Lexington Assisted Living

Allegation investigated: Staff do not assist resident with medical needs Staff do not treat resident with respect Staff yell at resident Unlawful eviction Staff did not provide breakfast to resident Staff do not assist resident with showering

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the above noted allegations. LPA met with Administrator Jonathan Wheeler and explained the reason for the visit. Entrance interview conducted. During an initial complaint visit conducted on 01/08/2026, LPA interviewed management at 10:47AM, toured the facility at 12:11PM, reviewed and obtained copies of relevant documents and interviewed Resident #1 (R1) at 01:46PM. Throughout the course of the investigation, LPA interviewed additional residents and staff and reviewed all documents obtained. The following was then determined: Report Continued on LIC 9099-C (p. 2) Unsubstantiated Allegation “Staff do not assist resident with medical needs:” The complaint alleges that Resident #1 (R1) is not assisted with their medication and medical needs. No further information was provided. LPA interviewed staff and residents, including R1, as well as reviewed documents for R1. Review of R1’s service plan dated 11/27/2024, R1 was independent and able to store and self-administer their own medications. Interviews revealed that at the time of the complaint, R1 was independent and able to meet their own medical needs, including scheduling appointments. The facility was able to assist R1 with transportation needs to and from their medical appointments. R1 indicated they felt their needs were not being met, but was unable to elaborate on specific needs not being met. 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 “staff do not assist with medical needs” is deemed Unsubstantiated at this time. Allegation “Staff do not treat resident with respect” and “Staff yell at resident:” It was alleged that staff do not treat R1 with respect and yell at R1. An incident was reported in which new residents were moving into the facility during the evening hours. R1 was in their room and the new residents were moving into the room next door. R1 became upset at the noise level during the move and went to the new residents’ room. Staff were present assisting the residents with their move. R1 knocked loudly on the door and was reportedly agitated. According to interviews with staff and resident present during the incident, R1 began yelling at the new residents and the staff. Interviews revealed that staff did ask R1 to return to their room and were initially kind in their request. When R1 continued to raise their voice and engage with the staff and residents, the staff became more direct in their approach. R1 was reported to threaten the staff, use offensive language, and was generally disruptive. Staff called police to the facility due to R1’s behavior. Witnesses to the incident indicated that staff were not yelling at R1, but did raise their voice and speak directly to R1 before calling police to intervene. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations “staff do not treat resident with respect” and “staff yell at resident” are deemed Unsubstantiated at this time. Allegation “Unlawful eviction:” Following the incident that occurred at the facility on 12/19/2025 involving R1, facility management issued R1 Report Continued on LIC 9099-C (p. 3) a 30-day eviction notice. Documents provided indicate this was not the first incident involving R1 that took place at the facility. There were previous instances of R1 violating house rules, such as using inappropriate language, interacting inappropriately with staff and residents, and general disruptive behavior. R1 had previously been issued both verbal and written warnings. LPA reviewed the eviction notice issued on 12/23/2025, which did contain the reason for eviction and all required resources. Interview with R1 revealed that they understood they had violated facility policies and therefore had to move. R1 moved out of the facility on 04/01/2026. 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 “unlawful eviction” is deemed Unsubstantiated at this time. Allegation “Staff did not provide breakfast to resident:” During an unrelated visit at the facility, LPA observed residents during a meal and interviewed staff and residents related to the allegation. Staff stated that the kitchen is open most of the day, with hours of service for breakfast, lunch, and dinner. Snacks are available between meals. Additionally, when the kitchen is closed, residents can still request food from the staff and staff will ensure the residents have food available. Interview with R1 revealed that R1 has their own food in their room to eat. R1 typically eats breakfast before leaving the facility for a walk. R1 did state they would prefer to have reminders for breakfast, but does not require regular reminders, as R1 is independent. Staff interviewed stated no resident, including R1 has ever been refused a meal. 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 “staff did not provide breakfast to resident” is deemed Unsubstantiated at this time. Allegation “Staff do not assist resident with showering:” R1’s care plan dated 11/27/2024 indicates R1 did require some assistance showering. However, staff interview revealed that upon move in and going forward, R1 was reassessed to not require assistance with showering and prefers to shower independently. For that reason, R1 was not added to the shower schedule that was provided during the complaint investigation. During the initial visit, LPA went to R1’s room to speak with them and when LPA knocked on the open door to R1’s room, the shower was running. R1 told LPA that they were showering and would be available after the shower was completed, so LPA waited outside in the hallway. No staff emerged from R1’s room and R1 stated they shower with no staff assistance. R1 informed Report Continued on LIC 9099-C (p. 4) LPA they did not want nor require assistance and was able to shower independently. 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 “staff do not assist resident with showering” is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 29-AS-20251230094949

Allegation investigated: Neglect/lack of care and supervision - Facility retained resident with prohibited health condition Staff did not properly administer medications to a resident in care

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the above noted allegations. LPA met with Business Office Manager Alysse Legere and explained the reason for the visit. Entrance interview conducted. During an initial complaint visit conducted on 10/31/2025, LPA interviewed staff at 09:50AM and Administrator at 10:23AM. LPA, along with Administrator and facility staff toured the facility at 11:04AM to ensure there are no immediate health and safety hazards. LPA interviewed Clinical Director at 12:26PM. LPA reviewed and obtained copies of relevant documents. LPA informed facility management that some allegations were referred to Community Care Licensing Division (CCLD)’s Investigations Branch (IB) for investigation. IB Investigator obtained and reviewed copies of additional pertinent records and interviewed residents, staff, and other relevant parties on the following dates: 11/10/2025, 11/11/2025, 11/12/2025, 11/17/2025, Report Continued on LIC 9099-C (p.2) Substantiated 11/24/2025, 12/04/2025, 12/05/2025, 12/08/2025, 12/09/2025, 12/15/2025, and 12/16/2025. During a subsequent visit conducted 04/07/2026, LPA reviewed medications at 11:15AM, briefly toured the facility, and interviewed four (4) staff and four (4) residents from 12:24PM to 04:55PM, and LPA reviewed and obtained copies of relevant documents. Throughout the course of the investigation, LPA reviewed all documents obtained and IB investigative reports. The following was then determined: Allegation: Neglect/lack of care and supervision – facility retained resident with prohibited health condition: The complaint alleges that while Resident #1 (R1) was receiving care at the facility, R1 sustained a wound and the facility retained the resident with the prohibited health condition. Interview revealed that facility staff and R1’s family were aware of the resident sustaining a pressure injury in August or September 2025. When staff initially discovered R1’s wound, it was described as appearing red and with intact skin. The wound was noted in R1’s care notes on 09/15/2025. On 09/16/2025, home health began treating R1’s pressure injury. Home health classified the buttock wound as stage 3. Notes document the progression of R1’s wound and ongoing treatment provided through the home health company. Documentation further indicates that the facility was notified of R1’s condition through external agency forms, however the facility did not request nor obtain an exception to retain R1 with the prohibited health condition. Additionally, staff did not initiate transfer to an acute care hospital for appropriate medical intervention. R1 was not admitted to the hospital until 10/28/2025 for unrelated concerns, not due to the wound. Interview with clinical director revealed they were unaware that the wound constituted a prohibited health condition, therefore, transfer to an appropriate level of care was delayed. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation is deemed SUBSTANTIATED at this time. Allegation: Staff did not properly administer medications to a resident in care: The complaint alleges that staff are popping medications for Resident #2 (R2) out of the bubble pack and then placing them back in the bubble pack and marking the medication as administered. Medication review and interview with facility staff revealed that R2’s Percocet is prescribed on an as needed basis and R1 can take ½ to 1 tablet as needed (PRN). Interview revealed that due to the way the prescription is written, facility staff are taking the pill out of the bubble pack and administering either 1/2 tablet or the whole tablet, depending on what R2 requests. If a 1/2 pill is administered, the medication technician will return the other Report Continued on LIC 9099-C (p.3) 1/2 to the bubble pack for later administration. The medication technician will then record the dosage administered to R2. Clinical Director interviewed stated they have attempted to obtain further clarification from R1's medical provider on this order, however, to date has not received the clarification requested. Additionally, during medication review on 04/07/2026, it was observed that R2s Ondesteron have 4 packs on the centrally stored medication and destruction record (CSMDR), however, only two (2) bottles and one (1) bubble pack were present. This medication is PRN and has not yet been opened, leaving one (1) pack of Ondesteron unaccounted for. R2's Lidocaine has no start date indicated on the CSMDR and initially contained 14 doses. Four (4) doses were indicated administered on the Medication Administration Record (MAR), however, twelve (12) doses were present. R2's aspirin had a start date indicated on 02/01/2026. This medication is not documented on the CSMDR. R2's Buproprion HCL XL 300 mg was indicated with a start date of 02/01/2026, however this medication is not documented on the CSMDR. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Facility Designee was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided. During a subsequent visit conducted 04/07/2026, LPA reviewed medications at 11:15AM, briefly toured the facility, and interviewed four (4) staff and four (4) residents from 12:24PM to 04:55PM, and LPA reviewed and obtained copies of relevant documents. Throughout the investigation, LPA reviewed all documents obtained and IB investigative reports. The following was then determined: Allegation: “Neglect/lack of care and supervision – Resident developed pressure injury due to facility neglect:” The complaint alleges that R1 developed a pressure injury due to the facility’s lack of care and supervision. Interviews revealed that when staff observe a resident is experiencing skin integrity concerns, staff will take proactive measures to mitigate any potential breakdown. When a resident’s skin appears red or irritated, staff will apply cream as a protective barrier. Staff report to the wellness coordinator or wellness director, who will communicate with the resident’s physician and family. Staff also indicated that they regularly reposition residents with limited mobility to limit the potential for pressure-related skin breakdown. In the case of R1, who did have limited mobility, staff were repositioning when they provided incontinence care. During the day, R1 was able to communicate their needs and would inform staff when they needed incontinence care. At night, staff stated they changed R1 one (1) to two (2) times during the overnight shift and would attempt to reposition R1 at those times. Staff also stated that R1 did not wish to be repositioned when they were in a comfortable position. Interview with wound specialist who treated R1 indicated the wound on R1’s buttocks “this was not a pressure sore.” Instead, the medical professional stated it was probably a result of “soiling, fecal soiling with wiping…it ate through the skin…” Another medical professional who treated R1 indicated they observed no signs of neglect and factors that may have contributed to the wounds were “lack of mobility and prevention from moving around.” Interviews revealed the facility staff was in communication with R1’s family related to R1’s skin breakdown and that the family was also in communication with R1’s medical team. 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 “resident developed pressure injury due to facility neglect” is deemed Unsubstantiated at this time. Allegations: “Facility did not provide timely medical transport” and "Staff did not ensure that resident attended medical appointments:" The complaint alleges that Resident #3 (R3) required blood transfusions and due to facility neglect, R3 missed appointments, placing R3 at risk of serious bodily harm. Records reviewed for R3 revealed that due Report Continued on LIC 9099-C (p.7) to R3’s medical diagnoses, R3 had their blood drawn weekly. Based on the results of that bloodwork, R3’s physician would inform R3’s family member whether a transfusion was required or not. It appears that at the time of the complaint allegation, R3 required transfusion one (1) to two (2) times a month. Interview revealed that R3’s family member would make the transfusion appointment and call the facility to arrange transport. The facility provides medical transportation for residents on Tuesday and Thursday, which is scheduled through the front desk. Once the appointment and transportation was scheduled, the facility staff was responsible for waking R3 up early those mornings and assisting R3 in preparing for the appointment. R3 stated they never missed an appointment, however, medical professionals and staff did indicate R3 had an appointment scheduled on 10/28/2025, which was missed. According to staff at the medical location, R3’s family member cancelled the appointment for an unknown reason. Some staff interviewed indicated there was a miscommunication between night and morning staff, while others stated transportation was not available. It is unclear of the reason for the missed appointment, however, medical staff who treated R3 indicated that every time R3 required transfusion, it was completed within a week. R3’s doctor emphasized that R3 “hasn’t been in danger and [R3] has always been okay.” R3 can “go two weeks without a transfusion and still be fine.” R3 had a documented transfusion on 10/23/2025 and their only missed appointment was on 10/28/2025. There is no evidence to suggest that the lapses in care caused by staff miscommunication and possible unavailable transportation resulted in an imminent risk of harm to R3. Additionally, interview revealed that even though the facility assists with transportation to medical appointments and assists in scheduling resident appointments as needed, it is up to the resident and/or their family member to ensure residents attend medical appointments. This is also documented in the facility's Admission Agreement and related policies. 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 allegations “facility did not provide timely medical transport” and "staff did not ensure that resident attended medical appointments" are deemed Unsubstantiated at this time. Allegation: "Staff are falsifying medication logs:" The complaint alleges that medications are marked as administered on the MAR for R2, even when pills are observed taped back into the bubble pack. As described in page two (2) and three (3) of the complaint report, R2's Percocet is ordered to be administered 1/2 to 1 tablet as needed (PRN) for pain. R2 is capable of communicating the requested dosage to the staff. If R2 only requests a 1/2 tablet, the medication Report Continued on LIC 9099-C (p. 8) technician will take the pill out, cut it, administer 1/2 to the resident, then return the unused portion to the bubble pack. The staff will then mark the R2's MAR according to the dosage requested and administered to the resident. The clinical director expressed frustration with how the order is written and indicated the resident's physician has not clarified the order per the facility's request. LPA suggested requesting the pharmacy pre-cut the medication and package the pre-cut pills in bubble packs. LPA did not observe any falsified logs. Staff interviewed also have not heard of or observed any falsification of medication logs. Residents interviewed stated they get their medications and have no concerns. 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. Allegation: "Staff are smoking in the facility:" LPA interviewed staff and residents related to the facility's smoking policies and observations. Both staff and residents interviewed indicated the facility has a smoking area on the outside patio on the second floor of the facility. There is an additional smoking area designated on the first floor exterior as well. Residents indicated that at times they can smell smoke coming inside the building from the smoking area, as doors and windows are left open for fresh air. No staff nor residents have ever seen anyone smoking inside the facility. Additionally, the complaint mentions marijuana is smoked inside the facility and no resident nor staff have observed any person smoking marijuana on the premises at all. 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. Allegation: "Staff are not showering residents in care:" The complaint alleges that residents are not showered regularly. Interviews revealed that most residents that require assistance with showering are on a two (2) showers a week schedule. The shower schedule has been modified a number of times, based on resident requests. Some prefer morning showers, some prefer to shower in the evening. Some residents prefer a particular staff person to assist with their showers, which the facility tries their best to accommodate, however, can't always accommodate everyone. The facility does document when a resident refuses their shower and has a process for informing family and physician when needed. Residents interviewed indicated that yes, there are some residents who refuse shower assistance, but the facility does their best to encourage adequate hygiene. Although the allegation may have happened Report Continued on LIC 9099-C (p.9) 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. Allegation: "Staff left a resident in soiled bedding for an extended period of time:" The complaint alleges that Resident #4 (R4) was soiled and left in their bed for an extended period of time. Interviews with staff revealed that R4 is bedbound and unable to transfer on their own. R4 does require assistance with incontinence care. Staff interviewed stated that incontinence care is provided at least two (2) times per shift, or more frequently as needed. Additionally, during change of shift, staff conduct rounds where both incoming and outgoing staff check on the residents and communicate to ensure continuity of care for the residents. Staff interviewed have never observed a resident left soiled for a lengthy period of time. Residents interviewed felt their care needs related to incontinence are met. 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. Allegation: "Staff did not ensure that hazardous items are inaccessible to residents in care" and "Staff did not ensure that medications are inaccessible to residents in care:" The complaint alleges that frequently items are left unlocked in the memory care unit, leaving a multitude of medications, creams, and other personal care items accessible to residents in care. LPA observed the facility's memory care unit during multiple visits throughout the course of the investigation and never once observed cabinets or storage areas to be unlocked. Interview with facility staff revealed there are locked storage areas in resident rooms and common areas for personal care items to be stored. Facility staff interviewed have not observed these items left out and/or accessible to residents in care. All medications for both the memory care unit and the assisted living unit are stored in a locked medication room, located in the Assisted Living. 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. Allegation: "Staff did not notify resident's responsible party of an injury:" The complaint alleges that Resident #5 (R5) sustained a bruise and R5's responsible party was not notified of the injury. LPA interviewed facility staff, who indicated if a resident is found with a bruise, progress notes Report Continued on LIC 9099-C (p.10) are added identifying the location of the bruising/injury to the resident. Staff also discuss any observations during crossover and document in the communication log. Care staff and medication technicians typically are not responsible for notifying residents' families of any injuries or bruises, unless they see the resident's family in person and they are asked. The clinical director and wellness coordinators are responsible for ensuring communication with resident families. Residents interviewed indicated they are happy with the communication between the staff, residents and their families and have no concerns. 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 related to the above allegations. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 29-AS-20251030151502

