Aasta Assisted Living

Allegation investigated: Resident #1 fell due to staff neglect, resulting in injury Facility staff failed to seek timely medical care for resident Staff did not notify resident's POA about incident

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit regarding the above noted allegations. The facility closed effective 05/11/2026, therefore this visit was conducted telephonically with the Licensee representative. During an initial complaint visit conducted on 04/16/2026, the LPA interviewed the Wellness Director and Administrator at 11:49AM, toured the facility with Administrator at 01:08PM, and the LPA reviewed and obtained copies of relevant documents. The complaint was referred to Community Care Licensing’s Investigative Branch (IB) for investigation. IB investigator obtained and reviewed copies of additional pertinent records and interviewed residents, staff and other relevant parties on the following dates: 04/20/2026, 05/11/2026, 05/12/2026, 05/14/2026. Throughout the course of the investigation, LPA Dulek reviewed all documents obtained and IB investigative reports. LPA also conducted additional interviews with residents and staff throughout the investigation. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation “Due to staff neglect, Resident #1 (R1) fell, resulting in injury:” Review of R1’s facility records revealed that R1 moved into the facility on 05/20/2022. At that time, R1’s physician’s report indicated a diagnosis of dementia and DM without complications. R1’s physician indicated they were non-ambulatory, with a note indicating “SBA [stand by assist] with bed mobility and transfers.” R1’s non-ambulatory status was identified to be based on mental condition. However, on 08/22/2024, a different doctor filled out an updated physician’s report for R1, which indicated no cognitive impairment and that R1 is ambulatory. No physician’s report nor care assessment reviewed indicated R1 required 1:1 supervision or that R1 is a fall risk. Internal incident report revealed R1 fell on 04/05/2026 while walking to their room. Then on 04/08/2026, the facility reported R1 was found on the floor in the hallway. According to the report, R1’s family member planned to take R1 to the doctor the following day. On 04/09/2026, while R1’s family member was at the facility, R1 experienced a change of condition and R1’s family member transported R1 to the hospital. Hospital admission indicates R1 was admitted to the hospital due to a “fall.” However, while at the hospital, additional medical tests revealed R1’s primary diagnosis to be “non-ST-elevation myocardial infarction.” According to the National Institutes of Health website, a non-ST-Segment Elevation Myocardial Infarction is a type of heart attack. There are several causes that could potentially lead to the NSTEMI, however, a fall is not listed as a potential cause, nor did the hospital records indicate the heart attack resulted from the fall R1 sustained at the facility. Additionally, staff were present and observed both falls immediately preceding R1’s hospitalization. R1’s family member was present during the change of condition, which was later identified as the heart attack event. Staff interviewed indicated that staff were nearby R1 when they fell, but were unable to prevent R1’s falls. Residents and family interviewed felt supervision was adequate at the facility to meet R1’s needs and none felt staff were neglectful to the 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. Allegation “Facility staff failed to seek timely medical care for resident:” It was alleged that when R1 has had medical emergency situations, the facility did not follow emergency protocols and instead notified a family member, causing a delay in obtaining further medical treatment. Incident report related to the 04/05/2026 incident indicates “resident did not want to be transferred to the Report Continued on LIC 9099-C (p. 3) hospital. Family was informed and MD was notified.” Staff filled out and asked R1 to sign a document entitled Emergency Transport Refusal. This form is dated 04/04/2026, however, this date appears incorrect, as R1 did not have a documented fall on 04/04/2026 and staff stated it was related to the fall on 04/05/2026. The medication technician indicated they “called [R1’s family member] and left a voicemail.” It is unclear why the facility staff requested R1, who has an advanced health care directive on file and a signed letter indicating they are unable to make an informed decision, sign a form to refuse services. Additionally, staff indicated 9-1-1 was not called, even though R1 had hit their head in the fall, as R1 refused. It is unclear whether facility staff attempted to contact any of R1’s other emergency contacts listed when they were unable to reach R1’s primary contact person. Incident report reviewed for R1’s 04/08/2026 fall indicates R1 had a fall in the hallway with a small skin scrape on their left elbow. “RP made aware, [RP] will transport resident to the doctor tomorrow. Resident and RP refused transfer for further evaluation.” Again, following this incident, no 9-1-1 call was made. Staff interviewed indicated R1 is “stubborn” in their behavior, has a history of refusing services, and will sometimes say “I’m fine” even when they’re not fine. Interview with R1 revealed the staff was getting frustrated with them because the staff believed it was a serious issue R1 had fallen. R1 did not agree that the falls warranted that level of attention or seriousness. R1’s family member said R1 “was arguing” with the staff about being sent to the hospital, but the family member agreed with R1 that emergency transport was not necessary, since R1 did not complain of any injuries. During the incidents in which R1 experienced falls, facility staff responded with assistance, attempted to send R1 to the hospital, but the resident refused. 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. Allegation “Staff did not notify resident's POA about incident:” During the investigation, LPA spoke with the complainant and requested documentation of R1’s Power of Attorney (POA) documents. There were two (2) separate documents provided to the LPA for review, one (1) of which is a General Durable Power of Attorney related to R1’s finances and financial decisions and the other document is titled Power of Attorney for Health Care. The General Durable POA document identifies one of R1’s children as being responsible for R1’s finances and all financial decisions. The POA for health care lists multiple agents in order. The initial designation was for R1’s spouse, who has since passed Report Continued on LIC 9099-C (p.4) away. The first alternate agent listed is one of R1’s children, and the second alternate agent is listed as the same child designated in the General Durable POA document. Review of R1’s facility documents revealed both the POA for finances and the POA for health care were on R1’s emergency contact list. Interviews revealed it was R1’s child designated in the Health Care POA document that regularly visited R1 at the facility and was the primary contact for any incidents that occurred at the facility. Staff interviewed stated this family member visited regularly and was always contacted when an incident occurred. This POA was also who was documented as notified in both falls R1 experienced in early April and was present when R1’s change of condition/heart attack occurred on 04/09/2026. Facility designee stated they were unaware R1 had another child and therefore hadn’t personally informed the individual named in the General Durable POA of any incidents, however, stated the POA for health care was always informed. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview was conducted. A copy of the report was provided via email for signature. Allegation “Facility staff did not ensure resident's blood sugars were being monitored properly while in care:” It was alleged that staff are not properly monitoring Resident #1 (R1)’s blood sugar. LPA reviewed R1’s physician’s report dated 08/22/2024. R1 had a primary diagnosis of Diabetes Mellitus II (DM II) at that time and R1’s medical provider indicated R1 is unable to administer their own injections and unable to perform their own glucose testing. Review of R1’s Medication Administration Record (MAR) for April 2026 revealed there were blood sugar readings for R1 taken before meals and bedtime. Interviews revealed that the facility did not have a licensed medical professional employed at the facility during that time period. As a result, medication technicians were performing R1’s blood sugar readings, which was verified through interviews and documentation on the MAR. Additionally, medication technicians not licensed professionals were also assisting R1 with injectable medications. LPA inquired what the purpose of taking the blood sugar readings was and whether this information was provided to R1’s physician, however staff interviewed were unaware. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation is deemed SUBSTANTIATED at this time. Allegation “Illegal eviction:” It was alleged that the facility refused to accept R1 back to the facility following their hospitalization, due to a diagnosis of dementia. Interview with facility Wellness Coordinator revealed that when R1 was ready to be discharged from the hospital, the facility requested a new medical assessment. The new medical assessment indicated a diagnosis of dementia and therefore R1 could not return to the facility’s Assisted Living unit, where R1 resided prior to their hospitalization. When R1 moved into the facility, a physician’s report dated 05/17/2022 was provided. This document indicated R1 had a diagnosis of dementia and was unable to leave the facility unassisted. However, R1 moved into the Assisted Living unit at that time. Review of R1’s hospital records indicate R1 was ready to be discharged back to the facility on 04/12/2026. Hospital staff reached the family on 04/13/2026 and family was agreeable to the resident returning to the facility that day. However, case manager notes indicate “spoke with Gloria/Wellness Coordinator at Aasta at 1455 about pt discharging back today but she said it was past their cutoff time of 1500 for accepting back a resident. Also spoke with Agnes [facility designee], she kept reiterating that pt needs to discharge to SNF because they are a non-medical ALF….she then demanded a new 602 form stating his condition has changed and will not take him back until she receives a new 602.” A new 602 medical assessment was Report Continued on LIC 9099-C (p.7) filled out by the hospital doctor and was provided to R1’s family member on 04/14/2026. Hospital staff were unable to reach the facility Designee until 04/15/2026, who then indicated she received the 602 form, however the form lists dementia as a new diagnosis – for this reason pt will need to be placed in a dementia unit. Facility designee indicated she spoke to R1’s family member and they do not want R1 housed in dementia. Wellness coordinator requested the hospital doctor modify the 602 to include “has mild dementia but able to function in an assisted living facility setting, pt not ready for memory care.” Doctor agreed and sent the new medical assessment. However, facility Designee still refused the resident returning to the facility, indicating they were not able to accept to the Assisted Living side with a diagnosis of dementia, mild or not, due to their licensing restrictions. After the doctor again modified R1’s medical assessment, facility Designee agreed to accept the resident back on 04/16/2026. Both hospital staff and R1’s family confirmed the facility caused a delay in R1 returning to the facility for a 4-day period. It is unclear why facility staff would not allow R1 to return to the facility’s assisted living unit when medically cleared to return on 04/12/2026, as regulation does not require residents with dementia to reside in a memory care unit. Additionally, R1 was admitted to the facility with a diagnosis of dementia and has always resided in the facility’s assisted living unit. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 18, 2026 · control 29-AS-20260415135801

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Sep 18, 2026

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose...and is able to administer his/her own medication ...apropriately skilled professional. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 could not perform their own glucose testing and the facility had medication technicians administering R1’s insulin and performing glucose testing, which posed an immediate health risk to R1.the state’s words, verbatim · CDSS document, Sep 18, 2026

Plan of correction: Facility closed effective 05/10/2026, therefore no POC is required.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Sep 18, 2026

87468.2 (a) (20) To be protected from involuntary transfers, discharges, and evictions..."involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident. 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 facility staff delayed R1’s return to the facility following a hospitalization and refused to allow R1 to return when medically cleared, which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 18, 2026

Plan of correction: Facility closed effective 05/10/2026, therefore no POC is required.

Allegation investigated: Due to insufficient staffing, facility residents sustained multiple injuries due to falls Facility staff failed to seek timely medical care for resident.

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit with the purpose of delivering findings for the above noted allegations. Due to the closure of the facility effective 05/11/2026, today’s visit was conducted telephonically with former licensee representative, Narinder Kumar. Entrance interview conducted. On 05/29/2025, The Department received a complaint of neglect/lack of care and supervision. It was alleged that due to insufficient staffing several residents at the facility sustained injuries due to multiple falls and that the facility staff failed to seek timely medical care for resident. It was further reported that Resident #1 (R1) sustained a fall and broke a bone. Resident #2 (R2) was hospitalized after a fall that occurred on 04/18/2025, resulting in a broken arm, and Resident # 3 (R3) experienced a fall on 05/28/2025 which resulted in a cut on the forehead along with a skin tear on the arm. Continued on LIC 9099-C Substantiated Continued from LIC 9099 Per the Reporting Party (RP) Resident #4 (R4) also sustained multiple falls while at the facility and that staff did not call emergency transport to take the resident to the ER after sustaining a fall. The complaint was referred to the Community Care Licensing Investigations Branch (IB). During an initial complaint visit on 05/29/2025 between 10:30AM and 04:45PM, LPAs Valeria Conway, Martha Arroyo and Kelly Dulek and Licensing Program Manager (LPM), Kristin Heffernan, briefly toured the facility with former Executive Director (ED), Monica Reyes. LPA Arroyo conducted a medication audit. LPAs and LPM interviewed the former ED, conducted a file review and obtained copies of pertinent documents relevant to the investigation. IB Investigator conducted both telephonic and in-person interviews with staff, residents, and other relevant parties on the following dates: 06/12/2025, 06/17/2025, and 08/07/2025. Additionally, IB Investigator also obtained and reviewed copies of medical records for all four (4) residents from St. John’s Hospital. Resident #1 (R1) was admitted to the facility on 10/18/2017. R1’s primary diagnosis included Parkinson’s disease, bipolar disorder, anxiety disorder, and dementia. R1 requires full assistance with ADLs, including personal hygiene, medication administration, and mobility. R1 is non-ambulatory and relies on a wheelchair, requiring two-person assistance for transfers and toileting, as well as 15-minute checks due to being a high fall-risk status. Despite these needs, R1 sustained multiple falls at the facility. On 04/06/2025, R1 fell from her wheelchair and sustained an intertrochanteric femur fracture. On 05/04/2025, R1 was found on the floor with no injuries. On 05/11/2025, R1 fell again while attempting to rise from bed, resulting in a comminuted left hip fracture requiring surgical intervention. These incidents occurred during a period of significant staffing shortages, during which increased supervision required by R1’s care plan was not consistently provided. Resident #2 (R2) was admitted to the facility on 03/24/2025. R2’s primary diagnoses include dementia (moderate Alzheimer’s), diabetes, a prior left femur fracture, and left wrist/radius fractures. R2 is confused and disoriented at baseline and requires maximum assistance for grooming and dressing, is dependent for bathing and toileting, and is unable to manage R2s medications. Although ambulatory, R2 has poor balance and is at very high risk for falls. Continued on LIC 9099-C Continued from LIC 9099-C On 04/07/2025, R2 was found on the floor without injuries. On 04/18/2025, R2 sustained a fall resulting in a broken arm. On 05/23/2025, R2 experienced another unwitnessed fall and suffered a displaced distal radius and ulnar styloid fracture, which required splinting after the ER was unable to reduce the fracture. On 06/10/2025, R2 slipped on water and hit R2s head, though without major injury. Despite repeated falls, R2s care plan was not updated, and monitoring was not increased during the period of facility understaffing. Resident # 3 (R3) was admitted to the facility on 05/14/2024. R3 has advanced dementia and multiple chronic medical conditions, including Type 2 diabetes, hypertension, coronary artery disease, hyperlipidemia, and a history of CABG surgery and sepsis. R3 requires assistance with dressing, grooming, and medication management, and although documented as non-ambulatory in facility records, medical documentation shows R3 ambulated independently within the memory care unit, often without using assistance, contributing to frequent falls. R3 experienced several falls at the facility. On 02/05/2025, R3 sustained a head injury after being pushed by another resident. On 02/23/2025 and 03/21/2025, R3 suffered unwitnessed falls with head contusions and skin injuries. On 05/25/2025, R3 fell again, sustaining additional head and hand injuries. On 05/28/2025, R3 experienced a fall resulting in multiple rib fractures. During this event, the NOC Med-Tech did not contact emergency services or provide first aid, delaying care until the morning shift. Resident # 4 (R4) was admitted to the facility on 09/13/2024. R4 has severe dementia as well as hypertension, COPD, hyperlipidemia, depression, and a history of breast cancer. Prior to R4s fall-related injury, R4 was ambulatory with a walker but required close supervision due to significant cognitive impairment. R4 required hands-on assistance with ADLs and safety monitoring. On 07/05/2025, R4 sustained a fall that resulted in a right leg/hip fracture. Internal staff communications showed discrepancies between what staff witnessed and what was documented in the incident report. On 07/06/2025, R4 underwent hip-repair surgery. Following surgery, R4 exhibited severely limited mobility, only able to take a few assisted steps, and required skilled nursing facility-level rehabilitation. Continued on LIC 9099-C Continued from LIC 9099-C Information gathered during the course of the investigation reflected that the facility was operating with critically insufficient staffing levels during April and May 2025. Multiple caregivers and Med-Techs resigned without notice, leaving the facility unable to meet required staffing ratios, particularly during the NOC shift. Interviews confirmed that required 15-minute safety checks were not consistently conducted during this period. Although rounds logs were initialed by staff, staff reported they were unable to complete checks as required due to inadequate personnel. During the same timeframe, residents sustained multiple falls. Several resulted in fractures requiring hospital treatment. All falls were unwitnessed, and there was no evidence that the facility updated residents’ Needs & Services Plans or increased monitoring despite repeated incidents and documented fall risks. Based on the information gathered, the Department has sufficient evidence to support allegations, “Due to insufficient staffing, facility residents sustained multiple injuries due to falls” and “Facility staff failed to seek timely medical care for resident.” Therefore, the above allegations are deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) A $250 immediate Civil Penalty was assessed for a repeat violation within the past twelve (12) months. Licensee was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview conducted telephonically, a copy of this report and the appeals will be sent to the licensee via email and certified mail. LPA requested licensee sign and return report to the LPA.the state’s words, verbatim · CDSS document, Jun 25, 2026 · control 29-AS-20250529054144

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 25, 2026

Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by… Based on interviews and record review the Licensee did not comply with the regulation above by not having sufficient support staff and supervision to perform essential duties for residents in care which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: No plan of correction required. Facility closed on 05/11/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jun 25, 2026

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional...When changes such as unusual...physical health condition...responsible person, if any. This requirement was not met as evidenced by: Based on interviews, and records review the Licensee did not obtain timely medical attention for several residents in care which posed an immediate health and safety concern to persons in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: No plan of correction required. Facility closed on 05/11/2026.

Allegation investigated: Staff did not ensure the resident's room was free of pests Staff did not ensure the facility was kept clean Staff did not ensure the facility was free of odors

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted an unannounced subsequent complaint visit regarding the above noted allegations. LPAs initially met with staff. Licensee represenative was contacted via telephone and arrived at 02:45 p.m. Entrance interview conducted. During today’s visit, LPAs reviewed relevant documents and toured the facility at 04:15 p.m. During an unrelated visit conducted on 05/09/2026, the LPA interviewed two (2) staff, toured the facility at 08:40 a.m., the LPA reviewed and obtained copies of relevant documents, and LPA interviewed facility designee at 10:00 a.m. During the initial visit conducted on 05/05/2026, the LPAs interviewed the designee at 10:30AM, conducted a telephonic interview with the licensee at 11:25AM, toured the facility with designee at 12:22PM, conducted interviews with three (3) staff and six (6) residents from 01:22PM to 03:45PM, and the LPAs reviewed and obtained copies of relevant documents. The following was then determined: Report continued on LIC 9099-C Unsubstantiated Allegation - Staff did not ensure the resident's room was free of pests: The complaint alleges that there are rat/mice feces inside a resident’s room, as there is a sliding door to the outside. LPAs observed various resident rooms throughout all facility tours and did not observe any evidence of rodents inside resident rooms. LPAs interviewed cleaning staff, all who indicated they have not seen any rodents, droppings, or any evidence in the resident rooms. Staff indicated there is monthly pest control service and there are rodent traps near the kitchen and outside trash enclosure. However, all staff indicated they have never personally seen any rodents in or around the facility. Monthly pest control includes checking the traps and emptying them if needed, however, staff were unsure if any rodents had been found in the enclosed traps. Resident interviews revealed no pests, such as rodents or insects had been observed indoors, only the occasional spider, which the resident stated is expected. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. Allegation - Staff did not ensure the facility was kept clean & staff did not ensure the facility was kept free of odors: The complaint alleges “the smell and filth of the facility is terrible.” Interviews with staff revealed housekeeping is scheduled 7 days a week at the facility and that each occupied room and all common areas are cleaned daily. LPAs observed multiple housekeeping staff present in the facility during all visits conducted at the facility. Each housekeeper has a designated hallway they clean during their shift. Housekeepers clean resident bathrooms, bedrooms, make resident beds, take trash, and clean the common area, including the hallway, in their designated station. Residents interviewed stated their rooms are cleaned daily and residents are satisfied with facility cleanliness. During facility visits, LPAs did not notice any significant odors throughout the facility. Residents interviewed did not indicate smelling anything out of the ordinary at the facility. Staff indicated they did not smell any odors nor have they had complaints from families related to odor. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today’s report was provided.the state’s words, verbatim · CDSS document, May 15, 2026 · control 29-AS-20260430160102

Allegation investigated: Staff did not treat resident(s) with dignity and respect

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted an unannounced subsequent complaint visit regarding the above noted allegation. LPAs initially met with staff. Licensee represenative was contacted via telephone and arrived at 02:45 p.m. Entrance interview conducted. During today’s visit, LPAs reviewed relevant documents and toured the facility at 04:15 p.m. During a subsequent visit conducted on 05/09/2026, the LPA interviewed two (2) staff, toured the facility at 08:40 a.m., the LPA reviewed and obtained copies of relevant documents, and LPA interviewed facility designee at 10:00 a.m. During the initial visit conducted on 05/05/2026, the LPAs interviewed the designee at 10:30AM, conducted a telephonic interview with the licensee at 11:25AM, toured the facility with designee at 12:22PM, conducted interviews with three (3) staff and six (6) residents from 01:22PM to 03:45PM, and the LPAs reviewed and obtained copies of relevant documents. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated It was alleged that a licensee representative was yelling at residents and harassing residents for their rent money. LPAs interviewed six (6) residents, including those listed in the complaint, related to the allegation. All residents stated that the licensee representative, Ashley, has never yelled or acted inappropriately at the facility. Residents stated Ashley has never been rude and is always nice to the residents. Some residents interviewed stated they are unsure if their rent was paid for the month of May since a family member handles their payments. One resident indicated the former designee, Agnes Gazaryan had informed them rent would be paid under a new company. However, most residents stated they made their checks to Aasta and paid as usual without issue. No staff nor resident interviewed reported any misconduct by the licensee representative. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 15, 2026 · control 29-AS-20260430153502

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted visit at this facility today to address concerns with the control of property. LPAs met with licensee representative Narinder Kumar at 02:49PM. Entrance interview conducted. On 05/08/2026, licensee representative notified LPA Dulek and Licensing Program Manager (LPM) Desaree Perera via telephone that the current lease agreement between the licensee and the property owner ends on 05/10/2026 and the licensee did not plan to renew or extend the lease. LPA and LPM had a conversation with the licensee representative related to maintaining control of property and education related to unlicensed operation. During today’s visit, LPAs confirmed with both the property owner and the licensee representative that there is no current lease agreement in place as of 05/11/2026, however licensee representative has continued operations at the facility, and therefore the facility is operating unlicensed. Licensee stated they will notify all families via email that a new operator would be taking over operations effective on today’s date. Licensee representative had a meeting with all employees and issued final payroll checks to the staff. A Notice of Operation in Violation of Law (NOVL) was issued. The licensee representative was advised that a retroactive civil penalty of $100 per day per tenant shall be assessed on the 16th day from the original date of the notice of Operation in Violation of the Law (May 15, 2026) for the operation of an unlicensed facility. If the licensee representative has not ceased unlicensed operation or a completed application for licensure has Report Continued on LIC 809-C not been submitted within 15 calendar days (May 31, 2026) of the issuance of this notice. On the 16th day from the notice, if the unlicensed operation continues to operate, $200 per tenant per day will be assessed until a completed application is submitted or the operation ceases. LPAs confirmed an application has already been submitted to the Centralized Application Bureau (CAB) for this property address, which is currently being reviewed. LPAs met with applicant representatives for the pending application during today’s visit. Exit interview conducted. Appeal rights and a copy of the report and NOVL was issued.the state’s words, verbatim · CDSS document, May 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.10 · Plan of correction due date: May 15, 2026

HSC: 1569.10. RCFE; license or permit; necessity: No person,… corporation... shall operate…conduct, or maintain a residential facility for the elderly in this state without a current valid license or current valid ...This requirement was not met as evidenced by: Based on interview and record review, the licensee did not maintain control of property with fifty seven (57) residents residing at the faciity that require assistance with aspects of care in activities of daily living, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 15, 2026

Plan of correction: LPAs confirmed an application has been submitted for the address.

