Glen Park at Ojai

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez alongside Tri Counties Regional Center Quality Assurance Specialist (QAS), Katy Robison conducted an unannounced subsequent Case Management-Incident inspection to follow up on a self reported Report of Suspected Elder Abuse SOC341 received. LPA and QAS initially met with staff and explained the reason for the visit. Executive Director Rafael Silva arrived shortly thereafter and was explained the reason for the inspection. On 07/07/2026, Community Care Licensing (CCL) received a self reported Report of Suspected Elder Abuse SOC341 regarding Resident 1 (R1) and a staff. It was reported that R1 alleged that a caregiver was rough with them, their hair was pulled, they were moved hard, and that they fell in the bathroom because they were pushed. Additionally, it was reported that R1 described the worker as a fat dark male by the name of Henry and works at night. On 07/09/2026, the LPA interviewed the ED, R1, five (5) staff, viewed video footage of the facility and collected pertinent documents relevant to the investigation. The ED revealed that a head to toe assessment for any physical changes had been performed on R1, and there weren't any changes. There were more staff the LPA needed to interview but they were not at the facility during that visit. On 07/14/2026, the LPA and QAS conducted one telephone interview with one staff. During today's visit the LPA and QAS conducted interviews with the ED and R1. The LPA reviewed R1's records. Report will continue on LIC809-C, 2nd page, A review of R1’s Physician Report, dated 10/09/2025, lists the resident's diagnoses as Dementia, Parkinson's disease, Major Depressive Disorder, Insomnia, Hypothyroidism, Hyperlipidemia, and Chronic Kidney disease. The report also notes a diagnosis of Major Neurocognitive disorder, specifying that while R1 can follow instructions, communicate needs, and feed themselves, they require staff assistance for self-care, repositioning, and transferring. Facility record reviews and staff interviews revealed that no employee by the name of Henry works at the facility. All interviewed staff denied ever being rough, pulling hair, or pushing any residents, and they affirmed that they would report any witnessed abuse. During the night shift, only one male staff member (S1) is on duty. S1 denied any rough handling and noted that interactions with residents are minimal because they are asleep. The Licensing Program Analyst (LPA) reviewed overnight video footage from Friday, 07/03/2026, to Saturday morning, 07/04/2026. The footage showed S1 assisting R1 to the restroom twice; while the interior of the restroom is not visible on camera due to privacy, no resident distress was observed in the footage. Furthermore, the LPA interviewed R1 on 07/09/2026, and 07/14/ 2026. During the initial interview, R1 reported feeling very safe and well-treated, but provided contradictory statements about "Henry" pulling their hair, first stating they did not know who Henry was and later claiming he was staff. When interviewed again on 07/14/2026, and asked if any staff had ever hurt them, R1 replied, "No, that's ridiculous." Based on the information gathered, there is no evidence to prove that a regulatory violation occurred at this time. No deficiencies are being cited at this time pertaining to this self-reported SOC 341. An exit interview was conducted, and a copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 14, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management-Incident inspection regarding a self reported Report of Suspected Elder Abuse SOC341 received. LPA met with Executive Director Rafael Silva at 10:50 AM and explained the reason for the inspection. On 07/07/2026, Community Care Licensing (CCL) received a self reported Report of Suspected Elder Abuse SOC341 regarding Resident 1 (R1) and a staff. It was reported that R1 alleged that a caregiver was rough with them, their hair was pulled, they were moved hard, and that they fell in the bathroom because they were pushed.. Additionally, it was reported that R1 described the worker as a fat dark male by the name of Henry and works at night. During today's visit the LPA interviewed the ED, R1, five (5) staff, viewed video footage of the facility and collected pertinent documents relevant to the investigation. The ED revealed that a head to toe assessment for any physical changes had been performed on R1, and there weren't any changes. There were more staff the LPA needed to interview but they were not at the facility. LPA will return at a later date to complete the investigation. Exit interview conducted. Copy of report and appeal rights issued.the state’s words, verbatim · CDSS document, Jul 9, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Deficiencies visit in conjunction with complaint control #29-AS-20260629104137. The LPA met with Executive Director Rafael Silva and informed them of the reason for the visit. During the investigation of complaint control #29-AS-20260629104137, the LPA obtain information that on 06/15/26, Resident 1 (R1) complained of leg pain, had old bruising, had an appointment with their doctor, and was sent to the hospital. A Special Incident Report (SIR) was not submitted to Community Care Licensing as required. In addition, during interviews, staff admitted they are not aware of the mandated reporting requirements. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency cited (refer to LIC 809-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Jun 30, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 14, 2026

87211 (a)(1) Reporting Requirements (a) Each licensee shall... (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 of any of the events specified in (A) through (D) below... This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not submit incident reports for a residents hospitalization, and staff are not aware of the manadated reporting requirements which poses...the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: Administrator agreed to submit a statement of understanding of regulation 87211, will submit incident report for R1 as soon as possible, and conduct mandated reporting training for all staff. Administrator agreed to submit proof of training and SIR by 7/14/23. a potential health and safety risk to residents in care.

Allegation investigated: Staff do not get timely medical care for residents

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit with the purpose of delivering findings for the above allegation. Upon arrival, LPA met with staff and explained the reason for the visit. Executive Director (ED) Rafael Silva was out of the facility at the time of the visit. Entrance interview conducted. During an initial complaint visit conducted on 08/01/2025, between 12:30 p.m. and 3:00 p.m., the LPA Esther Cortez toured the facility and observed fourteen (14) residents in the facility, interviewed the Administrator, one (1) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. During a subsequent visit conducted by LPA Dulek and Tri-Counties Regional Center Quality Assurance Specialist (QA) Katy Robison on 09/03/2025, LPA and QA interviewed ED at 09:58AM, interviewed three (3) staff and attempted to interview one (1) resident from 10:53AM to 11:55AM. At 12:06, Report Continued on LIC 9099-C Substantiated LPA, QA, and ED conducted a tour of the facility. LPA reviewed and obtained copies of documents relevant to the investigation. During a subsequent complaint visit on 10/01/2025, LPA and QA interviewed ED at 10:05AM, and interviewed 1 (one) staff at 11:14AM. Throughout the visit, LPA and QA conducted a tour of the facility. Throughout the course of the investigation, LPA and QA interviewed additional staff telephonically and LPA reviewed all documents obtained. The following was then determined: The complaint alleges that the facility did not obtain timely medical attention for Resident #1 (R1) when R1 was experiencing a high fever during the overnight (NOC) shift. At the time of the complaint, no staff working during the overnight shift were trained on medication administration, which was confirmed during interview with the ED and record review. Interviews with staff revealed differing information on the facility's medical plan during the NOC shift. Some staff interviewed stated that they have a list of staff and management to call when there is an emergency or a resident has an unmet medical need during the NOC shift. However, other staff indicated they are to call 9-1-1. Staff interviews revealed R1 did experience a fever one night and NOC staff were informed by the previous shift's medication technician that a hospice nurse would be arriving to tend to R1's needs. When R1's hospice care provider did not arrive, NOC staff were unaware of how to respond to R1's unmet medical need. Staff present at the facility were unable to administer prescribed as needed (PRN) fever reducing medication to R1, as no one present in the facility was trained on medication administration. Although staff interviewed indicated there are no residents that have regularly prescribed medications scheduled for administration during the NOC shift, PRN medications can be needed at any time, including the NOC shift. On 11/04/2025, a Corrective Action Plan was issued to the facility by Tri-Counties Regional Center related to this allegation. Based on the information gathered during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Designees were informed that failure to correct to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of today’s report and appeal rights were provided. to the investigation. During a subsequent complaint visit on 10/01/2025, LPA and QA interviewed ED at 10:05AM, and interviewed 1 (one) staff at 11:14AM. Throughout the visit, LPA and QA conducted a tour of the facility. Throughout the course of the investigation, LPA and QA interviewed additional staff telephonically and LPA reviewed all documents obtained. The following was then determined: On the allegation "Staff do not position resident in bed properly to avoid injury:" The complaint alleges that Resident #2 (R2) experienced upper body weakness and has injured their face on the bedrails due to staff not properly positioning R2 in bed. LPA and QA were unable to locate any incident reports relating to an injury to R2's face. Staff interviewed could not recall seeing R2 with any injuries to their face in the past several months. Staff interviews revealed that all residents who cannot reposition themselves are repositioned by staff regularly and at minimum every two (2) hours. 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. On the allegation "Staff do not change residents timely:" The complaint alleges that residents are sitting in soiled diapers for hours. Staff interviewed indicated that incontinence care is provided to residents every two (2) hours or more often as needed. During all complaint visits conducted at the facility, LPA and QA did not observe evidence of any unmet incontinence needs. All residents appeared clean and dry; no incontinence odors were observed. No additional information was provided relating to specific residents affected or a specific time frame during which the allegation was referring to. Management indicated training is provided to all staff relating to incontinence care and hygiene needs and to their knowledge, staff abide by all protocols relating to incontinence care. 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. Report Continued on LIC 9099-C On the allegation "Staff do not follow bio hazard practices:" It was alleged that all laundry is mixed, which is not sanitary. LPA reviewed the facility's infection control plan, which includes cleaning and sanitization procedures. Interviews revealed that housekeeping staff clean and sanitize the facility. Management indicated there have not been any recent diagnoses of infectious disease or any residents on isolation, therefore, regular cleaning has been completed and no enhanced cleaning protocols have been necessary. LPA and QA observed the facility's laundry room, which does have separate areas for clean laundry and dirty laundry, which complies with regulation. Staff interviewed did state that resident laundry is commingled during the washing process for efficiency purposes, but that at no time is dirty laundry mixed with clean laundry just that multiple residents' laundry is washed together. Staff also stated that if a resident is on quarantine, their dirty laundry is bagged and washed separately from other residents. 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 related to the above allegations. Exit interview conducted. A copy of today's report was reviewed and provided.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 29-AS-20250801083243