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Aug 4, 2026

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition...shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and record review, the facility did not comply with the above cited section, as R1 was retained in the facility with a stage 3 pressure injury from 09/16/2025 to 10/28/2025, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The staff that was involved in retaining the resident was terminated from employment. Facility Designee agreed to work with the facility Administrator to obtain additional documentation on steps the facility has taken to ensure compliance. Documentation will be sent to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 4, 2026

(a) A plan for incidental medical and dental care shall be developed by each facility...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication and record review, the facility did not comply with the above cited section, as R2's medication orders are not clear and staff are putting 1/2 pills back into the bubble pack and multiple documentation and administration errors were observed, which posed an immediate risk to residents.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The facility has since changed pharmacies and has changed and retrained clinical staffing. Facility Designee agreed to work with the Administrator to document the changes made and staff training and send to CCL by POC due date.

Allegation investigated: Staff did not properly check on resident Staff did not ensure resident was given food

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation visit regarding the above allegations. LPA met with Executive Director (ED) Jonathan Wheeler and explained the reason for today's visit. Entrance interview conducted. During today's visit, LPA interviewed management at 12:10PM, toured the facility with the ED at 12:44PM, interviewed staff at 01:11PM and from 02:20PM to 03:34PM, interviewed Resident #1 (R1) at 02:00PM, and reviewed and obtained copies of relevant documents. The following was then determined: The complaint alleges that facility staff did not check on R1 for a period of time, leaving the resident in their room unattended. LPA reviewed R1's medical assessment and care plan, both of which indicate R1 is bedbound and requires assistance with repositoning. In R1's room, LPA observed a repositioning log, which staff fills out when they assist R1 with repositioning. The log for the current week was observed to Report Continued on LIC 9099-C Unsubstantiated be complete. Resident and staff interviews revealed that R1 is checked on and repositioned about every two (2) hours during the day and night. Interviews revealed there has not been a time when staff did not check on R1 or that any other resident reported they were not checked on timely. R1 indicated they have a call button to push if assistance is needed and that staff respond fairly quickly. The information obtained during the investigation did not include sufficient evidence 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. Regarding the allegation "staff did not ensure resident was given food," it was alleged that R1's food was not delivered to their room. Interviews revealed that R1 is on tray service, as R1 is bed-bound. When R1 first moved in, there was one (1) occasion where R1's tray was brought to their room, but R1 did not wish to eat at that time and the tray was removed from R1's room prior to R1 eating. However, R1 indicated this was resolved and there have been no concerns related to their meals since. During today's visit, LPA observed R1 with their tray on the bedside table and R1 was eating and drinking. Staff interviewed indicated that either dining staff or caregiving staff, whichever is available earliest, delivers meals to the residents who are on tray service. Caregiving staff will then collect trays from the residents upon meal completion. Interviews revealed there has never been a time any resident did not receive a meal. The information obtained during the investigation did not include sufficient evidence 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. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 29-AS-20260310104054

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek conducted a required annual visit and discussed a recent self reported incident sent to Community Care Licensing on 10/28/2025 involving Staff #1 (S1) and Resident #1 (R1). LPA was greeted by the receptionist upon arrival. LPA met with the family liaison and wellness coordinator and explained the reason for the visit. LPA requested documents for review. Administrator SanJuana Joanna Enriquez arrived at 10:23AM. Entrance interview conducted. At 11:04AM, LPA along with Administrator and family liaison 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 noted: The facility is a 3-story building, with common areas and resident rooms on all three (3) floors. The facility's memory care unit is located on the first floor and there are Assisted Living resident rooms on all three (3) floors. BEDROOMS: LPA inspected ten (10) resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. LPA observed a sufficient supply of towels and linens. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. Hot water temperature was measured in various rooms in both the memory care and assisted living units and ranged from 106.2 degrees to 110.2 degrees Fahrenheit, which is within the required range. Report Continued on LIC 809C COMMON AREAS: Common areas include a theater, activity rooms, therapy room, game room, sweet shop, and dining room. Furniture in the common areas was observed to be in good condition. Carpet throughout the building was observed to be dirty and/or stained. Administrator stated the facility just purchased a carpet extractor, which will allow the facility to clean their carpets more thoroughly and regularly. The facility maintained a comfortable temperature throughout the visit. The fire extinguishers were fully charged and were last serviced May 6, 2025. LPA observed required postings throughout the common space. LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. The facility has an adequate supply of Personal Protection Equipment (PPE). The facility has a fenced in pool in the courtyard that has two locked gates. There was patio furniture and shade for residents. KITCHEN: LPA inspected the kitchen/food service area, which is shared between this facility and the neighboring Skilled Nursing Facility. 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 as well as an emergency supply of food and water kept in supply rooms on the third floor. Refrigerator and food pantry were checked for proper labels and expiration dates. RECORDS: LPA reviewed five (5) resident records; all records were complete. LPA reviewed five (5) personnel records; all records were complete. EMERGENCY DISASTER PLAN/INFECTION CONTROL PLAN: LPA reviewed the facility emergency disaster plan and infection control plan, both of which were complete and updated annually as required. The facility conducts monthly evacuation drills. Each month the drills are conducted during a different shift in order to meet quarterly training requirements. MEDICATIONS: Due to time constraints, medications will be reviewed during the annual continuation visit. DOCUMENTS OBTAINED: LPA obtained a copy of the facility's resident roster, personnel roster, and current liability insurance. LPA also reviewed and obtained copies of documents for R1 and S1 relevant to the self-reported incident. INTERVIEWS: LPA interviewed three (3) residents and four (4) staff; no concerns were noted. LPA will return at a later date to continue the annual inspection and to conduct further investigation into the self-reported incident. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Oct 31, 2025