Allegation investigated: Licensee does not allow residents to choose their own third-party health care provider

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced subsequent complaint visit regarding the above noted allegation. Upon arrival, LPAs were greeted by Agnes Gazaryan, Facility Designee. At 10:30 A.M. Facility Administrator, Denise Gilroy joined the visit. LPAs explained the purpose of the visit. Entrance interview conducted. During complaint visits conducted on 10/27/2025 and 03/10/2026, the LPAs conducted interviews with staff and residents, toured the facility, and the LPAs reviewed and obtained copies of relevant documents. All documents obtained were reviewed during the course of the investigation. The following was then determined: Continued on LIC 9099-C Substantiated Continued from LIC 9099 On the allegation: “Licensee does not allow residents to choose their own third-party health care provider”, it was alleged that an outside physician affiliated with a hospice agency conducted assessments on several residents without their knowledge or consent. During the investigation, it was revealed that the Marketing Director and a hospice nurse requested copies of residents’ care plans for residents they believe may meet the criteria for hospice admission. Interviews conducted with residents revealed that a physician visited the facility to evaluate whether they qualified to receive additional assistance from outside nurses that are not employed by the facility. Residents stated that facility informed them that the assessment was intended to determine whether they would benefit receiving additional care services. However, residents reported they were not informed that the assessment could result in admission into hospice services if they qualified. Interviews further revealed that the residents, who were their own responsible parties at the time, did not participate in the decision to have the assessment conducted. Additionally, information obtained during the investigation revealed that the facility did not provide residents with a list of hospice agency options or allow residents to select a hospice provider of their choice. The facility arranged for one hospice particular agency and physician to conduct assessments. LPA interviewed a family member of one resident who confirmed that the assessment was conducted without the family’s knowledge and without approval or referral from the resident’s primary physician referral. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Licensee does not allow residents to choose their own third-party health care provider” has been SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided. Continued from LIC 9099 On the allegation: “Staff are not properly trained or qualified” it was alleged that Marketing Director, Facility Designee and Wellness Director lacked sufficient knowledge, experience, and understanding of regulations and procedures necessary to properly operate an RCFE (Residential Care Facility for the Elderly). Interviews conducted with the Facility Designee revealed that staff training consists of completing online training modules, including videos and quizzes, prior to interacting with residents. In addition to prior work experience, newly hired staff participate in hands-on shadowing with senior staff members during their first two (2) weeks following completion of the initial training. Interviews with residents and staff indicated that management staff, including the Wellness Director, demonstrate appropriate qualifications and experience during daily operations and interactions with residents. Residents interviewed stated that since the change in management, the facility has become more organized, and the environment has improved and become more welcoming. During the course of the investigation, LPAs reviewed training logs, employee files, and in-service training records for the Marketing Director, Facility Designee, and Wellness Director. Interviews with residents and staff revealed that the Marketing Director does not participate in resident care and supervision, but primarily performs administrative duties including scheduling, on boarding paperwork, and collecting payments, among other office-related responsibilities. Record reviews revealed that the Facility Designee has held an administrator certificate for several years. Review of the facility designee’s resume and work history reflected prior experience relevant to operating an RCFE, although records indicated they had not recently managed an RCFE facility. Records reviewed further revealed that staff that Wellness Director an individual with an LVN license, had completed required training in accordance with regulations, including dementia care, resident care and supervision, fire safety, and emergency preparedness training. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff are not properly trained or qualified” is deemed unsubstantiated at this time. Continued on LIC 9099-C Continued from LIC 9099-C On the allegation: “Facility is not following reporting requirements”, it was alleged that management instructed staff not to report resident fall incidents. LPA interviewed six staff members who stated that staff complete internal incident reports to document unusual incidents occurring at the facility. Staff explained that the completed internal reports are provided to the Facility Designee, who then prepares and submits the required Unusual Incident Reports (SIR) to Community Care Licensing (CCL). Staff interviewed denied the allegation and did not express concerns regarding incidents not being reported. Interview with the Facility Designee revealed that staff are informed of the importance of reporting all incidents. The Facility Designee stated that all internal incident reports received from staff are reviewed and subsequently reported to CCL in accordance with reporting requirements. Additionally, they stated that residents’ primary physicians and responsible parties are notified regarding incidents involving residents. During the course of the investigation, LPA reviewed internal incident reports for September and October 2025 and compared them with incident reports submitted to CCL. LPA observed that the incidents documented internally during the reviewed time frame corresponded with the incidents reported to CCL. During the visit, LPA provided recommendations to the Facility Designee regarding reporting practices, including submitting reports prior to the seventh-day (7) deadline when possible and including follow-up information in incident reports submitted to CCL. The Facility Designee acknowledge the recommendations. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Facility is not following reporting requirements” is deemed unsubstantiated at this time. No citations are issued on this report. Exit interview.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 29-AS-20251027093701

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(7) · Plan of correction due date: May 13, 2026

87468.2 Additional Personal Rights... (a) In addition...shall have..the... rights: (7) ...The licensee shall provide necessary information and support to ensure that residents direct the planning of their care... This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above as residents were being assessed to get hospice services without their consent which poses a potential health risk to clients in carethe state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: The licensee and their designee will submit a statement of understanding acknowledging the importance of including residents in participating in the planning of their care and providing residents the necessary info and options. Submit statement no later than POC due date.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway arrived on April 28, 2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPAs met with Administrator Denise Gilroy. On October 24, 2025, the Department concluded a complaint investigation regarding the allegation of Neglect/Lack of supervision: Facility employees failed to provide an appropriate level of supervision resulting in a resident (R1) falling multiple times and sustaining a fracture. The licensee was cited for California Code of Regulations (CCR) 87464(f)(1) Basic Services. At the time of the complaint visit on October 24, 2025, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing care and supervision that resulted in R1’s multiple falls, sustaining a hip fracture, experiencing extreme physical pain, hospitalization, and operation. Report Continued on LIC 809-C Today, April 28, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on October 24, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Denise Gilroy and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Apr 28, 2026

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway arrived on April 28, 2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPAs met with Administrator Denise Gilroy. On October 24, 2025, the Department concluded a complaint investigation regarding the following allegation: Due to neglect, resident (R1) sustained a pressure injury. The licensee was cited for California Code of Regulations (CCR) 87613(a) General Requirements for Restricted Health Conditions. At the time of the complaint visit on October 24, 2025, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing appropriate care and supervision that led to R1’s wound worsening to an unstageable pressure injury. R1 required medical intervention at the hospital. Today, April 28, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Denise Gilroy and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Apr 28, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kelly Dulek and Angela Barutyan conducted a pre-licensing change of ownership visit to this property at 09:45AM. During the course of the visit, deficiencies were observed and addressed with the current Administrator Denise Gilroy, and designees Agnes Gazaryan and Gloria Morales. Facility tour began at 10:45AM. Hot water was measured in a sample of six (6) resident rooms. Temperature readings were inconsistent throughout the facility, measuring between 83.4 degrees Fahrenheit and 131.0 degrees Fahrenheit. Designee informed maintenance staff and called a plumber, who visited the facility during the visit. Water temperatures were adjusted during the visit. At 10:47AM, LPAs facility designee observed an unlocked drawer in the memory care common area, which contained wound cleanser, lotions, shaving cream, and other various personal care and grooming items. Staff holding the key was called to the area to secure the items during the visit. One (1) resident's room in Assisted Living was observed dirty, with feces on the toilet. Designee called housekeeping and requested additional cleaning in this resident's room. A light in a common bathroom, as well as one in the 200's hallway were observed flickering and/or too dim for sufficient visibility. Maintenance replaced the light bulbs during the visit. LPAs observed the two (2) delayed egress points at the end of the Memory Care hallways leading to the outside patio were not turned on during the visit. There are two (2) additional delayed egress points upon exiting the Memory Care patio, which were tested and functional at the time of the visit. LPA Dulek called and spoke with Fire Inspector Richard Martinez at 02:38PM, who indicated he will review facility layout, fire codes and contact LPA with an update on permissible use of the delayed egress. Report continued on LIC 809-C During resident file review, LPAs reviewed five (5) resident files. Of the five (5) residents (Resident #1 - R1, Resident #2 - R2, Resident #3 - R3, Resident #4 - R4, and Resident #5 - R5), LPAs observed two (2) resident files (R1 and R2) were missing updated appraisals, three (3) residents (R1, R3 , and R4) did not have proof of annual medical visit or an updated medical assessment, and three (3) residents (R1, R4 and R5) did not have proof of a TB test. During staff file review, LPAs observed five (5) staff files. Of the five (5) staff, three (3) staff (Staff #1 - S1, Staff #2 - S2, Staff #3 - S3) did not have proof of the twenty (20) hours of annual required training. One (1) staff (Staff #4 - S4) did not have the initial forty hours of training. Three (3) staff (S1, S2 and S4) did not have proof of first aid training. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Designees were informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Apr 22, 2026

87303 (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water....used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on observation, hot water was measured in 6 resident rooms and measured above 120 degrees in 5 rooms, measuring up to 131 degrees and was under 105 degrees in 1 room measuring at 83.4 degrees, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Designee contacted a plumber, who adjusted the temperatures during today's visit. Water temperatures will be remeasured during a subsequent visit to ensure temperatures remain within range.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87309(a) · Plan of correction due date: Apr 22, 2026

87309 (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions...and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage This requirement is not met as evidenced by: Based on observation, a drawer in the memory care unit's common area was left open and contained items such as wound cleanser and personal care items, and housekeeping cart was in the hallway and unlocked, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: During the visit, housekeeping secured the cart and the memory care staff was called to the common area with the key to lock the drawer. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Apr 28, 2026

87503 (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on record review, files were incomplete for all 5 residents reviewed. 3 did not contan proof of annual medical visit or updated medical assessment, 3 did not have proof of TB test, and 2 did not have updated reappraisals, which poses a potential health, safety or personal rights risk.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Designee agreed to obtain all identified items for the residents files reviewed. Designee will provide proof of items obtained to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c) · Plan of correction due date: Apr 28, 2026

87411 (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the above cited secton, as staff files did not contain proof of initial training for 1 staff, or annual training for 3 staff, and 3 staff did not have proof of first aid training, which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Designee agreed to properly document all trainings received for all staff and ensure all staff have first aid training. Proof of training will be provided to CCL by POC due date.

Allegation investigated: Facility staff did not appropriately respond to resident's request for assistance

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced subsequent complaint visit regarding the above noted allegation. Upon arrival, LPAs were greeted by the receptionist, who indicated neither the Administrator nor Facility Designee were present upon arrival. At approximately 12:00PM Facility Designee arrived at the facility. LPAs explained the purpose of the visit. Entrance interview conducted. During today's visit, LPAs interviewed six (6) residents, three (3) staff and Facility Designee. LPA also attempted to review video footage from the date of the alleged incident. During an initial complaint visit conducted on 03/10/2026, the LPAs interviewed the Wellness Director at 11:48AM, toured the facility with Wellness Director at 12:14PM, and the LPAs reviewed and obtained copies of relevant documents. LPAs interviewed Facility Designee at 02:35PM. All documents obtained were reviewed during the course of the investigation. The following was then determined: Report continued on LIC 9099-C Unsubstantiated The complaint alleges that on 03/04/2026, a female manager was wheeling a resident down the hallway, the resident indicated they needed to use the restroom and the manager left the resident alone in the hallway for 10-15 minutes. During today's visit, LPA attempted to review footage from 03/04/2026, however, footage was only available as far back as 03/11/2026. Facility Designee called the technician who recently serviced the recording system and the technician confirmed the system settings are configured to save footage for 20 days. However, technician stated that due to the amount of cameras installed and storage required to retain the 24-hour coverage recorded, the hard drive is not large enough to store the 20 days of footage. Interview with facility designee revealed that they had reviewed the footage, but it was too large to send to the Department. Facility Designee reviewed footage from all cameras for the date 03/04/2026 and did not observe any residents left in the hallway unattended in their wheelchairs. Interview with staff revealed that occasionally when staff are escorting residents to meals or activities, if they see a resident's call light on, they will stop to see what the resident needs before continuing on with the escort. However, no staff reported ever personally leaving a resident for a length of time or observing any resident left for any length of time. LPAs interviewed residents who use wheelchairs during the visit. One (1) resident interviewed did state they have been left in the hallway, but indicated they are able to wheel themselves in their wheelchair unassisted and do not require assistance. This resident was unsure of who the staff was when they were left in the hallway, the amount of time they were left, or how recently this occurred. All other residents interviewed have never been left, seen, nor heard of a resident being left in the hallway mid-escort. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 29-AS-20260309093143

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted a Case Management - Deficiencies visit in conjunction with a complaint visit conducted on today's date. LPAs met with facility designee, Agnes Gazaryan. The purpose of this report is to issue citations for a deficiency observed during the complaint investigation. During today's visit, the Administrator of record was unavailable. LPAs observed that the LIC 500 Personnel Report indicates the Administrator is scheduled Sundays and Mondays from 09:00AM to 09:00PM. However, the Administrator was not present on today's visit, nor the visit conducted on 01/26/2026, which was also a Monday. Interviews with staff revealed the Administrator has not been present in the facility in about a month or two (2) months. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 809-D.) Facility Designee was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87405(a) · Plan of correction due date: Apr 6, 2026

87405 (a) All facilities shall have a qualified and currently certified administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...by written documentation. This requirement is not met as evidenced by: Based on observation and interview, the Administrator has not been present in the facility on their scheduled days for 1-2 months and LPAs have never met the Administrator either by telephone or in person, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: Facility Designee will discuss with Licensee and Administrator and will submit a plan of action to ensure Administrator is present in the facility a sufficient number of hours. Plan will be submitted to CCL by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted a Case Management - Deficiencies visit in conjunction with a complaint visit conducted on today's date. LPAs met with facility designee, Agnes Gazaryan. The purpose of this report is to issue citations for a deficiency observed during the complaint investigation. During facility tour, which began at 12:14PM, LPAs observed that the fire pull station in the 200s hallway is non-functional and is taped into position. Interview revealed differing time frames that the fire pull has been non-functional, however the minimum reported time frame is a week without repair. LPA called and spoke with the Fire Inspector at 02:20PM, who confirmed that all fire protection systems need to remain in place at all times and since the pull station was engaged and is currently taped up, the facility is out of compliance. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 809-D.) A civil penalty was issued in the amount of $1000, as it is a repeat citation. Facility Designee was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87203 · Plan of correction due date: Mar 11, 2026

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation and interview, the fire pull station in the 200s hallway is non-functional, as it was pulled about a week ago and has not been repaired, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Facility Designee agreed to schedule a fire alarm contractor to repair the system. Will provide proof of scheduled visit by POC due date and will provide additional proof to CCL upon repair completion.

Allegation investigated: Staff did not ensure that resident's hygiene needs are being met

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 11:17 A.M. LPA met with back-up administrator/facility designee, Agnes Gazaryan and explained the purpose of the visit. During today’s visit a brief physical plant tour was conducted. During initial 10-day complaint inspection and subsequent visits, the LPAs briefly toured the facility with facility’s Marketing Director, Ashley Kumar and back-up administrator. LPAs interviewed staff and randomly selected residents and obtained copies of pertinent documents relevant to the investigation. The following was determined. Continued on LIC 9099-C Substantiated Continued from LIC 9099 Regarding allegation “Staff did not ensure that resident's hygiene needs are being met” it was the Reporting Party’s (RP’s) concern that Resident #1 (R1) had not been showered, had run out of shampoo, and that overall hygiene needs were not being adequately addressed at the facility. Interview with management revealed that the facility has experienced staffing challenges, however, caregivers reported that assigned care tasks are being completed. Management further explained that family members are responsible for providing resident’s personal hygiene items including shampoo. Management stated that if a resident runs out of hygiene supplies, the facility will provide these items at no additional cost. Staff interviews indicated that they are assigned specific daily duties, including assisting residents with showers and with incontinence care needs. Staff reported that due to short staffing required basic services such showering are sometimes delayed and not consistently provided. Staff also stated that when a resident declines assistance with showering, caregivers may request support from another staff member, however, the initial caregiver does not always follow up to confirm whether the grooming task was completed. Regarding the availability of hygiene supplies, staff stated that in some instances residents’ personal hygiene items are depleted because they are shared or used when other residents run out, and the facility does not always immediately replace these items. Resident and credible witnesses interviews revealed mixed responses. Some residents reported that their incontinence and basic care needs are being met, while others stated their needs are not consistently met due to short staff, language barriers and concerns that night shift staff are not completing required tasks. The LPA attempted to interview R1; however, R1 appeared uncomfortable answering questions and declined to comment on this matter. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff did not ensure that resident's hygiene needs are being met” has been SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $1,000 repeat violation is assessed today due to being cited for the same violation within 12 months. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 29-AS-20250822064211

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 27, 2026

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above by not not following shower schedules which posed a immediate personal to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Facility designee created a daily log to ensure compliance with the daily shower schedule. A statement of understanding on regulation cited will be sent to LPA before POC due date.

Allegation investigated: Facility does not have sufficient staffing to meet residents' needs Staff did not safeguard resident's personal belongings

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 11:17 A.M. LPAs met with the facility designee, Agnes Gazaryan, and explained the purpose of the visit. During today's visit, a brief physical plant tour was conducted. On 09/26/2025, LPA Conway initiated an unannounced complaint investigation for the allegations listed above. During the initial complaint visit LPA briefly toured the physical plant, interviewed the back-up administrator/facility designee, Resident #1, staff and reviewed and obtained pertinent documents relevant to the investigation. Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted interviews with additional credible witnesses and other relevant parties. The following was determined. Continued on LIC 9099-C Substantiated Continued from LIC 9099 Regarding allegation “Facility does not have sufficient staffing to meet residents' needs” it was reported that due to inadequate staffing levels, residents’ needs are not consistently being met. The Marketing Director, Ashley Kumar, stated that in occasions staff call out; however, the facility utilizes a staffing agency to cover shifts when employees fail to report for duty. The representative further stated that on some occasions it is difficult to obtain coverage due to short notice from staff who do not come to work. In such instances, caregivers on duty are asked to remain beyond their scheduled shifts to provide partial coverage. Staff interviews revealed that required tasks are often not completed because although the facility schedules an adequate number of personnel, not all scheduled staff report for duty. Additionally, staff reported that caregivers provided through the staffing agency are frequently unfamiliar with the facility and residents’ needs, and in some cases are unable to perform assigned duties. AM shift staff stated that at the beginning of their shift, several residents are observed to be wet and soiled, and assistance with incontinence care has not been completed. Residents interviewed revealed ongoing concerns regarding staffing levels across all shifts. Several residents stated that it is difficult to receive timely assistance during the night shift and that staff do not check on them as frequently as needed. LPA Conway requested and reviewed facility timesheets for the month of September 2025, with specific analysis of staffing on September 18 and September 19, 2025. Review of the records revealed that during the night shift hours of approximately 2:30 AM to 6:30 AM, there were only two (2) facility staff and one (1) agency staff assigned to provide care for approximately seventy (70) residents. Additionally, review of the timesheets identified multiple scheduled caregivers who failed to report for duty during their assigned shifts. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Facility does not have sufficient staffing to meet residents' needs” has been SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Regarding allegation “Staff did not safeguard resident's personal belongings” it was reported that a caregiver stole money from a resident and the administrator failed to take appropriate action. An interview with the backup administrator/facility designee, Agnes Gazaryan and Marketing Director, Ashley Kumar, revealed that staff reported the allegation to management, and a meeting was conducted with Resident #1 (R1) to gather additional information regarding the incident reported. During this meeting R1 denied that any staff member stole money from them. The facility representative acknowledged that, for several days following the allegation and R1’s consent, the resident’s wallet was secured in a locked cabinet for safekeeping. The facility representative further stated that after a few days, R1 requested that their wallet be returned, and the request was honored. An interview with R1 revealed that they frequently ask facility drivers to transport them to the bank to withdraw money and often request facility staff to purchase hygiene products on their behalf. During the interview, R1 denied tipping or providing money to staff for these additional services. LPA requested receipts for the reported purchases; however, R1 was unable to provide documentation. During the interview, the resident appeared forgetful and repetitive when recounting events. Staff interviewed acknowledged purchasing some hygiene items for residents, however, they denied receiving tips of stealing money. LPA reviewed R1’s most recent Physician’s Report dated January 24, 2025. Under the mental condition section, the physician indicated that R1 is not able to manage their cash resources, with a comment stating that family manages the resident’s finances. Additionally, review of the resident Pre-Placement Appraisal Information form date January 25, 2025, signed by Administrator, Monica Reyes, indicated the resident’s mental condition as “mild forgetfulness” and the section indication assistance with managing personal cash resources was marked “yes.” LPA reviewed the facility’s operation plan and does not have a surety bond or policy or procedure in place to safeguard resident cash resources in instances where residents are unable to independently manage their finances. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff did not safeguard resident's personal belongings” has been SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $1,000 repeat violation is assessed today due to being cited for the same violation within 12 months. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 29-AS-20250919123526

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 27, 2026

87411(a) Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by… Based on interviews and record review the Licensee did not comply with the regulation above by not having sufficient staff during the NOC shift to perform essential duties for residents in care which poses a immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Licensee agreed to adjust schedules to prevent lapses in coverage and create a backup/on call staff list in the event of call-offs or emergencies. Changes to schedule and on call list will be provided to LPA before POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(a) · Plan of correction due date: Jan 27, 2026

Safeguards for Resident Cash, Personal Property, and Valuables (a) A licensee shall not be required to handle residents' cash resources. However, if a resident incapable of handling his own cash resources... This requirement is not met as evidenced by… Based on interviews and record review the Licensee did not comply with the regulation above by allowing R1 to manage their cash resources which poses a immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Licensee agreed to contact R1's ohysician for a revaluation and to assess R1's condition to manage their resousces. Also, to get a public conservator. Email communication will be send to LPA prior to POC Due date.

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

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance. Upon arrival, the LPAs met with Facility Designee Agnes Gazaryan and explained the reason for the visit. LPAs were informed Administrator was not available during today's visit. The LPAs focused today’s visit on physical plant and medication administration in compliance with Title 22 Regulations. During today's visit, the LPAs, along with Facility Designee, conducted a physical plant tour beginning at 12:37PM and LPA Dulek conducted a medication review at 01:47PM. The following was noted: During the physical plant tour, LPAs observed feces in a planter in the outdoor area of the memory care unit. An unidentified brown substance was observed on the wall above the planter area where the feces was observed. Additionally, a hose was observed running down the outer wall of the memory care unit. Maintenance Director stated the gutter was damaged and fell off the wall during a recent storm. LPA Dulek reviewed medications for four (4) residents. Resident #1 (R1)'s medication trazodone 100mg was signed as administered, however was not popped from the bubble pack for one (1) day. For Resident #2 (R2), Rosuvastatin Calcium 20mg is initialed as administered, but was not found. All four (4) residents reviewed appeared to have medications administered for the 22nd during the day and the night shift on the 24th and 25th, however, they were not initialed as administered on the Medication Administration Record. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalties issued in the amount of $500, for repeat violations. Facility Designee was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of today's report was provided via email.the state’s words, verbatim · CDSS document, Jan 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Feb 2, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as feces was observed in the courtyard of the Meadows accessible to residents in care, additionally gutter was broken which poses an immediate health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Facility Designee called Maintenance Director and ensured the feces and outer wall were cleaned during today's visit. Gutter will be replaced within a week; proof of completion will be sent to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Feb 9, 2026

87465(a)(4) (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the above cited section, as R1's medication was marked administered but was still in the bubble pack, R2's medication could not be located, and MAR did not reflect medications administered, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Facility Designee plans to audit the medications for all residents and re-educate all medication technicians. Proof of re-education will be provided to CCL by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20250919123526.) LPAs met with facility designee, Agnes Gazaryan. The purpose of this report is to issue citations for deficiencies observed during the complaint investigation. During the course of the investigation, it was discovered that Resident #1 (R1) provided money to staff members to purchase items on the resident’s behalf, including hygiene products, snacks, and meals. These transactions were conducted directly between staff and the R1. No receipts, documentation, or ledger of these financial transactions were maintained in the resident’s file. Staff interviewed acknowledged purchasing some hygiene items for residents, however, they denied receiving tips of stealing money. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(f) · Plan of correction due date: Jan 27, 2026

(f) No licensee or employee of a facility shall make expenditures from residents' cash resources for any basic service specified in this Chapter, or for any basic services identified in a contract... This requirement is not met as evidenced by… Based on interviews and record review the Licensee did not comply with the regulation allowing staff/caregivers to make expenditures from residents' case resources which poses a immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Facility designee agreed to conduct an in-service training with ALL employees regarding this regulation. Licensee will submit proof of in service training before POC due date.