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(j) · Plan of correction due date: Dec 4, 2025

87465 (j) In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated... needed emergency medical services and for assisting residents as needed with self-administration of medications....and staff. 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 no staff scheduled during the overnight shift have medication training and staff were unaware of the facility's plan to meet residents' medical needs, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: ED stated one NOC staff was recently trained on medication administration. ED agreed to ensure a trained staff is present during the NOC shift at all times. ED will provide additional training on the facility's plan to meet residents' medical needs. ED will provide proof of staff schedule showing trained staff at night and proof of training on the facility plan by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 10/14/2025. The LPA met with Administrator Rafael Silva and explained the reason for the visit. The LPA conducted a tour of the physical plant with Administrator Rafael Silva to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double story residence, with the second story only for staff use. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 01/23/2025. The smoke alarms and carbon monoxide detectors were tested and functioned properly. KITCHEN: The kitchen is left locked so residents cannot enter. The kitchen was clean and the appliances appeared to be functional The facility's main pantry is air conditioned and located outside. The pantry had non-perishable foods, perishable foods, and three large freezers with perishable foods. Food was also stored in the kitchen and another pantry inside the facility which had more non-perishable food and emergency water. RESIDENT ROOMS: There are currently sixteen rooms available for residents of which ten (10) are being used by residents; these rooms can be shared or can be single rooms. There are two (2) rooms being used as model rooms and one (1) as an activity room. There are six rooms upstairs which are used as office space, staff rooms, and storage. The upstairs rooms can only be accessed by stairs so they are not in use for residents at this time. Rooms housing residents appeared to be clean with appropriate furnishings, bedding and sufficient lighting, however floors needed to be swept. Report will continue on LIC809-C, 2nd page. BATHROOMS: The facility has two shower rooms of which the toilet in one of the shower rooms is not working. Upon observation Administrator stated they would be fixing it by tomorrow 10/16/25. Four resident rooms have full bathrooms. The facility has eleven half bathrooms; some are private and others are "jack and jill" bathrooms between two rooms. Bathrooms appeared to be clean and had grab bars, however floors needed to be swept and mopped. The shower rooms had non-skid mats. Water temperature measured in four (4) restrooms ranged between 109.2 degrees Fahrenheit and 124 degrees Fahrenheit. Upon observation the Administrator adjusted the hot water temperature in the bathroom between bedroom 13 and 14 that measured 124 F and new water temperature measured at 113.6 degrees Fahrenheit. OUTDOOR: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water were observed. Interviews: The LPA conducted four (4) resident and two (2) staff interviews. No concerns were voiced. Medication Audit: The LPA conducted Medications audit for three (3) residents. The medications are locked in medication carts. Medications are labeled and checked for expiration dates. Medications were observed to not be properly documented on the centrally stored medications and destruction record (CSMDR) as the facility receives a pre-filled CSMDR from the pharmacy however start dates, expiration dates and number of refills for many medications were either not documented or documented incorrectly by the pharmacy. LPA and Med Tech discussed best practices of reviewing and correcting the CSMDR. During Resident 1's (R1's) audit the LPA observed one morning medication was not given on 10/09/25. Additionally, during R2's audit the LPA observed seven (7) morning medications were not given on 10/9/25. Upon observation staff stated that the MT (MT1) on 10/09/25 did not realize both residents had already left for Day Program and did not give them their morning medication. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 15, 2025

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At 09:45 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. The LPA met with Administrator Rafael Silva and informed them of the reason for the visit. Record Review: At 10:00 a.m., a review of facility files was initiated. The LPA observed documentation of Infection Control Plan, and Emergency and Disaster Plan. The LPA obtain copies of Client and Staff rosters, Surety Bond, and Insurance Liability. The LPA reviewed five (5) resident files for documents including but not limited to resident physician's report, needs and service appraisal, consent forms, and personal rights. The LPA observed that all 5 residents needs and service plans were not signed by the resident and/or their responsible party. The LPA reviewed five (5) staff files for documents including, but not limited to: health screening, TB test, staff training records, and fingerprint clearance. The LPA observed that two staff (S1-2) did not have their annual training on file. Otherwise all other documents were complete and current. Medication Audit: Medications audit was initiated during today's visit. The LPA observed medications for one (1) resident. All medications were stored properly in a med cart inaccessible to residents in care and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Due to time constraints the LPA will return at a later date to complete the annual. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator.the state’s words, verbatim · CDSS document, Oct 14, 2025

Allegation investigated: Staff caused an injury to a resident Staff mishandled a resident's medication

Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit to deliver findings for the above allegations. Upon arrival, LPA met with Activity Director Hollyn Heron and explained the reason for the visit. Executive Director (ED) Roman Sierra Tobar was unable to be at the facility during today’s visit, was explained the reason for the visit via phone and authorized Holyn Heron to sign and receive the report. However, ED arrived as LPA was issuing findings. On 03/14/2024, between 11:30 a.m. and 4:00 p.m., the LPA toured the facility with staff, interviewed the Administrator, two (2) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/07/2024, between 11:30 a.m. and 4:30 p.m., the LPA toured the facility with staff, interviewed the Administrator, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/08/2024, between 10:55 a.m. and 11:55 a.m., the LPA interviewed two (2) staff and obtained pertinent documents relevant to the investigation. On 08/14/2024, the LPA conducted one (1) staff telephone interview. Report will continue on LIC9099-C (2nd page). Substantiated On 10/04/2024, the LPA conducted a file review and one (1) staff and one (1) witness phone interview between 2:00 p.m. and 4:30 p.m. On 10/09/2024, the LPA conducted a file review, three (3) staff interviews, one (1) phone interview with Mission Hospice representative between 10:45 a.m. and 3:30 p.m. On the allegations "Staff admitted a resident with a prohibited health condition" and “Staff did not perform appropriate assessment for a resident”; it is the concern of the reporting party (RP) that Resident #1 (R1) was admitted to the facility on 02/19/24 and then asked to leave the facility the following day on 02/20/24 due to wounds that might violate licensing requirements. RP further reported that the wound in question was located on the residents’ leg, and they were Venous stasis and not a pressure wound, however the Administrator at the time believed they were a stage 3 pressure wound. Lastly, the RP reported that the facilities Administrator and additional staff had performed a pre-placement assessment on R1 prior to admitting them and should have caught the prohibited health condition if it was a stage 3 pressure wound. To investigate the allegation the LPA conducted a file review and interviews. A review of R1’s head-to-toe assessment form for any physical change, dated 2/14/2024, and completed by facilities Administrator and Retirement Counselor indicated that R1 had sign of redness or sore around the ankle area, however it did not indicate if it was a pressure injury. Additional assessment forms signed by previous Administrator Gary Lee indicated that they did not have any concerns regarding R1’s care plan. A review of R1’s physician’s report, dated 02/13/2024, indicated R1’s primary diagnoses was listed as cellulitis of left upper limb, and secondary diagnosis was listed as chronic kidney disease, stage 3A. The report indicated R1 had mild cognitive impairment, was able to follow instructions as well as communicate needs, and had history of skin condition or breakdown. R1’s physician report did not indicate any pressure injuries. A review of R1’s, Shoreline Care Center, skilled nursing facility records, dated 02/19/2024, obtained from Glen Park at Ojai indicated some of R1’s diagnoses were listed as cellulitis of left upper limb, venous insufficiency (chronic), non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity, among other diagnosis, however pressure wounds of any stage were not listed as a diagnosis. Interviews with Administrator Gary Lee revealed that on 02/14/24 they and the Retirement Counselor had performed a pre-placement assessment on R1, prior to admitting them to the facility. Administrator Gary Lee revealed they looked for injuries, they did a head-to-toe, and looked to see if R1 had any open skin. Report will continue on LIC9099-C (3rd page). Administrator saw a band-aid on R1’s left arm, and bandages on both legs; the Administrator removed the band-aid on the arm and asked for the bandages on the legs to be removed and revealed that they saw pinkness on R1’s arm and pinkness and scabs with cream on the legs and asked for the cream to be removed. Administrator Gary Lee further revealed that they were informed by the skilled nursing facility staff that the right injury on R1’s leg came from a fall R1 had, and the injury on the left leg looked the same but he was told that it looked reoccurring. The administrator observed a scab on the left leg injury that was solid black that raised above the skin, and although he didn’t measure, he believed it was about 3cm. Furthermore, Administrator Gary revealed that they asked for R1’s physician’s report, R1’s left leg was not mentioned in the report, they thought R1’s skin integrity was healed as they saw a scab on it and thought R1 was appropriate to move into the facility. Lastly, Administrator Gary Lee revealed that after R1 was admitted to the facility, on 2/20/2024, a MedTech (MT) was cleaning R1’s dressings, and when they took the dressings off the left leg with the reoccurring wound, the scab fell off. The MT called him to look at the wound, when he saw it, he believed it was a stage 3 wound due to being an open sore that is past the skin and being able to see flesh; he then informed R1’s authorized person that R1 could not be at the facility due to having a stage 3 wound. Administrator Gary Lee is not a medical professional. Administrator Gary Lee went on to reveal that a home health nurse staged the wound as a stage 3, however, facility staff was not able to provide any records for that nurse’s home health visit. On the allegations “Staff admitted a resident with a prohibited health condition" and “Staff did not perform appropriate assessment for a resident”. The Department’s investigation revealed R1 had a history of numerous health conditions including non-pressure chronic ulcer of unspecified part of right lower leg, however, R1 did not have any open wounds during the assessment and did not have any prohibited health conditions upon admission to the facility. Any open wounds R1 obtained were after they were admitted to the facility. Administrator Gary Lee performed an assessment for R1 and based on his observations and records that were provided to him at the time of the assessment, he believed R1 was a good fit for the facility. The information and evidence obtained during the investigation did not sufficiently support the allegations, therefore, the allegations are deemed Unsubstantiated at this time. Exit interview conducted. Today's report was reviewed and provided to the Executive Director. On 10/04/2024, the LPA conducted a file review and one (1) staff and one (1) witness phone interview between 2:00 p.m. and 4:30 p.m. On 10/09/2024, the LPA conducted a file review, three (3) staff interviews, one (1) phone interview with Mission Hospice representative between 10:45 a.m. and 3:30 p.m. On the allegation "Staff caused an injury to a resident"; it is the concern of the reporting party that on 02/20/2024, Resident #1 (R1) acquired a new gash to their lower left leg, and facility staff said R1’s leg was caught on wheelchair during transfer, and R1 said a caregiver’s thumb went through their skin and tore a gash in lower left calf. To investigate the allegation the LPA conducted file review and interviews. A review of R1’s physician’s report, dated 02/13/2024, indicated R1’s primary diagnoses was listed as cellulitis of left upper limb, and secondary diagnosis was listed as chronic kidney disease, stage 3A. The report indicated R1 had mild cognitive impairment, had motor impairment/ paralysis (weakness), was able to follow instructions as well as communicate needs, and was identified as non-ambulatory. A review of R1’s appraisal/needs and services plan, dated 02/19/2024, indicated R1 was a fall risk, needed help with mobility, bathing, dressing, and toileting, had MCI, was talkative and social, and was not aggressive and not a wanderer. Staff interviews revealed that R1 sustained an accident at the facility during a transfer. Interview with previous Administrator Gary Lee, revealed that Staff #1 and #2 (S1, S2) forgot to remove the wheelchair footrest when transferring R1 from a recliner to their wheelchair. R1 was very frail, both staff were at both sides of the resident, but when they were lifting R1 up, R1’s left leg got caught with a screw on the leg of the footrest and it caused a gash right above R1’s existing wound. LPA Cortez was not able to interview R1 or S1. Interview with S2 revealed that they witnessed R1’s accident, however they did not see exactly how everything happened. S2 revealed R1 was trying to get up from a recliner in the living room, S1 had R1 in their hand trying to transfer R1 to a wheelchair, at one point S2 asked S1 “What are you doing?” because two people should have been assisting R1, and the wheel chairs legs were up and S1 did not realize that the wheel chair legs was what cut R1. S2 stopped what they were doing and went over to check on them and notice blood and had to bandage R1’s new cut. S2 revealed R1’s injury could have been prevented by removing the legs from the wheelchair and by having two staff assisting R1. Report will continue on LIC9099-C (3rd page). Interview with Administrator Gary revealed that R1 was a one person assist, however interview with the Assistant Administrator revealed that R1 was a fall risk, and typically fall risk residents are a two person assist. Furthermore, four (4) staff revealed that R1 was a two-person assist, and one staff revealed that although they were not present during R1’s accident they were informed that staff attempted to transfer R1 without assistance and that led to R1’s fall, while other staff revealed they heard staff had dropped R1. On the allegation “Staff caused an injury to a resident,” the Department’s investigation provided sufficient evidence to substantiate the allegation. Based on staff interviews, it has been determined S1 failed to remove the wheelchair’s leg and failed to obtain a second person to assist when transferring R1 from a recliner chair to their wheelchair resulting in R1 sustaining a gash (skin tear) to their left leg, therefore, the allegation is deemed Substantiated at this time. On the allegation "Staff mishandled a resident's medication"; it is the concern of the reporting party that Resident’s #1 (R1) was not receiving all their medications due to R1’s Rx hemorrhoid cream for their chronic rectal prolapse not being with R1’s medication when they were collected. It was further reported that the medication had to be further searched for by a MedTech to be returned to R1’s responsible person and that the medication was not listed with R1’s inventory of medications. To investigate the allegation the LPA conducted file review and interviews. A review of R1’s, Shoreline Care Center, skilled nursing facility Order Review Report, dated 02/19/2024, obtained from Glen Park at Ojai indicated R1 was prescribed Anusol-HC External Cream 2.5% (Hydrocortisone), with an order date and start date of 02/16/2024. Per the order summary, “apply to rectum topically one time only for hemorrhoids for 1 Day start once available and apply to rectum topically every day shift for hemorrhoid.” A review of the facilities Medication Transfer sheet/Release of Responsibility form, dated 02/19/2024, revealed that R1’s Anusol-HC External Cream 2.5% (Hydrocortisone) was not listed in the inventory list of medications obtained from R1’s family. However, review of the facilities Medication Transfer sheet/Release of Responsibility form, dated 02/22/2024, revealed that two tubes of hydrocortisone were released back to R1’s responsible party by Staff #3 (S3). A review of R1’s Medication/Treatment Administration Record (MAR) from the facility for February 2024, revealed that R1’s hemorrhoid medication was not listed as one of the medications administered to R1 during their time at Glen Park at Ojai. Report will continue on LIC9099-C (4th page). Interview with previous Administrator Gary Lee revealed that R1 was admitted with medication provided by Shoreline Care Center and medication provided by R1’s family and there was some kind of ointment or cream for R1 (name not provided), but it was already expired, and they could not use. However, staff were unable to provide R1’s Centrally Stored Medications and Destruction Record (CSMDR). Interview with S3, revealed that when R1 was being discharged, and they were returning R1’s medication, R1’s family mentioned there was additional medication. S3 asked Administrator Gary Lee about the additional medication, and Mr. Lee let them know that there was additional medication, and they gave the medication back to the family. S3 does not believe the cream was administered to R1 but is not certain and believes that they did not have a doctor’s order for the cream. On 10/09/2024, the LPA and S3 reviewed R1’s MAR, R1’s hemorrhoid medication was not listed, and S3 advised the LPA that all medicines administered to the resident would be on the MAR, however they were using a different MAR when R1 was at the facility, and it got transfer to the new MAR. Staff was not able to provide R1’s original MAR. On the allegation, “Staff mishandled a resident's medication”; the Department has sufficient evidence to substantiate the allegation. Based on record review and interviews conducted, it has been determined that staff failed to administer R1’s Anusol-HC External Cream 2.5% (Hydrocortisone) during their stay at the facility, despite having it and having an order from the skilled nursing facility, additionally staff failed to provide R1’s CSMDR, therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited, and civil penalty is being issued (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, Oct 29, 2024 · control 29-AS-20240313134850

