Wisdom & Grace Senior Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct the required annual visit today. Upon arrival, the LPA was greeted by staff, Adolfo Gandia who then contacted the Administrator telephonically and informed them of the visit. The Administrator, Walfre Alvizures was unavailable to meet at the facility but gave permission for staff to assist LPA and sign report. Entrance interview conducted. Beginning at 09:05am, the 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 observed: Bedrooms: There are five (5) bedrooms for resident use. Four (4) bedrooms are designated as private / single bedrooms, and one (1) bedroom is designated as shared / double occupancy. Bedrooms were observed to be furnished appropriately and had sufficient lighting. There is a closet with additional clean linens and towels for resident use. There is a staff bedroom on premises which was observed inaccessible to residents at the time of the visit. Restrooms: There are three (3) restroom for resident use. Bathrooms were clean and sanitary and in operating condition with non-skid surfaces and grab bars. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 09:08am, the hot water temperature was measured in resident bathrooms, and they measured 112.1 and 113.5 degrees Fahrenheit, which is within the required range of 105 – 120 degrees Fahrenheit. Personal hygiene items were observed inaccessible to residents at the time of the visit. Report Continued on LIC 809C... Report Continued from LIC 809... Common Areas: This includes the living room and dining room area. Furniture in the common areas was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. The LPA observed a fire extinguisher to be fully charged with a charge date of 03/13/2026. Required postings were observed throughout the common space. There is a working telephone on premises. The LPA observed two (2) fireplaces, one in the dining room and the other in the living room; both adequately screened. A sufficient supply of emergency food and water was observed. No hazards/obstructions observed inside or out. Laundry Room: Washer and dryer were observed in the laundry room next to the kitchen. Detergents and cleaning supplies were observed inaccessible to residents in care at the time of the visit. Kitchen: The LPA inspected the kitchen/food service area at approximately 09:16am. Knives and sharps were observed in a locked cabinet. Cleaning supplies were observed locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Outdoors: The house is fully gated. The front yard has a covered patio area with adequate furniture for resident use. Emergency passageway was observed to be clear of any obstructions. There is one (1) side gate with latching mechanisms for emergency purposes. No bodies of water noted at the time of the visit. Records: Record review began at approximately 09:30am. Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent for treatment form, preplacement appraisals, appraisals, and current needs and services plan. All files were in order. Five (5) personnel files were reviewed for, but not limited to: personnel records, health assessments with negative TB test results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All personnel files were complete. The Administrator’s certificate is valid until 08/29/2026. Report Continued on LIC 809C... Report Continued from LIC 809C... Medications: Medication review began at approximately 12:15pm. Medications are centrally stored and kept in a locked cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appear to be administered as prescribed at the time of the visit. No citations issued at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 17, 2026

Allegation investigated: Neglect/Lack of Care and Supervision – resident sustained unexplained fracture Neglect/Lack of care and Supervision – staff did not properly supervise resident Neglect/Lack of Care and Supervision – staff did not seek timely medical attention for resident’s injury

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA met with Administrator, Walfre Alvizures and explained the reason for the visit. Entrance interview. On 05/07/2025, the Department received a complaint alleging neglect/lack of care and supervision. It was reported that facility failed to properly supervise Resident #1 which resulted in R1 sustaining an unexplained fracture. Moreover, it was also reported that facility failed to obtain timely medical attention for R1’s injuries. Per the Reporting Party (RP), R1 had bone exposure in the left knee, accompanied by swelling and redness. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... On 05/08/2025, LPA Arroyo conducted the initial complaint visit. During the visit, the LPA conducted a facility tour, interviewed two staff members and one family member, and reviewed and obtained copies of relevant documentation. Investigator Real conducted interviews on 05/12/2025, at approximately 10:30 a.m., with one staff member; at approximately 11:45 a.m., with a hospice nurse; at approximately 12:30 p.m., with R1’s family member; and at approximately 02:30 p.m. with the Administrator. An interview was also attempted with R1 at approximately 01:20 p.m.; however, R1 was unable to respond to questions, and no information was obtained. Additional interviews were conducted by Investigator Real on 07/23/2025, at approximately 12:30 p.m. and 01:30 p.m. with two