention. R1 was admitted in critical condition and was unstable for transfer. R1 was subsequently placed on comfort measures and passed away on 08/03/2022. The certificate of death revealed the cause of death was intracranial hemorrhage. Based on the interviews conducted and records obtained during the course of the investigation, the Department determined that there is sufficient evidence to support the allegation of “Neglect/Lack of Care and Supervision: The facility failed to respond to resident in a timely manner” and “Questionable Death due to a lack of neglect and lack of supervision”. Therefore, the allegations are deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. Administrator were informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 29-AS-20230411162428

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(5) · Plan of correction due date: Feb 22, 2024

(f) Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c (5) Regular observation of the resident's physical and mental condition..... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above.Facility staff failed to assess R1 completely for fall prevention and develop a service plan as R1 had a history of falls, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 21, 2024

Plan of correction: Licensee will submit a plan how you will ensure appropriate resident care and supervision. Submit to CCL by due date. Civil Penalty: An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2 · Plan of correction due date: Feb 22, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff did not respond to R1 in a timely manorthe state’s words, verbatim · CDSS document, Feb 21, 2024

Plan of correction: Licensee will submit a plan how you will ensure staff will monitor and respond to residents in a timely manner. Submit to CCL by (date) to prevent civil penalty from accruing. when R1’s resident representative notified the facility multiple times with concerns they could not reach R1. Staff did not check on R1 until R1 was found at approximately 2:15pm unresponsive with a head injury resulting in death, which posed an immediate health and safety risk to residents in care.

Allegation investigated: Facility's bed bug issue was not handled promptly. Inadequate staffing to meet the needs of residents. Staff yell, scream and mock residents. Medications are not being distributed.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation finding. Upon arrival LPA met with Administrator and explained the reason for the visit. On 12/08/2023, Community Care Licensing Division received the above complaint allegations. Investigation into the allegations consist of records review, tour of resident rooms, interview with residents and staff on 12/13/2023, from approximately 10am-3:30pm. Following is a summary of the allegations and investigation finding: Allegations) Facility's bed bug issue was not handled promptly: Information was provided that the facility management did not address the facility bed bug issue promptly. It was alleged that there are four residents that had bed bugs and bed bug bites all over about 6 months and management kept denying it and would just have maintenance spray the rooms. (continue LIC9099c) Unsubstantiated On 12/13/2023, between 10am-3:30pm, LPA toured the facility with staff and inspected ten (10) resident rooms (101A, 101B, 105A, 210, 224, 226, 227, 228, 231, and 250) and interviewed six (6) residents. Room observation and interview with residents revealed no current bed bug activity. Residents interviewed did confirm bed bug activity in the past but reported that when it was reported to staff and management the issues was addressed promptly. Interview staff confirmed that the bed bug issues was reported on 5/31/2023 and since then facility Maintenance Director and ECO Lab have worked to rectify the bed bug issues. Records reviewed identified work orders/invoices from ECO Lab from 6/01/2023 to 12/1/2023. The identified rooms were inspected, and treatment was provided for the rooms which were positive with bed bug activity. Also, according to staff and residents’ new mattresses were provided. Six (6) out of six (6) residents interviewed during to tour confirmed that the bed bug issue was addressed promptly. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation that “facility’s bed bug issues was not handled promptly”. Therefore, the allegation is deemed unsubstantiated at this time. Allegation) Inadequate staffing to meet the needs of residents: It was alleged that management schedule only two caregivers for 64 residents and the resident are not getting the quality care that they need. On 12/13/2023, facility staffing schedule provided by management revealed that there are six (6) caregivers total for am/pm shift (3 assigned to Assited Living and 3 assigned to Memory Care) and two (2) med-techs covering the assisted living side and memory care unit. One (1) caregiver and one med-tech for the NOC shift. Interview with staff revealed that at this time the staffing is sufficient. Administrator reported that they also utilize a staffing agency incase it is need if there are call outs or in case additional staffing is needed. Administrator and staff reported that additional staff have been added to ensure residents quality of care is maintained. Staff interviewed confirmed staffing is much better since COVID times. Ten (10) out of ten (10) residents interviewed reported being satisfied with the services provided by the caregiving staff. Based on the above information gathered, although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “inadequate staffing to meet the needs of residents” is deemed unsubstantiated at this time. Allegation) Staff yell, scream and mock residents: It was alleged that staff yell, scream and mock residents. Staff interviewed denied the allegation and reported that they have never mistreated any resident and they have not witnessed any staff to be disrespectful with any resident. Ten (10) out of ten (10) residents interviewed on 12/13/2023, denied ever being mistreated by any staff and reported that they have not witness any staff yell, scream or mock any resident of this facility. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff are not cleaning resident room” is deemed unsubstantiated at this time. Allegation) Medications are not being distributed: It was reported that residents’ medications are not being given. No specific details were provided regarding this allegation. On 12/13/2023, random sample of residents medication administration records (MAR) were checked and reviewed with med-tech and no discrepancies were observed. Ten (10) out of ten (10) random residents interviewed did not report any issues with receiving their medications on time. Residents interviewed confirmed receiving medication daily by staff. Staff interviewed denied allegation and expressed that no residents medication is with held unless it is ordered by their physician. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Medications are not being distributed” is deemed unsubstantiated at this time. Exit interview conducted. Copy of the report provided.the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 29-AS-20231208113406

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian conduct a Required Annual visit to this facility. Upon arrival LPA met with Madison Lewis. LPA was informed that the Executive Director was not in today. Reason for the visit was stated. Entrance interview was conducted with Ms. Lewis and the inspection process was explained. Copy of the entrance checklist was reviewed and provided to Ms. Lewis to assist with the inspection process. Ms. Lewis confirmed that the facility plan of operation has not changed since licensure. Ms. Lewis was informed that, prior to any changes to the facility or facility plan of operation the licensee needs prior approval for Community Care Licensing. Between 11am-3pm, the LPA and staff Precious Gardner 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 08/01/2023. The carbon monoxide, smoke alarms and fire suppression system were last tested 09/29/2023 by the Venture County Fire Department and all functioned properly. BEDROOMS and RESTROOMS: The LPA observed total of ten (10) randomly chosen rooms in both assisted living and memory care. Rooms were appropriately furnished, clean and had sufficient lighting. Restrooms inside the randomly chosen rooms were clean and sanitary and in operating condition. The hot water temperature ranged from 113*F to 116*F. Room 221 thermostat was observed not functioning properly during room inspection however the room temperature was within required range (81*F) and comfortable. During the tour LPA also conducted interview with staff and residents who were able to communicate. COMMON SPACES: The lobby, activity rooms, dining rooms, 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 areas in both memory care and assisted living were equipped with furniture for residents' use. KITCHEN: The commercial kitchen was toured and observed to be clean and appliances all appeared operable. The facility perishable and non-perishable and food supply was observed to be sufficient during todays visit. Due to time constraints it is determined that the annual inspection will continue on a later date. Exit interview conducted. Copy of the report provided.the state’s words, verbatim · CDSS document, Nov 22, 2023