Type of visit: Office

On 08/21/2025, an Informal Conference was held at the Woodland Hills North Adult and Senior Care Regional Office. In attendance included Licensing Program Manager (LPM) Kristin Heffernan, Licensing Program Analyst (LPA) Kelly Dulek, Administrator SanJuana “Joanna” Enriquez, Clinical Director David Rivas, RN, Market Leader Ann Margaret Zavela, RN, Interim Executive Director (ED) Monica Guardian, and Clinical Market Leader Roanne de los Reyes. The purpose of this Informal Conference is to discuss complaint investigation 29-AS-20240829092756 and a self-reported altercation that occurred on 08/05/2025 between a resident and staff. Prior to the start of the Informal Conference, the Licensee was given the opportunity to review the Community Care Licensing (CCL) file for Lexington Assisted Living (565850111), containing licensing reports for the past three years. The facility was licensed on 11/30/2020 and the current census is 69. On 08/29/2024, the RO received a complaint with allegations that included a questionable death, medications not being given as prescribed, and a resident’s room left unkempt. The investigation was referred to the Department’s Investigations Branch, and it was concluded that Resident #1 (R1) was not given their seizure medication during the approximate 10 days that R1 resided at the facility. As a result, R1 suffered a seizure on 08/13/2024, that required hospitalization. While hospitalized, R1 suffered a second, fatal seizure and expired on 08/20/2024. However, due to R1’s previous diagnosis, the facility was not found liable for R1’s death. The physical plant allegation of an unkempt room was also unsubstantiated. Report Continued on LIC 809-C During today’s conference, the licensee stated they have since augmented their intake procedures to include immediately logging all medications received into the facility’s centrally stored medication record. Additionally, facility staff review what medications are received upon move in and cross-reference a medication list the resident’s physician has signed to ensure all medications are received and can be administered as prescribed. In addition, on 08/05/2025, the RO received an incident report detailing a verbal altercation that took place between multiple staff members and R2. Subsequently, one staff sought medical treatment after the incident and was put on medical leave. Clinical Director explained the situation with R2 and the staff and steps that have been taken since the date of the incident. Staff have been attempting to redirect R2 and using additional de-escalation techniques. Training will be conducted with staff on Thursday 08/28/2025 to address concerns raised during this incident. Training will also be provided to all new incoming staff. Proof of training will be sent to CCL upon completion. Exit interview conducted and copy of today's report was provided to the licensee representatives.the state’s words, verbatim · CDSS document, Aug 21, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kelly Dulek and Licensing Program Manager (LPM) Kristin Heffernan met with Acting Administrator SanJuana “Joanna” Enriquez, Clinical Director David Rivas, RN, Market Leader Ann Margaret Zavela, RN, Interim Executive Director (ED) Monica Guardian, and Clinical Market Leader Roanne de los Reyes at the Woodland Hills Regional Office on 08/21/2025 to follow up on a substantiated allegation of a complaint investigation. On January 21, 2025, the Department concluded a complaint investigation regarding the following allegation: Neglect/Lack of Care and Supervision – Resident #1 (R1) required medical attention due to staff’s failure to dispense prescribed medication while in care of the facility. The licensee was cited for California Code of Regulations (CCR) 87465(a)(4) Incidental Medical and Dental Care. At the time of the complaint visit on January 21, 2025, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. The Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code§ 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the staff not administering prescribed medication to R1, which resulted in a seizure that required medical attention and hospitalization. Report Continued on LIC 809-C Today 08/21/2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on January 21, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report was issued. Appeal rights provided. SanJuana (Joanna) Enriquez and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 21, 2025

Allegation investigated: Staff did not provide adequate supervision resulting in resident leaving the facility.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegation. LPA met with Interim Executive Director (ED) Joanna Enriques and Clinical Director Davi Rivas, RN, and explained the reason for the visit. On 5/15/2025, LPA reviewed documents and video, interviewed the clinical director, and interviewed Resident 1 (R1). On 7/10/2025, LPA reviewed documents and was informed R1 moved out of the facility as they preferred living with relatives. During LPA's interview with R1 on 5/15/2025, R1 was oriented to time, place, and person. R1 recalled the incident which occurred on the day they moved into the facility. R1 stated they were looking for their daughter after furniture had been delivered. R1 did not realize their daughter had left to use the (continued to LIC9099C) Unsubstantiated (continued from LIC9099) restroom and thought their daughter had gone downstairs to greet other family who were coming to visit that evening. R1 was only confused about where their daughter went, not where they were. R1 went to the facility to recover from a medical condition. R1 needed to use a wheelchair due to being weak from recovery but could maneuver the wheelchair on their own. R1's physician's report stated they needed physical transfer assistance. R1 does not have a cognitive disability. Based on documents, interviews and observation, this allegation is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 29-AS-20250509105450

Allegation investigated: Facility staff did not assist resident with hygiene as needed Facility staff did not assist resident with medical care as needed Facility staff maintained a resident beyond their level of care

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegation. LPA met with Interim Executive Director (ED) Joanna Enriques and Clinical Director Davi Rivas, RN, and explained the reason for the visit. On 6/26/2025, LPA conducted the initial complaint investigation visit and reviewed pertinent documents. On 7/10/2025, LPA reviewed further documents, interviewed the Clincial Director, and interviewed Resident 1 (R1) at the adjacent skilled nursing facility. (continued on LIC9099C) Unsubstantiated (continued from LIC9099) Regarding the allegations "Facility staff did not assist resident with hygiene as needed" and "Facility maintained a resident beyond their level of care": R1 has a healing wound which is not related to a pressure injury. Due to the type of wound, it can result in tissue breakdown which may cause a release of volatile compounds sometimes creating a strong odor. The facility staff followed physicians' orders to keep the wound covered, however the smell was sometimes offensive. Residential Care Facilities can keep residents who have healing wounds not caused by pressure. R1 was receiving home health services for the wound care. In addition, R1 was on a shower schedule of two days per week. R1 would occasionally refuse assistance with showers which is noted in the facility's records. Based on this information, these allegations are deemed UNSUBSTANTIATED at this time. Regarding the allegation "Facility staff did not assist resident with medical care as needed": The Clinical Director was working with R1's representative to get R1 to a physician to further address the care needed for the wound on R1's head. R1's primary physician referred R1 to a dermatologist. The dermatologist told R1 and their representative they could not treat the wound and R1 would need to see a plastic surgeon. The dermatologist did address other skin concerns and R1 visited the dermatologist four times over a four month period. During that time, R1's representative and the Clinical Director made attempts to find a plastic surgeon that would accept R1's insurance. On 5/9/2025, R1 was sent to a local hospital and then to a skilled nursing facility (SNF). When visiting with R1 on 7/10/2025, the wound was completely covered but there was still some odor. R1 stated they were unhappy staying at the SNF and they preferred the care they received at the facility. R1 felt their medical needs were addressed by the facility staff and did not have any complaints. Based on these observations and interviews, this allegation is deemed UNSUBSTANTIATED at this time. No deficiencies cited. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 29-AS-20250620120900

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

Licensing Program Analyst (LPA) Teresa Camara conducted a case management legal/non-compliance visit. LPA met with Interim Executive Director (ED) Joanna Enriquez and Clinical Director David Rivas, RN, and explained the reason for the visit. At 11:56 a.m. LPA conducted a medication audit for five residents' medications, which included medications on-cycle, medications not on-cycle, and PRN medications, including narcotics. All of the medications were correctly documented and all had physicians' orders. The ED and Clinical Director have set up frequent medication training to address any issues regarding documentation and plan to utilize a pharmacy representative for quarterly audits as well. No citations issued. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 17, 2025

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

Licensing Program Analyst (LPA) Teresa Camara conducted a case management legal/non-compliance visit. LPA met with Interim Executive Director (ED) Joanna Enriquez and Clinical Director David Rivas, RN, and explained the reason for the visit. At 1:45 p.m. LPA conducted a brief tour of selected areas of the facility. LPA toured the memory care unit and the kitchen. There was a sufficient supply of perishable and non perishable food. LPA started a medication audit at 2:13 p.m. Further review of the medications is needed to ensure an appropriate number of samples have been reviewed. LPA will return at a later date to finish the medication audit. No citations issued. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 10, 2025

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

Licensing Program Analyst (LPA) Teresa Camara conducted a case management legal/non-compliance visit. LPA met with Clinical Director David Rivas, RN, and explained the reason for the visit. LPA's focus during this visit was to audit medications. LPA reviewed medications for Resident 1 (R1) and found the following: The centrally stored medication and destruction record (CSMDR) was missing the start dates on nearly all of R1's medications. Some of the medications are "on cycle" meaning they were started on the first of each month but some of R1's medications are not "on cycle" meaning they were started on different dates which were not noted on the bubble pack nor were they noted on the CSMDR. One of the medications was started on cycle. The medication administration record stated the medication was given each day but there were still pills in the bubble pack for 6/5,6,7,10,17/2025. 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. An immediate civil penalty of $1,000 is assessed for a repeat violation within one year. Failure to correct the deficiencies may result in further civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jun 26, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 3, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed, the licensee did not comply with the section cited above. R1's medications were not given as prescribed; staff did not properly document medication administration or start dates, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2025

Plan of correction: The Clinical Director will conduct training with the medication technicians on proper documentation and medication administration by 7/3/2025.

Type of visit: Case Management - Other

Licensing Program Analyst, Teresa Camara arrived on June 13, 2025, for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation (complaint control number 29-AS-20210226132843). LPA met with Clinical Director Davi Rivas, RN. On February 24, 2022, the Department concluded a complaint investigation regarding the following allegation: Resident #1 (R1) sustained multiple fractures while in care. The licensee was cited for Health and Safety Code §1569.312 Basic Services Requirements. At the time of the complaint visit on February 24, 2022, 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(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing proper care and supervision for R1 that resulted in multiple fractures from multiple falls. (continued LIC809C, page 2) (continued from LIC809, page 1) Today, June 13, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on February 24, 2022, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided to Clinical Director David Rivas, RN and 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 have not reassessed resident for change in level of care Staff do not ensure facility carpeting is clean Staff do not ensure facility elevator is maintained

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegation. LPA met with Administrator Jill Morris Chapman and explained the reason for the visit. At 10:35 a.m. LPA requested pertinent documents. At 10:55 a.m. LPA spoke with the maintenance director. At 11:00 a.m. LPA spoke with the administrator and reviewed documents. At 11:40 a.m. LPA and Administrator attempted to locate Resident 1 (R1) at the facility, however R1 left for a walk and was not going to be back for an extended time. At 12:05 p.m. Administrator texted R1 who responded the complaint "was a mistake based on a misunderstanding." R1 stated after meeting with the Administrator and Long Term Care Ombudsman everything was clarified and R1 does not wish to pursue this complaint. Based on this information, the above noted allegations are deemed Unsubstantiated at this time. Exit interview conducted and report issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 17, 2025 · control 29-AS-20250108110215

Allegation investigated: Staff does not ensure residents care needs are being met