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Oct 30, 2024

HSC 1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2.This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above. Facility staff failed to properly transfer R1 which caused R1 to sustain a skin tear on their left leg. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: S1 is no longer working at the facility. Licensee will submit a plan how they will ensure staff to properly transfer residents. Submit to CCL by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 30, 2024

CCR 87465(a)4 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 evidence by: Based on record review and interviews, the licensee did not comply with the section cited above as medications are not being given to R1 and failed to provide R1’s CSDMR which posed an immediate health and safety concern to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Licensee agreed to review section cited and submit a statement of understanding, how they plan to ensure residents will receive their medications as prescribed, and how they will ensure staff properly documents medication on the CSMDR and submit to CCL by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit regarding a self-reported incident which occurred at the facility on or about 9/29/2024. LPA met with administrator Roman Tovar and assistant administrator Leticia Hernandez and explained the reason for the visit. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Katy Robison. LPA and QAS first met with the assistant administrator and requested pertinent documents. LPA and QAS conducted interviews with staff and resident 1 (R1) starting at 1:42 p.m. There were more staff LPA and QAS needed to interview but they were not at the facility. LPA will return at a later date to complete the investigation. It had been reported that on 9/29/2024, R1 reported to staff they were handled roughly by staff 1 (S1). This was reported to Community Care Licensing (CCL) on 10/9/2024. The facility conducted their own internal investigation and shared the information they obtained. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC809-D). Exit interview conducted. Copy of report and appeal rights issued.the state’s words, verbatim · CDSS document, Oct 15, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Oct 22, 2024

87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited as licensee waited 10 days to report this incident, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: Licensee will provide a written understanding of reporting requirements to CCL on or before 10/22/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara conducted a required annual visit. LPA met with administrator Roman Tovar and assistant administrator Leticia Hernandez and explained the reason for the visit. At 3:00 p.m. LPA conducted a physical plan tour accompanied by the assistant administrator. LPA toured resident rooms, bathrooms, outdoor areas, and the kitchen. KITCHEN: The kitchen is left locked so residents cannot enter. The kitchen was clean and the appliances appeared to be functional The facility's main pantry is air conditioned and located outside. The pantry had non-perishable foods, perishable foods, and three large freezers with perishable foods. Food was also stored in the kitchen and another pantry inside the facility which had more non-perishable food and water. There was a sufficient supply of perishable, non-perishable foods and water. RESIDENT ROOMS: There are currently thirteen rooms for residents. These rooms can be shared or can be single rooms. There are three rooms used as model rooms. There are six rooms upstairs which are used as office space and storage. The upstairs rooms can only be accessed by stairs so they are not in use for residents at this time. Rooms housing residents appeared to be clean with appropriate furnishings, bedding and sufficient lighting. BATHROOMS: The facility has two shower rooms. Two of the resident rooms have full bathrooms; one is a model room and the other has a resident. The facility has eleven half bathrooms; some are private and others are "jack and jill" bathrooms between two rooms. Bathrooms appeared to be clean and had grab bars. The shower rooms had non-skid mats. OUTDOOR: The facility has three patio areas equipped with seating and shade for residents. This annual will continue at a later date. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Oct 15, 2024

Allegation investigated: Staff did not prevent a resident from drinking another resident's drink Staff did not prevent a resident from running naked while in care

Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegations. Upon arrival, LPA met with Executive Director Roman Sierra Tobar and was explained the reason for the visit. On 03/14/2024, between 11:30 a.m. and 4:00 p.m., the LPA toured the facility with staff, interviewed the Administrator, two (2) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/07/2024, between 11:30 a.m. and 4:30 p.m., the LPA toured the facility with staff, interviewed the Administrator, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/08/2024, between 10:55 a.m. and 11:55 a.m., the LPA interviewed two staff and obtained pertinent documents relevant to the investigation. On 10/04/2024, the LPA conducted a file review and one (1) staff and one (1) witness phone interview between 2:00 p.m. and 4:30 p.m.During today's visit the LPA conducted a file review, three (3) staff interviews, one (1) phone interview with Mission Hospice representative between 10:45 a.m. and 3:30 p.m. Report will continue on LIC9099-C 2nd page. Unsubstantiated On the allegations that " Staff did not prevent a resident from drinking another resident's drink and Staff did not prevent a resident from running naked while in care,” it is the reporting parties concern that Resident #2 (R2), took and drank Resident #1’s (R1) drink on two occasions, and on the night of 2/21 to 2/22, R2 was running through the facility naked until they could be guided to their room. Staff interviews revealed that R2 does exhibit certain behaviors, such as trying to drink other residents’ drinks and getting out of their room undressed, however all staff interviewed regarding these allegations revealed that they provide support by re-directing R2 and provide care and supervision. Staff stated that they try to intervene as soon as they notice certain behaviors, that the other residents are aware of R2’s behaviors, and they inform new residents as well. They try to prevent it but when R2 takes drinks from other residents, they provide the residents a new drink. Walking around without clothes is not something that is allowed, and if staff sees R2 without clothes they will re-direct them and R2 will go with the staff to get dressed. Staff stated that R2’s behaviors have been discussed by staff and the administrator to address them. Furthermore, assistant Executive Director revealed that R2 has a service coordinator from Tri-Counties Regional Center, and they are currently trying to work with them to get R2 a 1:1 to provide further support for R2. File review revealed that R2 experiences certain challenges, which include fixation on food and challenges with maintaining appropriate social boundaries, however these challenges have been addressed by staff, and R2's service coordinator. R2’s service care plan dated 04/04/2024, revealed that R2 went through medication changes/adjustments the previous quarter that show improvement in their behavior. On the allegations “Staff did not prevent a resident from drinking another resident's drink and Staff did not prevent a resident from running naked while in care.” Information obtained from interviews and file review revealed, R2 does present behavior challenges, however R2’s behaviors have been addressed by Staff and TCRC Service coordinator. Although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegations are deemed Unsubstantiated at this time. Exit interview conducted. Today's report was reviewed and provided to the Executive Director.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 29-AS-20240313134850