Allegation investigated: Licensee did not ensure phone calls are answered appropriately

Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegation. At 10:45 A.M. LPA met with facility designee Agnes Gazaryan and explained the purpose of the visit. Administrator, Denise Gilroy, was unavailable during today’s visit. During initial 10-day complaint inspection and subsequent visits, the LPAs briefly toured the facility with facility’s Marketing Director and back-up administrator. LPAs interviewed staff and randomly selected residents and obtained copies of pertinent documents relevant to the investigation. During today’s visit, the LPAs conducted a plant tour at 12:07 P.M. to ensure there are no health and safety concerns. The following was determined. Continued on LIC 9099-C Substantiated Continued from LIC 9099 Regarding allegation “Licensee did not ensure phone calls are answered appropriately” the Reporting Party (RP) expressed concern that the facility’s main phone line is not answered in a timely manner, making it difficult to get in contact with Resident #1 (R1). The RP and a case manager further reported difficulty communicating with staff at AASTA and R1, noting that R1 does not have a personal cellphone and the only means of communication is through the facility’s main phone line. Staff interviews conducted revealed that staff are sometimes unable to answer the facility phone because they are responsible for transporting residents to appointments, conducting daily activities within the facility, assisting with brief changes and showers, medication distribution, and performing other essential care services. The LPA interviewed R1, who confirmed they do not have a personal cellphone and stated that staff rarely approach them to inform them that they’ve received a call. Interviews with facility representatives denied the allegation, stating that although the facility has encountered challenges maintaining a full-time receptionist, there is always a staff member assigned to answer phone calls throughout the day. During the course of the investigation, the LPA attempted to contact the facility by phone on four (4) separate occasions and at different times of the day. On the first attempt, the LPA reached a live person; however, it took approximately 25 minutes after navigating all menu extensions and being redirected by voice commands. On the remaining three attempts, the LPA was unable to reach a live person, as no one answered the phone. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Licensee did not ensure phone calls are answered appropriately” has been SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $1,000 repeat violation is assessed today due to being cited for the same violation within 12 months. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 29-AS-20250822064211

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 26, 2025

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…. This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not comply in the section cited above as facility staff were unable to answer and transfer telephone calls for R1, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Licensee agrees to provide a written plan to CCLD as to how the facility will be diligent in answering telephone calls and responding to family members and responsible parties through telephone communication. Written plan will be submitted to LPA before POC due date.

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.

Allegation investigated: Due to staff Neglect / Lack of Supervision – Questionable Death Staff failed to assist R1 with self-administration of medication which attributed to R1’s death.

Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted a subsequent complaint visit to deliver findings for the above allegations. LPAs met with Facility Designee Agnes Gazaryan and explained the reason for the visit. The Executive Director, Denise Gilroy was unavailable during today’s visit. Entrance interview. On 05/13/2025, the Department received a complaint alleging neglect/lack of care and supervision. The complaint alleges that Resident #1 (R1) died as a result of neglect and/or lack of care and supervision due to staff failing to assist R1 with the self-administration of medication. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Veronica Padilla. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... On 05/14/2025, LPA Valeria Conway conducted the initial complaint visit and subsequent complaint visits were conducted on 05/21/2025 and 05/22/2025 by LPA Kelly Dulek, and on 05/29/2025 by LPAs Martha Arroyo, Valeria Conway, Kelly Dulek and Licensing Program Manager (LPM) Kristen Heffernan. During the initial visit on 05/14/2025, between 9:30 a.m. and 1:30 p.m., LPA Conway briefly toured the facility, conducted interviews with the Executive Director (ED), Monica Reyes and one facility staff, and conducted a medication audit and obtained copies of pertinent documents relevant to the investigation. On 05/21/2025 and 05/22/2025, LPA Dulek reviewed and obtained copies of facility video surveillance relevant to the investigation. On 05/29/2025, LPAs Arroyo, Conway, Dulek, and LPM Heffernan conducted a plant tour starting at 11:05 a.m., conducted interviews with the ED, Monica Reyes and two staff members between 9:54 a.m. and 1:00 p.m., conducted a medication review starting at 1:00 p.m., and obtained copies of pertinent documents relevant to the investigation. On 07/15/2025, approximately between 10:33 a.m. and 01:30 p.m., Investigator Padilla conducted interviews with the ED, Monica Reyes and two staff members: on 07/21/2025, at approximately 10:20 a.m. with R1’s family member and at approximately 11:00 a.m. with Investigator with the Medical Examiner’s Office; on 08/14/2025, at approximately 10:35 a.m. with the local Ombudsman; on 09/12/2025, at approximately 12:06 p.m., with a Sargeant from the Camarillo Police Department; on 09/18/2025, at approximately 10:35 a.m., with one staff member; and on 09/19/2025, approximately between 12:06 p.m. and 12:17 p.m., with two staff members. Investigator Padilla also requested and reviewed copies of Camarillo Police Department Report #25 – 57592, Emergency Medical Services (EMS) Report, County of Ventura Medical Examiner’s Office Autopsy / Coroner’s Report #0795 – 25, Ventura County Clerk’s and Recorder’s Office Death Certificate, and facility file documents related to the investigation. Record review and interviews conducted revealed that R1 was admitted to the facility on 10/01/2024. A review of R1’s Physician’s Report, dated 04/22/2024, listed R1’s primary diagnosis as muscle weakness, hyperlipidemia, hypertension, edema, osteoporosis, glaucoma, and chronic kidney disease stage 3. Report Continued on LIC 9099C... Report Continued from LIC 9099C... The report indicated R1’s mental condition as not being confused/disoriented, or exhibiting inappropriate, aggressive, wandering and sundowning behaviors. It noted that R1 was able to follow instructions and communicate their needs. The report also described R1 as non-ambulatory. However, required assistance with activities of daily living (ADLs) such as bathing, dressing/grooming, and toileting needs. The investigation revealed that on 05/11/2025, R1 was found unresponsive in their bedroom by facility staff. Staff then called 911 and began administering Cardio Pulmonary Resuscitation (CPR). Upon arrival, law enforcement personnel continued CPR until paramedics arrived on scene. Staff interviews revealed that R1 maintained a consistent medication schedule. R1 received morning medication in the dining room at approximately 7:00 a.m., noon medication in their room, and evening medication in the dining room at approximately 4:00 p.m. Staff confirmed that R1 received their evening medication on May 10, 2025, during dinner time. Further staff interviews revealed that on that same day, R1 appeared “normal, as usual—nothing had changed,” with no observed changes in behavior or health status. According to the Coroner’s Report, the cause of death was hypertensive heart disease, with contributing factors including chronic kidney disease and aortic valve disease. The manner of death was determined to be natural. The report also indicates that a toxicology examination was conducted on R1, which identified several medications listed in R1’s medication record, further confirming that R1 was receiving their prescribed medications while residing at the facility. Similarly, the death certificate listed the causes of death as acute myocardial infarction, coronary artery disease, hypertension, and hyperlipidemia. Furthermore, law enforcement found no evidence of foul play and closed their investigation. Based on the information gathered during the course of the investigation, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, allegations “Due to staff neglect/lack of care and supervision resulting in a questionable death” and “Staff failed to assist R1 with the self-administration of medication which attributed to R1’s death” are deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided. Report Continued from LIC 9099... During the initial visit on 05/14/2025, between 9:30 a.m. and 1:30 p.m., LPA Conway briefly toured the facility, conducted interviews with the Executive Director (ED), Monica Reyes and one facility staff, and conducted a medication audit and obtained copies of pertinent documents relevant to the investigation. On 05/21/2025 and 05/22/2025, LPA Dulek reviewed and obtained copies of facility video surveillance relevant to the investigation. On 05/29/2025, LPAs Arroyo, Conway, Dulek, and LPM Heffernan conducted a plant tour starting at 11:05 a.m., conducted interviews with the ED, Monica Reyes and two staff members between 9:54 a.m. and 1:00 p.m., conducted a medication review starting at 1:00 p.m., and obtained copies of pertinent documents relevant to the investigation. It was alleged that staff did not respond to Resident #1 (R1) calls for assistance. It was reported that R1 repeatedly called the facility at approximately 3:00 a.m. the morning before their passing. A review of R1’s cell phone call log revealed that R1 attempted to contact the facility’s front desk numerous times during the early morning hours of 05/11/2025. According to the record, between 12:32 a.m. and 3:29 a.m. on 05/11/2025, R1 placed a total of thirty (30) calls to the facility. Staff interviews revealed that although a caregiver observed R1’s call light activated that night, they chose not to respond. Staff reported that R1’s call light was frequently activated and often ignored, as R1 was known to request assistance frequently throughout the day and night. Staff further stated that although certain residents require status checks every fifteen (15) minutes, not all staff consistently followed this guideline. Based on the information obtained and reviewed during the course of the investigation, the Department has sufficient evidence to support the allegation of “staff did not respond to R1’s call for assistance”. Therefore, this allegation is deemed Substantiated at this time. Report Continued on LIC 9099C... Report Continued from LIC 9099C... It was also alleged that staff falsified information. It was reported that medication records indicated R1 had received their medications on 05/11/2025, at 8:00 a.m. and 12:00 p.m. However, R1 had already expired earlier that morning. Records reviewed and interviews conducted confirmed that R1 was found unresponsive in their bedroom between 6:00 a.m. and 7:00 a.m. on 05/11/2025. According to R1’s Medication Administration Record (MAR) for 05/11/2025, staff initials indicated that medications were administered at 8:00 a.m. and 12:00 p.m. Additional staff interviews verified that R1 did not, in fact, receive any medications during the morning hours of 05/11/2025 as staff admitted to pre-filling medications and medication logs several days in advance. This confirms that the MAR contained inaccurate documentation regarding the administration of medications to R1. Based on the information obtained and reviewed during the course of the investigation, the Department has sufficient evidence to support the allegation of “staff falsified information”. Therefore, this allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (refer to LIC9099-D). Additional violations will be cited at a later date. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 29-AS-20250513145158

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 26, 2025

In addition to the rights listed in Section 87468.1…residents have shall have the following: care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as R1 was continuously calling for help and staff did not respond or assist R1, which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: The Licensee has agreed to create and submit a plan on how the facility staff will respond to resident’s call buttons in a timely manner and submit to CCL no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Dec 26, 2025

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as R1’s MAR was inaccurate due to staff signing off on medication administration prior to administering it, which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: The licensee has agreed to review Reg 87207 and submit a statement of understanding to CCL no later than POC due date.

Allegation investigated: Facility does not have adequate emergency plans to meet the needs of all residents

Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 10:45 A.M. LPA met with facility designee Agnes Gazaryan and explained the purpose of the visit. Administrator, Denise Gilroy, was unavailable during today’s visit. During the initial 10-day complaint, the LPAs briefly toured the facility with facility’s Marketing Director and back-up administrator. LPAs interviewed staff and randomly selected residents and obtained copies of pertinent documents relevant to the investigation. During today’s visit, the LPAs conducted a plant tour at 12:07 P.M. to ensure there are no health and safety concerns. The following was determined. Continued on LIC 9099-C Unsubstantiated Continued on LIC 9099 Regarding allegation “Facility does not have adequate emergency plans to meet the needs of all residents” the Reporting Party (RP) expressed concern that Memory Care (MC) residents are locked in their rooms unable to exit in the event of an emergency. Interviews conducted with staff revealed that residents are able to exit their rooms freely, as the doors are not locked from the inside. Facility representatives explained that in the MC unit, resident doors are equipped with storeroom locks which can lock from the outside but remain unlocked from the inside at all times. This measure was implemented due to incidents involving wandering residents attempting to enter other residents’ rooms, as well as residents forgetting which room belongs to them and attempting to open multiple doors. LPA observed a few residents wandering within the MC unit who attempted to open various doors. Also, LPA inspected eight (8) random resident rooms and confirmed that all locks lock from the outside but remain unlocked from the inside at all times. With regard to the allegation that the facility lacks an adequate emergency plan, facility representatives stated that all staff receive training and are assigned responsibilities and specific roles to ensure the safe evacuation and accounting of all residents during an emergency. The facility conducts emergency disaster drills and maintains an up-to-date Emergency Disaster Plan. LPA reviewed the most recent drill documentation and the updated Emergency Disaster Plan and found the facility to be in compliance with applicable regulations. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Facility does not have adequate emergency plans to meet the needs of all residents” is deemed UNSUBSTANTIATED at this time. No deficiency related to the allegations were cited. Exit interview conducted. A copy of the report was reviewed and provided. Continued from LIC 9099 Regarding the allegations of “Licensee did not ensure that oxygen tanks were properly stored” and “Licensee do not ensure staff are sufficiently trained”, the Reporting Party (RP) expressed concern on how oxygen tanks are being stored inside resident’s rooms and indicated that the improper storage suggest staff may not be adequately trained. Interviews with staff, including housekeeping personnel, revealed that they could not recall the last time they received training on the proper storage of oxygen tanks. During the interviews, a housekeeper stated that staff responsible of cleaning and tidying residents' rooms often place the oxygen tanks on top of the concentrators while performing their duties. A facility representative further stated that staff training had not been provided on how to properly handle and store oxygen since beginning their employment several months ago. LPA requested documentation of the most recent staff training on proper oxygen handling and storage. The facility presented training conducted on 03/2024 where eight (8) Med-Techs attended this training; however, six (6) of them are not longer employed at the facility. Additionally, caregivers and housekeeping staff were not included in the training. During the visit, LPA entered rooms where oxygen was being used and observed unsecured oxygen tanks lying on their side on top of an oxygen machine and/or standing on the floor next to an oxygen machine. Based on the information gathered during the investigation, the department has sufficient evidence to confirm these allegations occurred. Therefore, the allegations of “Licensee did not ensure that oxygen tanks were properly stored” and “Licensee do not ensure staff are sufficiently trained” have been SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 29-AS-20250826092433

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(3)(E)and(5) · Plan of correction due date: Dec 26, 2025

87618 Oxygen Administration - Gas and Liquid (b)... (E)Oxygen tanks that are not portable shall be secured in a stand or to the wall and (5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. This requirement was not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above per tour of the facility, it was observed oxygen tanks not being properly stored and staff are not up-to-date on how to handle and store oxygen tanksthe state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Licensee will develop and maintain a current list of all residents who use oxygen, including their names and room numbers. Staff will conduct an inspection of these rooms to ensure that all oxygen tanks and concentrators are properly stored and secure in accordance with regulations and correct deficiencies immediately. Also, the licensee will provide comprehensive training to all staff including housekeeping personnel on the proper handling and storage and submit proof of completed training before POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 2 29-AS-20250513145158). The purpose of the visit is to issue citations for deficiencies observed during the investigation. During the course of the investigation, it was discovered that staff had been pre-filling residents’ medications several days in advance. During interviews, employees admitted to preparing medications in separate containers at least two (2) days ahead of time and signing off on their administration in advance. Although the administrator stated that they were unsure why staff were pre-filling and documenting early and acknowledged that this practice was a clear violation of policy, staff have continued to engage in pre-filling the residents’ medications. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Dec 26, 2025

The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Based on interviews and observation, the licensee did not comply with the section cited above as facility staff are pre-filling residents’ medications in separate containers several days in advance, which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: The Licensee has agreed to have a third party vendor conduct staff training on properly assisting and documenting centrally stored medications and submit proof to CCL no later than POC due date.

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Valeria Conway conducted an unannounced Case Management Visit - Other to the facility above. At 11:30 A.M. LPA met with Marketing Director, Ashley Kumar. Licensee and Back-up administrator were in a meeting at the time of LPA arrival. After the meeting LPA explained the reason for the visit. The licensee authorized representatives to sign today's report. Entrance interview conducted. The purpose of today's visit was to obtain the missing signatures from the visit conducted on Friday 10/24/2025. Updated/Amended reports were provided to representativesthe state’s words, verbatim · CDSS document, Oct 27, 2025

Allegation investigated: Staff are not providing activities for residents in care

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegation. At 9:32 A.M. LPAs met with back-up administrator Agnes Gazaryan and explained the purpose of the visit. Marketing Director, Ashley Kumar arrived shortly after. Back-up Administrator is authorized to sign today's report. Entrance interview conducted. During the initial 10-day inspection visit, between 10:05 A.M. and 4:22 P.M., the LPAs briefly toured the facility with the Marketing Director and back-up administrator. LPAs interviewed staff and random selected residents and obtained copies of pertinent documents relevant to the investigation. The following was determined. Continued on LIC 9099-C Substantiated Continued from LIC 9099 Regarding allegation “Staff are not providing activities for residents in care” the Reporting Party (RP) expressed concern that the facility does not provide sufficient enrichment activities for residents. Interviews conducted with the Executive Director (ED), Monica Reyes, confirmed that the facility has experienced staffing challenges. The ED explained that when the facility is short-staffed, other personnel assist with resident activities as needed. For example, when the driver resigned on 02/07/2025, the Activity Director assumed the driving responsibilities. Subsequently, the staff member assigned to assist the front desk also resigned, and the Activity director was reassigned to cover the front desk duties. The ED further explained that activities cannot always be conducted as scheduled by the same employee in both units simultaneously as scheduled, acknowledging that there is no separate activity schedule tailored specifically for each unit, the Assisted Living (AL) and Memory Care (MC). During prior LPAs visits, staff were often not observed conducting activities offered by the facility. This was due either to the Activity Director covering the front desk or the Activity Director conducting activities in the AL unit, leaving no personnel available to provide activities for the MC residents. Resident interviews revealed that a new driver was hired on 8/5/2025, so that the Activity Director could resume assisting with activities as scheduled. However, due to the receptionist’s Part-time hours and departure on 9/24/2025, the Activity director has been assigned to cover front desk duties, resulting in limited activity programming. Interviews with the Activity Director confirmed that, due to staffing shortages and the lack of a receptionist, activities are not being conducted as planned. LPA observed that the facility provides the same activity schedule for both units. Additionally, LPA compared the facility's monthly activity schedule with the personnel report and observed that the activity schedule lists activities seven (7) days a week, whith the last activity starting at 6:00 P.M. However, the Activity Director is scheduled to work Monday through Friday from 8:30 A.M.to 5:00 P.M. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff are not providing activities for residents in care” has been SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C A $250 civil penalty is assessed for the citation related to CCR 87219(f) for a repeat violation. The back-up Administrator, Agnes Gazaryan and Marketing Director, Ashley Kumar were informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were providedthe state’s words, verbatim · CDSS document, Oct 24, 2025 · control 29-AS-20250822064211

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: Nov 7, 2025

87219 Planned Activities (f) Planned Activities. In facilities licensed for fifty persons or more, one staff member shall have full-time responsibility to organize, and shall be given such staff assistance as… This requirement is not met as evidenced by… Based on interviews, the licensee did not comply with the section cited above as the facility lacks of sufficient personnel to conduct activities for all residents in care which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: As of 9/14/2025, the Licensee hired a new Activity Director. Back-up Administrator agreed to develop an activity schedule tailored to the MC and to assign a staff member to regularly conduct activities (including weekends and after 5 PM) in both the AL and MC uint

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Neglect/Lack of supervision: facility employees failed to provide an appropriate level of supervision resulting in Resident #1 (R1) falling multiple times and sustaining a fracture Due to neglect, resident sustained a pressure injury Staff do not serve food of quantity to meet resident needs