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegation. LPA met with Administrator Jill Morris Chapman and explained the reason for the visit. At 10:35 a.m. LPA requested pertinent documents. At 10:55 a.m. LPA spoke with the maintenance director. At 11:00 a.m. LPA spoke with the administrator and reviewed documents. At 11:40 a.m. LPA and Administrator attempted to locate Resident 1 (R1) at the facility, however R1 left for a walk and was not going to be back for an extended time. At 12:05 p.m. Administrator texted R1 who responded the complaint "was a mistake based on a misunderstanding." R1 stated after meeting with the Administrator and Long Term Care Ombudsman everything was clarified and R1 does not wish to pursue this complaint. Based on this information, the above noted allegation is deemed Unsubstantiated at this time. Exit interview conducted and report issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 17, 2025 · control 29-AS-20250116105947

Allegation investigated: Facility staff locked resident in bedroom Facility staff did not ensure resident’s records were complete

Licensing Program Analyst (LPA) Teresa Camara conducted a complaint investigation visit regarding the above noted allegations. LPA met with administrator Jill Morris Chapman and explained the reason for the visit. At 1:05 p.m. LPA interviewed administrator. At 1:25 p.m. and 1:40 p.m. LPA interviewed staff. At 1:50 p.m. LPA conducted a room inspection in the former room of resident 1 (R1). Regarding the allegation facility staff locked resident in bedroom: The door was locked so that other residents could not wander into R1's room. This was for R1's safety and preference as R1 did not like other residents in their room. R1's door could be opened from the inside by just turning the door lever; R1 would not have to unlock the door themselves. Based on this information, this allegaiton is deemed Unsubstantiated at this time. (continued on LIC9099-C) Unsubstantiated (continued from LIC9099) Regarding the allegation facility staff did not ensure resident's records were complete: This allegation was regarding R1 being on hospice but not having a completed POLST document. R1 was not conserved nor did R1 have anyone with Power of Attorney over their medical decisions. R1 did not have a next of kin or other responsible party known to the facility. The administrator had been reaching out for assistance from the Long Term Care Ombudsman and Ventura County Adult Protective Services since October of 2024 to get a public guardian for R1. The administrator worked with the hospice agency to get R1 on hospice. The hospice agency obtained reports from two independent physicians as well as their own physician to approve R1 for hospice services. However, all of the physicians stated they could not ethically complete the POLST/DNR (do not resucitate) for R1. R1 was not able to make decisions for themselves. Therefore, the POLST was incomplete. Based on this information, this allegation is deemed Unsubstantiated at this time. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 29-AS-20250311133256

Allegation investigated: Neglect/Lack of Care and Supervision – Resident #1 (R1) required medical attention due to staff’s failure to dispense prescribed medication while in care of the facility.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with administrator Jill Morris Chapman and explained the reason for the visit. On 08/29/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding neglect/lack of care and supervision. The complaint alleged that Resident #1 (R1) required medical attention due to staff’s failure to dispense prescribed seizure medication while in care of the facility. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Sonia Torre. (continued on page 2, LIC9099-C) Substantiated (continued from page 1, LIC9099) On 08/30/2024, from 11:49 a.m. to 12:10 p.m., LPA Camara conducted an initial complaint investigation visit regarding the above allegation. At 9:18 a.m., the LPA interviewed Staff 1 (S1). Starting at 9:39 a.m., the LPA reviewed and obtained pertinent documents. On 11/21/2024, from approximately 10:55 a.m. to 1:02 p.m., Investigator Torre conducted interviews with the facility Clinical Director, staff, and Administrator; on 12/17/2024, at approximately 4:58 p.m., with a former staff; and on 12/19/2024, at approximately 8:44 a.m., with R1’s primary Neurologist. In addition, the investigator reviewed Community Memorial Hospital medical records, Sevita NeuroRestorative Rehabilitation medical records, Hoag Hospital medical records, 911 audio call, and facility file documents related to the investigation. According to the Physician’s Report, dated 08/01/2024, R1’s primary diagnosis was listed as astrocytoma (brain cancer) and the secondary diagnosis was shunt revision (medical device to drain excess cerebrospinal fluid from the brain to the abdomen). Physical health status was noted as fair with motor impairment. R1 was noted to being confused and able to communicate occasionally indicating expressive aphasia. R1 required assistance with activities of daily living (ADLs) and instructions to the facility were to monitor head for swelling. The prescribed medication section indicated to see provided list, which was the medication review report. The medication review report revealed the prescribed medication included the following: Lacosamide Oral Tablet 100 MG – one tablet by mouth two times a day for seizure disorder. Levetiracetam Oral Tablet 750 MG – two tablets by mouth two times a day for seizure disorder. R1’s service plan indicated R1 needed medication administration and/or treatment assistance required on a regular basis, including PRN medication. A review of the Sevita NeuroRestorative Rehabilitation medical records revealed that R1’s past medical history included brain cancer with astrocytoma, asthma, hyperlipidemia, history of seizures and status post multiple VP shunt revisions done by the Neurosurgical team at Hoag Hospital. On 08/03/2024, at 3:00 p.m., R1 was discharged from Sevita NeuroRestorative Rehabilitation to the Lexington Assisted Living facility. (continued to page 3, LIC9099-C) (continued from page 2, LIC9099-C) A review of the facility Medication Assistance Records (MARs) for R1 revealed nine prescribed medications. R1 was administered the seizure medication Levetiracetam Oral Tablet 750 MG two tablets, twice a day which began on 08/04/2024. The record revealed a blank entry on 08/11/2024. The record also did not list R1’s other prescribed seizure medication Lacosamide Oral Tablet 100 MG – one tablet by mouth two times a day. Furthermore, a review of the missed medication report revealed on 08/11/2024, the following medication was not administered to R1 – Levetiracetam 750 MG – two tablets by mouth; Megestrol Acetate 20 MG – one tablet by mouth; and Acetazolamide 250 MG – one tablet by mouth. In addition, the Centrally Stored Medication and Destruction Record and Facility Active Medication Report revealed only one seizure medication was documented. The review of the Unusual Incident Report revealed on 08/13/2024 at approximately 11:00 a.m., R1 was found in bed shaking uncontrollably by staff. Staff called 911 and R1 was transported to Community Memorial Hospital. According to the medical records, R1 was admitted to the hospital for tonic-clonic seizure due to not being given the right dosages of seizure medication. R1 was diagnosed with acute respiratory failure, metabolic encephalopathy, on mechanically assisted ventilation, seizure, shock, and hydrocephalus. The secondary diagnosis included anxiety with depression, hypertension, limited code, physical debility, glioblastoma, and metabolic acidosis. R1 was intubated and sedated. On 08/15/2024, R1 was transferred to Hoag Hospital for further evaluation and management. Based on the Department’s investigation, the medical records revealed R1 was prescribed two seizure medications that were administered at the rehabilitation facility R1 was admitted to prior to R1’s discharge to the facility. The facility records revealed the Medication Assistance Records (MARs) did not capture one of the prescribed seizure medications (Lacosamide 100MG) which was on the medication list attached to the Physician’s Report. Furthermore, review of the facility MARs revealed the seizure medication (Lacosamide 100MG) was not listed on R1’s medication list or ever administered to R1. The interview of the facility Clinical Director revealed the facility did not compare the medication bottles R1 arrived with at admission with the (continued on page 4, LIC9099-C) (continued from page 3, LIC9099-C) medication list provided on the Physician’s Report. The review of the 911 audio call revealed the caller stated R1 was observed “experiencing a seizure” before becoming unresponsive. The interview of R1’s primary Neurosurgeon revealed that both seizure medications were equally important and the failure to administer one of the two would result in a seizure. Thus, the missed dosages of R1’s seizure medication during the 10-day stay at the facility, more than likely caused the seizure. Therefore, the allegation “Neglect/Lack of Care and Supervision – Resident #1 (R1) required medical attention due to staff’s failure to dispense prescribed medication while in care of the facility” is deemed Substantiated at this time. A $1,000 immediate civil penalty is assessed today due to licensee was cited for the same deficiency within a 12-month period (87465(a)(4) on 08/22/2024). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. (continued from LIC9099A, page 1) On 08/30/2024, from 11:49 a.m. to 12:10 p.m., LPA Camara conducted an initial complaint investigation visit regarding the above allegations. At 9:18 a.m., the LPA interviewed Staff 1 (S1). Starting at 9:39 a.m., the LPA reviewed and obtained pertinent documents. On 11/21/2024, from approximately 10:55 a.m. to 1:02 p.m., Investigator Torre conducted interviews with the facility Clinical Director, staff, and Administrator; on 12/17/2024, at approximately 4:58 p.m., with a former staff; and on 12/19/2024, at approximately 8:44 a.m., with R1’s primary Neurologist. In addition, the investigator reviewed Community Memorial Hospital medical records, Sevita NeuroRestorative Rehabilitation medical records, Hoag Hospital medical records, 911 audio call, County of Orange certificate of death, and facility file documents related to the investigation. According to the Physician’s Report, dated 08/01/2024, R1’s primary diagnosis was listed as astrocytoma (brain tumor) and the secondary diagnosis was shunt revision (medical device to drain excess cerebrospinal fluid from the brain to the abdomen). Physical health status was noted as fair with motor impairment. R1 was noted to being confused and able to communicate occasionally indicating expressive aphasia. R1 required assistance with activities of daily living (ADLs) and instructions to the facility were to monitor head for swelling. The prescribed medication section indicated to see provided list, which was the medication review report. The medication review report revealed the prescribed medication included the following: Lacosamide Oral Tablet 100 MG – one tablet by mouth two times a day for seizure disorder. Levetiracetam Oral Tablet 750 MG – two tablets by mouth two times a day for seizure disorder. R1’s service plan indicated R1 needed medication administration and/or treatment assistance required on a regular basis, including PRN medication. A review of the Sevita NeuroRestorative Rehabilitation medical records revealed that R1’s past medical history included brain cancer with astrocytoma, asthma, hyperlipidemia, history of seizures and status post multiple VP shunt revisions done by the Neurosurgical team at Hoag Hospital. On 08/03/2024, at 3:00 p.m., R1 was discharged from Sevita NeuroRestorative Rehabilitation to the Lexington Assisted Living facility. (continued on LIC9099C, page 3) (continued from LIC9099C, page 2) The review of the Unusual Incident Report revealed on 08/13/2024 at approximately 11:00 a.m., R1 was found in bed shaking uncontrollably by staff. Staff called 911 and R1 was transported to Community Memorial Hospital. According to the medical records, R1 was admitted to the hospital for tonic-clonic seizure due to not being given the right dosages of seizure medication. R1 was diagnosed with acute respiratory failure, metabolic encephalopathy, on mechanically assisted ventilation, seizure, shock, and hydrocephalus. The secondary diagnosis included anxiety with depression, hypertension, limited code, physical debility, glioblastoma, and metabolic acidosis. R1 was intubated and sedated. On 08/15/2024, R1 was stable to be transferred to Hoag Hospital for further evaluation and management. A review of the Hoag Hospital medical records revealed R1 presented to the hospital from Ventura Community Hospital on 08/16/2024, at approximately 2:30 p.m., complicated by respiratory failure with suspicion from aspiration pneumonia. R1 was intubated following a witnessed seizure. The records noted R1 was last hospitalized in July 2024 with sepsis due to cellulitis of the skull with wound dehiscence of surgical site. In addition, R1 had a history of astrocytoma status post multiple surgical resections and now with VP shunt followed by Neurologist Dr. Duma. Due to unlikelihood of R1 making any meaningful progress, R1’s resident representatives opted for comfort focused care. On 08/18/2024, R1 was extubated, and NG tube was removed. R1 remained on IV seizure medications. R1 expired at the hospital on 08/20/2024, at 3:38 p.m. The cause of death was pulmonary arrest within minutes, aspiration pneumonia (no choking) within days, and end stage astrocytoma within months. Multiple surgical tumor resections since 2023 and seizure disorder were noted. Based on the Department’s investigation, the medical records revealed R1’s medical history included astrocytoma (brain tumor) diagnosed in 2016 with recurrence, history of hydrocephalus (water in the brain) status post VP shunt placement in November 2023, and recent (07/01/2024) VP shunt revision. The interview of R1’s primary Neurosurgeon, Dr. Duma revealed he did not contribute R1’s death to the missed medication and subsequent seizure. Dr. Duma stated R1’s death was inevitable due to R1’s extensive medical history and medical condition (“very bad, large brain tumor”). Therefore, the allegation “Questionable Death – Resident #1 (R1) sustained multiple seizures and subsequently expired due to staff’s neglect” is deemed Unsubstantiated at this time. (continued on LIC9099C, page 4) (continued from LIC9099C, page 3) During a visit to the facility on 1/16/2025, LPA Camara conducted a brief tour of the memory care unit starting at 3:35 p.m. and toured several rooms which all appeared clean and tidy. LPA interviewed two staff at 3:40 p.m. and 3:43 p.m. who both worked at the facility during R1's stay at the facility. Both staff recalled R1, both staff recalled R1 had some incontinence care needs, however neither staff ever recalled seeing R1's room left unkempt or R1's shower chair being left soiled. One staff indicated sometimes during showers residents will have bowel movements during the shower which requires extra cleaning. The staff will clean it during the shower, however it requires scrubbing after the shower is completed. That staff did not recall seeing R1's chair left dirty. Based on the observations of the rooms in the memory care unit and interviews with staff, the allegation R1's room was left unkempt is deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report issued.the state’s words, verbatim · CDSS document, Jan 21, 2025 · control 29-AS-20240829092756