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

Allegation investigated: Residents left soiled for an extended amount of time. Residents are not awarded privacy. Staff did not provide adequate supervision.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival, LPA met with Executive Director Roman Sierra Tobar and was explained the reason for the visit. On 4/10/2023 LPAs Cortez and Kelly Dulek along with facility ED toured the facility at 10:15AM, interviewed staff at the following times: 12:29PM, 01:14PM, 01:55PM, 02:42PM, 04:25PM, and 05:22PM, interviewed Administrator throughout the visit, and reviewed records at 04:15PM. On 08/01/2023, LPA Cortez toured the facility from 9:40 a.m. - 9:50 a.m., reviewed documents with the ED and Assistant adminisrtator at 10:12 a.m. and interviewed residents at 11:14 a.m., 11:32 a.m., 11:40 a.m., 11:44 a.m. and staff at 2:32 p.m. During the week of 5/20/2024, LPA Cortez interviewed R2's Tri-Counties Regional Center (TCRC) Service Coordinator via email correspondence. 08/07/2024, between 11:30 a.m. and 4:30 p.m., the LPA toured the facility with the ED, and obtained copies of pertinent documents relevant to the investigation. Report will continue on LIC9099-C 2nd page. Unsubstantiated On 10/01/2024, the LPA toured the facility and observed all residents starting at 3:50 p.m., interviewed five (5) residents and two (2) staff. During today's visit, the LPA conducted a file review, and interviewed two (2) staff. On the allegation "Residents left soiled for an extended amount of time."; it is the concern of the reporting party that two staff often leave residents in soiled clothing sometimes for up to 30 minutes. It was further reported that a third staff, Staff #1 (S1), has told residents to just use the restroom by themselves. To investigate the allegation the LPA conducted a file review, staff and resident interviews, and observations. File review revealed that the facility did not have staff by the names that the RP provided for the two staff that allegedly leave residents soiled for up to 30 minutes, however does have staff with similar names. Staff interviews revealed they have not observed any residents left soiled for a long period of time, and when a resident are soiled staff immediate assist the resident with incontinence care and clothing change if needed. S1 denied the allegation and stated that they call a caregiver over their walkie-talkie to change the residents if they notice a resident needs to changed and they ensure it gets done. S1 further stated that they are not a caregiver and do not have current proper training in changing residents, therefore they get a care giver or MedTech to assist the residents. Residents interviewed stated they were not left soiled for an extended amount of time, and that staff help when needed. On 08/07/2024, at 1:10 p.m. the LPA observed a resident coming out of their room with soiled pants, as soon as S1 saw them, they called for a caregiver to assist the resident get changed. The LPA observed a caregiver acknowledge the request from S1 and headed towards the resident. After a few minutes the LPA observed the resident with clean pair of pants on. The LPA did not observe any evidence of the allegation while at the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time. On the allegation " Residents are not awarded privacy"; it is the concern of the reporting party that residents are being changed with their room doors open and other residents are walking by looking at them. To investigate the allegation the LPA conducted interviews and observations. Staff interviews revealed that residents are changed in their rooms, or the bathrooms and the doors are always being closed to award the resident’s privacy. Staff revealed that they have not observed the doors being left opened. Residents revealed that staff always close the doors when changing them. On 08/07/2024 at approximately 1:08 p.m. the LPA observed a caregiver assist a resident to the restroom and closed the door awarding privacy to the resident. Report will continue on LIC9099-C 3rd page. The LPA did not observe any evidence of the allegation while at the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time On the allegation " Staff did not provide adequate supervision"; it is the concern of the reporting party that Resident #2 (R2) had fallen out of the recliner in the television room, three (3) times (unknown if any injuries) because there were no staff checking on the residents. No dates were provided for the falls. To investigate the allegation the LPA conducted file review and interviews. A review of the Unusual Injury/Incident reports, dated 01/20/2023, and 03/16/2023 documented that on 01/20/2023 and on 03/15/2023, R2 obtained falls, however during both falls there were care givers present and they were in R2’s bedroom or shower. No other falls were reported to CCL regarding R2 obtaining falls from the facility prior to the complaint received in April of 2023. A review of R2’s admission agreement, dated 11/12/2021, revealed that R2 was not under one-to-one supervision program that is offered as optional items and services for and added rate. Staff interviews revealed that residents are supervised regularly by a caregiver, and that R2 did not require 24-hour supervision, however they would closely monitor R2 due to their seizure disorder. Caregivers make their rounds supervising residents and ensuring the safety of the residents. However, it is standard that residents may be left alone for short periods of time while caregivers are assisting other residents. Staff also reveal that there are always two care givers, one MedTech, and front office staff providing supervision to residents in care. In addition, there is cameras in the common areas including the television room to provide an added source of supervision for staff who is at the front office and are able to look at the cameras. R2’s service coordinator interview revealed that they are not aware of any issues or concerns by or about any of the residents, and that R2’s needs were met. During all the LPA’s visits throughout the investigation, the LPA observed staff making rounds and assisting residents when needed. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 4, 2024 · control 29-AS-20230403161332

Allegation investigated: Staff unlawfully evicted a resident

Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegation. Upon arrival, LPA met with Executive Director Roman Sierra Tobar and was explained the reason for the visit. On 03/14/2024, between 11:30 a.m. and 4:00 p.m., the LPA toured the facility with staff, interviewed the Administrator, two (2) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/07/2024, between 11:30 a.m. and 4:30 p.m., the LPA toured the facility with staff, interviewed the Administrator, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/08/2024, between 10:55 a.m. and 11:55 a.m., the LPA interviewed two staff and obtained pertinent documents relevant to the investigation. During today's visit the LPA conducted a file review and one (1) staff and one (1) witness phone interview between 2:00 p.m. and 4:30 p.m. Report will continue on LIC9099-C 2nd page. Substantiated On the allegation " Staff unlawfully evicted a resident"; it is the concern of the reporting party that Resident #1 (R1) was unlawfully evicted from the facility without any kind of eviction notice. To investigate the allegation the LPA conducted a file review and interviews. File review revealed that the Executive Director did not obtaining prior written eviction approval from the licensing and did not issue an eviction notice to R1 and or their responsible party. Interviews with the previous Executive Director, Gary Lee revealed that on 02/20/2024, R1 was observed with what they thought to be a stage 3 wound, and stated R1 could not be at the facility with a stage 3 wound. They went on to state that R1’s family had home health assess the resident and they confirmed it was a stage 3. The ED discussed with R1’s family possibilities to place R1 on hospice, however after the ED discussed with their director what was going on, the director did not allow for R1 to stay at the facility, according to the ED. Furthermore, the ED revealed that they did not obtained a prior written approval from licensing because everything happened so fast and R1’s responsible person wanted R1 out of the facility right away. Interview with R1’s responsible party revealed that they were not given a 3 day or 30 day notice and were told that R1 could not be at the facility, despite their attempts to place R1 on home health and hospice to ensure that R1 could stay. Based on records reviewed and interviews conducted, it has been determined that Executive Director did not submit a proper letter of eviction to CCL, nor did Executive Director provide Responsible Party with a proper letter of eviction. Therefore, the allegation that Staff unlawfully evicted a resident is Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. ED was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 4, 2024 · control 29-AS-20240313134850

