Colony of Thousand Oaks at Greenfield

Allegation investigated: Resident sustained multiple injuries due to staff neglect or physical abuse. Staff are not meeting the care needs of resident in care.

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above-mentioned allegations. Upon arrival at approx 10 a.m. LPA was greeted by staff, and co-Administrator Eleanor Jimenez and explained the purpose of the visit. The staff contacted the Administrator Dr. Rashita Aggarwal who was available telephonically throughout the visit and the purpose of the visit was explained, and an entrance interview was conducted. On 06/09/2026 the Department received a complaint regarding the following allegations Resident sustained multiple injuries due to staff neglect or physical abuse and Staff are not meeting the care needs of resident in care. On 06/18/2026 LPA Mosley conducted the initial 10-day complaint visit, toured the physical plant areas to ensure compliance with title 22 regulations, conducted interviews with Resident #1 (R1), Authorized Representative (AR) for R1, four (4) staff interviews including the Administrator, a file review for R1 and obtained copies of pertinent documents relevant to the investigation. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC 9099... During today's visit starting at 10:10 a.m. LPA and staff briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. On the allegation, Resident sustained multiple injuries due to staff neglect or physical abuse, it is the concern of the Reporting Party (RP) that R1 had unexplained bruises and scratches on their back and buttocks area. To investigate this complaint, LPA conducted in person interviews, file and record review, and obtained copies of pertinent documentation relevant to the investigation. Interview with R1 revealed that they are alert, oriented, and demonstrate appropriate decision-making capacity. R1 has lived in the home for approximately one (1) year and reported having no concerns regarding the quality of care provided by staff. R1 stated they are not abused or neglected by staff. When asked about the bruises and scratches, R1 explained that they frequently scratch themselves due to ongoing issues with itchy skin. Regarding the bruises on their back, R1 stated that their insurance delivered the incorrect bed gel; they were supposed to receive an air loss mattress but were sent a different product. R1’s authorized representative has already contacted the insurance provider to request a replacement. In the meantime, staff assist R1 by placing a wedge and repositioning them regularly. Interview with the AR revealed that R1 is alert, oriented, and able to communicate their needs. The AR stated that if any issues were occurring, R1 is capable of expressing their concerns, including concerns related to neglect or physical abuse. The AR reported having no concerns regarding the care being provided to R1. Staff interviews revealed that R1 is alert and able to communicate their needs. Staff deny neglecting R1 and deny witnessing any other staff neglect R1. Staff also deny physically abusing R1 and deny witnessing any staff engage in physical abuse. Staff reported that R1 had recently been discharged from hospice and was previously using an air loss mattress. When R1 transitioned to home health services, the mattress was changed, which has caused some discomfort. The AR was informed and contacted R1’s insurance, though the replacement process has taken some time, which may explain the bruising. Staff report that they regularly reposition R1 and utilize a wedge for comfort. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099-C PAGE 2... Records review, including but not limited to the medical assessment, body assessments, resident appraisal, needs and services plan, physician visit forms, outside agency documentation (including wound care), and home health records, revealed that R1 does not have a Major Neurocognitive Disorder (NCD) diagnosis. Documentation shows that R1 has multiple wounds on their legs, is able to communicate, follow directions and instructions, express frustration, and is bedridden due to advanced age and disease progression. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Resident sustained multiple injuries due to staff neglect or physical abuse is deemed unsubstantiated at this time. On the allegation, Staff are not meeting the care needs of resident in care, it is the concern of the Reporting Party (RP) that it appeared R1 had months of dead skin on their legs and feet. To investigate this complaint, LPA conducted in person interviews, file and record review, and obtained copies of pertinent documentation relevant to the investigation. Interview with R1 revealed that they have a wound on their left leg that was previously treated by hospice and is now being treated by home health. R1 stated the facility provides minimal assistance with the wound, as treatment is primarily the responsibility of the wound care specialist. R1 reported that aside from the wound on their left leg, facility staff meet their care needs, respond promptly to their requests, and R1 has no concerns regarding the quality of care they receive. Interview with the AR revealed that R1 is alert, oriented, and able to communicate their needs. The AR stated that R1 is capable of expressing any concerns related to their care. The AR reported having no concerns regarding the care being provided to R1. The AR also noted that R1 is in the process of obtaining an appointment with a podiatrist; however, insurance approval has been delayed, and the AR clarified that this issue is unrelated to facility staff. Interviews with staff revealed that R1 is currently receiving services from a wound care specialist for a wound on their leg, with a nurse addressing the wound once a week. Staff stated that R1 was previously on hospice and later transitioned to home health services. Staff described R1 as alert, oriented, and able to communicate their needs. Staff believe R1’s care needs are being met and reported that R1 would vocalize concerns directly to staff if needs were not being met. Report continued on LIC 9099-C PAGE 4... (PAGE 4) Report continued from LIC 9099-C PAGE 3... Records review, including but not limited to the medical assessment, body assessments, resident appraisal, needs and services plan, physician visit forms, outside agency documentation (including wound care), and home health records, revealed that R1 does not have a Major Neurocognitive Disorder (NCD) diagnosis. Documentation indicates that R1 has multiple wounds on their legs, is able to communicate, follow directions and instructions, express frustration, and is bedridden due to advanced age and disease progression. Wound care documentation notes wounds on the left leg and buttock area. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff are not meeting the care needs of resident in care is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Aug 28, 2026 · control 29-AS-20260609152054