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted a subsequent complaint investigation with the purpose of delivering findings for the above noted allegations. LPAs were greeted by front desk staff and met with Facility Designee Agnes Gazaryan upon arrival. Entrance interview conducted. During an initial complaint visit conducted on 05/20/2025 between 10:47AM and 04:00PM, LPAs Valeria Conway and Kelly Dulek interviewed the administrator and conducted a physical plant tour to ensure there are no health and safety concerns. Additionally, the LPAs reviewed files and obtained copies of pertinent documents relevant to the investigation. At 1:39 P.M., LPA Conway conducted a medication audit. LPAs informed Administrator that the allegation was referred to Community Care Licensing Division (CCLD)'s Investigations Branch (IB.) Investigator Douglas Real conducted both telephonic and in person interviews Report Continued on LIC 9099-C Substantiated with staff, residents, and other relevant parties on the following dates: 05/28/2025, 06/25/2025, 06/26/2025, 07/22/2025, 07/31/2025, 08/01/2025, 08/18/2025, 09/23/2025, 09/24/2025, and 09/25/2025. Investigator Real also reviewed copies of R1’s medical records, including but not limited to facility medical documents, physician’s documents and outside medical provider records. LPA then reviewed all information obtained by Investigator Real. The following was then determined: Allegation “Neglect/Lack of supervision: facility employees failed to provide an appropriate level of supervision resulting in R1 falling multiple times and sustaining a fracture:” The complaint alleges that R1 fell multiple times while at the facility which resulted in R1 sustaining a hip fracture. Interviews and documents reviewed revealed that R1 moved into the facility on 05/19/2023, had a diagnosis of dementia, and was ambulatory at that time. Staff interviewed stated that R1 was very active and walked around the facility’s Memory Care unit often. Incident reports reviewed revealed that R1 had an unwitnessed fall on 08/25/2024 and the fall resulted in no injury. Although no incident report was able to be located, interview and hospital records revealed R1 fell again on 03/04/2025 and was transported to the emergency department for further evaluation. This fall resulted in no injury and R1 returned to the facility the same day. Hospital records and staff interview revealed on 03/08/2025, R1 fell in the common area of the Memory Care unit. R1 was transported to the emergency department, where R1 was diagnosed with a closed comminuted intertrochanteric fracture of the proximal end of the left femur. R1 remained hospitalized for treatment prior to returning to the facility on 03/11/2025. Interview revealed that following R1’s hospitalization, R1 was placed on 15-minute checks, however no documentation was provided to indicate 15-minute checks were completed. Staff interviewed stated the Memory Care unit was understaffed frequently, leaving two (2) caregivers for 20-25 residents with dementia diagnoses. Staff interviews revealed when understaffed, staff were unable to conduct 15-minute checks for the ten (10) residents that required such additional supervision. Staff stated when checks are unable to be completed, the 15-minute check forms were left blank. Incident report and hospital records revealed R1 had another fall on 04/24/2025. Activity staff found R1 on the floor in their room around 05:15PM, R1 appeared to be in pain. R1 was transported to the emergency room, where R1 was diagnosed with an acute periprosthetic fracture (a broken bone that occurs around an orthopedic implant) about the left femoral stem with angulation and an acute Report Continued on LIC 9099-C (p.3) right inferior pubic ramus fracture with no right-sided hip fracture. The staff assigned to R1’s care that day had initially been scheduled for Assisted Living but had been asked to work in Memory Care instead due to staff call outs. This staff was unaware they were assigned R1’s care, therefore had not completed any 15-minute checks from 02:00PM until the time R1 was found on the floor around 05:15PM. Interview revealed there were two (2) staff working in Memory Care at the time of R1’s fall. R1 returned to the facility on 05/04/2025. LPAs noted that during the initial visit on 05/20/2025, R1 was not listed on the facility’s 15-minute check list nor the facility’s repositioning list. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation “Neglect/Lack of supervision: facility employees failed to provide an appropriate level of supervision resulting in R1 falling multiple times and sustaining a fracture” is deemed SUBSTANTIATED at this time. Allegation: “Due to neglect, resident sustained a pressure injury:” Interviews revealed that when R1 moved into the facility, R1 was ambulatory and did not have any pressure injuries at that time, however physician’s report dated 05/19/2023 indicated R1 has a history of skin breakdown with a comment indicating “tailbone.” LPA reviewed documents such as hospital records, facility incident reports, and hospice records for R1. Record review revealed R1 had sustained a broken femur on 03/08/2025 and was bedbound/non-ambulatory following their hospitalization. R1 was then taken to the emergency room on 03/31/2025 for evaluation of a sacral wound. Wound was identified as a stage II at that time. R1 returned to the facility the same day. There was no documentation indicating R1 was admitted to Home Health to assist in caring for the restricted health condition. When R1 returned to the emergency department following their 04/24/2025 fall, hospital notes indicate “seems as if they [facility staff] were unaware that the patient needed to be rotated.” Photographs were taken at the hospital of the wound; however, staging was not provided on hospital documents. On 04/25/2025, hospital notes indicated there was a wound consultation, which identified an open sacrococcygeal pressure injury and stated R1 would be discharged with orders for home health care. By 05/04/2025, R1 had returned to the facility and R1 was admitted to hospice care. Hospice notes from 05/07/2025 identified two (2) wounds on R1 – one (1) sacral wound which was listed as unstageable, and one (1) low buttock wound stage II. On 05/08/2025, Wound Pros visited R1 and resumed wound care. Notes indicated the sacral wound had been present for two (2) months and had increased in size. Staff interviewed stated R1 had a small pressure injury, but this wound was not open until after R1’s second hospital visit. However, facility staff did take R1 to the hospital for Report Continued on LIC 9099-C (p.4) wound assessment on 03/31/2025 which was well before R1’s second fall and the wound was identified as stage II at that time. Staff interviewed stated they were unaware of any pressure injuries at that time and therefore did not assist R1 with repositioning or offer assistance in obtaining wound care. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation “Neglect/Lack of supervision: Due to neglect, resident sustained a pressure injury” is deemed SUBSTANTIATED at this time. Allegation “Staff do not serve food of quantity to meet residents’ needs:” Throughout the course of the investigation, LPA interviewed residents and observed food served. Although some residents felt the food had improved more recently, at the time the complaint was received, residents interviewed felt the portions were too small. Meals are served three (3) times a day, with breakfast served at 07:00AM, lunch at 11:00AM, and dinner is at 04:00PM. Staff indicated snacks are available in the Bistro and the Bistro is stocked by kitchen staff between meals. However, residents stated they need to ask staff when they want a snack and LPAs observed that snacks were not consistently provided. The facility does have two (2) fully stocked vending machines, however, residents are required to purchase these items at an additional cost. LPAs took photos of a sample of some meals served and observed a meal consisting of a small pile of meat, two (2) pieces of cauliflower, two (2) potato wedges, and five (5) baby carrots. Another meal observed contained the following: a ½ piece of salmon, three (3) small pieces of cauliflower, and a slice of sweet potato. According to the United States Department of Agriculture (USDA - fns.usda.gov), an average older adult with a 2,000 calorie diet requires the following daily: two (2) cups of vegetables, five and a half (5 ½) ounces of protein, two (2) cups of fruit, 6 ounces of grains, and three (3) cups of dairy. Food served and menus observed did not contain the appropriate amounts of dairy, fruit, or vegetables on any day reviewed. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation “staff do not serve food of quantity to meet resident needs” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) A $1000 Immediate Civil Penalty was assessed. Facility Designees Agnes Gazaryan and Ashley Kumar were informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided. with staff, residents, and other relevant parties on the following dates: 05/28/2025, 06/25/2025, 06/26/2025, 07/22/2025, 07/31/2025, 08/01/2025, 08/18/2025, 09/23/2025, 09/24/2025, and 09/25/2025. Investigator Real also reviewed copies of R1’s medical records, including but not limited to facility medical documents, physician’s documents and outside medical provider records. Throughout the course of the investigation, LPAs also conducted resident and staff interviews and made observations related to this complaint during various unrelated visits at the facility. LPA reviewed all information obtained. The following was then determined: Allegation "Staff do not change resident's diapers/clothes timely:" LPAs observed residents and interviewed staff and residents related to this complaint allegation. During all facility visits, residents in the Memory Care, including R1, appeared to have relatively clean clothing. Staff stated residents are dressed every morning and clothing is changed throughout the day if soiled or dirtied during the shift. LPAs observed laundry hampers in each resident room for resident's dirty clothing. Laundry is washed weekly by facility staff. Staff interviewed stated they provide incontinence care every two (2) hours or more frequently if needed to keep the residents clean and dry. As some residents urinate more frequently than others, their needs may vary. Residents interviewed felt their incontinence needs are being met. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff do not change resident's diapers/clothes timely” is deemed UNSUBSTANTIATED at this time. Allegation "Staff did not ensure resident's nail hygiene was met:" The complaint alleges that in May of 2023, R1's family requested their nails be cut during the podiatrist's next monthly visit, however, it was discovered on 04/09/2025 that R1 has what "appears to be roughly 2 years of unattended nail growth." R1's toenails were cut on 04/18/2025. Facility staff interviewed stated the facility does have a podiatrist who visits the facility regularly and the facility provides a sign up sheet for those residents who are interested in using the outside service. Administrator stated that the podiatrist does require payment up front for those residents whose insurance does not cover the service fee. In the case of R1, there is a fee for this third-party service and the fee needs to be paid before service is provided. This was explained Report Continued on LIC 9099-C (p. 9) to R1's family. Based on the third-party podiatrist's policy, even if services were requested, if payment was not provided, the podiatrist would not provide service to R1. It is unclear whether services were requested at any time between May 2023 and 04/09/2025. All parties interviewed did agree that once services were requested and paid for on 04/09/2025, R1's toenails were cut on 04/18/2025. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not ensure resident's nail hygiene was met” is deemed UNSUBSTANTIATED at this time. No citations issued related to the above allegations. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 29-AS-20250519143156

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 27, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c) This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 had numerous falls at the facility and was on 15-minute checks which were not provided, resulting in another fall and fracture, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Facility Designees indicated staffing has been changed and there are minimum 3 caregivers in Memory Care at all times. Staff is augmented with agency staff as needed. Designees will send a staffing and inservice plan to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87613(a) · Plan of correction due date: Oct 27, 2025

87613 General Requirements for Restricted Health Conditions (a) Prior to admission of a resident with a restricted health condition, the licensee shall: This requirement is not met as evidenced by: Based on record review and interviews, R1 had a stage II pressure injury identified on 03/31/2025, but no outside care provider caring for the wound or staff training provided until 05/04/2025, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Facility designee indicated they now have an LVN who comes in and does body checks on the residents weekly and other medical professionals on site and available to train facility staff. Designee agreed to provide a written statement of current policies related to this regulation to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(a) · Plan of correction due date: Nov 7, 2025

87555 (a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances...safe and healthful manner. This requirement is not met as evidenced by: Based on interview and observation, the licensee did not comply with the above cited section, as portions for residents do not contain the recommended daily amounts of dairy, fruit, or vegetables, which posed an immediate health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Facility designee stated the facility has contracted with a dietician to provide services to the facility. Dietician will be on site next week. Following the dietician visit, Designee will provide proof to CCL of the visit and plan for food service going forward upon completion of the visit.

Allegation investigated: Facility staff are not providing incontinence care as needed Staff sleeps while on duty Staff does not respond to residents’ calls for assistance in a timely manner

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 9:32 A.M. LPA met with back-up administrator Agnes Gazaryan and explained the purpose of the visit. Marketing Director, Ashley Kumar arrived shortly after. Back-up Administrator is authorized to sign today's report. Entrance interview conducted. During initial 10-day complaint inspection, between 1:33 P.M. and 3:01 P.M., the LPAs briefly toured the facility with the Marketing Director. LPAs interviewed the Marketing Director, conducted interviews with random residents and obtained copies of pertinent documents relevant to the investigation. Continued on LIC 9099-C Substantiated Continued from LIC 9099 Regarding allegation “Facility staff are not providing incontinence care as needed” it was reported that during the nocturnal (NOC) hours, staff are not checking on residents regularly, leaving them soiled for extended periods of time. An interview with the Marketing Director revealed that night and NOC staff have been reporting to work as scheduled and they have not received formal complaints from residents regarding un-met incontinence needs. Interviews with the morning (AM) staff indicated that residents are often found soiled at the beginning of their shift and have expressed frustration about waiting for long periods before receiving assistance after activating the call light system. NOC staff denied the allegation, stating that all required checks and incontinence care are being provided as scheduled. Resident interviews, however, revealed consistent concerns regarding staffing levels during all shifts. Several residents stated that it is difficult to receive timely assistance at night and that staff do not check on them as frequently as needed. Some residents reported feeling neglected and described instances where staff where “nowhere to be found” when they were wet and soiled and assistance with incontinence care was required. One resident in particular, Resident #1, reported activating the call cord for restroom assistance and waiting approximately 40 minutes without receiving help. Eventually attempted to get up independently, lost balance, and sustained a fall that required hospitalization. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Facility staff are not providing incontinence care as needed” has been SUBSTANTIATED at this time. Regarding allegation “Staff sleep while on duty” it was the reporting party’s concern that Nocturnal (NOC) staff sleep throughout their shift, resulting in residents not being monitored, rounds not being conducted, and residents not receiving assistance during the nighttime hours. NOC staff denied the allegation, stating that required rounds and resident checks are being conducted as scheduled. Interviews with residents revealed that it is difficult to receive timely assistance at night and that staff do not check on them as frequently as needed. Some residents reported feeling unattended and that staff are frequently not present or available when assistance was required. Continued on LIC 9099-C Continued from LIC 9099-C An interview with the back-up administrator indicated that on the night of 09/28/2025, security camera footage was reviewed at approximately 3:00 AM and it appeared that Staff #1 (S1) was covered with a blanket and asleep on the couch located in the main entrance area. S1 was released from their duties on 09/29/2025. During the interview, S1 denied being asleep but stated that they were not feeling well that night and chose to come to work instead of calling out sick. S1 further stated that after conducting resident checks, they decided to rest briefly before completing the next round of checks. Additional staff interviews confirmed that some staff members have observed or heard that NOC staff occasionally sleep in the library during their shift, leaving residents unattended for extended periods. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff sleep while on duty” has been SUBSTANTIATED at this time. Regarding allegation “Staff does not respond to residents’ calls for assistance in a timely manner” it was reported that staff fail to respond promptly when residents request help. During a physical plant tour conducted with the back-up administrator on 09/26/2025, LPA tested the functionality of the call light system. After confirming that all prior calls had been cleared from the switchboard, LPA activated the call cord in room #522 and observed that multiple room indicator lights, including those in rooms where no assistance was needed, illuminated on the system board located at the main entrance. The back-up administrator explained that the facility’s call light system is outdated and not function as intended. Marketing Director explained that staff are able to identify which room is calling for assistance because, even though multiple rooms light up, the light corresponding to the room calling for assistance illuminates brighter on the switchboard. Interviews with staff stated that some hallway signal lights, which are designed to activate when a resident pulls the call cord, were burnt and not operational. As a result, staff are sometimes unable to identify which residents require assistance unless the resident verbally calls out to staff passing by. Interviews with residents revealed consistent concerns regarding delayed response times across all three (3) shifts after pulling the call cord before receiving assistance. Several residents also expressed concerns that having only two (2) caregivers on duty is not sufficient to meet the needs of the entire assisted living unit. Additionally, some residents alleged that staff intentionally place call cords out of reach so staff are not disturbed during the night. Continued on LIC 9099-C Continued from LIC 9099-C During different visits to the facility, LPA observed shared resident rooms in which the call cord system was located in the middle of the room between who (2) resident beds, with only one (1) cord available for both residents. LPA also observed that in some rooms, the call system consisted of a fixed wall switch rather than a traditional muti-directional pull cord. When LPA tested some of these switches, they did not engage properly, preventing activation of the call light system. LPA asked Resident #2 (R2) how they request assistance when the call cord does not engage. R2 stated that when assistance is needed, they verbally call out to staff members passing by in the hallway since the call cord system in their room is not functioning properly. R2 added that this is very difficult and often takes a long time, as it can be some time before a staff member is seen walking through the hallway. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff sleep while on duty” has been SUBSTANTIATED at this time. A $250 civil penalty is assessed for the citation related to CCR 87464(f)(1) for a repeat violation. The back-up administrator, Agnes Gazaryan and Marketing Director, Ashley Kumar were informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 29-AS-20250820091101

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 27, 2025

87625(b)(3) Managed Incontinence...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on interviews, record review and observation, the licensee did not comply with the section cited above, as they did not ensure residents’ incontinence was properly managed, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: The Administrator agreed to submit a Plan of Action, indicating how staff will care for residents' needs before POC due date AND hold an in-service training with all staff regarding regulation 87625 Managed Incontinence. Submit sign-in sheet but no later than 10/27/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 27, 2025

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when staff were not providing care and supervision while using their personal cell phones and laying on the couch which posed a immediate personal to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: The back-up administrator agreed to submit an action plan on how to ensure staff adequate supervise residents during the NOC shift AND have an in-service training with ALL staff regarding policy about the use of personal cell phones while on duty no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Nov 7, 2025

87303(i)(1)(C)Facilities shall have signal systems which shall meet the following criteria:(1)All facilities licensed for 16 ...shall have a signal system which shall:(A)-(C). This requirement was not met by Based on observation and interviews the licensee did not comply by having a signal system malfunction. Which poses a potential risk to resident in carethe state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Back-up Administrator and Marketing Director agreed to contact a third party vendor to come to check on call light system. Representatives will send confirmation of scheduled visit and conduct temp or necessary repairs before POC due date

Allegation investigated: Licensee does not ensure enough staff are present to meet the needs of residents Staff do not provide adequate food service to residents

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 9:32 A.M. LPA met with back-up administrator Agnes Gazaryan, and explained the purpose of the visit. Back-up Administrator is authorized to sign today's report. Marketing Director, Ashley Kumar arrived shortly after. Entrance interview conducted. On 05/20/2025, from 10:14 A.M.– 5:03 P.M., LPAs initiated an unannounced complaint investigation for the allegations listed above. During prior visits, LPAs toured the physical plant, interviewed staff, residents, and reviewed and obtained pertinent documents relevant to the investigation. Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined: Continued on LIC 9099-C Substantiated Continued on LIC 9099-C Regarding allegation of “Staff do not speak appropriately to residents in care” the RP expressed concern that staff demonstrate poor communication practices, including making inappropriate remarks such as telling residents to leave the facility if they are dissatisfied. Interviews conducted with residents and family members revealed mixed responses. Some residents and family members reported that there is a language barrier between staff and residents and that on certain occasions, staff members have used an unfriendly or dismissive tone when interacting with residents. Other residents denied experiencing any inappropriate behavior or communication issues with the staff. Interviews with staff denied the allegation and expressed that, at times, some residents can be verbally abusive or rude toward staff, which may lead to challenging interactions. The administrator stated that staff are continuously reminded to maintain professionalism when interacting with residents. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff do not speak appropriately to residents in care” is deemed unsubstantiated at this time. Exit interview conducted and a copy of this report was provided. Continued from LIC 9099 Regarding allegation “Licensee does not ensure enough staff are present to meet the needs of residents,” the Reporting Party (RP) expressed concern that the facility was short-staffed on Easter night (4/20), and the night of Saturday 5/10/25. Interviews with the Licensee and the ED confirmed that the facility has experienced staffing challenges. However, the ED stated that the facility maintains sufficient staffing levels to cover for employees who resign or call out due to illness using caregiver from a staff agency. LPA requested and reviewed facility timecards and staffing records, including any documentation of agency staff used to provide coverage during the specified dates. Per ED, agency personnel were not called in to cover staff call-outs on those days. LPA Conway conducted a comprehensive review of the facility’s timecards, which revealed that on 4/20/2025, five (5) scheduled staff members did not report to work, and on 5/10/2025, six (6) scheduled staff members did not report to work. Additionally, it was observed that some staff took their lunch breaks simultaneously rather than staggering their breaks which resulted in temporary service interruption and reduced supervision of residents. Staff reported feeling overworked and stressed due to persistent staffing shortages. They indicated that they are frequently required to assume additional responsibilities and take on extra shifts. Staff reported that this level of understaffing has led to them rushing through tasks leading to careless, delays in assisting residents, and longer response times to resident call signals. Interviews with residents revealed that occasionally staffing levels are insufficient to meet care needs of residents. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Licensee does not ensure enough staff are present to meet the needs of residents, has been SUBSTANTIATED at this time. Continued from LIC 9099-C Continued from LIC 9099-C Regarding allegation “Staff do not provide adequate food service to residents” the RP expressed concern that there are often not enough staff available to feed residents in the Memory Care (MC) unit. Interviews conducted with the administrator revealed that the facility has experienced staff challenges due to staff call-outs, which have occasionally affected daily operations. However, the administrator denied that residents in the MC unit have ever missed meals or gone unfed. A review of group text messages among staff indicated that residents in the MC unit have complained of hunger on two (2) consecutive days due to not being served dinner. Interviews conducted with credible witnesses including staff, residents, and family members, revealed consistent concerns that residents are not receiving sufficient meals or snacks. Family members also reported taking upon themselves to bring additional food and snacks during their visits to ensure residents have enough to eat. Other residents also reported dissatisfaction with both the quantity and quality of the food. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff do not provide adequate food service to residents” has been SUBSTANTIATED at this time. A $250 civil penalty is assessed for the citation related to CCR 87411(a) for a repeat violation. Facility designees, Agnes Gazaryan and Ashley Kumar were informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 29-AS-20250520120552

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 27, 2025

87411(a) Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by… Based on interviews and record review the Executive Director did not comply with the regulation above by not having sufficient support staff to perform essential duties for residents in care which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Back-up administrator agreed to write a statement of understanding reg 87411 (a), submit a plan of action and ensure staff are not taking lunch at the same time. Statement due date 10/24/25.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway arrived on October 24, 2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with facility designees Agnes Gazaryan and Ashley Kumar. On November 25, 2024, the Department concluded a complaint investigation regarding the following allegations: Neglect/lack of supervision leading to questionable death; neglect/lack of supervision: facility employees failed to properly supervise resident resulting in an unwitnessed fall and injuries to the resident; licensee did not meet resident’s ADL needs; licensee did not provide resident’s responsible party an updated care plan; and licensee did not comply with reporting requirements. The licensee was cited for California Code of Regulations (CCR) 87464(f)(4) Basic Services; CCR 87411(a) Personnel Requirements – General; CCR 87705(c)(6) Care of Persons with Dementia; and CCR 87211(a)(1)(B) Reporting Requirements. At the time of the complaint visit on November 25, 2024, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the facility not providing proper care and supervision which led to a resident (R1) falling, sustaining fractures and brain Report Continued on LIC 809-C bleeding that resulted in R1’s death. Today, October 24, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on November 25, 2024, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Facility Designees Agnes Gazaryan and Ashley Kumar and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Oct 24, 2025

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway arrived on October 24, 2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with Facility Designees Agnes Gazaryan and Ashley Kumar. On March 21, 2024, the Department concluded a complaint investigation regarding the following allegations: Facility did not assist resident with obtaining medical care; facility staff did not assist resident with administering medications as prescribed and questionable death. The licensee was cited for California Code of Regulations (CCR) 87464(f)(1) Basic Services and Section 87465(a)(4) Incidental Medical and Dental Care. At the time of the complaint visit on March 21, 2024, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. The Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing the Report Continued on LIC 809-C necessary care and supervision to meet the resident’s (R1) health care needs when they did not assist R1 with obtaining the physician ordered medications necessary to prevent and/or minimize symptoms associated with fluid build-up (overload). The facility did not report to the primary care physician that R1 was not receiving medications resulting in serious bodily injury, including but not limited to fluid overload, hypoxia, pneumonia, and an acute exacerbation of resident’s chronic heart condition (CHF) that required hospitalization and aggressive treatment. Today, October 24, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $ 500 was previously issued on March 21, 2024, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Agnes Gazaryan and signature on this report acknowledge receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Oct 24, 2025

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway arrived on October 24, 2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPAs met with Facility Designees Agnes Gazaryan and Nandita (Ashley) Kumar. On July 7, 2023, the Department concluded a complaint investigation regarding the following allegation: Facility failed to seek timely medical attention for resident in care, illegal eviction, staff are not sufficient in numbers and competent to provide services necessary to meet resident’s needs, and licensee did not allow resident(s) to select their own health care provider. The licensee was cited for California Code of Regulations (CCR) 87465(g) Incidental Medical and Dental Care and CCR 87468.2(18) Additional Personal Rights of Resident’s in Privately Operated Facilities. At the time of the Noncompliance Conference on February 8, 2024, the licensee was informed that a civil penalty may be assessed based on Health and Safety Code §1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility’s failure to provide timely medical care; a violation of personal rights; a failure to appropriately respond when the observation of the Report Continued on LIC 809-C resident (R1) showed a change in condition of increased falling; a failure to obtain a re-appraisal; and a failure to provide adequate care and supervision to meet the needs of R1. These deficiencies led to the R1 falling, again, and caused extreme pain as evidenced by R1 screaming. The fall caused a hip fracture and head trauma, which required hospitalization. Today, October 24, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Nandita (Ashley) Kumar andAgnes Gazaryan and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Oct 24, 2025

Allegation investigated: Staff are not dispensing medication as prescribed

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounce 10-day innicial complaint visit to investigate the allegation listed above. Upon arrival LPAs met with Executive Director/Administrator, Monica Reyes, and explained the reason for the visit. During today’s visit from 11:23 A.M.– 1:00 P.M. LPAs and administrator toured the physical plant to ensure there are no health and safety concerns, and the facility is in compliance with Title 22 regulation. A case management report will be issued to address deficiencies observed during the physical plant tour. Additionally, LPAs interviewed staff, residents, and reviewed and obtained pertinent documents relevant to the investigation. Continued on LIC 9099-C Substantiated Continued from LIC 9099 Throughout the course of the investigation, LPAs reviewed all documents obtained and conducted medication audit. The following was then determined: Regarding allegation of “Staff are not dispensing medication as prescribed” it was alleged that resident medications were not being administered as scheduled, and this has resulted in the resident exhibiting aggressive behavior towards others. Furthermore, the Responsible Party (RP) stated that staff have been crushing Resident #1’s (R1) medication without a physician’s prescription. Interviews conducted with morning Med-Techs staff revealed that there are currently no residents refusing medications. The Med-Tech assigned to the Meadows (Memory care unit) stated that approximately one month ago, R1 had changes to two (2) of their prescribed medications. Staff also stated that R1's medication is currently being administered in a crushed form. LORazepam 0.5 mg to be given as routine medication and not as a PRN and QUEtiapine (generic for Seroquel) changed from 25 mg to 50 mg on 07/17/2025. During the course of the investigation, LPAs conducted a medication audit and reviewed Centrally Stored Medication and Destruction Record (CSMDR), Medication Administration Records (MARs), physician’s orders and pill count for R1. The following was observed, medication QUEtiapine 25 mg, 1 tablet two (2) times a day at 8 AM and 8 PM and also give one (1) every 12 hours as needed, was filled and given for the first time on 08/04/2025 with a starting quantity of one hundred and twenty (120). At the time of the audit, one hundred and four (104) pills remained in the medication container for QUEtiapine 25 mg. Based on medication count and interview with Med-Tech, staff continued administering 25 mg medication instead of the 50 mg that was prescribed on 07/17/2025. Additionally, the documentation review revealed that LORazepam 0.5 mg recorded as being administered daily at 8 P.M. on both the CSMDR and the MARs. However, on the Controlled Drug Record, the same employee who initialed the MARs documented the administration time as 5 P.M. It is therefore inconclusive what time the medication was actually given. Furthermore, LPAs observed discrepancies in the documentation for Atorvastatin 40 mg. The refill date on the medication label was 05/17/2025 and the “opened date” recorded by staff was 05/05/2025. Continued on LIC 9099-C Continued on LIC 9099-C LPAs requested documentation reflecting the date that LORazepam 0.5 and QUEtiapine 50 mg were changed from a PRN (as needed) medications to scheduled/routine medications, as well as documentation showing that R1 has a physician’s prescription authorizing their medication to be crushed. Med-Tech staff were unable to locate or provide the requested documentation at the time of the visit. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegations above are deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties. As this is a repeat violation of the same regulation 87465(a)(4) within 12 months a civil penalty in the amount of $250 for a repeat violation is being assessed on the attached LIC 421FC. The Administrator, Monica Reyes was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 29-AS-20250806133828

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 13, 2025

A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, the Licensee did not comply with the section cited above as medication audit revealed discrepancies for R1 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: The ED agreed to follow up with R1's physician to obtain clarification regarding the authorization for crushing medications. The Ed also stated they will issue a formal write-up and require Med-Tech staff to provide written statements acknowledging the importance of following physician orders and administering medications as scheduled.