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 29, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not dispense prescribed medication to R1, which resulted in a seizure and required medical attention, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2025

Plan of correction: Licensee will submit a plan how you will ensure residents receive prescribed medication. Submit to CCL by 1/29/2025. An immediate civil penalty of $1,000 as this is a repeat violation and is warranted in accordance with California Health and Safety Code Section 1548(d).

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240829092756). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation unrelated to the complaint. During today’s visit, LPA met with administrator Jill Morris Chapman and the reason for the visit was explained. During the complaint investigation, the following deficiencies were observed: The facility Clinical Director indicated the practice for new residents who arrived at the facility with medication was to centrally store the medication and manually input each medication into their MAR (Medication Assistance Record) system. However, the physical medication was not cross-referenced with the LIC602 Physician Report medication list. The Clinical Director was unable to confirm R1’s medication list was cross referenced with the centrally stored medication R1 arrived with to ensure all of R1’s prescribed medication was accounted for and available. This caused R1 to not receive one of the seizure medications for 10-days, which resulted in a seizure and hospitalization. A review of R1’s Physician Report revealed the report was not complete as the physician’s signature was missing. 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 conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jan 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(j) · Plan of correction due date: Jan 29, 2025

Incidental Medical and Dental Care (j) In all facilities licensed for 16 persons or more, one or more employees shall be designated…for assisting residents as needed with self-administration of medications... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1’s medication was not cross referenced with the prescribed medication list which caused R1 to not receive one of the seizure medications for 10 days, which resulted in a seizure and hospitalization, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2025

Plan of correction: The licensee will submit the policies and procedures regarding medication audits and reconciliation in order to ensure new residents and existing residents receive all medication as prescribed. Submit proof to CCL by 1/29/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: Jan 29, 2025

87458(a) Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1’s medical assessment was missing physician signature, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2025

Plan of correction: The licensee will submit a plan how you will ensure resident documents are complete, including signatures and dates. Submit proof to CCL by 1/29/2025.

Allegation investigated: Lack of supervision resulting in injury.

THIS IS AN AMENDED REPORT Licensing Program Analyst (LPA) Erika Miller (Miller) conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Jill Morris Chapman, Administrator and explained the purpose of the visit. Previously, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit to investigate the above allegations and met with Ashley Villarreal, Community Liaison. LPA Yee conducted an interview with Ashley Villarreal and collected relevant documentation. Allegation: It was alleged that there was a lack of supervision resulting in injury. Resident 1 (R1) was admitted to facility on 6/13/23 and admitted to hospice on 6/14/23. Based on the 6/16/23 incident report created by facility, R1 was found on the floor of their room at 8:30 a.m. and subsequently transported to hospital per family member request. R1 moved out of the facility on 6/19/23. Administrator advised that R1 did not return to Faciilty, as such hospital discharge paperwork was not provided. (Contintued on 9099-C) Unsubstantiated As of 12/30/24, R1’s family could not be contacted as the phone number was no longer in service, as such R1 could not be contacted. Administrator at the time of the incident is no longer employed at the facility and current administrator has no knowledge of the incident that occurred on 6/16/23. LPA Miller reviewed 6/12/23 LIC 602, that stated R1 had end stage dementia and no capacity for self-care. R1 is non-ambulatory based on both physical and mental condition. LPA reviewed R1’s Needs and Services Plan that indicated R1 required one person assistance with oral, skin and daily grooming and requires a reminder assistance with dressing and undressing. Based on the information available, there was no indication R1 required additional supervision that was not provided and that led to the injury. Administrator, Jill Morris Chapman stated that that on 6/15/23, there were 14 Memory Care residents and 68 independent and assisted living residents. Based on the records, on 6/15/23 there was 1 staff working NOC shift in Memory Care and on 6/16/23 there were 2 staff working AM shift Memory Care. Administrator stated that facility currently has 12 residents in memory care and 1 NOC staff is sufficient, as clients are settled down between the hours of 10:00 p.m. and 6:00 a.m. Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. An Exit interview conducted and a copy of this report an appeal rights were issued. LPA reviewed 6/16/23, Incident Report, that indicates R1 was observed on floor at 8:30 a.m. The document states, “Hospice Notified” and R1 taken to Ventura County Medical Center. It is unclear who prepared the report. It is relevant to note that there is no record that this document was submitted to Community Care Licensing. It appears that Mission Hospice was notified. There is no evidence to support that family member was notified as required by regulations. Based on LPAs record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D. An Exit interview conducted and a copy of this report an appeal rights were issued.the state’s words, verbatim · CDSS document, Jan 6, 2025 · control 29-AS-20230620161947

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Jan 13, 2025

Each licensee shall furnish to ... licensing ...such reports as the Department may require, (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...... This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when staff did not notify person responsible for resident within seven days of the fall, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2025

Plan of correction: Administrator agrees to ensure that staff review reporting requirements and send statement of understanding to LPA Erika Miller.

Allegation investigated: Staff are not meeting the resident's medical needs. Staff do not administer medications as prescribed.

Licensing Program Analyst (LPA), Martha Arroyo 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 04/26/2024 and a subsequent complaint visit was conducted on 05/22/2024, both by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Jill Morris Chapman. Entrance interview. During the initial visit on 04/26/2024, LPA Arroyo conducted an interview with one (1) staff member at 10:12 a.m., conducted a resident file review at 10:45 a.m., and obtained copies of pertinent documents. On 05/22/2024, LPA Arroyo conducted interviews with one (1) staff, four (4) randomly selected residents, and two (2) randomly selected residents’ responsible person between 11:23 a.m. and 2:09 p.m. LPA also conducted a medication audit on two (2) randomly selected resident’s centrally stored medications between 2:10 p.m. and 3:30 p.m. and obtained copies of pertinent documents. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff are not meeting the resident’s medical needs. It was reported that Resident #1 (R1) is very sick with bed sores, has sustained falls, and is not getting the care they need at this facility. The physician’s report for R1, dated 03/29/2024, lists R1's primary diagnoses as type 2 diabetes mellitus and mild cognitive impairment. The report also indicates that R1 has a history of skin conditions or breakdowns, including a stage 2 pressure ulcer on the right buttock. Although the report notes R1’s mental state as confused and disoriented, R1 is able to communicate their needs. According to staff, Buena Vista Home Health was contacted to provide wound care for R1 starting on 04/10/2024, with visits scheduled once a week. Additionally, staff communicated regularly with R1’s Primary Care Physician (PCP), continuously reporting on R1’s fall, which occurred on 04/04/2024, as well as any pain or discomfort R1 experienced between 04/08/2024 and 04/10/2024. While no injuries were noted by staff and no pain was reported by R1 following the fall, the facility staff made sure to inform the PCP about the incident. Interviews with residents revealed that staff assist when called and that residents feel their needs are being met. Residents also reported having no concerns while living at the facility. Furthermore, interviews with family members revealed that they have no concerns regarding facility staff not meeting the resident’s needs. Based on the information obtained during the course of the investigation, the Department has insufficient evidence to support the allegation of “staff are not meeting the resident’s medical needs”. Therefore, this allegations is deemed Unsubstantiated at this time. It was also alleged that staff do not administer medications prescribed. It was reported that R1 is not receiving their medication prescribed for their diabetes. Records reviewed and interviews conducted revealed that R1 was admitted to the facility on 04/02/2024 from a skilled nursing facility (SNF). Staff reported that, while at the SNF, R1's insulin was administered according to parameters and sliding scales, allowing nurses to give insulin as needed. Additionally, staff communicated with R1’s PCP on 04/04/2024 to inform them that the facility could not administer insulin through sliding scales and requested clarification on the medication administration. However, R1’s PCP declined to prescribe the same medication as at the SNF, leaving the facility unable to administer insulin. Despite R1 continuing to request insulin, staff could not proceed without the proper order from the doctor, leading to R1 being sent to the hospital to ensure their health and safety. Interviews with other residents revealed that they received their medications daily without issues. Report Continued on LIC 9099C... Report Continued from LIC 9099... Furthermore, a medication audit of randomly selected residents revealed that medications were being administered as prescribed during the visit. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not administer medications as prescribed”. Therefore, this allegations is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 29-AS-20240418165616