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:45 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator / Licensee Representative, Dr. Rashita Aggarwal and Co-Administrator Christopher Romo arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and staff / 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. COMMON AREAS: This includes the living room, and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 12:01 p.m., hardwire combination of smoke / carbon monoxide detectors and fire door were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 11/14/2025. The emergency exiting plans/sketch are posted. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 10/04/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. Auditory alarms at the entrances and exits were observed and functional at the time of the visit. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C... INTERVIEWS: Starting at 9:55 a.m. and throughout the visit two (2) staff and two (2) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit. BEDROOMS: There are eight (8) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and two (2) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. Five (5) out of six (6) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are three (3) total restrooms. Two (2) are designated as a shared / common resident restroom, and One (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 105.0 - 112.5 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use. KITCHEN: The LPA inspected the kitchen/food service area at 10:18 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 112.1 degrees Fahrenheit at 10:19 a.m. Cleaning supplies and other chemicals are kept locked under the sink, the hallway chemical closet and in the garage locked and inaccessible to residents in care. GARAGE: LPA observed the attached garage accessible through the kitchen, which was locked at the time of the visit. LPA observed emergency food and water, personal protection equipment (PPE) , incontinent supplies, and an extra refrigerator/freezer that was checked for proper labels and expiration dates. LPA observed laundry units and laundry detergent. LPA observed a storage closet with supplies. Report Continued on LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... RECORDS: Resident Records: were reviewed beginning at 10:32 a.m. six (6) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Personnel Records were reviewed beginning at 11:33 a.m. five (5) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. MEDICATIONS: Medication review began at approximately 12:05 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the dining room. Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. LPA observed the first aid supplies to be complete, including a thermometer and a current version of a first aid manual. DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster and copy of the Limited Liability insurance. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report reviewed and provided.the state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced at 11:36AM to conduct an annual inspection. LPA initially met with facility staff. Facility Designees and Licensee/Administrator were contacted via telephone. Facility Designee Eleanor Jimenez arrived shortly after the visit began; remaining 3 (three) managers arrived throughout the visit. Entrance interview conducted. Beginning at 12:11PM, the LPA, along with facility management 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: Fire extinguishers were observed to be fully charged and recently serviced 10/04/2024. Hardwired combination smoke and carbon monoxide detectors were tested at 02:10PM. All were functional at the time of the visit. BEDROOMS: There are (8) eight bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (2) two staff rooms. Both staff rooms are kept locked. Lighting in the resident rooms appeared adequate. All resident rooms were observed and were furnished appropriately at the time of the visit. BATHROOMS: There is (1) half bath and (1) full bathroom in the hallway. There is (1) one additional private bathroom for resident use; the half bathroom in the hallway is designated for staff and guests, the full bathroom in the hallway is designated for resident use. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in shared resident bathroom measured at 115.1 degrees Fahrenheit, which is within the required range. COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. All furnishings were observed in good condition. All required postings were observed in common areas. Report Continued on LIC 809-C EXTERIOR: The exterior passageway was clean and clear of any obstructions. There is a patio area in the backyard with a shaded table and chairs for resident use. The back and sides of the house are separated from the front yard by a gate with a self-latching mechanism. KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer next to the sink. Cleaning supplies are locked in an under-sink cabinet. The supply of perishable and nonperishable food is adequate. Appliances in the kitchen were clean and appeared functional. There is an adequate supply of emergency food and water. GARAGE: The garage was observed locked and inaccessible to residents in care. The garage contained storage, a refrigerator/freezer containing extra food, as well as the facility's laundry area. FILES: Beginning at 12:33PM, LPA observed 5 (five) resident files for items including but not limited to physician's report, physician's orders, needs and service appraisals, and personal rights. All resident files were in order. LPA observed 2 (two) staff files for items including but not limited to health screening, TB test, criminal record clearance, and training records. All staff records were observed to be complete. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: The facility has an infection control plan and emergency disaster plan; both of which were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill documented on 11/03/2024. MEDICATIONS: Medications are stored in a locked cabinet in the kitchen. The first aid supplies were complete, including a first aid manual. At 01:45PM, medications for 2 (two) residents were observed. Medications for both residents were observed to be properly stored and documented per regulation. INTERVIEWS: During today's visit, LPA conducted interviews with both staff and residents. No concerns were noted during interviews. No citations issued. Exit interview was conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 14, 2024