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

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance. Upon arrival, the LPAs met with Executive Director (ED), Monica Reyes and explained the reason for the visit. The LPAs focused today’s visit on physical plant, resident files and incident reporting in compliance with Title 22 Regulations. During today's visit, the LPAs, along with ED, conducted a physical plant tour beginning at 11:23AM and LPA Dulek conducted file review at 01:26PM. The following was noted: Upon arrival to the facility, LPAs observed the delayed egress gate on the north side of the memory care was observed to be tied shut with a plastic bag, preventing the gate from opening. During facility tour, at 11:50AM, the other delayed egress exit gate was observed to be locked with a key. Maintenance staff confirmed that the gate had been locked since Sunday 08/10/2025. During file review, LPA Dulek reviewed files for 7 (seven) residents for documents including but not limited to: physician's reports, needs and service appraisals, and admission agreements. 2 (two) of 7 (seven) residents' files reviewed (Resident #1 - R1 and Resident #2 - R2) had needs and service appraisals that were more than 1 year old. Resident #3 (R3) has a needs and service appraisal dated 01/31/2025. However, based on review of incident reports and interview with staff, R3 has had a change in condition as evidenced by increased aggression and sexual behaviors, but staff did not complete a new needs and service appraisal for R3. Report Continued on LIC 809-C Additionally during today's visit, LPAs discussed with ED Reyes recent incident reports sent to Community Care Licensing. ED reported 3 (three) separate incidents involving R3, who resides in the facility's Memory Care unit. 2 (two) of these incidents occurred on 07/24/2025 and involved R3 showing aggressive behavior towards care staff and Resident #4 (R4). The third incident occurred on 08/03/2025 and involved R3 hitting R4, resulting in R4 requiring outside medical treatment. R3 was observed to be ambulatory and staff interview revealed that all resident doors are to remain locked to prevent R3 from unwanted/unsafe access to other resident rooms, as R3 had been involved in additional incidents previously. When touring the facility, ED stated that R4 had been moved to another room, so R3 and R4 no longer have a shared jack-and-jill style restroom. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalties issued in the amount of $1000, for a repeat violation. Executive Director was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of today's report was provided via email.the state’s words, verbatim · CDSS document, Aug 12, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Aug 13, 2025

87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal…district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as both delayed egress exits from the memory care yard were observed to be locked and/or tied shut, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: Executive Director ensured lock was unlocked, and plastic was removed during the visit. During today's visit, a door repair person visited the facility and identified a problem with the door latch. Repair person will complete repairs tomorrow and ED will provide proof to CCL by POC due date. Additionally, the lock will be changed to limit access to and prevent staff from locking the back gate. Proof to be provided to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87464(f) · Plan of correction due date: Aug 13, 2025

87464 (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interview and observation, the licensee did not comply with the above cited section, as R3 was allowed continued unsupervised access to R4, although R3 displayed aggressive behaviors towards others, resulting in R4 sustaining injury, which poses an immediate safety risk.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: ED agreed to install a lock on the door from the shared restroom to the adjoining room. ED further agreed to assess potential residents R3 may have access to through the shared restroom for compatibility and safety prior to moving anyone into that room. ED will provide proof by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 26, 2025

87463 (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Based on record review and observation, the licensee did not comply with the above cited section, as 2 of 7 files reviewed did not have a reappraisal within a 12-month period and 1 of 7 had a change of condition with no reappraisal, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: ED agreed to complete reappraisals for the 3 residents identified and submit proof to CCL by POC due date.

Allegation investigated: Staff are engaging in conduct inimical to the health and safety of residents Reporting requirements are not being met

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 9:41 A.M. LPAs met with Executive Director, Monica Reyes, and explained the purpose of the visit. On 05/29/2025, LPAs Conway, Dulek and Arroyo and Licensing Program Manager, Kristin Heffernan, conducted an unannounced 10-day complaint visit to the facility regarding the above noted allegations. Between 10:30 A.M. and 4:15 P.M., the LPAs and LPM briefly toured the facility with the ED. LPA Arroyo conducted a medication audit, the ED was interviewed, a file review was conducted and copies of pertinent documents were obtained. Continued on LIC 9099-C Substantiated Continued from LIC 9099 During today’s visit, LPAs conducted a health and safety check tour of the facility at 11:19 A.M. During the walk-through, LPAs observed deficiencies unrelated to the complaint allegations, which will be addressed in a case management report. Throughout the course of the investigation, LPA Conway reviewed all documents previously obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined: Regarding the allegation “Licensee did not comply with reporting requirements”, it was alleged that facility staff and the ED selectively report incidents to Community Care Licensing (CCL) and that serious falls and injuries are not consistently reported. Interviews with the ED revealed that the facility utilizes an internal incident reporting form completed by staff when an incident occurs. Once completed the report is submitted to the ED, who then determines whether the incident is reportable to CCL. Based on documentation and prior communication, on 4/15/2025, LPA Conway emailed the ED a reminder that incident reports must be submitted to the licensing agency, the Primary Care Physician (PCP), and the resident’s responsible party within seven (7) days of the occurrence, pursuant to Title 22 regulations. During prior visit and prior to this complaint, LPAs Conway and Dulek informed the ED that all incidents, regardless of perceived severity, must be reported to CCL. The ED acknowledged the reporting expectations and explained that while efforts are made to notify appropriate parties, the ED manages a heavy workload. However, further investigation and interviews with credible witnesses revealed that a reportable incident involving two residents, which occurred in March 2025, was not disclosed by the facility to the residents’ PCPs, hospice agencies, and/or responsible party. Instead, some of those parties became aware of the incident through contact initiated by hospital staff. Additionally, in May 2025, another resident was hospitalized, and once again, no formal notification, either verbal or written, was provided by the facility staff to the resident’s responsible party. The RP learned of the hospitalization only after being contacted directly by the hospital. Staff interviews confirmed that facility staff are not responsible for submitting incident reports directly to CCL. Instead, internal incident reports are reviewed solely by the ED, who decides whether to complete and submit a formal incident report form (LIC 624) to CCL and which are not, raising concerns about consistency and compliance in the facility’s reporting practices. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegations above are deemed SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C As to the allegation of “Staff are engaging in conduct inimical to the health and safety of residents” It was alleged that, surveillance cameras within the facility were deliberately covered with blue paper, obstructing their ability to record footage and monitor resident care. Interviews conducted with the ED confirmed that the cameras were intentionally covered with blue tape. The ED explained that this action was taken due to a former employee retaining unauthorized access to the facility’s camera system through their personal phone, even after resigning from their position. The ED stated that the decision to cover the cameras was made to protect resident confidentiality and privacy. Further, the ED reported that attempts were made to contact the former employee to disable their remote access; however, these efforts were unsuccessful. Additionally, the individual who initially installed the camera system is no longer affiliated with the facility and is unavailable to reset or reconfigure the system. Investigation determined that from early May until mid-July 2025, an unauthorized individual continued to have remote access to the facility’s surveillance camera system, accessing sensitive facility operations and compromising resident privacy and confidentiality. LPAs Conway and Dulek and IB investigators visited the facility three more times after receiving this complaint allegation and the surveillance camera system was still not operational. On 7/11/2025, the ED reported that an IT professional was hired to reset the surveillance system. The technician removed the central processing unit (“main brain”) of the system to reconfigure it off-site, with the intent to reinstall it and eliminate any unauthorized access. Today, 07/22/2025, the ED stated that the surveillance camera system password has been reset and that the system is now functioning. However, LPAs observed that surveillance cameras located in office areas, including, but not limited to, the ED’s office, the licensee’s office, the medication room, and the chart room, remained covered with blue tape. At this time, only cameras in common areas are actively recording footage. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegation above are deemed SUBSTANTIATED at this time. Continued on LIC 909-C Continued from LIC 9099-C Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties. A $250 civil penalty is assessed today for the citation related to CCR 87211(a)(1)(B) and a $250 civil penalty related to health and safety code 1569.58(a)(2) for repeat violations within 12 months. The Administrator Monica Reyes was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 29-AS-20250529054144

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Aug 5, 2025

Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...(B) Any serious injury...under facility supervision. This requirement is not met as evidenced by: Based on interviews the facility did not comply with the above cited section, as incidents were not consistently reported to CCL, resident's responsible parties, PCPs, and/or other appropriate agencies, which posed an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: ED agreed to write a statement of understanding about regulation 87211 and submit incident reports within 7 days from occurrence including detailed information about the incident, what happened after the incident and a list of all parties informed.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.58(a)(2) · Plan of correction due date: Jul 23, 2025

1569.58 (a) (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California. This requirement is not met as evidenced by: Based on observations the facility did not comply with the above cited allegation by allowing a former employee to have access to surveillance video footage from late May until mid-July 2025, which posed an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: During today's visit, ED stated that surveillance system passwords were changed and that the Licensee and the ED has access to facility's video footage.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff are not dispensing medication as prescribed

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 9:41 A.M. LPAs met with Executive Director, Monica Reyes, and explained the purpose of the visit. On 05/20/2025, LPAs initiated an unannounced complaint investigation for the allegations listed above. During the visit and on a subsequent visit on 07/11/2025, LPAs toured the physical plant, interviewed staff, residents, and reviewed and obtained pertinent documents relevant to the investigation. During today’s visit, LPAs conducted a health and safety check tour of the facility at 11:19 A.M. During the walk-through, LPAs observed deficiencies unrelated to the complaint allegations, which will be addressed in a case management report. Throughout the course of the investigation, LPA Conway reviewed all documents previously obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined: Continued on LIC 9099-C Substantiated Continued from LIC 9099 Regarding allegation of “Staff are not dispensing medication as prescribed” it was alleged that resident medications were not being delivered on time. During the course of the investigation, LPAs conducted a medication audit and reviewed the Medication Administration Records (MARs) for two residents. The review revealed that Resident #1 (R1) had discrepancies with two medications. The PRN medication Lorazepam 0.5 mg, 1 tablet up to 2 times per day as needed, was filled on 06/05/2025 with a quantity of six (6). At the time of the audit, only two (2) pills remained in the medication container for Lorazepam and the MARs log for June and July 2025 did not reflect any documentation of administration. Also, Quetapine (generic for Seroquel) 50 mg, 1 tab every morning, 2 tabs in the afternoon and 4 tabs at bedtime, with a start date of 07/03/2025 containing 100 pills had 17 pills left, however if administered as prescribed, should have been empty as of 07/17/2025. MARs log from 07/15/2025-07/22/2025 was incomplete. The absence of MedTech initials on the MAR indicates that medication was not recorded as having been dispensed to the resident. LPAs observed that medications for all residents were being stored in two (2) medication carts positioned against the wall adjacent to the file room. At 1:19 P.M., LPAs observed several loose pills on the floor between the two (2) medication carts. When the carts were pulled away from the wall, LPAs and Med-Techs present discovered several unidentified pills scattered on the floor. Med-techs stated they were unaware of those pills and were unable to identify which resident(s) the medications belonged to. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegations above are deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties. A $250 civil penalty is assessed today for the citation related to CCR 87465(a)(4) for repeat violation within 12 months. The Administrator Monica Reyes was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 29-AS-20250520120552

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 23, 2025

A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, the Licensee did not comply with the section cited above as medication audit revealed discrepancies for R1 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: ED has agreed to conduct a meeting with all staff responsible for dispensing medications. Per ED each staff member involved will issue a formal write-up as appropriate. All staff will read and write a statement of understanding on regulation cited.

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 - Deficiencies

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted an unannounced visit at the facility in conjunction with a complaint investigation that occurred today. LPAs met with Executive Director (ED) Monica Reyes and explained the reason for today’s visit. Entrance interview conducted. During today’s facility tour, conducted with the ED and began at 11:19AM, LPAs observed the exhaust fan in the facility’s commercial kitchen to be non-operational. Staff interviewed stated that the exhaust fan has been broken for 2 (two) weeks. Kitchen staff have continued to use the burners and ovens located underneath the exhaust fan/hood, even though the hood is clearly labeled “CAUTION Exhaust fan must be turned on before lighting cooking appliances.” While in the kitchen, LPAs observed a kitchen staff with a burner lit and pot on the stovetop cooking. LPA Dulek spoke with Fire Inspector over the phone, who indicated the exhaust fan is an integral part of the facility’s fire safety system and must be functional at all times. Additional concerns in the kitchen related to maintenance are as follows: walk in freezer is broken and is being utilized as a refrigerator, kitchen vent is very dirty and does not allow air to flow into the kitchen area, and dishwasher is broken. During medication review, which began at 12:53PM, LPAs observed Resident #1 (R1) was recently hospitalized twice related to their diabetes diagnosis. Prior to R1’s hospitalization, R1 was prescribed oral medication for diabetes control and had an order to check blood sugar twice daily before meals. Following the first hospitalization, R1’s medications were changed and R1 required regular daily insulin injections as well as blood sugar checks twice daily. After R1’s second hospitalization, R1’s medications were changed again, and as of 07/19/2025, R1 was prescribed insulin on a sliding scale. R1 has a diagnosis of dementia Report Continued on LIC 809-C and is residing in the facility’s memory care unit. R1 is unable to determine the amount of insulin to be injected per the sliding scale. Staff interviewed stated residents requiring injectable insulin are assisted by medication technicians using hand-over-hand; the medications are not administered by skilled professionals. Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D). Civil penalties issued in the amount of $1000, as this is a repeat citation. Executive Director was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, today's reports, civil penalties and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Jul 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jul 23, 2025

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the above cited section, as the exhaust fan has been broken for 2 weeks, is not repaired and staff have continued to cook with an inoperable fan, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: During today's visit, ED called the company that conducted the recent inspection and is now scheduled at the facility tomorrow morning. ED understands the cooktop and ovens beneath the exhaust hood are not permitted to be used until the fan has been repaired. Proof of completed repairs will be sent to CCLDprior to using the commercial kitchen equipment again.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87628(a) · Plan of correction due date: Jul 23, 2025

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to... medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 has injectable medication prescribed on a sliding scale and a diagnosis of dementia and unable to check their own blood sugar and determine the amount, which poses an immediate health risk.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: ED agreed to contact R1's physician and obtain medically appropriate orders for R1 to self-administer. ED will provide a written statement of understanding related to diabetic care and residents' ability to self-administer medications.

Allegation investigated: Licensee does not ensure staff are adequately trained

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 10:17 A.M. LPA met with Executive Director, Monica Reyes, and explained the purpose of the visit. On 05/20/2025, from 10:14 A.M.– 5:03 P.M., LPAs initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant at 10:20 A.M, interviewed staff, residents, and reviewed and obtained pertinent documents relevant to the investigation. Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined: Continued on LIC 9099-C Substantiated Continued from LIC 9099-C It was reported that “Licensee does not ensure staff are adequately trained” as it was alleged that temporary agency staffing does not appear to be trained adequately.” Information gathered during the course of the investigation revealed that, due to ongoing staffing shortages, management made the decision to utilize a temp agency to fill in for staff who resigned or called out due to illness. Resident interviews revealed that both the temporary agency caregivers and the facility’s current and recently hired staff are not adequately trained to meet their care needs. Residents consistently reported that staff often appeared unsure of how to assist with their activities of daily living, such as bathing, dressing, transferring and toileting. Several residents expressed concerns that staff frequently did not know what to do or how to properly support them. Interviews with facility staff revealed concerns regarding proper training. While some staff reported that training is being provided regularly and they strive to meet residents’ needs, they also indicated that staffing shortages and extended work hours have impacted their ability to consistently provide quality care. A review of staff training records during the annual inspection on 04/29/2025, revealed that the facility uses an online provider to conduct annual training for their employees. However, training records were unavailable for four (4) out of eight (8) employees’ files reviewed, and one staff member had not received documented training since 2018. When LPA Conway requested training records and/or resumes for the temp agency caregivers, management were unable to provide any documentation to verify training or prior work experience. The Marketing Director and the Administrator stated they had requested the documentation form the agency, and while the agency initially indicated they would email the records, they later stopped responding to phone calls and emails. LPA Conway requested copies of any email correspondence, but these were not provided. Based on the information gathered during the course of the investigation, record review, and lack of documentation, there is sufficient evidence to determine that both facility staff and temp agency caregivers were not sufficiently trained. Therefore, the above allegation “Licensee does not ensure staff are adequately trained” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided. Continued on LIC 9099-C Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. A $250 immediate civil penalty is assessed today for repeat violation of 1569.312(a) Basic Services as licensee was previously cited on 10/14/2024. The Executive Director/Administrator, Monica Reyes, was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 29-AS-20250520120552

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(6) · Plan of correction due date: Jul 14, 2025

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records...For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not providing adecuate training to staff and not verifiying training for agency staff, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: The Administrator will conduct a comprehensive review of all staff training records to identify any staff members who are not up to date with their required training.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted an unannounced visit at the facility in conjunction with a complaint investigation that occurred today.Executive Director and LPA attempted to call Licensee to review the report via telephone, however, Licensee did not answer the calls. During the investigation, LPAs observed deficiencies unrelated to the complaint allegations, which will be addressed in this report. An Interim Management Service Agreement was sent by email to the LPAs on 07/07/2025, which indicates "new operator is taking over as of today under management agreement." The management agreement was signed by authorized representative of Affinity Garden Manor, LLC Pogos Tofalyan on 07/07/2025. Both Administrator and representative of Affinity Garden Manor LLC also indicated that Affinity Garden Manor is acting as a management company for the current Licensee, as described in the terms of the Interim Management Service Agreement. Residents interviewed during today’s visit stated that they were given new Admission Agreements for the change of ownership and residents reported the new owners have taken over operations of the facility this week. Aasta Assisted Living issued payroll checks labeled "final check" to employees on 07/07/2025, but were unsure which entity will be issuing ongoing payroll checks. Review of Interim Management Service Agreement indicates "IMC shall be responsible for the supervision, staffing and employment of employees...all employees of the facility shall be employees of the IMC." LPAs observed that all of the licensee's belongings have been removed from the facility. LPA contacted CCLD's Centralized Applications Bureau (CAB) to inquire whether an application had been submitted for the management company, per regulation. CAB indicated that there had not been an application to include a Management Company under the current license, nor had a change of ownership Report Continued on LIC 809-C application been received for the property at the time of the LPA's inquiry. LPA reviewed an online webpage for Affinity Garden Manor located at this address although the application has not yet been received nor approved, but is being advertised as in operation. Additionally, interviews revealed that an excluded individual, Anna Hakobyan, was present at the facility on Monday 07/07/2025. Record review revealed that representative Agnes Gazaryan Lazar has been present at the facility every day since 07/07/2025 and does have a criminal background clearance, however was not associated to the facility until 07/10/2025. Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D). Civil penalties issued in the amount of $900. Executive Director was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, today's reports, civil penalties and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Jul 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.58(a)(2) · Plan of correction due date: Jul 11, 2025

1569.58 (a) (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the above cited section, as on 07/07/2025, an excluded individual was present at the facility, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: Executive Director understand and will ensure going forward excluded individuals will not be present at the facility. POC cleared

From the deficiency page — Deficiency type: Type B · Section cited: CCR87355(e)(3) · Plan of correction due date: Jul 11, 2025

87355 (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) 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 an individual began working at the facility on 07/07/25 and background clearance was not transferred until 07/10/25, which posed a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: Executive Director associated the staff on 07/10/2025. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.191(b) · Plan of correction due date: Jul 18, 2025

§1569.191 Sale of licensed facility; resulting issuance of new license; procedure (b) Except as...the property and business shall not be transferred until the buyer qualifies for a license or provisional license within the appropriate provisions of this chapter. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the above cited section, as interim management service agreement is in effect 07/07/25 and no application was submitted to CCLD to reflect the addition of a management company, which poses a potential risk to residents.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: Executive Director agreed to discuss with Licensee and Licensee will communicate with CCLD related to the change of ownership by POC due date.

Allegation investigated: Staff do not ensure residents are provided a mattress in good condition.

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek and Investigator from the Community Care Licensing Division (CCLD) Investigations Branch (IB) Rocio Flores conducted an unannounced initial complaint visit to investigate the allegation listed above. Upon arrival LPAs and Investigator met with Executive Director/Administrator, Monica Reyes, and explained the reason for the visit. During today’s visit from 9:50 A.M.– 2:30 P.M. LPAs, investigator, and administrator toured the physical plant to ensure there are no health and safety concerns, and the facility is in compliance with Title 22 regulation. A case management report will be issued to address deficiencies observed during the physical plant tour. Additionally, LPAs and investigator interviewed staff, residents, and reviewed and obtained pertinent documents relevant to the investigation. Continued on LIC 9099-C Substantiated Continued from LIC 9099-C Regarding the allegation: “Staff do not ensure residents are provided a mattress in good condition” as it was alleged that resident’s bed at the facility has a hole in the middle and the facility refuses to replace it. During today’s visit, LPAs and investigator conducted a physical plant tour and inspected multiple resident rooms. In two (2) of the rooms visited, the mattresses were observed to be worn down and had a visible dip in the middle. Resident interviews revealed concerns regarding the quality of the mattresses. Residents reported that the mattresses are hard, uncomfortable, and due to their deteriorated condition, they are unable to turn, reposition themselves, or sleep comfortably. LPAs and investigator observed that mattresses in question were not in good condition and presented with noticeable dents and signs of wear. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that some beds had visible dents and signs of wear. Therefore, the above allegation “Staff do not ensure residents are provided a mattress in good condition” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeal rights discussed, and a copy of report issued.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 29-AS-20250624085732

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(A) · Plan of correction due date: Jul 16, 2025

87307(a)(3)(A) Personal Accommodations and Services.(a) Living accommodations...The facility shall...provide comfortable living accommodations...The following provisions shall apply:(3) ...the licensee shall assure provision of:(A)A bed for each resident...Each bed shall...good springs, a clean and comfortable mattress...This requirement is not met as evidenced by… Based on observation, the licensee did not comply with the section cited above by not providing a comfortable mattress to residents in care, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Administrator will assess all resident rooms create list identifying any worn-out matressess and replace all mattresses to be in poor condition. A copy of the completed list, including room numbers and confirmation of replacements, will be submitted to LPA before POC due date.

Allegation investigated: Staff did not provide adequate supervision resulting in resident sexually assaulting another resident.