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara conducted a required annual visit. LPA was greeted by the receptionist at 9:20 a.m. LPA met with the administrator Jill Morris Chapman and explained the reason for the visit. LPA requested documents for review. At 10:47 a.m. LPA along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: KITCHEN: 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 as well as an emergency supply of food and water kept in supply rooms on the third floor. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: Furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguishers were fully charged and were last serviced November 2024. LPA observed required postings throughout the common space. LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. 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 a fenced in pool in the courtyard that has two locked gates. There was patio furniture and shade for residents. (Report Continued on LIC 809C...) (Report Continued from LIC 809...) BEDROOMS: LPA inspected fourteen (14) resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. LPA observed a sufficient supply of towels and linens. Each room has a combination smoke detector and carbon monoxide detector, eleven (11) were tested and were operable at the time of the visit. RESTROOMS: The 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; towels and washcloths are not shared in the private rooms. The hot water temperature was measured at 10:51 a.m. at 121.6 degrees Fahrenheit in a memory care unit. The plant manager explained the hot water heaters are shared with the adjoining skilled nursing facility (SNF) and the water heaters are located on the SNF's property. The plant manager stated he would work with the SNF plant manager to ensure the water temperature for all floors of this facility are within the regulatory requirement of 105 - 120 degrees Fahrenheit. RECORDS: LPA reviewed five (5) resident records; all records were complete. LPA reviewed five (5) personnel records; all records were complete. LPA reviewed the last fire suppression system inspection which was just completed on 11/13/2024. The report stated the facility needs to replace some of the sprinkler heads due to visible rust. There was also a pressure control valve that required repair. The facility plant manager is working with the inspection company to obtain a bid for the repairs. He was expecting the bid today and would be following up with them. He stated once they get the bid and the work is approved by the facility's corporate office, the repairs should only take one day to complete. LPA reviewed the facility emergency disaster plan which was just reviewed for any needed updates on 7/19/2024. The facility conducts monthly evacuation drills. Each month the drills are conducted during a different shift in order to meet quarterly training requirements. LPA obtained a copy of the facility's current certificate of liability insurance. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) MEDICATIONS: LPA reviewed medications at 2:51 p.m. Medications are centrally stored in the medication room. Medications are labeled and checked for expiration dates. LPA observed the centrally stored medication and destruction record (CSMDR) was lacking the medication start date for resident 1 (R1). LPA observed the medication start dates on other CSMDRs for other residents were also missing. The medication technician explained they have started a new system where they put a sticker on the bubble pack or bottle cap indicating the start date so they can go back to complete the start dates on the CSMDRs. However, R1's bubble packs were missing those stickers, did not indicate the start date, nor were R1's bubble pack medications on cycle (meaning starting at the first of the month). Therefore, LPA was unable to determine if R1's medications were being given as prescribed. INTERVIEWS: LPA interviewed three (3) residents and three (3) 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 conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Nov 20, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Incident visit regarding a self-reported suspicion of elder financial abuse by a staff at the facility. LPA met with the administrator/executive director Jill Morris Chapman and explained the reason for the visit. At 10:00 a.m. LPA conducted an interview with the administrator. At 10:45 a.m. LPA collected pertinent documents. Further investigation is necessary. Exit interview conducted and a copy of the report issued.the state’s words, verbatim · CDSS document, Oct 11, 2024

Allegation investigated: Staff did not seek medical attention of residents in care Facility does not provide nutritious meals for residents in care Staff do not aid resident with incontinence needs Staff do not ensure resident's room is free from malodorous

Licensing Program Analysts (LPA) Esther Cortez arrived at 10:10 a.m., unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Jill Morris Chapman and explained the reason for the visit. On 03/06/2023, LPAs Esther Cortez and Martha Arroyo conducted facility tour at 12:27pm, toured the kitchen and observed food supply at 12:32pm, conducted interviews with the interim executive director, two staff, and one resident between 12:27pm and 3:55pm. The LPAs also conducted a file review and obtained copies of resident files and other pertinent document revelant to the investigation at 1:15pm. On 03/15/2023 LPA Cortez and Teresa Camara interviewed (3) three residents at 10:04 a.m., 10:16 a.m., 11:08 a.m.; and, interviewed (3) three staff at 2:40 p.m., 2:44 p.m., and 3:34 p.m. On 09/19/2024 LPA Cortez toured the Kitchen, observed lunch in the dinining room, and interviewed six (6) residents,one (1) staff, and the Executive Director. During today's visit, LPA Cortez briefly interviewed the ED, and obtained copies of pertinent documents revelant to the investigation. Report will continue on LIC9099-C: 2nd page. Unsubstantiated On the allegations that Staff do not ensure resident's room is free from malodorous; it is the reporting parties concern that Resident #1, and Resident #2’s room reeked of urine. It was further reported that R1’s bedding, clothing and carpet were saturated with urine and the urine odor was on the walls. To investigate the allegation, interviews and physical plant tours were conducted. Staff Interviews conducted revealed that the facility had a plumbing issue in the facility during February/March of 2023 on the same floor as R1 and R2’s room and the residents had been informed that the facility was working on the situation. The LPA was given a copy of the letter that was provided to the residents. Interview with R2, conducted on 03/06/2023 in the resident’s room, revealed that their room had smelled liked pee a few days prior, that it smelled like a bathroom, and that they had been given a flyer informing them of a bathroom leak at the facility. LPA Cortez did not detect any scents or smell of urine in R1’ and R2’s apartment or from any of the rooms or common areas toured during their visits at the facility. In addition, six (6) out of (eight) 8 residents interviewed regarding this allegation revealed that they have not had any issues or concerns of urine odors in their rooms or in the facility. The other two (2) residents interviewed referred to the plumbing issue in 2023, which was resolved. Based on the information gathered, although the allegation may have happened or is valid, the above allegation is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued. Facility’s menu obtained by LPA Cortez on 02/06/2023 reflected that the facility provided a variety of food options including Vegetarian options in 2023. Menu meals included stuffed peppers over marinara, baked potato, salads, spinach & cheese tortellini among other meals. Staff interviews revealed that the facility always has alternatives if residents do not like the meal for the day, including vegetarian alternatives such as a garden burger, pasta, tofu, grilled cheese sandwiches and others. Lastly, on 09/19/2024 the LPA observed resident’s eating a variety of foods in the dining room, some were eating spaghetti with meatballs, and others a chicken salad sandwich which based on the menu could be accompany with a garden salad, soup of the day, a dessert, and a beverage. Based on the information gathered, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that "Facility does not provide nutritious meals for residents in care," is deemed UNSUBSTANTIATED at this time. On the allegation that Staff do not aid resident with incontinence needs; it is the reporting parties concern that resident #1 and resident #2 were in need of diapers, could not leave the facility to purchase them, and nobody provided them for the residents. To investigate the allegation, LPA Cortez conducted a file review and interviews. File review revealed that according to R1 and R2's admission agreement the community shall not be responsible for furnishing or paying for any health care items or services not expressly included in the agreement, including but not limited to incontinence products under section 1.5 Services not included. Additionally, R1 and R2 were unable to leave the community unassisted according to their Physician's report (LIC602). Executive Director Jill stated that residents and or their responsible person are responsible for supplying incontinence supplies, and residents are encourage to order them from services such as Amazon. They further stated that R1' and R2's responsible person was not good at providing incontinence supplies. Staff interviews revealed that if residents run out of diapers staff will call the residents family/ responsible person for an emergency supply, or grab from the communities emergency supply that were donated. Furthermore, staff interviews revealed that staff have purchase supplies out of their own money for residents. Interview with a resident who requires incontinence supplies stated that residents provide their own supplies and did not think it would be fair for the staff to pay. Based on the information gathered, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that " Staff do not aid resident with incontinence needs," is deemed UNSUBSTANTIATED at this time. Report will continue on LIC9099-C: 4th page. On the allegation that Staff did not seek medical attention of residents in care: it is the reporting parties concern that Resident #1 and Resident #2 (R1, R2) did not have a doctor or medical support during the first year living at the facility. It was further reported that both residents had severe medical issues and their physical and cognitive faculties declined as nobody was taking them to the doctor or making sure they were getting all their previous medications. To investigate the allegation, LPA Cortez conducted a file review and interviews. Residential Care Facilities for the Elderly (RCFE) are non-medical facilities that are not required to have nurses or doctors on staff. Reviewed admissions agreement for R1 and R2 revealed that the residents and/or their authorized person are responsible for obtaining and paying for all health care services they require. Interview with (previous) Wellness Director revealed that if a resident needs medical attention it is protocol for the MedTech to assess the situation and make the decision to get medical help or the family if they have a Power of Attorney, depending on the situation. In addition, staff assist in arranging doctor appointments, however the Wellness Director stated that R1 and R2 did not have a doctor because they did not have insurance. Furthermore, the Wellness Director stated that they did everything they could to assist the residents and contacted the resident’s insurance to transfer it from their previous city to their current city but were having difficulties trying to assist them because they were not the resident’s family. They were able to contact other agencies, to get support for the residents. File review also revealed that the facility obtained medical attention for R2 in different occasions and submitted Incident Reports (LIC624) to CCL. Based on the information gathered, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that "Staff did not seek medical attention of residents in care,” is deemed UNSUBSTANTIATED at this time. On the allegation that Facility does not provide nutritious meals for residents in care, it is the reporting parties concern that the food at the facility is not nutritious, that Resident #2 (R2) is vegetarian, and that staff served R2 a scoop of over cooked spinach and old rice, and R1 was given two cooked frozen fish sticks and broth. It was further reported that R1 and R2 are not getting the calories or nourishment that they need causing their health to decline since placement. To investigate the allegation, LPA Cortez conducted interviews, file review and observations. Interviews with Seven (7) out of nine (9) residents who eat at the facility revealed that the food that the community provides is nutritious, well balanced, and that there is a variety of food. Residents also revealed that the facility provides options, and if a resident does not like something they are having, they can have staff fix them something that they want to eat, like a sandwich or a salad. Report will continue on LIC9099-C 3rd page.the state’s words, verbatim · CDSS document, Sep 30, 2024 · control 29-AS-20230301115936

Type of visit: Case Management - Incident

THIS IS AN AMENDED REPORT Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management-Incident visit due to deficiencies observed in the course of a complaint investigation (complaint control number 29-AS-20240829092756). LPA met with Administrator Jill Morris Chapman and explained the reason for the amended report. Resident (1) had a medical emergency on or about 8/13/2024. Staff called for emergency services and R1 was taken to the hospital. On or about 8/20/2024, R1 passed away at the hospital. Community Care Licensing (CCL) did not receive an incident report for R1's medical emergency. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted. Report and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Aug 30, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Sep 6, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report... within seven days of the occurrence... (A) Death of any resident from any cause regardless of where the death occurred... This requirement was not met as evidienced by: Based on record review, the licensee did not comply with the section cited above as CCL did not receive a death report regarding R1's passing on or about 8/20/2024, which poses a potential health, safety, or personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: Licensee will review reporting requirements and provide CCL with a written statement of understanding. Licensee will also submit the death report for R1. The written statement and death report are due on or before 9/6/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Sep 6, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report... within seven days of the occurrence...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as CCL did not receive an incident report when R1 suffered a medical emergency on or about 8/13/2024, which poses a potential health, safety, or personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: Licensee will review reporting requirements and provide CCL with a written statement of understanding. Licensee will also submit the death report for R1. The written statement and incident report are due on or before 9/6/2024.