facility residents and on 07/28/2025 at approximately 01:00 p.m. with one staff member. On 07/14/2025, medical records were requested from Simi Valley Hospital and received on 07/24/2025. On 07/15/2025, hospice records were requested from Comforting Care Services and received on 07/29/2025. A review of R1’s Physician’s Report, dated 04/01/2024, listed R1’s primary diagnosis as Alzheimer’s disease and dementia, with a secondary diagnosis of unspecified protein-calorie malnutrition. The report described R1’s mental condition as confused and disoriented, exhibiting wandering and sundowning behaviors. It noted that R1 was unable to follow instructions when confused or agitated but could follow basic instructions when not. R1 was also reported to be unable to communicate needs, except for basic and very minimal communication. The report also described R1 as non-ambulatory, with no capacity for self-care, and in need of assistance with all activities of daily living (ADLs). The investigation revealed that on 04/13/2025, R1 reportedly sustained an unwitnessed fall from their bed. Interviews conducted with staff revealed that, following the fall, they assessed R1 and contacted the hospice agency, the facility administrator, and R1’s family. Upon arrival, the hospice nurse assessed R1 and ordered a mobile X-ray, which confirmed that R1 had suffered a fracture to the left femur. Although the fracture was confirmed, R1’s family chose to pursue comfort care at the facility. Staff reported that a brace was applied to R1’s leg. However, due to R1’s significant agitation, frequent movement, and fragile skin condition, they believe R1’s skin may have torn as a result of movement. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Further interviews revealed that on 05/06/2025, R1 began complaining of leg pain, and staff observed that the leg was swollen and irritated. A change in R1’s condition was noted at that time, including a slight protrusion of bone through the skin. Facility staff contacted the hospice agency, which then advised both the family and the facility to call 911, as R1’s situation was out of their realm of care. According to hospital records dated 05/06/2025, R1, who is on hospice care, was brought in from the facility following a fall that had occurred approximately two weeks prior. At the time of the fall, staff had noted that the skin over the fracture site was taut but not broken. However, by the time of hospital admission, there was an open wound with exposed bone. Hospital staff applied traction in an effort to close the wound but noted that healing was unlikely due to R1’s age and overall condition. During the hospital stay, R1’s family reiterated their decision not to pursue aggressive treatment, prioritizing comfort, pain management, and infection prevention instead. They again declined surgical intervention. R1 was subsequently discharged back to the facility under hospice care. Verbal and written wound care instructions were provided to R1’s family to ensure appropriate ongoing care. Additionally, R1 experienced only one fall while residing at the facility, which resulted in the reported injury. Facility staff responded promptly by notifying the hospice agency, the facility administrator, and R1’s family to ensure timely medical attention. Based on the information obtained during the course of the investigation, the Department has insufficient evidence to support the allegations, therefore allegations due to staff “Neglect/Lack of Care and Supervision – resident sustained unexplained fracture, staff did not properly supervise resident, and staff did not seek timely medical attention for resident’s injury” are deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 29-AS-20250507152203

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Staff contacted the Administrator telephonically and informed them of the visit. The Administrator, Walfre Alvizures arrived at the facility at approximately 09:40am. Entrance interview conducted. Starting at 09:45am, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA inspected the kitchen/food service area at 09:45am. Knives and sharps were observed in a box locked under the kitchen sink. Cleaning supplies are kept locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed the fire extinguisher to be fully charged with a date of 03/13/2025. Required postings were observed throughout the common space. Report Continued on LIC 809C... Report Continued from LIC 809... The LPA observed two (2) fireplaces adequately covered at the time of the visit. Activities were observed in the living room and dining room. There is a working telephone on premises. The LPA observed a closet in the hallway with additional clean linens and towels. Auditory alarms were observed at the time of the visit. The LPA observed an adequate supply of emergency food and water. No obstructions or hazards observed inside or out. LAUNDRY ROOM: The laundry room is next to the kitchen. Laundry detergents and toxins were observed locked and inaccessible at the time of the visit. RESTROOMS: There are two (2) restrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. Hand washing signs were observed posted at the time of the visit. The bathrooms were sufficiently stocked with supplies and paper towels. Personal hygiene items were also observed locked and inaccessible to residents in care. Starting at 09:54am, the hot water temperature was measured in bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit at the time of the inspection. BEDROOMS: There are five (5) bedrooms for resident use. One (1) bedroom is designated for double occupancy and four (4) bedrooms are designated for private / single occupancy. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a staff room on premises which was inaccessible to residents in care at the time of the inspection. Report Continued on LIC 809C... Report Continued from LIC 809C... OUTDOORS / SURROUNDING AREAS: The backyard was observed with two (2) sheds used for storage purposes inaccessible to residents at the time of the visit. There is one (1) side gate that self-latches. Property is fenced all around. The front yard has a covered patio area with patio furniture for resident use. All passageways were observed to be clear of any obstructions. No bodies of water noted at the time of the visit. RECORDS: The LPA reviewed Resident Records and Personnel Records starting at 10:15am. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, preplacement appraisals, consent for treatment form, and current needs and services plan. During record review, it was revealed that 3 out of 6 residents did not have a preplacement appraisal on file, 4 out of 6 residents did not have an appraisal and/or needs & service plan on file, and 5 out of 6 residents do not have a signed consent for treatment for on file. The Administrator stated they would complete the missing forms for all residents. Per record review of Resident #1's (R1's) physician's reports dated 03/05/2025, it indicates R1's ambulatory status as bedridden and facility does not have an approved fire clearance for bedridden. R1 was moved out of the facility during today's inspection. Five (5) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. During record review, it was revealed that facility does not have a staff training binder; therefore, LPA was unable to verify yearly training for all staff. The Administrator stated they would work on completing all training for staff. Report continued on LIC 809C... Report Continued from LIC 809C... INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. MEDICATIONS: Medications review began at approximately 12:50pm. Medications are centrally stored in a locked cabinet by the kitchen. First Aid Kit and manual were observed and complete at time of the visit. Medications appeared to be given as prescribed at the time of the visit. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). An immediate civil penalty in the amount of $500 for fire clearance violation is being assessed today. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 25, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with staff and explained the reason for the visit. Administrator Walfre Alvizures arrived shortly after. The LPA 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. LPA began the inspection in the kitchen/food service area at 10:40 a.m. Knives are stored in a locked cabinet underneath the sink. Kitchen appliances observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored. Cleaning supplies were observed locked and inaccessible under the kitchen sink. At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 74 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 03/11/2024. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space. The backyard has a covered outdoor area equipped with furniture for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted. LPA observed two (2) sheds, both were observed to be inaccessible to residents in care. LPA observed both sheds to store extra furniture, medical equipment and other items for facility use. There is a separate laundry room that was observed inaccessible for residents at the time of the visit. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six (6) designated resident rooms. One wing of the home is designated as a private staff wing where staff reside. LPA observed it to be empty at this time. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. Records review began at 11:30am. Five (5) resident records were reviewed for the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, appraisals, and current needs and services plan. At approx 11:30am, LPA observed Resident #1 (R1), Resident #2 (R2), Resident #3(R3), Resident #4(R4) and Resident #5 (R5), to have incomplete files. Missing documents are specified on 809-D. LPA reviewed staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. At approx 12pm, LPA observed Staff #1 (S1) and Staff #2 (S2) to have criminal background clearance, but they were not associated to this facility. Administrator's file was missing the following - Education Verification, LIC 501, LIC 503, TB Test / Result, LIC 9052, SOC 341A .Last emergency disaster drill conducted last quarter. Administrator will conduct drill by end of month. Medications review began at 02:00 p.m. The medications are centrally stored and locked in a cabinet inside the kitchen. Medications are labeled and checked for expiration dates. No errors found during medication audit. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. Continued from 809-C LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. Staff and residents were interviewed during the visit. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $1,000. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 13, 2024