Licensing Program Analysts (LPAs) Valeria Conway, Kelly Dulek and Investigator from the Community Care Licensing Division (CCLD) Investigations Branch (IB) Rocio Flores conducted a subsequent complaint visit to deliver findings for the above allegation. LPAs and investigator met with Executive Director/Administrator, Monica Reyes, and explained the reason for the visit. On 3/17/2025, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. Facility Resident #1 (R1) was digitally penetrated in the anus by facility Resident #2 (R2) without consent as a result of facility lack of supervision. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jose Santana. Continued on LIC 9099-C Substantiated Continued from LIC 9099-C On 03/17/2025, from 12:28pm to 1:35pm, Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegation. LPA Camara met with Executive Director/Administrator Monica Reyes and explained the reason for the visit. Starting at 12:40pm, the LPA reviewed and obtained pertinent documents. At 1:11pm, the LPA conducted a health and safety check of the memory care (Meadows) side of the facility. The LPA determined further investigation was needed prior to issuing findings. On 03/19/2025, from approximately 9:45am to 12:25pm, Investigator Santana conducted interviews with facility staff, Administrator, and attempted an interview with R1 (R1 unable to be interviewed due to condition of dementia); on 03/25/2025, from approximately 11:40am to 3:45pm, with R1’s resident representative, staff, Resident Care Coordinator, and attempted an interview with R2 (R2 unable to be interviewed due to condition of dementia); on 04/01/2025, at approximately 11:35am, with Ventura County Sheriff’s Office (VCSO) Detective; on 04/08/2025, from approximately 11:30am to 1:05pm, with facility executive director where R2 previously resided, Administrator, and R2’s resident representative; on 04/09/2025, at approximately 4:30pm, with staff; on 04/24/2025, at approximately 3:40pm, with VCSO Detective; on 05/07/2025, at approximately 3:50pm, with Tranquility Care Hospice case manager; on 05/08/2025, at approximately 4:05pm, with Tranquility Care Hospice CEO; on 05/12/2025, from approximately 11:55am to 1:25pm, with Tranquility Care Hospice LVN and CEO; on 05/15/2025, from approximately 1:50pm to 1:55pm, with VCSO Detective and R2’s Primary Care Physician (PCP), and on 05/23/2025, at approximately 11:25am, with R1’s resident representative. In addition, Investigator Santana reviewed facility surveillance footage, VCSO Report #25-31644, Body Worn Camera (BWC) footage, crime scene photos, 911 recording, Oxnard Police Department Report #2023-00014555, Tranquility Care Hospice records, Internal Medicine of Ventura medical records, Link Neuroscience Institute medical records, and resident and staff facility documents. Continued on LIC 9099-C Continued from LIC 9099-C According to R1’s facility file review, R1’s physician report, dated 05/09/2024, listed mild cognitive impairment, R1 required the use of a wheelchair due to weakness, and needed assistance with all activities of daily living (ADLs) with the exception of eating. R1 was admitted to the facility on 05/16/2024. The physician report, dated 12/11/2024, listed R1 as having chronic congestive heart failure and dementia. R1 was admitted to hospice on 12/11/2024 with a primary diagnosis of Alzheimer’s disease after being discharged from a skilled nursing facility and being admitted to the facility’s memory care unit. R1’s Needs and Services Plan was incomplete and did not list any needs or services for R1. The facility logs review revealed that R1 was on 15-minute checks, and incontinence checks every two hours. According to R2’s facility file review, R2’s physician report, dated 01/08/2025, listed the primary diagnosis as dementia and noted wandering behavior. R2 was admitted to the facility on 02/03/2025. R2’s Needs and Services Plan was incomplete and did not list any needs or services for R2. The facility logs review revealed that R2 was on 15-minute checks, and incontinence checks every two hours. A review of the Oxnard Police Department Case Report 2023-00014555 revealed that on 02/28/2023, R2 was arrested and charged with domestic violence. Information obtained from the Link Neuroscience Institute medical records revealed that on 12/26/2023, after performing testing, the neuropsychologist assessed that R2’s mental status and gross cognitive functioning were significantly reduced. After reviewing the remaining tests, the Dr. concluded that R2 fulfilled a diagnostic criterion for a major neurocognitive disorder, with the most likely explanation being probable Alzheimer’s disease. Continued on LIC 9099-C Continued form LIC 9099-C The Internal Medicine of Ventura medical records revealed that on 03/04/2025, R2’s Primary Care Physician (PCP) was informed that R2 was fearful, anxious, and aggressive when trying to defend self and “girlfriend” at the facility due to delusions of persecution. The PCP was informed that R2 pushed a caregiver aggressively and caused injury. In response, the PCP increased the Seroquel dosage. R2 stated they did not like the rules of the memory care unit, admitted to feeling frightened and said they would be willing to fight. R2’s resident representative reported that Seroquel was not being given by the facility because R2 was refusing it. Further information obtained through interviews revealed R2 was noted to be agitated and aggressive with caregivers at previous facilities R2 resided in. According to the Administrator, R2 was evicted from their previous facility due to aggression. According to the Unusual Incident/Injury Report (UIR) submitted by the facility, on 03/14/2025 at 8:50pm, Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) were in memory care’s common area preparing to start their next diaper changes when they noticed someone opening and closing R1’s door. S2 tried opening the door, but R2 kept pushing the door closed. When staff made their way inside, R2 left the room. R1 alleged that “the man” tried touching her private part. When asked for details, R1 said the man touched her legs and her “hole”. Staff called the Resident Care Supervisor, who in turn called 911. The report states that R1’s hospice agency was notified so a nurse could assess R1, but R1 said she was not hurt or in any pain. (The Department’s investigation revealed that the facility did not contact the hospice agency. The hospice agency was made aware of the incident from R1’s resident representative on 03/16/2025.) Continued on LIC 9099-C Continued from LIC 9099-C A review of the facility surveillance footage showed that on 03/14/2025, at around 8:31pm, the lead staff used their key to access R1’s room. When the lead staff emerged about a minute later, they pulled the door closed. At 8:48pm, S1, S2, and S3 were all in the common area, R2 sat in the same area. R2 stood up and left he common area at 8:50pm, making their way down the hallway, as the three staff remained in the common area. As R2 walked down the hallway, R2 turned the knob of one door and continued walking after realizing the door was locked. Then at around 8:51pm, as R2 turned the knob to R1’s door, R2 realized the door opened, so R2 walked inside. At about 8:57pm, the staff ran down the hallway and went inside R1’s room. Seconds later, R2 emerged and continued walking down the hallway, checking every doorknob as R2 walked by. Based on the review of the Ventura County Sheriff’s Office (VCSO) Report #25-31644, the VCSO investigation found probable cause that R2 pulled R1’s diaper down and digitally penetrated R1’s anus without consent. The evidence consisted of R1 telling deputies that a man entered R1’s room and inserted his finger in R1’s anus; and the facility staff statements that R2 was in R1’s room and that R1’s diaper had been pulled down. Due to R2’s mental capacity, R2 was not arrested. Although the facility’s practice is to lock all memory care residents’ rooms to prevent other residents from entering, it is evident that R1’s door was not adequately secured the last time a facility staff member entered R1’s room on 3/14/2025 at 8:30pm before R2 did at 8:50pm. R1 was to be checked every 15-minutes and was due to be checked at 8:45pm, but the video footage and the “15-minute checks” log show no one checked on R1 at that time. Had a staff completed that check, there is a possibility that R1’s door would have been correctly secured afterward. Additionally, when R2 left the common area and walked down the hallway, none of the three staff monitored R2’s activities despite all standing in the common area and knowing R2’s history of wandering and attempting to access other residents’ rooms. As a result, R2 accessed R1’s room and remained there for six minutes before being discovered by staff. Continued on LIC 9099-C Continued from LIC 9099-C Facility interviews revealed that R2 had at least two prior nonconsensual intimate interactions with two other residents, but such behaviors were not reported to R2’s Primary Care Physician (PCP). The PCP stated that had they been notified they would have requested for R2 to be seen for an assessment. Therefore, the allegation that R2 sexually assaulted R1 as a result of facility neglect is Substantiated at this time. A $1000 immediate civil penalty is assessed today for repeat violation of 1569.312(a) Basic Services as licensee was previously cited on 10/14/2024. The Executive Director/Administrator, Monica Reyes, was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 29-AS-20250317094418

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Jul 3, 2025

§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 and records review, the Licensee did not comply with the section cited above. As a result of facility staff neglect R2 sexually assaulted R1, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Executive Director/Administrator will schedule a third party training regarding dementia triggers, redirection and supervision. Before POC due date ED will submit proof that training was scheduled and after completing a training log will be submitted to the LPA.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway along with Investigations Branch (IB) Investigator Rocio Flores conducted an unannounced visit at the facility in conjunction with a complaint investigation conducted today. During the investigation, LPAs and Investigator observed deficiencies unrelated to the complaint allegations. During facility tour, which began at 09:52AM, LPAs and Investigator observed both delayed egress gates from the memory care were closed and unable to be opened. The gate on the north side of the memory care was observed to be tied shut with a plastic bag, preventing the gate from opening. The other exit gate was observed to be locked with a key. There was also feces observed outside in the memory care courtyard and medications observed in the back garden bed. 3 (three) loose pills were observed near the base of a tree. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalties issued in the amount of $1500. Executive Director was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Jul 2, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Jul 2, 2025

87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal…district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as both delayed egress exits from the memory care yard were observed to be locked and/or tied shut, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Executive Director ensured lock was unlocked, and plastic were removed during the visit. ED spoke to the caregiver lead, who will ensure the doors are functional and unlocked every morning. ED will create a morning checklist and ensure it is filled out daily.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Jul 3, 2025

87303 (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA observations, the licensee did not comply with the section cited above as feces was observed in the courtyard of the Meadows accessible to residents in care, which poses an immediate health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: ED confirmed that the maintenance staff cleaned the area during today's visit. ED will create a morning checklist and ensure it is filled out daily. Checklist will be sent to CCL by POC due date.

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

Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as 3 loose pills were observed in the memory care courtyard and therefore the resident did not take them as prescribed, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Medications were picked up today and removed from the courtyard. Executive Director agreed to contact the resident's physician and request a crush order to ensure the resident receives their medications. Proof of contact with physician will be provided to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(2) · Plan of correction due date: Jul 3, 2025

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as LPAs have observed multiple repeat citations and non-compliance with regulation while Administrator has been designated at the facility, which poses an immediate health, safety, and personal rights risk to residents.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Executive Director will participate in additional certified trainings relating to administrator qualifications. Proof of scheduled training will be provided to CCL by POC due date. ED will send proof of completed training upon completion.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced case management visit to issue an amended report. LPA met with Executive Director, Monica Reyes, and explained the purpose of the visit. On 05/09/2024, a 1-year required annual inspection was conducted. During the annual visit, citations were issued for Fire Clearance and Criminal Record Clearance. Based on information provided in an appeal, the 05/09/2024 citations are being revised. Please refer to LIC 809-D issued today for the amended citations. Exit interview, report given, deficiencies cited on 809-D.the state’s words, verbatim · CDSS document, Jun 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 9, 2024

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in two out of ten rooms inspected they did not have smoke detectors, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: Administrator had the facility maintenance person install new smoke detectors in these rooms during LPAs' visit. Administrator will ensure all rooms are inspected for smoke detectors after rooms are renovated. POC cleared 05/09/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87355(e) · Plan of correction due date: May 9, 2024

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in two out of five staff files. LPA reviewed Guardian roster and found 2 staff had fingerprint/background clearance but were not associated to this facility, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: Administrator associated both staff to the facility during the LPAs' visit. Administrator will ensure the Guardian roster is reviewed on a regular basis to confirm all staff are cleared and associated to the facility. POC cleared 05/09/2024.

Type of visit: Case Management - Other

At 9:35 A.M. Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced case management visit to offer Executive Director (ED), Monica Reyes, the opportunity to be referred to the Technical Support Program (TSP), as previously mentioned during prior visits. LPA met with ED and explained the purpose of the visit. A physical plant tour was conducted to ensure there are no health and safety concerns. During today’s visit, the LPA encouraged the ED to consider participating in the TSP. This is a non-enforcement program offered by the Community Care Licensing Division (CCLD) that provides services and resources to assist providers in meeting licensing requirements. The TSP is designed to help facilities achieve and sustain compliance through training, support, and access to relevant tools. LPA provided the ED with the following contact information for TSP services. TSP email address TechnicalSupportProgram@dss.ca.gov and their phone number (916) 654-1549. Additionally, LPA advised the ED to review the Provider Information Notices (PINs) on CCLD's website (www.ccld.ca.gov) for further guidance and updates. ED agreed to contact TSP for further information and assistance. Exit interview, report provided.the state’s words, verbatim · CDSS document, Jun 6, 2025

Allegation investigated: Due to lack of supervision, resident hit another resident causing injury

Licensing Program Analysts (LPAs) Valeria Conway, Kelly Dulek, Martha Arroyo and Licensing Program Manager (LPM) Kristin Heffernan, conducted a subsequent unannounced complaint visit to the facility above to deliver final findings of the complaint allegations. At 10:30 A.M., LPA Conway met with Executive. Director (ED), Monica Reyes, and explained the purpose of the visit. On 02/26/2025, LPA Conway interviewed Wellness Director at 8:55 AM, ED at 9:30 A.M., toured Memory Care (MC) with ED at 10:30 A.M., reviewed residents’ files for Resident #1 (R1) and Resident #2 (R2) at 9:45 A.M., and requested time cards and department schedule for staff working at the time of the incident. LPA also reviewed and obtained copies of documents pertinent to the investigation. The following was determined. Continued on LIC 9099-C Substantiated Continued from LIC9099 On the allegation: “Due to lack of supervision, resident hit another resident causing injury" The Responsible Party (RP) expressed concern that they believes the staff to resident ration is poor or inadequate. During the initial visit, LPA Conway conducted interviews with the two (2) residents involved in the reported incident. However, due to both individuals having a diagnosis of dementia, neither resident was able to clearly recall or articulate the events that took place on that day. LPA interviewed facility ED stating that she was not present at the facility when the incident occurred but reported that staff responded to the residents promptly. During staff interviews, it was consistently reported that the facility is experiencing ongoing staffing shortages, which has made it increasingly difficult for caregivers to adequately attend to all residents' needs. Staffs acknowledged that facility policy mandates 15 minute safety checks, however, these are not being properly conducted due to insufficient personnel, stating that it is not possible to conduct these checks as require and as a result, residents are at risk of injury. In fact, due to the current staffing situation, there have been multiple incidents involving resident hitting other residents and falls that required hospitalization. Additionally, staff reported that certain caregivers are frequently observed using their personal phones during work hours, resulting in inadequate supervision and reduced attention to residents' needs and safety. Based on information and the evidence gathered during the course of the investigation, there is sufficient evidence to determine that due to lack of supervision a resident hit another resident causing an injury. Therefore, the above allegation “Due to lack of supervision, resident hit another resident causing injury” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $1,000 repeat violation is assessed today due to being cited for the same violation within 12 months. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 29, 2025 · control 29-AS-20250225161613

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 30, 2025

87411(a) Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by… Based on interviews and record review the Executive Director did not comply with the regulation above by not having sufficient support staff and supervision to perform essential duties for residents in care which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: ED stated that four new indiviuals are in the process of being hired by AASTA and agrees to write a statement of understanding reg 87411 (a), submit a plan of action to prevent these events before POC due date.

Allegation investigated: Staff are engaging in behaviors that put the residents’ health and safety at risk

Licensing Program Analysts (LPAs) Valeria Conway, Kelly Dulek, Martha Arroyo and Licensing Program Manager (LPM) Kristin Heffernan, conducted a subsequent unannounced complaint visit to the facility above to deliver final findings of the complaint allegations. At 10:30 A.M., LPA Conway met with Executive. Director (ED), Monica Reyes, and explained the purpose of the visit. On 05/14/2025, between 9:30 A.M. and 1:30 P.M., the LPA briefly toured the facility with the administrator. Also, LPA interviewed the Administrator and caregivers. Additionally, LPA conducted a medication audit, file review and obtained copies of pertinent documents relevant to the investigation. The following was determined. Continued on LIC 9099-C Substantiated Continued from LIC 9099 On the allegation: “Staff are engaging in behaviors that put the residents’ health and safety at risk" The RP expressed concern that three (3) caregivers and one (1) Med-Tech were observed consuming alcohol while on duty inside the staff lunchroom. LPA Conway conducted interviews with Reporting Parties (RP) as well as additional staff members who were not involved in the incident. All interviewed parties were able to identify the same three (3) caregivers and one (1) Med-Tech as those involved in the alleged misconduct. The LPA also interviewed the facility ED, who confirmed that progressive disciplinary actions were issued to the three (3) caregivers and one (1) Med-Tech on 01/27/2025. The individuals who received disciplinary action were the same individuals identified by RP and other staff during interviews. Documentation provided by the ED confirms that these staff members violated AASTA's policy 8.6 (Drug and Alcohol Use) by being under the influence of alcohol while on duty and on AASTA's property. Additionally, the LPA obtained video evidence clearly showing all staff members involved in the incident consuming alcoholic beverages, with visible cans present during the recording. Based on information and the evidence gathered during the course of the investigation, there is sufficient evidence to determine that staff were dinking alcohol while on duty. Therefore, the above allegation “Staff are engaging in behaviors that put the residents’ health and safety at risk” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 29, 2025 · control 29-AS-20250513154404

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.58 · Plan of correction due date: May 30, 2025

a) The department may prohibit any person from being a licensee...,any employee, prospective employee, or person who is not a client and who has done any of the following: This requirement was not met as evidenced by: Based on interviews conducted and evidece received the three caregivers and one Med Tech were drinking during their scheduled work shift which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: ED gave a progressive disciplinary action to all employees involved. ED will have a third-party vendor conducting training on appropriate work conduct and proper care and supervision of the residents. Schedule of training should be provided to LPA before POC due date.

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

Licensing Program Analysts (LPAs) Martha Arroyo, Valeria Conway, and Kelly Dulek along with Licensing Program Manager (LPM) Kristen Heffernan conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance. Upon arrival, the LPAs and LPM met with Executive Director (ED), Monica Reyes and explained the reason for the visit. The LPAs and LPM focused today’s visit on ensuring medications are in order and in compliance with Title 22 Regulations. During today's visit, the LPA conducted a medication review starting at 1:00 p.m. The following was noted: On 05/14/2025, the Centrally Stored Medication and Destruction Records (CSMDR) and medications for Resident #1 (R1) were reviewed. The review revealed that the PRN medication Lorazepam 0.5 mg, 1 tablet up to 2 times per day as needed, was filled on 03/27/2025. However, the medication had not been administered to R1, as staff were unable to locate it. During today’s visit, a follow-up medication review revealed that the facility still had not received the Lorazepam for R1. Furthermore, staff were unable to provide documentation indicating that the medication had been reordered since the last review on 05/14/2025. As a result, R1 is not receiving the prescribed medication because it is not available on-site. Staff reported that they had contacted the pharmacy to place an order, but they were unsure why the medication had not been delivered. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D). Exit interview conducted. A copy of report and appeal rights were provided. This report has been amended to include a civil penalty of $1,000 due to repeat violation of Section 87465(a)(4) as it has been cited three times within 12 months - 10/10/2024, 04/29/2025, and 05/16/2025.the state’s words, verbatim · CDSS document, May 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 30, 2025

A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, the Licensee did not comply with the section cited above as medication for R1 was not available as of today and staff was unable to provide documentation that medication was reordered, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: The Licensee will have third party vendor training scheduled for all med-techs including proper medication ordering / refilling and documentation and submit proof to CCL no later than POC due date. Civil penalties in the amount of $1,000 issued today due to repeat violations from 10/10/2024, 04/29/2025, and 05/16/2025.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted an unannounced visit at the facility in conjunction with an investigation of complaint control # 29-AS-20250519143156. During the investigation, LPAs observed deficiencies unrelated to the complaint allegations. During facility tour, which began at 10:47AM, LPAs observed both delayed egress gates from the memory care were closed and unable to be opened. The gate on the north side of the memory care was observed to be wired shut at the bottom and have a bungee cord attaching the exit gate to the fence, preventing the gate from opening. The other exit gate was observed to be locked with a key. LPAs also observed feces outside in the memory care courtyard. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, May 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: May 21, 2025

87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal…district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as both delayed egress exits from the memory care yard were observed to be locked and/or wired shut, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Executive Director ensured lock was unlocked, wiring and bungee cord were removed during the visit. ED discussed with maintenance staff the importance of leaving delayed egress exit gates unlocked and free of obstruction. ED will provide a statement of understanding to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: May 20, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA observations, the licensee did not comply with the section cited above as feces was observed in the courtyard of the Meadows accessible to residents in care, which poses an immediate health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: ED confirmed that the maintenance staff cleaned the area during today's visit. POC cleared.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted a case management visit related to a self-reported incident report. LPAs arrived at the facility at 10:14AM and met with Executive Director (ED) Monica Reyes shortly after the visit began. Entrance interview conducted. An incident report was received at the Woodland Hills Regional Office on 05/19/2025. Incident report indicated that on 05/17/2025, at approximately 06:30PM, staff observed Resident #1 (R1) in their room on their cell phone. R1 was observed with "excessive blood dripping" from R1's left arm. Additional staff were called for assistance. Facility staff attempted but were unable to stop the bleeding. 9-1-1 was called and R1 was transported to the hospital. Report indicates that the resident passed away in the hospital. During today's visit, LPAs interviewed ED, toured the facility with ED at 10:47AM, reviewed R1's file and obtained documents relevant to the investigation. Executive Director was informed that either LPA or Community Care Licensing Division (CCLD) Investigations Branch (IB) investigator will follow up related to the self-reported incident. No citations issued related to this report. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, May 20, 2025

Allegation investigated: Staff are not providing activities for residents in care Staff did not safeguard resident's medications Staff did not administer medication as prescribed Insufficient staffing