Allegation investigated: Staff member inappropriately handled resident Staff not answering call lights timely Staff member spoke to resident inappropriately Staff unable to communicate with resident Food is inadequate in quantity and quality

Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a subsequent complaint visit. The LPA met with Marketing Director and explained the reason for the visit. Executive Director Jill Chapman was unavailable during today's visit. Entrance interview conducted. During today's visit, LPA obtained additional records and conducted a brief tour of the facility. During an initial complaint visit conducted on 02/06/2023, the LPA conducted an interview with Community Liason Director Ashley Villareal at 10:55AM, the LPA reviewed and obtained copies of pertinent documents, toured the facility along with Ashley Villareal at 11:18AM, viewed lunch service at 11:36AM, and conducted interviews with residents and staff from 11:38AM to 4:00PM. No health and safety hazards were identified during the visit. Throughout the course of the investigation, LPA reviewed relevant documents. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 (p.1) Allegation: "Staff member inappropriately handled resident:" The complaint alleges that staff handled Resident #1 (R1) roughly while transferring R1 to their wheelchair. LPA interviewed R1, who indicated that while some of the staff are really nice and gentle, there are some who twist and pull her arm, which hurts R1. LPA reviewed R1's physician's report and resident assessment. R1 has a diagnosis of dementia and physician's report indicates R1 has motor impairment/paralysis with a note stating "right arm movement." Resident did report to LPA that they have difficulty with their right arm, which makes dressing difficult. R1's physician's report and care assessment indicate R1 requires assistance with dressing and grooming as well as transfer assistance. Staff interview revealed that as R1 has limited mobility with their right arm, it is difficult to assist R1 with dressing and transfers, but that staff are gentle with R1 when providing care. Staff interviewed indicated that R1 hits the caregivers when they come into R1's room to provide care. R1 stated to LPA that R1 had not informed the caregivers that R1 has pain in their right arm and to avoid moving that arm when possible. However, later in the interview, R1 stated R1 threatened to hit the caregivers if they did touch her right arm. Interview with various residents revealed that staff are kind and gentle when assisting with care needs. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "staff member inappropriately handled resident" is deemed UNSUBSTANTIATED at this time. Allegation: "Staff not answering call lights timely:" The complaint alleges that when R1 called for assistance the staff do not respond timely. Record review revealed that R1 moved into the facility on 01/22/2023. Interviews revealed that prior to moving into the facility, R1 was residing in a private residence with a private 1:1 caregiver. Staff interviewed indicated that R1 was used to having a 1:1 staff, but that the facility does not have a 1:1 ratio. In the facility, there are 3 caregivers staffed at a time and that at times, although they hear a call, staff are busy assisting other residents and they have to wait up to 10 (ten) minutes for a response. Residents interviewed indicated that there are some times that are busier than others, but that typically the response time is pretty quick. Residents interviewed felt their needs were met timely and had no concerns with response time. Staff interviews revealed that the facility is fully staffed, no agency staffing was being used at the time of the complaint and that all staff are trained in the facility's policies regarding call response times. Based on Continued on LIC 9099-C (p.3) Continued from LIC 9099-C (p.2) interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "staff not answering call lights timely" is deemed UNSUBSTANTIATED at this time. Allegation: "Staff member spoke to resident inappropriately:" The complaint alleges that a member of the management staff yelled at R1 while in the elevator. LPA interviewed staff and residents regarding this allegation. R1 could not recall an incident where any member of management raised their voice or yelled at R1, stating "no they don't yell. I may yell because my husband couldn't hear, but they don't yell. They just don't listen." R1 had no recollection of an incident in the elevator. Staff interviewed have never witnessed any staff yell or be disrespectful with R1 or any other residents. Residents interviewed indicated the staff are nice and they have never heard staff yelling at residents. Although the allegation may be valid, based on interview, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that "staff member spoke to resident inappropriately" is deemed UNSUBSTANTIATED at this time. Allegation: "Staff unable to communicate with resident:" The complaint alleges that staff do not speak English and were not able able to communicate with R1. Interview with R1 revealed that there is a particular staff who "speaks Mexican" and did not understand R1. Interview with staff revealed that there are staff working at the facility that do not speak English as their primary language, however, when providing care to R1, the staff indicated in the complaint does take another staff with them into the room to help with any translation that might be needed. R1 confirmed that during the alleged incident that another staff was present and able to communicate with R1. During staff interviews, LPA was able to understand all staff interviewed. Residents interviewed indicated they have no problems related to staff communication or a language barrier. Based on interview, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "staff unable to communicate with resident" is deemed UNSUBSTANTIATED at this time. Allegation: "Food is inadequate in quantity and quality:" LPA interviewed staff and residents with regard to food. R1 did indicate that on the date of the LPA's initial visit, that R1 had fallen asleep in the recliner chair, so when R1 awoke from their nap to eat, the breakfast Report Continued on LIC 9099-C (p. 4) Continued from LIC 9099-A (p.5) Allegation: "Staff did not assist resident with self-administration of medications as prescribed:" The complaint alleges that R1 did not receive medication assistance for the first few days when they moved into the facility. Documents reviewed indicate that R1 was tentatively scheduled to move into the facility on Friday 01/20/2023, however, interview revealed that R1 moved in on Sunday 01/22/2023 at 04:00PM. LPA spoke with the medication technician who was in charge of the facility on Sunday. Interview revealed that R1's medications were brought to the front desk when R1 moved in on Sunday afternoon. Medication technician picked up the medications and administered the appropriate medications to R1 that evening. R1's medications were not immediately entered into the computer system, since the Wellness Director was not present at the time of R1's move in. Interview revealed that due to this, staff logged R1's medications on a paper Medication Administration Record (MAR) rather than the electronic MAR until R1's medications were input into the computer. LPA reviewed documents for R1, which did reflect medications recorded in the electronic system beginning Monday 01/23/2023 at 08:00PM. However, paper MAR records for Sunday and Monday were unable to located, nor was R1's centrally stored medication and destruction record (CSMDR). Additionally, although R1's medication list was provided, there were no quantities of medications listed, so there is no way of knowing which medications, if any, were administered during this time period. Interview with staff revealed that R1 was not given medications on Monday until R1's family member was at the facility Monday evening yelling at the staff. Based on interview and record review, the allegation that "staff did not assist resident with self-administration of medications as prescribed" is deemed SUBSTANTIATED at this time. Allegation: "Staff did not shower resident:" The complaint alleges that R1 did not receive a shower during their first week residing at the facility. Interview with R1 revealed that staff did not offer a shower "not at all" to R1 during that time period. Interview with staff revealed that typically residents are placed on the shower schedule the day of move in or the following day. R1 moved in at 04:00PM on a Sunday, so staff interviewed surmised that R1 was likely placed on the schedule on Monday once the staff got to know the resident and her shower preference. R1 was on the schedule on Tuesday and Friday in the afternoon shift for shower assistance. Interview with R1 revealed that now staff tell R1 that their daughter insists R1 showers, so R1 does comply with the current twice a week shower schedule, but again reiterated that no showers were offered in the first week R1 resided at the facility. Report Continued on LIC 9099-C (p.7) Continued from LIC 9099-C (p.6) R1's assessment indicates that R1 requires physical assist with bathing twice weekly. Staff interviewed stated that R1 was showered once during that first week and was unsure what occurred with the second shower. Staff indicated that likely R1 refused, but that shower refusals are documented. The facility was unable to provide any written proof that R1 had refused a shower during that time period. Documents provided indicated R1 received a shower on their 8th day residing at the facility. Therefore, based on interview and record review, there is sufficient evidence to support the allegation and the allegation that "staff did not shower resident" is deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted. A copy of the report and appeal rights were reviewed and provided. Continued from LIC 9099-C (p.4) that R1 had ordered and had been delivered was cold. R1 stated that often R1's food is cold when R1 is ready to eat. R1 stated if staff are available, they are able to reheat the food for R1 in a microwave provided in R1's room. Other residents interviewed indicated that for the most part they are happy with the food and feel it is of adequate quality and quantity. Residents indicated they have a choice in the meal provided and can order from an alternate menu should they choose. LPA observed lunch service and noted the meal did contain food from all food groups and residents appeared to enjoy their meal. The LPA observed sufficient amounts of varied food choices in all food groups, as well as emergency food and water available at the facility during the visits. Staff interviewed indicated that R1 chooses not to eat in the dining room and instead orders food to be delivered. Often, R1 falls asleep prior to ordering the meal in the morning or while the meal is being prepared. Staff did deliver a microwave to R1's room and will assist in heating the food at R1's request. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "food is inadequate in quantity and quality" is deemed UNSUBSTANTIATED at this time. No citations issued related to the above allegations. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 29-AS-20230201105127

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 22, 2024

87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 moved into the facility on 01/22/2023 and medications were not documented as administered until 01/24/2023, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Previous management indicated a retraining of all staff was conducted following the incident. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 22, 2024

87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the preadmission appraisal, with those activities of daily living such as dressing, eating, bathing... This requirement is not met as evidenced by: Based on interview and record review, R1 required assistance with 2 showers per week and according to documents reviewed, R1 did not reveive a shower for 8 days following move in, which poses a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Management staff indicated the facility now has a new computerized system to track all ADL care needs being provided to residents to ensure this does not happen in the future. POC cleared.