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a-b) · Plan of correction due date: Oct 5, 2024

87224(a)The licensee may evict a resident... Thirty (30) days written notice to the resident is required ..(b) upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. ...This regulation is not met as evidenced by: Based on interviews and record review, the ED did not ensure that they provided R1 and/or their responsible person with a proper eviction notice and did not get prior approval from licensing, which posed an immediate health and safety risk to resident(s) in care.the state’s words, verbatim · CDSS document, Oct 4, 2024

Plan of correction: Executive Director agrees to read and review Regulation 87224 Evictions Procedures and submit a letter of undestanding, and train all staff that provide notices on the proper way to evict residents in care and provide proof to CCL by 10/05/2024.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit due to three self-reported incidents of medication being found on the floor in three residents' rooms. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Katy Robison. LPA explained the reason for the visit to acting administrator Roman Sierra Tovar. At 1:38 LPA and QAS spoke with administrator. At 1:50 p.m. LPA and QAS reviewed and obtained pertinent documents. At 2:04 p.m. LPA and QAS conducted a brief tour of the facility. At 2:12 LPA and QAS interviewed medication technician staff 1 (S1). On 9/18/2024, a medication technician found a medication on the floor in the room of resident 1 (R1). On 9/20/2024, a medication technician found a medication on the floor in the room of resident 2 (R2). On 9/23/2024, a medication technician found a medication on the floor in the room of resident 3 (R3). S1 stated they always make sure all medication is taken by a resident before they leave the room. S1 is not on the same shift as other medication technicians so they were not sure how other medication technicians distribute medications. S1 found a medication on the floor, properly discarded the medication and reported it to management. R1, R2, and R3 all have physicians' reports which state they cannot have access to medication. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC809-D). Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Oct 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(B) · Plan of correction due date: Oct 9, 2024

87465 Incidental Medical and Dental Care (h) The following requirements... which are centrally stored: (1) Medications shall be centrally stored...: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement was not met as evidenced by: Based on record review, R1, R2 and R3 cannot have access to medications but all had medication found in their room, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Administrator will ensure all medication technicians are immediately told they must ensure all medications are taken by residents before leaving the room. Formal training will be conducted and evidence of the training will be sent to CCL on or before 10/9/2024.

Allegation investigated: Facility not providing adequate food service.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegation. Upon arrival, LPA met with Executive Director Roman Sierra Tobar and was explained the reason for the visit. On 4/10/2023 LPAs Cortez and Kelly Dulek along with facility ED toured the facility at 10:15AM, interviewed staff at the following times: 12:29PM, 01:14PM, 01:55PM, 02:42PM, 04:25PM, and 05:22PM, interviewed Administrator throughout the visit, and reviewed records at 04:15PM. On 08/01/2023, LPA Cortez toured the facility from 9:40 a.m. - 9:50 a.m., reviewed documents with the ED and Assistant adminisrtator at 10:12 a.m. and interviewed residents at 11:14 a.m., 11:32 a.m., 11:40 a.m., 11:44 a.m. and staff at 2:32 p.m. On 08/07/2024, between 11:30 a.m. and 4:30 p.m., the LPA toured the facility with the ED, and obtained copies of pertinent documents relevant to the investigation. During today's visit the LPA toured the facility and observed all residents starting at 3:50 p.m., interviewed five (5) residents and two (2) staff. Report will continue on LIC9099-C 2n page. Unsubstantiated On the allegation that the Facility is not providing adequate food service; it is the concern of the reporting party that Residents are being provided dinner at 3:30 PM and also being provided the same meal that they had for lunch. To investigate the allegation a file review and observations were conducted, and staff and residents were interviewed. On 08/07/2024, the LPA observed lunch time approximately at 12:00 p.m. and did not observe lunch take place at 3:30 p.m. File review revealed that the communities Plan of Operation indicates that Breakfast is at 6:30 a.m. and dinner at 5:30 p.m. during the week and on weekends breakfast is at 8:00 a.m. and dinner is at 6:00 p.m. Majority of the Staff that were asked regarding the meal scheduled revealed that breakfast is at 7:00 a.m. and dinner is at 4:00 p.m., with some stating that dinner is at 5:00 p.m. Five (5) out of five (5) Residents interviewed regarding the allegation revealed that they like the food that is served at the facility. File review and staff interviews revealed that food is prepared based on the menu. During today’s visit the LPA observed staff getting residents ready and assisting them to the dining room for dinner starting at 4:30 p.m. to be served dinner at 5:00 p.m. The LPA also observed left over food from lunch in the kitchen that consisted of fish and a broccoli soup at 4:00 p.m. and observed BBQ chicken, vegetables, and bread being served for dinner at 5:00 p.m. One resident interviewed today confirmed that they ate fish, noodles with a cream on top and a salad for lunch and that they do not get served the same meals for lunch and dinner. The LPA observed one (1) out of the fifteen (15) residents eating noodles with cream at dinner, and staff revealed that they had offered the BBQ chicken meal and the resident did not want to eat it, and they offered a meal that they know they like and will eat. Based on the information gathered during the investigation, there is insufficient evidence to support the claim that Facility not providing adequate food service;. Therefore, this allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 29-AS-20230403161332

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

Allegation investigated: Staff are stealing the residents personal funds Staff are allowing residents with prohibited health conditions to reside in the facility