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent unannounced complaint visit to the facility above to deliver final findings of the complaint allegations. At 9:15 A.M., LPA met with Executive. Director (ED), Monica Reyes, and explained the purpose of the visit. The following was determined. On 05/07/2025, during the initial investigation visit, between 10:30 A.M. and 2:45 P.M., the LPA briefly toured the facility with the administrator and the director, interviewed the Administrator, residents, and caregivers. Additionally, LPA conducted a medication audit, file review and obtained copies of pertinent documents relevant to the investigation. Continued on LIC 9099-C Substantiated Continued from LIC 9099 During today’s visit, the LPA briefly toured the facility with the administrator On the allegations: “Staff are not providing activities for residents in care” The RP expressed concern that the lack of staff directly impacted the facility’s ability to offer scheduled activities to residents. Interviews conducted with the ED confirmed that the facility has been experienced staffing challenges. The ED explained that during staffing shortages front desk personnel assisted with resident activities as needed. Management acknowledged that, due to these staffing issues, the facility had been unable to consistently provide scheduled activities to residents in care until recently. Management further stated that as of Monday (05/05/2025) a caregiver has been formally assigned to lead activities while the facility continues to hire additional care giving staff. Caregivers interviewed corroborated this and also revealed that when the driver position became vacant, the Activities Director was temporarily reassigned to perform transportation duties, resulting in the cancellation of daily activities. Resident interviews supported these claims. Several residents stated that after the prior driver left, activities were minimal and often limited to sitting in front of the television doing stretching exercises, or informal singing led by residents. However, residents also expressed optimism, noting that as of Monday, the facility has resumed structured activities such as Bingo. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that scheduled daily activities were not being provided by the facility. Therefore, the above allegation “Staff are not providing activities for residents in care” is deemed SUBSTANTIATED at this time. As to the allegation of Staff did not administer medication as prescribed and Staff did not safeguard resident's medications It was alleged that, due to understaffing, staff negligence, and an excessive workload, Resident #1’s (R1’s) eyedrops were missing for a couple of days, and medication prescribed for osteoporosis was missing for a few weeks, leading to a lapse in medication administration. Interviews with the Licensee and the ED revealed that for residents who are unable to manage their own medications, the facility stores the medication in the Med-Room. Continued on LIC 9099-C Continued from LIC 9099-C Medication Technicians (Med-Techs) are responsible for ensuring proper administration, storage and timely refills of medications. Both the Licensee and ED acknowledge that the medication management system, particularly with regard to the Med-Techs and in-room storage, requires significant improvement due to instances of careless errors made by staff. Interviews with the Reporting Party (RP) reveal concerns regarding insufficient staff and prescribed medications not being administered as prescribed. Per RP, R1 allegedly received their medication dosage later than scheduled, with a second dosage administered earlier than directed. On one occasion, R1 did not received their prescribed P.M. medication due to facility staffing shortages. During interviews, Med-Techs reported that assigning a single individual to manage all responsibilities, including preparing medication, administering them in a timely manner, and overseeing prescription refills, is not sufficient to ensure safe and effective medication management. An internal review, along with staff interviews, revealed occasional lapses in medication management within the facility. Specifically, it was found that medications were not consistently stored in the med-room, administered and proper documented. Additionally, staff express concerned regarding insufficient training, lack of consistent oversight by management, and inconsistencies across shifts. LPA reviewed and compared on-hand pill counts, Medication Administration Record (MAR) and Centrally Stored Medication and Destruction Record (CSMDR). Medication audit conducted revealed discrepancies where the pill counts within bubble packs did not match the records documented. These findings corroborate that the facility failed to appropriately safeguard residents’ medication. Morning Med-Tech on duty was unaware of these discrepancies, while evening Med-Techs reported uncertainty about how these errors occurred, stating that often there is a breakdown in communication, documentation and medication administration between shifts. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that staff are not administering resident’s medication in a timely manner. Therefore, both allegations “Staff did not administer medication as prescribed and Staff did not safeguard resident's medications” are deemed SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C As to the allegation of Insufficient staffing, it was alleged that R1 did not received their prescribed P.M. medication and daily activities due to facility staffing shortages. It is the concern of the RP that due to ongoing staff shortages the facility is not providing adequate supervision and care to the residents. Interviews with the Licensee and the ED confirmed that the facility has experienced staffing challenges. However, both the Licensee and the ED stated that the facility maintains sufficient staffing levels to cover for employees who resign or call out due to illness using caregiver from a staff agency. Residents interviewed stated that staffing deficits have directly impacted the quality and timeliness of care provided to them. Specifically, concerns have been raised regarding delays in medication management, including missed or late medication administration, as well as extended wait times for resident assistance. Interviews with staff revealed ongoing concerns related to workload and staffing levels. Staff reported feeling overworked, stressed, and overwhelmed due to persistent staffing shortages. They indicated that they are frequently required to assume additional responsibilities and take on extra shifts. Staff reported that this level of understaffing has led to them rushing through tasks leading to careless errors related to medication administration, missing timelines, delays in assisting residents, and longer response times to resident call signals. To further investigate these concerns, LPA conducted a comparison of staff schedules, timecards, and personnel reports (LIC 500). The review confirmed that facility has occasionally employees calling out of their schedule resulting in other staff members being required to work double shifts. In certain instances, employees were asked to report to work on their scheduled days off to ensure adequate coverage. Additionally, the LPA observed staffing gaps during shifts, with only two (2) caregivers and one (1) Med-Tech on duty to provide care for all residents including the Meadows (Memory Care). Based on information gathered during the course of the investigation, there is sufficient evidence to determine that shortage of staff is causing medication issues and longer wait times. Therefore, the above allegation “insufficient staffing” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Continued on LIC 9099-C Continued from LIC 9099-C A $250 immediate repeat civil penalty for the citation related to CCR 87411(a) is assessed today. Another $250 civil penalty is assessed for the citation related to CCR 87465(a)(4) for a repeat violation. The Administrator Monica Reyes was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 14, 2025 · control 29-AS-20250501125233

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 16, 2025

87465 (a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above by not ensuring medications are giving on a regular basis to residents in care which poses a immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: ED will work with Licensee to have 2 med techs each shift and a supervisor present in the Med-Room. Licensee and ED will submit a written plan to ensure that extra help will be provided to current Med-Techs. Send to LPA before POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 28, 2025

87411(a) Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by… Based on interviews and record review the Executive Director did not comply with the regulation above by not having sufficient support staff to perform essential duties for residents in care which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: ED agreed to hire more caregivers. Once they are hired, ED will provide a new LIC 500. Additionally, a written statement of understanding reg 87411 (a), submit a plan of action and ensure staff are not taking lunch at the same time. Statement due date 5/16/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: May 29, 2025

87219 Planned Activities (f) Planned Activities. In facilities licensed for fifty persons or more, one staff member shall have full-time responsibility to organize, and shall be given such staff assistance as… This requirement is not met as evidenced by… Based on interviews, the licensee did not comply with the section cited above as the facility temporarily reassigned the Activities Director to perform transportation duties, resulting in the cancellation of daily activities, which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: ED will hire a new driver and the activity director will go back to conduct scheduled activities. In the meanwhile, caregiver will continue daily activities.

Allegation investigated: Facility did not provide written notice to the resident for rate increase

At 10:00 A.M., Licensing Program Analysts (LPAs) Valeria Conway conducted an unannounced 10-day visit complaint visit to the facility regarding the above noted allegation. At 10:20 A.M. LPA met with Marketing Director, Ashley Kumar. At 11:00 A.M. Licensee, Mr. Kumar arrived at the facility and at 11:20 A.M., Administrator, Monica Reyes joined the visit. LPA explained the reason for the visit. Entrance interview conducted. During today's inspection, between 10:30 A.M. and 2:45 P.M., the LPA briefly toured the facility with the administrator and the director, interviewed the Administrator, residents, and caregivers. Additionally, LPA conducted a medication audit, file review and obtained copies of pertinent documents relevant to the investigation. Continued on LIC 9099 Substantiated Continued from LIC 9099 On the allegation: Facility did not provide written notice to the resident for rate increase. it was alleged the administrator mailed an invoice to Resident 1's (R1’s) Responsible Party (RP) on 04/15/25 with a 6.5% rent increase due by 05/01/25. RP is concerned that the facility only gave them a two (2) week notice when regulation states that the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives., LPA reviewed facility’s Admission Agreement. Per the admission agreement, under section VI. Fees, subsection E 3-Adjustments to Range of Rates (rate increase): Facility shall give sixty (60) days’ prior written notice to you of any change in the rates for levels of care for the apartment you have chosen. LPA was able to get a copy of the letter mailed to RP. The written invoice reviewed, dated 04/15/2025, includes the new increased rate and states monthly rate (annual increase applied) as of 05/01/2025. On 05/02/2025, director, contacted LPA via phone to inquire about the matter. During the conversation, the Director expressed uncertainty as to whether a 60-day written notice to residents or their responsible parties was required, adding that rate change information is included in the admission agreement signed upon entry. LPA requested the Administrator to be included in the phone conversation. Administrator joined the call and when asked, they acknowledged that a 60-day written notice should always be provided prior to any rate change. During today’s visit, LPA clarified that, pursuant to updated Health and Safety regulation effective January 2025, on and after January 1, 2025, a licensee must provide no less than 90 days written notice for rate increases. The written notice must include the amount of the increase, the reason or reasons for the increase, and a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident (PIN 24-08-ASC page 4-5). LPA requested a revised version of facility’s admission agreement under section VI-E-3 to reflect new changes. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that “Facility did not provide written notice to the resident for rate increase” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights werethe state’s words, verbatim · CDSS document, May 7, 2025 · control 29-AS-20250501125233

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655 · Plan of correction due date: May 14, 2025

1569.655 (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents...the licensee shall provide no less than 90 days' prior written notice...the amount of the increase...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when they issued a general rate increase with less than 60 days’ notice, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Administrator will rescind letter issue to RP and issue a new one with correct effective date and submit proof that the admission agreement section Fees has been updated to reflect 90 days instead of 60 days.

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: Required - 1 Year

Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:40 A.M. Upon arrival, the LPAs met with the receptionist, who advised administrator, Monica Reyes of the LPAs presence. Administrator was unavailable during today's visit. Nandita Ashley Kumar, Marketing Director, arrived at 10:10 A.M. and explained that Resident Care Coordinator (RCC), Esmeralda Elizarraraz will be authorized to sign today's reports. At this time, the reason for the visit was explained. Entrance interview conducted. The LPAs conducted a physical plant tour starting at 10:31 A.M along with the RCC and the Marketing Director. The physical plant areas were inspected inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This facility doesn’t have a staff room, facility will provide 24/7 care. The following was observed: BEDROOMS: The facility consists of 106 total bedrooms, of which LPAs observed 15 random resident bedrooms; five (5) in the Meadows (Memory Care) and ten (10) in Assisted Living. All resident rooms observed were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The LPAs checked smoke detectors in the 15-bedroom observed and they were functional at the time of the visit. Continued on LIC 809-C Contined from LIC 809 RESTROOMS: Each resident room contains its own private restroom. Resident restrooms observed contained sufficient grab bars and slip-resistant surfaces. The LPAs conducted an inspection of 5 restrooms in the Meadows and 10 restrooms in the Assisted Living Unit. The LPAs observed that one (1) out of five (5) restrooms did not have toilet paper available. Additionally, 5 out of the 5 restrooms in the Meadows were observed to have paper towel dispensers empty and regular trash cans. LPAs observed used gloves and used incontinence bed pads inside trash cans at the time of the visit. Between 10:44 A.M. and 12:21 P.M. the LPAs measured hot water temperatures in all fifteen (15) restrooms, six (6) out of fifteen (15) restrooms measured above the regulation range of 120 degrees Fahrenheit. COMMON AREAS: Consisting of the lobby, library, activity room, dining room, bistro, and theater room in the Assisted Living side and activity room and dining room in the Meadows side. The LPAs observed common areas to be clean and properly furnished at the time of the visit. The LPAs observed two (2) unlocked drawers in the Meadows common areas with a heavy-duty metal 3-hole puncher, a tape dispenser and two (2) metal staplers accessible to residents in care. Fire extinguishers were observed throughout the facility and were fully charged and last serviced on 02/20/2025. All smoke alarms as well as fire doors and sprinkler system were inspected during the five-year fire inspection which took place on 05/18/2022 and were functional at that time. The combination smoke/carbon monoxide detectors in the hallways were tested and functioned properly. During today’s visit, 5 emergency exits were tested and two (2) out of five (5) required new batteries and the emergency exit leading to staff parking lot was deactivated when tested. RCC activated door immediately and maintenance personnel replaced batteries for the emergency exit for the other two (2) doors. However, the emergency exit on the theater room must be replaced. The temperature was maintained at a comfortable level throughout the building. Cleaning supplies and disinfectants are stored locked per regulation. The LPAs observed cameras in the common areas. The LPAs observed the required postings in the common area. Continued on LIC 809-C Continued from LIC 809-C OUTDOOR SPACE: The LPAs observed the building and grounds in both Assisted Living and Memory Care. Multiple seating areas were observed with tables and chairs and shaded seating areas for resident use. During today’s visit, the LPAs inspected the two (2) side delayed egress doors located in the Meadows. At 11:11 A.M. LPA Conway applied pressure to the egress door from the metal frame and observed the egress door connecting the Meadows to the Assisted Living unit did not secure properly. Additionally, the door failed to trigger the required alarm when opened. RCC called maintenance personnel to check on the door. Maintenance staff stated that the magnet keeping the door shut was out of place and need it to be adjusted. Furthermore, LPAs observed fecal matter through the perimeter of the Meadows’s courtyard, accessible to residents in care. RECORD REVIEW: Between 1:03 P.M. and 3:20 P.M. LPA Arroyo reviewed 8 staff and 8 resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. During record review, the LPAs were unable to determine the number of training hours completed per regulation for the past twelve (12) months as training records were unavailable during the inspection for four (4) out of eight (8) staff files. All other staff records reviewed contained all required documentation. Eight (8) out of eight (8) resident files reviewed contained all documents, however, on the appraisal/needs and services plan pages two (2) to five (5) did not contain required information to identify individual needs or to develop a service plan for meeting resident needs. Also, two (2) out of eight (8) forms did not have required signatures from the facility’s representative and resident or resident’s responsible party. Additionally, one (1) out of eight (8) resident files reviewed indicated that resident has no capability for self-care, is not on hospice, and there were no records indicating that an exception request was submitted to the department. Continued on LIC 809-C Continued from LIC 809-C MEDICATION REVIEW: At 2:25 P.M. LPA Conway and RCC conducted a medication review of five (5) residents. Facility documents prescribed medications in the Centrally Stored Medication and Destruction Record (CSMDR). CSMDR lacked a start date. The LPA observed start dates written on the cap of each bottled medication, however, one medication observed did not have a start date and neither Med-Techs present during the inspection or the RCC were aware of medication’s start date on the medication bottle. Additionally, the LPA found discrepancies in five (5) out of five (5) resident’s medication, where the pill counts within bubble packs and the medication bottles did not match the records documented on the CSMDR. Med-Techs on duty were unaware of these discrepancies or how these errors occurred. KITCHEN: The LPAs observed the kitchen/dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including emergency supply of food and water. The LPAs inspected food for expiration dates; dates were clearly marked. INFECTION CONTROL: During today’s visit, the LPAs spoke with staff regarding the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency drill was documented on 03/21/2025. INTERVIEWS: Throughout today’s visit, LPAs interviewed 4 (four) staff and 4 (four) residents. No concerns noted. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. A repeat violation civil penalty was issued for $1000.00the state’s words, verbatim · CDSS document, Apr 29, 2025

Allegation investigated: Staff handled resident in a rough manner

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegation listed above. LPAs arrived at the facility at 11:17AM and met with Executive Director (ED) Monica Reyes. Entrance interview conducted. During an initial complaint visit conducted on 03/21/2024, LPAs Dulek and Arroyo interviewed ED at 02:18PM, toured the facility at 02:20PM, and obtained current resident roster and staff schedule. During a subsequent complaint visit completed on 02/04/2025, LPAs Dulek and Conway interviewed ED at 10:45AM, toured the facility at 11:24AM, interviewed residents and staff from 12:17PM to 03:40PM and obtained current resident roster and staff schedule. Throughout the course of the investigation, LPA also conducted telephonic interviews with staff and other relevant parties. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated It was alleged that Staff #1 (S1) is physically rough when working with Resident #1 (R1). Interview revealed that R1 preferred for S1 to provide their care and that R1 regularly asked for S1 to work with them. Staff interviewed indicated that R1 requested male caregivers often, particularly S1. LPA was unable to interview R1 related to this allegation. Staff interviewed indicated that they had never observed any staff handling R1 roughly. Other residents interviewed indicated that the care provided is adequate and they had never personally been handled roughly or were aware of other residents being handled roughly. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued related to the above allegation. Exit interview conducted. A copy of today’s report was provided. The complaint alleges that staff make rude and disparaging comments about Resident #1 (R1) related to their mental health condition, which creates an uncomfortable and unsafe environment for R1. Although management denied the allegation, interviews with staff revealed that they have heard multiple other staff members comment and make fun of R1 behind their back. Additionally, LPA spoke with 2 (two) other witnesses not employed by the facility, both of whom indicated they had overheard certain staff talking and laughing about R1. While LPAs were only able to briefly discuss this particular complaint with R1 during the initial complaint visit, R1 did express to LPA at that time and in previous interviews that staff are rude to R1 and that staff made fun of R1 and their condition. R1’s physician’s report indicated R1 had a diagnosis of paranoid schizophrenia. As a result of R1’s diagnosis, R1 would “call for help constantly,” according to staff. R1 reported that staff would come to assist, but would be rude and short with them. At times, R1 indicated that staff would purposely put the pull cord out of reach of R1, who was bedbound, and R1 had to use their cell phone to call the front desk for assistance. Staff interviewed indicated there was no specific mental health training provided or training on how to address R1’s particular needs, and as a result staff were unaware of how to talk to R1 appropriately. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegations that “staff made inappropriate comments towards resident” and “staff are not providing a safe and comfortable environment for resident” are deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 29-AS-20240320110032

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Mar 7, 2025

87468.1 Personal Rights of Residents in all Facilities (a) (3) to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...or elimination This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the above cited section, as multiple staff and witnesses reported staff being disrespectful and rude to R1 and making fun of R1, which posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Executive Director agreed to provide training to all staff on personal rights of all residents with a Community Care Licensing certified vendor and will provide proof of scheduled training to CCL by POC due date. Proof of completed training to be provided upon completion.

Allegation investigated: Staff did not respond to residents’ calls for assistance in a timely manner Staff did not treat residents with dignity and respect

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 11:20 A.M., LPAs met with Executive Director (ED), Monica Reyes, and explained the purpose of the visit. During initial visit, between 10:30 A.M. and 4:00 P.M., LPA interviewed ED, nine (9) random residents, one (1) family member and five (5) staff members about above allegations. The Reporting Party (RP) was anonymous therefore, the LPA was unable to obtain additional information regarding the allegations. Also, during the visit, LPA conducted a review of timecards and obtained copies of pertinent documents relevant to the investigation. During today’s visit, the LPAs conducted a brief physical plant tour, to ensure there are no health and safety concerns and the facility is in compliance with Title 22 regulation. Continued on LIC 9099-C Substantiated Continued on LIC 9099-C Regarding allegation “Staff are engaging in behaviors that put the residents’ health and safety at risk” it has been reported that staff members have exhibited inappropriate conduct while on duty during the PM shift and nocturnal (NOC) shift. Interviews with the Executive Director (ED) revealed that management is not aware of staff playing loud music or leaving the floor unsupervised during the NOC shift. Staff interviews did not corroborate these allegations. Residents interviewed indicated that some residents occasionally hear loud noises during the PM and NOC shift; however, they were unsure whether the sounds were from staff, residents playing music or singing or televisions. During the investigation, the LPAs inspected the staff break room for any prohibited items but found no evidence to support the allegations. Based on the information obtained during the investigation the LPA does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation “Staff are engaging in behaviors that put the residents’ health and safety at risk” is deemed UNSUBSTANTIATED at this time. Exit interview conducted, copy of this report and was provided. Continued from LIC 9099 Regarding allegation “Staff did not respond to residents’ call for assistance in a timely manner” it has been reported that during the night shift, residents pulling the emergency cord to request assistance from staff had to wait approximately one (1) hour before being attended to by a staff member. LPAs interviewed staff and residents related to the facility’s pull cord system and response time. The facility contains a pull cord system; each resident room has one cord in the bed area/living space of the room and a second pull cord in the resident bathroom. When a resident pulls the cord, a light illuminates outside the resident room and on a switch boards located at the front desk and in the dining room. Interviews with the ED revealed that staff members are trained to assist residents within ten (10) to fifteen (15) minutes after a call cord is pulled. The most recent in-service training for call light monitoring was conducted on 08/2024. Additionally, the ED stated that after a resident communicated concerns about long response times, a group chat message addressing call cord wait periods was sent to all staff via text on 12/16/2024. This message served as a reminder that is unacceptable for residents to wait longer than fifteen (15) minutes for assistance. Interviews with staff revealed that caregivers may become occupied when multiple residents pull the emergency cord simultaneously. In such cases, staff prioritize responses based on the urgency of each call, which may result in less urgent request experiencing longer wait times. However, staff members stated they make every effort to assist all residents within fifteen (15) of the initial call. Interviews with residents revealed that seven (7) out of nine (9) residents reported experiencing long wait times across all three shifts after pulling the call cord. Most residents stated that response times could sometimes take forty-five (45) minutes to an (1) hour. Additionally, some residents expressed concerns that having only two (2) caregivers on duty is not sufficient to meet the need of the entire assisted living unit. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that “Staff did not respond to residents’ calls for assistance in a timely manner” is deemed SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Regarding allegation “Staff did not treat residents with dignity and respect” it has been reported that staff members have been yelling at residents, despite concerns being brought to management, issue has not been addressed. Interviews with the ED revealed that management is not aware of any instances of staff mistreating or disrespecting residents. The ED stated that no residents or visitors have reported such concerns to management. Staff interviews presented mixed responses – some staff members reported witnessing colleagues speaking loudly or rudely to residents, while others denied any instances of mistreatment or disrespect. Additionally, those who denied such behavior stated that they had not witnessed any abusive conduct toward residents in care. Interviews with residents and family members revealed concerns regarding staff conduct. Resident #1 (R1) reported being spoken to disrespectfully, with sarcasm and dismissiveness by a Staff #1 (S1). Resident #2 (R2) stated that they have occasionally been handled roughly during transfers by Staff #2 (S2). Resident #3 (R3) reported being criticized by a staff member regarding their weight by Staff #3 (S3). Furthermore, several residents expressed concerns that the new hires do not appear to be receiving proper training. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that “Staff did not treat residents with dignity and respect” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 29-AS-20250128143532

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 21, 2025

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interview, the facility did not comply with the above cited section, as residents reported having to wait on average 45-60 minutes for staff assistance when residents use their call buttons, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Executive Director (ED) agreed to conduct a staff in-service related to resident call lights. ED will provide proof of training to CCL before POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 21, 2025

87468.1(a)(1) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when residents were not treated with dignity, which posed a immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Executive Director (ED) agreed to provide training to all staff on personal rights of all residents with a Community Care Licensing certified vendor and will provide proof of scheduled training to CCL by POC due date. Proof of complete training to be provided upon completion.

Allegation investigated: Facility staff is sleeping during NOC shift. Facility staff do not treat residents with dignity and respect.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 03/11/2024 by LPAs M. Arroyo and K. Dulek and a subsequent complaint visit was conducted on 01/02/2025 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Monica Reyes. Entrance interview. During the initial visit on 03/11/2024, LPAs Arroyo and Dulek interviewed the Administrator at 09:07am, toured the facility at 09:32am, reviewed and obtained copies of documents pertinent to the investigation, interviewed staff at 10:45am, 10:48am and 1:24pm, residents at 10:42am and 10:53am, and reviewed medications beginning at 1:44pm. On 01/02/2025, LPA Arroyo conducted interviews with one staff and six residents between 12:55pm and 1:45pm and obtained copies of pertinent documents. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that facility staff is sleeping during NOC shift. It was reported that staff will sleep 4 – 5 hours before getting up and assisting the residents in the morning. During the facility walkthrough, the LPAs observed that there was no camera in the 400’s hallway, and two rooms, 403 and 408, were both unlocked and vacant. However, the vacant rooms appeared clean during the walkthrough. Cameras were observed throughout the common areas and other hallways. During interviews with staff, they denied sleeping or observing other staff members sleeping during their shifts. Further interviews revealed that residents had not reported or made any complaints regarding a lack of assistance during the day or night. In interviews with residents, they denied observing or hearing about staff sleeping while working. Based on interviews conducted with staff and residents, the Department does not have sufficient evidence to support the allegation of “facility staff is sleeping during NOC shift”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that facility staff do not treat residents with dignity and respect. It was reported that residents have reported staff being rude, disrespectful, and handling rough when assisting. Interviews conducted with residents revealed that the staff are friendly and have not been treated differently from the other residents. Additionally, residents denied experiencing disrespect from facility staff or witnessing staff disrespecting other residents during assistance. Furthermore, six out of six residents interviewed expressed no concerns or complaints about how the staff treat them. Based on interviews conducted with residents, the Department has insufficient evidence to support the allegation of “facility staff do not treat residents with dignity and respect”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided. Report Continued from LIC 9099... It was alleged that staff did not assist residents with self-administration of medication as prescribed. It was reported that medications are not being administered to residents at the appropriate times and other times medications are being left unattended causing residents to miss their dosage. On 03/11/2024, LPAs observed two random resident medications, the medication list, and the centrally stored medication and destruction records (CSMDR). According to Resident #1’s (R1’s) Medication List, dated 03/11/2024, it lists twenty (20) routine medications and eight (8) PRN medications for R1. Although R1’s Medication Administration Record (MAR) indicated that all prescribed medications were being administered, as the facility staff initials inidcated, certain medications such as Calcium Carbonate 1500mg, 600mg (1 tablet twice a day), Preservision AREDS Capsules (2 capsules daily), and Terbinafine HCL 250mg (1 tablet daily) were not observed or present with the other routine medications. Additionally, three (3) out of the eight (8) PRNs were found to be missing and not with R1’s medications. These missing PRNs included Albuterol Sulfate HFA 108, Mucus Relief 600mg, and Tizanidine HCL 4mg. Moreover, Resident #2 (R2) has a PRN medication, Albuterol Sulfate HFA 108 (inhale 2 puffs by mouth every 6 hours as needed for shortness of breath). However, during the medication review, it was revealed that R2’s PRN medication was empty and had not yet been refilled. Furthermore, residents’ medications were either missing or had not been refilled during medication review indicating residents are not taking their medications as prescribed. Based on medication review and LPAs observations, the Department has sufficient evidence to support the allegation of “staff did not assist residents with self-administration of medications as prescribed”. Therefore, this allegation is deemed Substantiated at this time. It was also alleged that facility staff is not sufficient in numbers and competent to provide adequate services to residents in care. Record review and interviews conducted revealed that Staff #1 (S1) was hired by the facility on 02/05/2024 and began working on 02/15/2024. According to the staff schedule dated 02/18/2024 – 03/03/2024, S1 worked the NOC shift on 02/23/2024, 02/24/2024, 02/25/2024, 02/28/2024, 02/29/2024, 03/01/2024, and 03/02/2024. Interviews also revealed that S1 had been assisting residents with their activities of daily living (ADLs) prior to reaching the age of eighteen (18). Report Continued on LIC 9099C... Report Continued from LIC 9099C... Furthermore, although two staff members were assisting residents, one of them did not meet the minimum qualifications required by state regulations. Based on the information obtained during the course of the investigation, the Department has sufficient evidence to support the allegation of “facility staff is not sufficient in numbers and competent to provide adequate services to residents in care”. Therefore, this allegation is deemed Substantiated at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 13, 2025 · control 29-AS-20240304113219

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 17, 2025

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage... and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the section cited above as R1’s MAR indicates medication is being administered but medication was not found and R2 has missing PRN as staff has not reordered yet, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 13, 2025

Plan of correction: Licensee will schedule medication training for all med-techs that includes documentation and medication distribution and submit proof to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a)(b) · Plan of correction due date: Jan 17, 2025

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… All persons who supervise employees or who supervise or care for residents shall be at least eighteen (18) years of age. This requirement was not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the section cited above as S1 was assisting residents with ADLs but was not eighteen (18) years of age, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2025

Plan of correction: Licensee will review Regulation 87411 and submit statement of understanding to CCLD no later than POC due date.