Allegation investigated: Neglect/Lack of Care and Supervision: Facility staff failed to provide medication for Resident #1 (R1) which contributed to R1’s death. Staff did not ensure a resident's pendent was properly functioning while in care. Staff did not communicate effectively with an authorized representative.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Arroyo met with Executive Director, Jill Morris Chapman and explained the reason for the visit. On 10/20/2023, the Department received a complaint regarding an allegation of Neglect/Lack of Care and Supervision. It was alleged that facility staff failed to provide medication for Resident #1 (R1) which contributed to R1’s death. Concerns were that R1 was not receiving proper medications from the facility which caused a major stroke leading to death. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Laarni Santiago. Continued on LIC 9099C... Unsubstantiated Continued from LIC 9099... On 10/23/2023, from 10:00 a.m. to 3:30 p.m., LPA Arroyo arrived unannounced to conduct the initial 10-Day complaint visit. During the visit, the LPA conducted a tour of the facility to ensure there were no health and safety concerns at 10:20 a.m., conducted a file review at 11:00 a.m., obtained copies of pertinent documents relevant to the investigation, and conducted interviews with three (3) staff and nine (9) random residents between 2:00 p.m. and 3:00 p.m. During today’s visit, LPA Arroyo conducted interviews with three (3) staff, four (4) randomly selected residents, and two (2) randomly selected resident responsible persons between 10:53 a.m. and 2:09 p.m. and obtained copies of pertinent documents. Investigator Santiago conducted interviews on 11/22/2023, at approximately 2:48 p.m., with R1’s Resident Representative (RP); on 11/30/2023, from approximately 9:45 a.m. to 4:15 p.m., with various facility staff and former staff; on 12/01/2023, from approximately 5:15 a.m. to 7:51 a.m., with facility med techs and R1’s pain management physician; on 01/12/2024, from approximately 11:00 a.m. to 11:58 a.m., with the administrator and med tech; on 01/17/2024, at approximately 4:13 p.m., with R1’s primary care physician (PCP); on 01/19/2024, at approximately 9:41 a.m., with a former staff; and on 03/19/2024, from approximately 10:30 a.m. to 12:35 p.m., with R1’s resident representative and pharmacist. In addition, the investigator reviewed medical records from St. John’s Regional Medical Center, Ojai Health and Rehabilitation, Community Memorial Hospital (CMH), Pacific Pain Management, Inc., Ventura County Medical Center, County of Ventura Certificate of Death, and facility file documents related to the investigation. According to R1’s physician report, dated 03/09/2023, the primary diagnosis was listed as Chronic Obstructive Pulmonary Disease (COPD), secondary diagnosis listed as aortic/valve stenosis, HTI, depression, diabetes mellitus, and back pain. The report indicated R1’s mental condition as being able to communicate needs and able to follow instructions. R1 was not able to administer prescription medications, injections, perform their own glucose testing, PRN medications, or store their medications. The report lists R1 as ambulatory and can independently transfer to and from bed. The preplacement appraisal information indicated no diet limit, and medication managed by the facility. Continued on LIC 9099C... Continued from LIC 9099C... During the investigation, interviews were conducted with R1’s RP, medical providers, facility staff and outside sources. Medical and facility records were also obtained and reviewed. R1’s death certificate revealed that R1 died on 06/22/2023 of acute respiratory failure with hypoxia, aspiration pneumonia and acute ischemic stroke. R1’s PCP indicated that R1’s history of transient ischemic accident (TIA) could have contributed to a cerebral vascular accident (CVA) and not due to missing R1’s stroke prevention medication. The PCP also denied that any of R1’s medications contributed to R1’s death. R1’s PCP stated that the reason for the acute respiratory failure with hypoxia was due to pneumonia. Evidence obtained from hospital records revealed that after the medical provider consulted with R1’s resident representatives about the poor prognosis, they decided to place R1 on comfort care and was later extubated on 06/20/2023. Furthermore, R1’s pain management doctor indicated that although R1 revealed similar symptoms of buprenorphine (suboxone) withdrawal, the doctor could not confirm that it was due to not receiving those medications. Medical records further corroborate that R1 did not present any signs of opiate withdrawal. Based on interviews and records review, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “Neglect/Lack of Care and Supervision: Facility staff failed to provide medication for Resident #1 (R1) which contributed to R1’s death” is deemed Unsubstantiated at this time. It was alleged that staff did not ensure a resident’s pendant was properly functioning while in care. It was reported that resident was left with a pendant that didn’t work causing long wait times for someone to respond. Records reviewed and interviews conducted revealed that the facility is actively testing the residents’ pendants throughout the month to ensure they are working properly. Additionally, there is a tablet available by the front desk which is used by staff to conduct the monthly pendant testing. Staff further added that pendants displaying a battery life of 25% or less, will typically have the batteries replaced before they run out. Interviews conducted with random residents revealed that they use the pendants provided by the facility whenever they need assistance from the staff. Furthermore, residents added that although it may take a while before staff respond to the call, they know the pendants are working as the staff still arrive and check in at some point. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not ensure a resident’s pendant was properly functioning while in care”. Therefore, this allegation is deemed Unsubstantiated at this time. Continued on LIC 9099C... Continued from LIC 9099C... It was further alleged that staff did not communicate effectively with an authorized representative. It was reported that resident’s responsible person was never called once regarding any issues that pertained to resident. During staff interviews, staff stated that resident’s responsible person is usually notified shortly after an incident has occurred. Interviews further revealed that different staff members are responsible for communicating certain information with the resident’s responsible person. If any information involving medications need to be discussed with the resident’s responsible person, either the Wellness Director or Wellness Coordinator will communicate with the resident’s responsible person. Similarly, if it involves notifying them of an incident during the night, the night medication technician will be the person communicating with the resident’s responsible person. Interviews conducted with random resident’s responsible person revealed that the facility does reach out to them after the resident has been involved in an incident at the facility. Responsible persons also added that the facility does in fact communicate when needed. Based on interviews conducted with facility staff and residents’ responsible persons, the Department does not have sufficient evidence to support the allegation of “staff did not communicate effectively with an authorized representative”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued. Continued from LIC 9099... The complaint alleged that between 05/02/2023, to 06/22/2023, R1 was in and out of the hospital due to not receiving the proper medications from the Lexington Assisted Living facility. Additional concerns were that facility staff sometimes took 35 minutes or more to respond to R1’s pendant request. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Laarni Santiago. On 10/23/2023, from 10:00 a.m. to 3:30 p.m., LPA Arroyo arrived unannounced to conduct the initial 10-Day complaint visit. During the visit, the LPA conducted a tour of the facility to ensure there were no health and safety concerns at 10:20 a.m., conducted a file review at 11:00 a.m., obtained copies of pertinent documents relevant to the investigation, and conducted interviews with three (3) staff and nine (9) random residents between 2:00 p.m. and 3:00 p.m. During today’s visit, LPA Arroyo conducted interviews with three (3) staff, four (4) randomly selected residents, and two (2) randomly selected resident responsible persons between 10:53 a.m. and 2:09 p.m. and obtained copies of pertinent documents. Investigator Santiago conducted interviews on 11/22/2023, at approximately 2:48 p.m., with R1’s Resident Representative (RP); on 11/30/2023, from approximately 9:45 a.m. to 4:15 p.m., with various facility staff and former staff; on 12/01/2023, from approximately 5:15 a.m. to 7:51 a.m., with facility med techs and R1’s pain management physician; on 01/12/2024, from approximately 11:00 a.m. to 11:58 a.m., with the administrator and med tech; on 01/17/2024, at approximately 4:13 p.m., with R1’s primary care physician (PCP); on 01/19/2024, at approximately 9:41 a.m., with a former staff; and on 03/19/2024, from approximately 10:30 a.m. to 12:35 p.m., with R1’s resident representative and pharmacist. In addition, the investigator reviewed medical records from St. John’s Regional Medical Center, Ojai Health and Rehabilitation, Community Memorial Hospital (CMH), Pacific Pain Management, Inc., Ventura County Medical Center, Electronic medication administration record (E-Mar), pendent alert record, and facility file documents related to the investigation. Continued on LIC 9099C... Continued from LIC 9099C... According to R1’s physician report, dated 03/09/2023, the primary diagnosis was listed as Chronic Obstructive Pulmonary Disease (COPD), secondary diagnosis listed as aortic/valve stenosis, HTI, depression, diabetes mellitus, and back pain. The report indicated R1’s mental condition as being able to communicate needs and able to follow instructions. R1 was not able to administer prescription medications, injections, perform their own glucose testing, PRN medications, or store their medications. The report lists R1 as ambulatory and can independently transfer to and from bed. The preplacement appraisal information indicated no diet limit, and medication managed by the facility. On the allegation “Neglect/Lack of Care and Supervision: Facility staff failed to provide medication for Resident #1 (R1)”. During the investigation, interviews were conducted with R1’s RP, facility staff, medical providers, and outside sources. It was alleged that R1 did not receive Buprenorphine medication on 04/20/23 to 04/22/2023 and 04/26/2023 to 04/30/2023. The Electronic medication administration record (E-Mar) showed that those dates were marked “X” denoting that it is “inactive.” However, pharmacy staff verified that they received prescription orders on 04/19/2023, but insurance declined to approve since it revealed that R1’s Buprenorphine had not reached the end of its previous refill. Therefore, the medications could not be released at the facility. Although the med-tech refuted the claim that R1 did not receive their medications on those dates despite the “inactive” status, Investigator Santiago could not corroborate based on interviews and the E-Mar that the medications were or were not received, or that there were still medications available at the facility. However, in May of 2023, R1 was admitted to the hospital on 05/03/2023, and transferred to a rehab facility on 05/11/2023. R1 was discharged back to the facility on 05/23/2023, with new medication orders that included Aspirin 81mg and Ticagrelor among others. Evidence obtained from Lexington’s pharmacy revealed that the only time they received a prescription for Aspirin 81 mg was on 06/07/2023, which was delivered to the facility on 06/08/2023. Furthermore, pharmacy staff confirmed that they never delivered the Ticagrelor to the facility as they never received proper authorization from R1’s cardiologist. R1’s E-mar did not document that any of those medications were given to R1 after R1 returned to the facility on or around 05/22/2023. In addition, R1’s E-Mar was not updated with new medication orders and the facility did not document that R1 received any of their medications when R1 returned to the facility around 05/22/2023 to 05/28/2023, prior to another hospital stay. Continued on LIC 9099C... Continued from LIC 9099C... Therefore, evidence obtained from the medication and hospital record does not corroborate that R1 received all their medications while at the facility. It was evident that R1 did not receive their Ticagrelor and Aspirin medications until it (aspirin) was delivered to the facility on 06/08/2023. Therefore, based on information gathered from interviews and pertinent records, the allegation “Facility staff failed to provide medication for Resident #1 (R1)” is deemed Substantiated at this time. On the allegation “Neglect/Lack of Care and Supervision: Facility staff failed to attend to Resident #1’s (R1’s) request for assistance in a timely manner”. Interviews were conducted with residents, R1’s resident representatives and staff. A review of the pendant alert record was also obtained and reviewed. A review of the pendant alert record revealed that there were some calls that took about 20 minutes to an hour to respond. Interviews with staff revealed that they tried to respond immediately depending on the level of priority, such as an emergency. Although the records revealed that some alerts took longer to respond to than others, the time stamp did not necessarily mean that they did not tend to the resident right away. Staff indicated that there were times when they didn’t clear the pendants immediately, which could mean that they tended to the resident first before clearing the pendant or forgot to reset the pendant. However, multiple staff admitted that they took a while to respond to residents, sometimes as long as 30 minutes to an hour to respond, due to lack of staffing. Although the residents denied expressing any concerns about staff failing to tend to their needs in a timely manner, the staff’s admission yielded that there were not enough staff present to provide sufficient supervision and respond in a timely manner. Therefore, based on the information gathered, the allegation “Neglect/Lack of Care and Supervision: Facility staff failed to attend to Resident #1’s (R1’s) request for assistance in a timely manner” is deemed Substantiated at this time. 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, May 22, 2024 · control 29-AS-20231020083938

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 22, 2024

(a)A plan for incidental medical and dental care shall be developed by each facility... and provide for assistance in obtaining such care(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. Facility staff failed to provide R1’s Buprenorphine, Ticagrelor, and aspirin as prescribed, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee will submit a plan how you will ensure residents will receive medications as prescribed. Submit to CCL no later than 05/31/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 22, 2024

(a) In addition to the rights listed in Section 87468.1. Residents shall have all of the following personal rights: (4) To care, supervision, and services that 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 records review and interviews, the licensee did not comply with the section cited above. Facility staff failed to respond to R1 in a timely manner, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee will submit an LIC500 Personnel Report which reflects there is an adequate amount of staffing 24/7. Submit to CCL no later than 05/31/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Deficiency visit in conjunction with complaint visit (CC #29-AS-20231020083938). LPA Arroyo met with Executive Director, Jill Morris Chapman. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. The facility was not able to provide all of Resident #1’s (R1s) medication records and advised that they archived all records and marked medications as “discontinued” when the residents move out or expire. Citation issued, exit interview, appeal rights given.the state’s words, verbatim · CDSS document, May 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(e) · Plan of correction due date: May 31, 2024

A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information... ...(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee will submit plan how you will ensure resident records are maintained for a minimum of three (3) years and readily available to licensing staff. Submit to CCL no later than 05/31/2024. During the complaint investigation, the facility was unable to provide all of R1’s records, which posed a potential health and safety risk to residents in care.