At 10:10 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent complaint visit to deliver findings for the above allegations. The LPA met with interim Executive Director (ED) Leticia Hernandez and the reason for the visit was explained. On 03/23/2023, during the initial 10-day visit, LPAs Cortez and Chochian toured the facility from 9:50 a.m. - 10:40 a.m. along with the ED. LPAs also conducted interviews with six (6) facility residents between 10:45 a.m.-12:15 p.m. and six (6) facility staff between 2:45 p.m.- 5:30 p.m. Moreover, during the visit, LPAs conducted a file review and obtained pertinent documentation between 1:15 p.m. – 2:40 p.m. Additional documentation was requested and obtained from ED on 03/27/2023 and 03/29/2023. On 03/29/2023 at 1:58 p.m., LPA Cortez conducted a phone interview with Staff #1 (S1). On 03/30/2023, LPAs Cortez and Dulek along with TCRC QAS Aced-Arnett and facility ED toured the facility between 11:03 a.m. – 11:30 a.m. Additional interviews were done with four (4) staff between 10:00 a.m.- 12:25 p.m. Report will continue on LIC9099-C (2ND PAGE). Unsubstantiated File review began at 12:30 p.m. and one (1) resident interview at 1:16 p.m. During the week of 5/20/2024, LPA Cortez interviewed six (6) Tri-Counties Regional Center (TCRC) Service Coordinators (SC) via email correspondence. On 08/07/2024, LPA Cortez toured the facility with Interim Administrator Leticia at 12:43 p.m. and conducted a file review at 1:18 p.m. In addition, Interviews and file reviews conducted by LPA Cortez on 02/16/2024, 05/23/2024 and 05/24/2024 as part of a separate compliant investigation (CC# 29-AS-20230406155619) with similar allegations were incorporated and reviewed for the purpose of this investigation; this includes any relevant findings, witness statements, and documented evidence. Staff are stealing the residents personal funds On the allegation that Staff are stealing the residents’ personal funds it is the concern of the reporting party that staff are stealing resident’s money. No additional information was provided about the residents’ identifiers. No contact information was provided for the reporting party to obtain additional information about this allegation. To investigate the allegations resident and staff interviews and file reviews were conducted by LPA Cortez and LPA Cortez also conducted interviews with residents’ Service Coordinators from TCRC. Resident interviews conducted regarding the above allegation revealed that they have not had anything go missing or stolen from their rooms. Staff interviews conducted revealed that they were not aware of any issues or concerns of any stolen items. Interview with past administrator Gary revealed that they or staff do not touch any of the resident’s money. For residents who do not receive services through TCRC, the administrator will purchase anything necessary for them with the money provided by the facility and then the resident’s family will reimburse the administrator. Furthermore, for the residents with TCRC, they have a process in place where the resident's funds are managed by the facility’s corporate office accounting staff alongside Trust Management Services (TMS) provided by TCRC. Anytime a resident wants to purchase something the money is given to them and the resident signs receipt for the amount given. If there’s a particular item that the resident wants to make online, the administrator will assist the resident with the purchase and will save copy of the receipt. Administrator interview and file review also revealed that the administrator keeps records of all transactions and receipts and sends out to accounting for reimbursements. Interviews conducted with TCRC SC revealed that almost all the residents have a service coordinator who visits them once every three months and provide services depending on the resident. Six (6) of six (6) service coordinators interviewed revealed that residents’ funds are managed by TMS and have no concerns regarding the residents’ finances. Based on the investigation, there is insufficient evidence to support the claim that Staff are stealing the resident’s personal funds. This allegation is deemed Unsubstantiated at this time. REPORT WILL CONTINUE ON LIC9099-C (3RD PAGE). Staff are allowing residents with prohibited health conditions to reside in the facility. On the allegation that Staff are allowing residents with prohibited health conditions to reside in the facility; it is the concern of the reporting party that staff are keeping residents with prohibited health conditions and hiding skin tears and prohibited health conditions. No additional information was provided by the reporting party about the resident(s) who exhibited prohibited health conditions, or how to the reporting party acquired the information. No contact information was provided for the reporting party to obtain additional information about this allegation. To investigate the allegation, the LPA conducted a tour of the facility on 08/07/2024, conducted a file review for six random selected residents and conducted interviews with staff and resident’s service coordinators from TCRC. During the tour the LPA observed all residents who were present either eating in the dining room, watching TV in the living room, or in their room and did not observe any gastrostomy tubes, naso-gastric tubes, tracheostomies, or any other type of visible prohibited health conditions. File review revealed that one (1) out of six (6) residents had a history of a stage 2 wound on their left foot in 2023 however they were being treated by home health and the wound healed. Six (6) out of six (6) staff interviewed regarding this allegation revealed that they do not have any resident with prohibited health conditions including open wounds. Interviews conducted with TCRC SC revealed that almost all the residents have a service coordinator who visits them once every three months and provide services depending on the resident. Services can range from crisis support, funding, and supplemental support among other services. Six (6) of six (6) service coordinators interviewed revealed that all ten (10) residents that they assist do not have any history of skin tears or prohibited health conditions. Based on the investigation, there is insufficient evidence to support the claim that Staff are allowing residents with prohibited health conditions to reside in the facility. This allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued to the Interim Executive Director Leticia Hernandez.the state’s words, verbatim · CDSS document, Aug 8, 2024 · control 29-AS-20230315122126

Allegation investigated: Staff sexually abused residents Facility illegally evicted residents. Facility not safeguarding residents’ personal belongings. Facility denied food to residents. Residents are threatened while in care. Residents are bullied while in care.

Licensing Program Analyst (LPA) Esther Cortez arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Gary Lee and explained the visit. On 4/10/2023, LPAs Cortez and Dulek along with facility ED toured the facility at 10:15AM, interviewed staff at the following times: 12:29PM, 01:14PM, 01:55PM, 02:42PM, 04:25PM, and 05:22PM, interviewed Administrator throughout the visit, and reviewed records at 04:15PM. On 7/28/2023, LPA Smith toured the kitchen/food service area from 11:50 a.m. - 12:05 p.m., reviewed fifteen (15) resident files from 12:10 p.m. - 2:00 p.m., interviewed staff at 11:30 p.m., 12:49 p.m., and 1:07 p.m., and interviewed residents at 2:02 p.m., 2:03 p.m., and 2:10 p.m. On 02/16/2024, LPA Cortez toured the facility, interviewed staff and residents, conducted a file review and obtained copies of pertinent documents from 10:35 a.m. to 3:00 p.m. During the week of 5/20/2024, LPA Cortez interviewed six (6) Tri-Counties Regional Center (TCRC) Service Coordinators via email correspondence. Report will continue on LIC9099C (2nd Page). Unsubstantiated (2nd page continued...) On 05/23/2024, LPA Cortez toured the facility, interviewed two (2) residents, and one (1) staff, observed residents at lunch, conducted a file review and obtained pertinent documents. During today's visit, LPA Cortez conducted a medication audit, toured the facility and interviewed staff. Staff sexually abused residents On the allegation that Staff sexually abused residents; it is the concern of the reporting party that Staff#1 (S1) has been sexually abusing residents for decades. To investigate the allegations LPA Cortez conducted interviews and physical tours of the facility. Staff and residents were interviewed on 04/10/2023, 07/28/2023, 02/16/2024, and 05/23/2024. LPA Smith interview former staff on 07/27/2023 and LPA Cortez also interviewed residents TCRC Service Coordinators (SC). Interviews conducted with staff revealed that staff did not have any concerns or knowledge of sexual abuse occurring at the facility. Interviews with S1 revealed that S1 was consistently working at the facility for about four to five months in 2022 and now only visits the facility one to two times a year and denied ever abusing any of the residents in any form. In addition, S1 stated that their interactions with the residents was mainly checking in on them and making sure they were fine, and that the facility has a zero tolerance for abuse. Staff interviews revealed that S1 was very nice to the residents, and that S1 has never been seen mistreat the residents. Furthermore, all staff interviewed regarding the above allegation stated that any abuse would be reported. Interviews conducted with the residents revealed that staff treats residents well, and residents did not voice any concerns of sexual abuse. Interviews conducted with TCRC SC revealed that almost all the residents have a service coordinator who visits them once every three months and provide services depending on the resident. Services can range from crisis support, funding, and supplemental support among other services. Five of six service coordinators interviewed revealed that they have no concerns regarding the residents at the facility and that the residents are doing well. One of six service coordinators interviewed revealed that there have been previous concerns in the past, those concerns have been addressed with staff, and the concerns voiced were not related to sexual abuse. On 04/10/2023, 02/16/2024 LPA Cortez toured the facility and did not observe any health or safety concerns. Report will continue on LIC9099-C (3rd page). (3rd page continued...) On 05/24/2024 LPA Cortez toured the physical plant and observed all sixteen (16) residents either sleeping, watching TV, on the phone or interacting with one another and did not observe any health or safety concerns. No concerns were voiced during today’s visit. Based on the investigation, there is insufficient evidence to support the claim that Staff sexually abused residents. This allegation is deemed Unsubstantiated at this time. Facility illegally evicted residents. On the allegation that Facility illegally evicted residents; it is the concern of the reporting party that residents are being wrongly evicted out of the home and that residents that had Covid-19 are being put on the streets to die. RP did not provide any information as to which residents have been evicted from the facility. To investigate the allegation interviews were conducted with staff, current administrator and two (2) former administrators. LPA Smith conducted an interview with the current administrator on 07/28/2024. Interview conducted with the Administrator revealed that they have not had to issue any evictions during their time here at the facility and has not heard anything about any illegal evictions. Interviews conducted with former administrators revealed that during their time at the facility they did not have to serve any eviction notices. Interviews also revealed that staff have eviction protocols which includes serving the residents with a 30-day notice and sending it to licensing for approval before serving it to the residents. Furthermore, interviews revealed that staff tries to work with the resident to make sure the resident do not end up homeless. Four of four staff that were asked regarding the above allegation revealed that they have not seen any residents being evicted or have not heard of residents being evicted. Based on the investigation, there is insufficient evidence to support the claim that Facility illegally evicted residents. This allegation is deemed Unsubstantiated at this time. Report will continue on LIC9099-C (4th page). (4th page continued...) Facility not safeguarding residents personal belongings. On the allegation that Facility is not safeguarding residents’ personal belongings; it is the concern of the reporting party that resident’s money, medication, and belongings are being stolen. To investigate the allegations resident and staff interviews and file reviews were conducted by LPA Cortez and LPA Smith. LPA Cortez also conducted interviews with resident’s service coordinators from TCRC. Lastly during today’s visit, LPA Cortez conducted a medication audit for five (5) residents. All resident interviews conducted regarding the above allegation revealed that they have not had anything go missing or stolen from their rooms. All Interviews conducted with staff revealed that they were not aware of any issues or concerns of any stolen items. Administrator’s interview revealed that they or staff do not touch any of the resident’s money. For residents who do not receive services through TCRC, the administrator will purchase anything necessary for them with the money provided by the facility and then the resident’s family will reimburse the administrator. Furthermore, for the residents with TCRC, they have a process in place where the resident's funds are managed by the facility’s corporate office accounting staff alongside Trust Management Services (TMS) provided by TCRC. Anytime a resident wants to purchase something the money is given to them and the resident signs receipt for the amount given. If there’s a particular item that the resident wants to make online, the administrator will assist the resident with the purchase and will save copy of the receipt. Administrator interview and file review revealed that the administrator keeps records of all transactions and receipts and sends out to accounting for reimbursements. Interviews conducted with TCRC SC revealed that almost all the residents have a service coordinator who visits them once every three months and provide services depending on the resident. Services can range from crisis support, funding, and supplemental support among other services. Six (6) of six (6) service coordinators interviewed revealed that residents’ funds are managed by TMS and have no concerns regarding the residents’ finances. During the Med audit conducted today for five (5) of sixteen (16) residents, the LPA observed medications centrally stored and locked in a medication cart; medications are labeled and checked for expiration dates. All medications were accounted for. The LPA interviewed the Assistant Administrator (AA) during the med audit. Interview with the AA revealed that there is only two (2) sets of keys to the med cart, and only the med techs, administrator and assistant administrator have access to those keys. If any individual from corporate would want to access the Med cart they would need to ask staff, and that has not happened to their knowledge. In addition, Med audit and file review revealed that MT's conduct a Narcotic count at the beginning and the end of their shift. Report will continue on LIC9099-C (5th page). (5th page continued...) Based on the investigation, there is insufficient evidence to support the claim that facility is not safeguarding residents’ personal belongings. This allegation is deemed Unsubstantiated at this time. Facility denied food to residents. On the allegation that residents are denied food, the RP only stated that residents are being denied food. To investigate the allegation staff and residents were interviewed, and on 05/23/2024, LPA Cortez observed lunch time at approximately 12:00 p.m. The LPA observed approximately twelve (12) residents in the dining room, either eating on their own or residents were being fed by staff. The LPA also observed care staff requesting kitchen staff meals to be deliver to residents in their room who were not going to eat at the dining room. At approximately 12:10 p.m. the LPA observed two (2) residents asking for more food, which was provided to them. One of the two residents continue to ask for more food approximately two to three more times, which was provided to them. Per the staff interviews, four (4) of the residents were served in their room due to not feeling well. Five out of five residents interviewed throughout the investigation regarding this allegation revealed that the facility provides meals and snacks. One (1) of four (4) residents stated that the facility food was good and that they even got extras. Ten (10) of ten (10) Staff interviews conducted regarding this allegation revealed that staff have never denied food to the resident. Eight (8) of ten (10) staff revealed that they have no knowledge of any staff denying food to residents. Two (2) of ten (10) staff interviewed revealed that there has been concerns about staff denying food to residents, however those concerns were addressed by the administrator or themselves. Based on the information received through interviews, and observation, there is insufficient evidence to support the claim Facility denied food to residents. Therefore, this allegation is deemed Unsubstantiated at this time. Report will continue on LIC9099-C (6th page). (6th page continued...) Residents are threatened while in care and Residents are bullied while in care. On the allegations that Residents are threatened while in care and Residents are bullied while in care; it is the concern of the reporting party that residents are being threatened with bodily harm and financial abuse if they complain to licensing and are bullied. To investigate the allegations LPA Cortez and LPA Smith conducted interviews and physical tours of the facility. Staff and residents were interviewed on 04/10/2023, 07/28/2023, 02/16/2024, 05/23/2024 and 05/24/2024. LPA Smith interview former staff on 07/27/2023 and LPA Cortez also interviewed resident TCRC service coordinators (SC). Six (6) of eight (8) staff, including former staff, interviewed regarding of the above allegation stated that they have no knowledge of any mistreatment occurring at the facility. Two (2) of eight (8) staff stated that there have been concerns of mistreatment, however that those concerns were reported to CCL and addressed. Furthermore, all staff interviews regarding the above allegation stated that any abuse would be reported, and all staff denied threatening or bullying residents and that residents have not voiced any concerns to them. Interviews conducted with the residents revealed that staff treats residents well, and residents feel safe at the facility, and they have no concerns regarding the above allegations. Interviews conducted with TCRC SC revealed that almost all the residents have a service coordinator who visits them once every three months and provide services depending on the resident. Services can range from crisis support, funding, and supplemental support among other services. Five (5) of six (6) service coordinators interviewed revealed that they have no concerns regarding the residents and that the residents are doing well at the facility. One of six service coordinators revealed that there have been previous concerns in the past, however those concerns have been addressed by the administrator and were not regarding the the resident being threatened or bullied. On 04/10/2023, 02/16/2024, 05/23/2024 LPA Cortez toured the facility and did not observe any health or safety concerns. During today’s visit the LPA toured the physical plant and observed all sixteen (16) residents either sleeping, watching TV, on the phone, or interacting with one another. No concerns were voiced during today’s visit. Based on the investigation, there is insufficient evidence to support the claims that Residents are threatened while in care and Residents are bullied while in care. These allegations are deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 24, 2024 · control 29-AS-20230406155619

Allegation investigated: Residents are locked in facility.

Licensing Program Analyst (LPA) Esther Cortez arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Gary Lee and explained the visit. On 4/10/2023, LPAs Cortez and Dulek along with facility ED toured the facility at 10:15AM, interviewed staff at the following times: 12:29PM, 01:14PM, 01:55PM, 02:42PM, 04:25PM, and 05:22PM, interviewed Administrator throughout the visit, and reviewed records at 04:15PM. On 7/28/2023, LPA Smith toured the kitchen/food service area from 11:50 a.m. - 12:05 p.m., reviewed fifteen (15) resident files from 12:10 p.m. - 2:00 p.m., interviewed staff at 11:30 p.m., 12:49 p.m., and 1:07 p.m., and interviewed residents at 2:02 p.m., 2:03 p.m., and 2:10 p.m. During today’s visit, LPA Cortez toured the facility, interviewed staff, and residents, conducted a file review and obtained copies of pertinent documents from 10:35 a.m. to 3:00 p.m. Report will continue on LIC9099C. Unsubstantiated On the allegation Residents are locked in facility, it is the reporting party’s concern that the facility is not allowing residents to leave the building, and are tying the doors up, so they cannot be opened. To investigate the allegation, the LPA conducted a file review for all the residents, conducted interviews and toured the facility. File review revealed that all residents cannot leave the facility unassisted based on their Physicians Report LIC602. Staff interviews revealed that facility doors are always locked from the outside, however never locked from the inside and residents can go outside on outings with their family or with a staff member. Furthermore, staff interviews revealed that they need to know where the resident are in case, they need to take their medication. The administrator stated that residents are able to leave whenever they want but due to their safety they need to be supervised based on their Physicians report. The administrator also stated that residents are usually sleeping at night, and only two care givers are available during the night shift, however if a resident would want to go out during the night they can call the administrator and he would be able to take them out. During the facility tour the LPA did not observe any exiting doors locked from the inside, and was able to exit the facility from any of the exiting doors. In addition, the LPA observed that the resident bedroom doors can only be locked from the outside. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Residents are locked in facility”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 16, 2024 · control 29-AS-20230406155619

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