Allegation investigated: Neglect/lack of supervision leading to questionable death Neglect/lack of supervision: facility employees failed to properly supervise resident resulting in an unwitnessed fall and injuries to the resident Licensee did not meet resident’s ADL needs Licensee did not provide resident’s responsible party an updated care plan Licensee did not comply with reporting requirements

Licensing Program Analysts (LPAs) Kelly Dulek and Emily Peraldi conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 01:56PM and initially met with facility staff. LPA met with Executive Director (ED) Monica Reyes at 02:00PM. Entrance interview conducted. During an initial complaint visit conducted on 01/04/2024, LPA interviewed staff at 11:43AM, 01:09PM, and 01:25PM, interviewed ED at 11:55AM, toured the facility with ED at 12:15PM, and LPA reviewed and obtained copies of documents pertinent to the investigation. No immediate health and safety concerns were identified during that facility tour. ED was informed that the allegations were referred to Community Care Licensing Division (CCLD)’s Investigation Branch (IB). IB Investigator Douglas Real obtained copies of Resident #1 (R1)’s medical records, interviewed staff, residents and other relevant parties both telephonically or in person on the following dates: 01/22/2024, 01/31/2024, 02/13/2024, and attempted Report Continued on LIC 9099-C (p. 2) Substantiated interviews on 02/27/2024, 03/15/2024, and 03/25/2024. Throughout the course of the investigation, LPA, IB Investigator and CCLD’s Program Clinical Consultant reviewed relevant documents for R1, including medical documents. A summary of documents reviewed and interviews conducted is as follows: Review of documents for R1 revealed that R1 had resided at this location since 12/31/2011 (formerly licensed as Royal Gardens of Camarillo). Physician’s reports were reviewed for the years 2020, 2021 and 2023. Physician’s report dated 06/17/2020 indicated “fall risk, [R1] recently moved to secure memory care unit on 06/16/2020 for close monitoring.” Physician’s report dated 03/24/2021 indicated R1 had motor impairment/paralysis, with a comment indicating “unsteady gait.” Physician’s report dated 03/09/2023 indicated R1 had a motor impairment/paralysis and assistive device was listed as walker, wheelchair. All physicians’ reports dated 2020 to present indicate R1 had a diagnosis of dementia and R1 required assistance with all activities of daily living except assistance with feeding. IB investigator requested copies of all incident reports related to R1 during the time they resided at the facility, however Administrator only provided 1 (one) report indicating R1 had previously fallen. Review of incident reports submitted to CCLD revealed an additional 2 (two) falls R1 sustained at the facility since operating as Aasta Assisted Living. Interviews with staff also revealed that R1 was “definitely becoming a fall risk” at the time of the incident on 12/28/2023. Incident report related to this complaint states that R1 was last checked on in their room at 6:00AM, when care staff assisted R1 with getting dressed. “Care staff went to [R1’s] room to remind [R1] it was breakfast time. When Ana walked in she saw [R1] laying face down in the middle of the room, she noticed blood on [R1’s] head and called medtech.” After interviews and document review, the following was then determined: Allegations: Neglect/Lack of supervision leading to questionable death & Neglect/Lack of supervision: facility employees failed to properly supervise resident resulting in an unwitnessed fall and multiple injuries to the resident: The complaint alleges the facility employees failed to provide an appropriate level of supervision, which resulted in R1 falling, hitting their head causing periorbital fractures as well as a brain hemorrhage. Complaint alleges R1 died in the hospital several days later as a result of the injuries sustained in the fall. Incident report reviewed indicated staff found R1 on the floor of their room around 06:30AM on 12/28/2023. Internal incident report indicates R1 had last been observed by staff at 06:00AM, when care staff assisted R1 Report Continued on LIC 9099-C (p.3) with dressing. Interview revealed that both documents were originally authored by staff that had initially found R1 after the fall and included additional details, but were rewritten inaccurately by another staff. LPA observed that the incident report indicates R1’s right side of their face was affected, however hospital documents indicate injuries were sustained on R1’s left side. Interview revealed that although R1’s annual physician’s reports and care assessments indicated R1 required a full assist with all personal grooming and hygiene needs, care staff reported regularly leaving R1 in their room unsupervised to brush their own hair and wash their own face. Additionally, physician’s report dated 03/24/2021 indicated R1 is “at risk if allowed direct access to personal grooming and hygiene items” yet care staff allowed R1 access to said items unsupervised to complete their own ADL care. Staff interviews revealed that as expected as R1 was aging and due to R1’s overall medical condition including their diagnosis of dementia, R1 was becoming less capable of completing tasks independently and R1 regularly forgot to use their walker, which made R1 a fall risk. In spite of documentation on both R1’s care assessment and R1’s physician’s reports indicating R1 requires a full assist with ADL care (except feeding,) on 12/28/2023, care staff left R1 in their room to complete personal hygiene and grooming tasks without any required staff assistance or supervision. Additionally, staff interviewed were aware R1 did require transfer assistance “at times” and that R1 needed regular verbal reminders to use their walker, staff did not return to R1’s room to assist R1 prior to breakfast time. Staff did realize around 06:30AM that R1’s roommate was present in the dining room and R1 wasn’t present as expected, so care staff went to R1’s room to check on them and found R1 in their room, face down on the floor with blood pooling by R1’s head. Med tech then assessed R1 and dialed 9-1-1 for further medical assistance. Medical documentation for R1 revealed R1 was taken to Saint John’s Pleasant Valley Hospital Emergency Department (in Camarillo) via ambulance. R1 had a significant laceration and soft tissue swelling on the left side of their face in the periorbital area and R1 was transferred to the Saint John’s Regional Medical Center (in Oxnard) direct observation unit for further management. CT head scan showed left frontal subarachnoid hemorrhage (bleeding from a damaged blood vessel), 3mm small left subdural hematoma, left zygomatic arch fractures. CT maxillofacial showed nondisplaced fracture involving the lateral aspect of the left orbit posterior inferior left maxillary sinus mildly displaced fracture with soft tissue within the left maxillary sinus likely representing hemorrhage, buckling type fracture involving the left zygomatic Orange. The resident was admitted to the hospital. R1 was admitted to the Direct Observation Unit (DOU) and had neuro checks every 2 hours as per unit protocol. Prior to the fall, R1’s physician’s report indicated R1 had no concerns Report Continued on LIC 9099-C (p.3) swallowing and R1 could self-feed. However, while in the hospital DOU, R1 experienced dysphagia on 12/29/2023 and failed swallow evaluations on 12/30/2023 and 12/31/2023. On 12/30/2023, a neurology consultation was conducted, and it was determined that R1 had a traumatic intracranial hemorrhage, facial fracture, status post-fall. On 01/01/2024, R1 experienced respiratory distress and with the development of tachycardia, the medical team discussed comfort care with R1’s responsible party. R1 was placed on palliative care and subsequently passed away in the hospital on 01/04/2024. Certificate of death listed sequelae of subdural and subarachnoid hemorrhage and blunt head trauma as the immediate cause of death. Coroner indicated the ground level fall took place on 12/28/2023 at approximately 06:15AM was the cause of the injury related to R1’s death. Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegations “neglect/lack of supervision leading to questionable death” and “neglect/lack of supervision: facility employees failed to properly supervise resident resulting in an unwitnessed fall and multiple injuries to the resident” are deemed SUBSTANTIATED at this time. Allegation: Licensee did not meet resident’s ADL needs: All of R1’s annual physician’s reports dated 2021 – 2023 indicate R1 is unable to meet their own ADL needs and required assistance with the following: bathing, dressing/grooming, caring for toileting needs, and assistance with managing cash resources. R1’s care assessment dated 03/01/2023 also indicated R1 required “full assistance” with grooming and hygiene as well as dressing. This same care assessment indicated R1 used a walker for mobility and that R1 required transfer assistance “at times.” However, interview revealed that on the morning of 12/28/2023, staff went into R1’s room sometime between 05:30AM and 06:00AM and assisted R1 in getting dressed, but that staff had left R1 unsupervised in their room to comb their own hair and wash their own face. Staff stated they expected R1 to complete their own ADL care before walking themselves to the dining room. Both R1’s physician’s report dated 03/09/2023 as well as care assessment dated 03/01/2023 indicated R1 required full assistance with personal grooming and hygiene. Additionally, staff interviewed indicated that R1 used to be more independent but over time, has needed more assistance. Care staff admitted to not providing the ADL care outlined in R1’s care assessment, as they only provided assistance with dressing R1 and allowed R1 to complete additional ADL tasks without assistance or supervision, although R1 required full assistance with these activities. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation “Licensee did not meet resident’s care needs” is deemed SUBSTANTIATED at this time. Report Continued on LIC 9099-C (p.4) Allegation: Licensee did not provide resident’s responsible party an updated care plan: LPA reviewed care plans for R1, as well as conducted interviews with management and other facility staff. LPA also spoke with R1’s responsible party. R1’s responsible party stated they had not received a copy of R1’s care plan, nor had R1’s care plan been reviewed with R1’s responsible party. R1’s responsible party stated they “assumed that staff were assisting a 93 year old with dressing and personal care needs,” but stated they were never provided with a document specifying what ADL care was being provided to R1. Staff interviewed indicate they conduct care assessments every 6 (six) months on all residents, but that these are not reviewed with the residents nor their responsible parties. Care assessments reviewed for R1 did not contain a signature line to indicate the resident nor their responsible party had reviewed the document. The facility does not utilize the form Community Care Licensing Division (CCLD) provides on the Department website which does include a signature line, but instead the Licensee uses and in-house form. Facility Management was unable to provide written proof that a current care plan was provided to R1’s responsible party. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation “Licensee did not provide resident’s responsible party an updated care plan” is deemed SUBSTANTIATED at this time. Allegation: Licensee did not comply with reporting requirements: The complaint alleges that R1’s responsible party was not informed either verbally nor in writing of the incident that occurred on 12/28/2023. Interview with R1’s responsible party revealed that they were out of town at the time of R1’s incident. R1’s responsible party indicated that they received a voicemail from the hospital on 12/29/2023, but that no voicemail nor missed call was received on their cell phone from the facility phone number or any other phone number possibly related to the facility. R1’s family member called the facility on 12/29/2023 to inquire about R1’s status, but the front desk staff could only confirm that R1 had been sent to the hospital but did not have any other details as to R1’s status and neither the med tech nor the Administrator were available at that time to speak with R1’s family member. The med tech did call R1’s responsible party back later that day. The med tech on duty at the time of the fall reported to CCL and to R1’s responsible party that they did not leave a message for R1’s responsible party. Med tech indicated they left a message for another one of R1’s family members, however, could not recall time the call was made nor whether the call was made using the facility telephone or the staff’s personal cell phone. Med tech did not allow LPA to review the call log on their personal cell phone, so LPA was unable to confirm whether either of the calls to R1’s family had been made. R1’s responsible party stated they spoke to the other family member Report Continued on LIC 9099-C (p.5) and this person also had not received a missed call nor message from facility staff. Additionally, staff interviewed indicated although they did write an incident report related to R1’s fall and subsequent hospitalization, the written document was not provided to R1’s family member. Staff interviewed stated they do not provide a written report to any resident’s responsible party unless it is requested. Based on interview and record review, the preponderance of evidence standard has been, therefore the allegation “Licensee did not comply with reporting requirements” is deemed SUBSTANTIATED at this time. A $1000 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 29-AS-20240102113855

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Nov 26, 2024

87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking...Postural Supports This requirement is not met as evidenced by: The licensee did not comply with the above cited section, as R1 was not provided full assist with ADL care as required in care assessment, which resulted in R1 falling and sustaining multiple fractures and R1 passing away as a result of injuries sustained, which posed an immediate health and safety risk.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Executive Director agreed to conduct an inservice training to all staff on this regulation section. Training will be scheduled and proof will be provided to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 26, 2024

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...adequate services. This requirement is not met as evidenced by: The licensee did not comply with the above cited section, as staff were aware of R1's care needs and that R1 was a fall risk, however did not provide supervision as required, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Executive Director indicated there are additional staff scheduled on each shift to ensure adequate coverage. Training will be provided concurrent with the above basic services requirements and will provide proof of training to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(6) · Plan of correction due date: Nov 25, 2024

87705 Care of Persons with Dementia (c) (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by: The licensee did not comply with the above cited section, as R1 did not have a reappraisal reviewed with with R1 or their responsible party, which posed a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: ED indicated the facility is now using the LIC 625 form for all reappraisals and have started reviewing the care plans with residents and responsible parties. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Nov 25, 2024

87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...(B) Any serious injury...under facility supervision. This requirement is not met as evidenced by: The facility did not comply with the above cited section, as no written report was provided to R1's responsible party, which posed a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: ED indicated that following this incident, the med room began utilizing a call log to document all telephone calls with resident families. ED will provide written reports by taking a photo and sending the report via text message to families. POC cleared.

Allegation investigated: Facility is retaining a resident needing a higher level of care Licensee did not ensure resident's hygiene needs were met Licensee did not ensure resident's home health needs were met Licensee did not ensure resident's medical documents were complete

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway arrived at the facility unannounced to conduct subsequent complaint visit with the purpose of delivering findings for the allegations listed above. LPAs initially met with facility staff, then Resident Care Coordinator at 10:03AM and explained the reason for today’s visit. Executive Director/Administrator (ED) Monica Reyes arrived at 11:35AM. Entrance interview conducted. During today's visit, LPAs interviewed ED at 11:35AM, during an initial complaint visit conducted on 09/15/2023, LPA Dulek interviewed Wellness Director at 11:30AM, ED at 12:20PM, toured Memory Care with ED at 12:40PM, reviewed medications for Resident #1 (R1) at 12:47PM, and staff between 01:32PM and 2:20PM. LPA also reviewed and obtained copies of documents pertinent to the investigation. Throughout the course of the investigation, LPA reviewed all pertinent documents and conducted additional interviews with relevant parties. The following was then determined: Report Continued on LIC 9099-C (p.2) Substantiated Allegation: “Facility is retaining a resident needing a higher level of care:” The complaint alleges that R1, who resided in the facility at the time of the complaint, needs a higher level of care than can be provided in a Residential Care Facility for the Elderly (RCFE) setting. LPA reviewed documents for R1, including but not limited to physician’s report, needs and service appraisal, and hospital discharge records. Record review revealed that R1 initially moved into the facility on 02/17/2023, following a hospitalization. Preplacement appraisal found in R1’s facility file was left blank. A care assessment and service plan was filled out by the facility’s Resident Care Coordinator on the date of R1’s admission, however the document is not signed by R1 nor their responsible party. The document is also incomplete, does not address R1’s functional capabilities and R1’s mental condition indicates “A/O x2” with no additional information provided. R1 was hospitalized prior to admission. LPA reviewed hospital discharge records dated 02/12/2023, which indicate R1’s diagnoses include, but not limited to: generalized anxiety disorder, major depressive disorder, psychotic disorder, and pressure ulcer. R1 resided at the facility and was hospitalized on 04/03/2023 following a reported incident of suicidal ideation. Hospital discharge records indicate “discharge now, intermediate care facility.” Even though Aasta is licensed as an RCFE and as thus cannot accept or retain any resident that requires intermediate care, R1 returned to the facility the same day. R1 was again brought to the Emergency Department on 04/11/2023 with a diagnosis of infected cyst and a skin infection. Again on 04/14/2023 and 04/17/2023, R1 returned to the Emergency Department on both dates with an infected open wound noted. Record review revealed that R1 was then subsequently hospitalized from 05/30/2023 to 07/28/2023 and R1 was readmitted to the facility on 07/31/2023. A care assessment was completed upon readmit but again was not signed, so it is unclear whether the care assessment was reviewed with R1 or their responsible person. No pre-admission appraisal was completed upon re-admit. Hospital records reflect R1 was treated in the Emergency Department on 08/14/2023 after R1 fell at the facility. On 09/07/2023, a credible witness visited the facility and reported that R1 “has psychiatric illness and is taking anti-psychotic medications. The medications do not seem to be effective.” The credible witness initiated an evaluation into R1’s capacity for self-care and indicated R1 scored 0/8, meaning R1 is incapable of completing any self-care tasks, which is a prohibited health condition. Interview with staff revealed R1 has needs outside the scope of typical RCFE residents, and staff are unable to meet R1’s needs. R1 was again hospitalized for psychiatric service on 09/10/2023. Record review revealed that R1 was again readmitted to the facility on 10/12/2023. Based on interview and record review, there is sufficient evidence to support the allegation, therefore, the allegation “facility is retaining a resident needing a higher level of care” is deemed SUBSTANTIATED at this time. Report Continued on LIC 9099-C (p.3) Allegations: “Licensee did not ensure resident’s hygiene needs were met” and “Licensee did not ensure resident’s home health needs were met:” The complaint alleges that R1’s hygiene needs and home health needs were not met, as R1’s body as well as their facility room was observed dirty, with dirty sheets and a malodorous smell in R1’s private resident room. A credible witness documented that R1’s hair was greasy and body odor was noted during a facility visit on 09/07/2023. The credible witness also indicated there was a strong foul odor in the room. R1 was reported to be curled in a fetal position on their bed, difficult to rouse and did not wake up or engage, although staff and the credible witness were attempting to communicate with R1. Staff interviews revealed that R1 regularly refused care, including assistance with basic hygiene as well as home health provided wound care. Interview with Administrator revealed that Administrator reported the concerns related to self-neglect to APS as well as to the resident’s physician. Administrator stated they had attempted to contact R1’s family member, but R1’s family member was not returning the facility’s calls. LPA requested documentation of these various contacts, however no written proof was provided. LPA reviewed documents provided by APS, which did not include any information indicating the facility filed a report for self-neglect. Additionally, while fax communication with R1’s pharmacy was provided, there was no proof of communication with R1’s physician related to R1’s refusal of care. Based on interview and record review, the allegations “Licensee did not ensure resident’s hygiene needs were met” and “Licensee did not ensure home health needs were met” are deemed SUBSTANTIATED at this time. Allegation: “Licensee did not ensure resident’s medical documents were complete:” The complaint alleges that R1’s medication log was not completed and also alleges that R1 was incapable of making their own decisions but did not have a medical Power of Attorney (POA) on file with the facility. Interview with facility staff and Administrator confirmed R1 did have a POA which designated R1’s family member authority to make decisions related to R1’s finances, however, R1 did not have a POA related to medical decisions. The facility did not retain a copy of any such POA document. Additionally, as outlined above, the facility did not obtain a pre-admission appraisal upon any of R1’s admits to the facility. R1 only had one Admission Agreement in their file, which was not signed nor dated, as the only date on the document indicates date of occupancy 10/12/2023, and the document was missing pages. Blank documents in R1’s file included the pre-admission appraisal, personal property and valuables, personal rights, and release of medical information. R1’s care assessment and service plans were incomplete and R1’s MAR was Report Continued on LIC 9099-C (p.4) missing information as well, as indicated by blank spaces and x marked with no clarification for these dates. Consent for emergency medical treatment was signed by R1’s family member on 10/17/2023 although R1 was initially admitted to the facility on 02/17/2023. Based on record review, the allegation “Licensee did not ensure resident’s medical documents were complete” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 14, 2024 · control 29-AS-20230908154939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87456(a) · Plan of correction due date: Oct 15, 2024

87456 Evaluation of Suitability for Admission (a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the above cited section, as R1 did not have proof of a pre-admission appraisal nor interview prior to admission and R1 was identified to require an Intermediate Care Facility, but was accepted to care at this RCFE, which posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Oct 14, 2024

Plan of correction: Executive Director agreed to ensure all residents have a pre-admission appraisal and are assessed prior to admission to the facility. A statement of understanding will be sent to CCL by POC due date to confirm understanding of this section.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Oct 15, 2024

87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living...Postural Supports. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the above cited section, as R1 either refused (not documented) or was not offered hygiene care, incontinence care, and home health services for restricted health conditions, which posed an immediate health risk to R1.the state’s words, verbatim · CDSS document, Oct 14, 2024

Plan of correction: Executive Director agreed to provide vendorized training to all staff on this section. Training will be planned by POC due date; ED will submit to CCL the plan to include trainer information and date. Proof of training, including sign in roster will be sent to CCL upon completion of the training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Oct 28, 2024

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on record review and observation, the licensee did not comply with the above cited section, as R1's file did not contain a completed Admission Agreement or pre-placement appraisal, and other incomplete documents, which posed a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 14, 2024

Plan of correction: Executive Director agreed to audit all resident files and ensure complete and accurate records for all residents in care. A statement of understanding will be sent to CCL by POC due date.

Allegation investigated: Staff did not address a resident's behavior that posed a risk to other residents in care

Licensing Program Analysts (LPAs), Valeria Conway and Kelly Dulek, conducted a subsequent complaint visit to the facility above to issue final findings of the allegation. Upon arrival, LPAs met with front desk staff. Administrator, Monica Reyes, was called via phone. At 11:35 a.m., Administrator arrived at the facility. Reason for the visit was explained. Entrance interview. On 08/12/2024, from 9:30 A.M. – 2:15 P.M., LPAs initiated an unannounced complaint investigation for the allegation listed above. During the visit, LPAs toured the physical plant, interviewed staff, residents, resident Responsible Party (RP) and reviewed and obtained pertinent documents relevant to the investigation. It was reported that “Staff did not address a resident's behavior that posed a risk to other residents in care” as it was alleged that staff did ensure to protect Resident #1 (R1) from another resident who was causing R1 distress. Unsubstantiated Continued from LIC 9099 Information gathered during the course of the investigation revealed that R1 resided at this facility from 06/24/2024 to 07/31/2024. LPA conducted interviews with staff and resident. Staff stated that resident’s rooms are locked at all times including the side doors leading to the garden area. Additionally, staff explained that some residents might try to enter to a room that is not theirs, however, staff will re-direct them. LPA was unable to interview private caregiver. LPA requested evidence from Reporting Party (RP), however, RP was unable to provide it. Additionally, none of the staff had witnessed R2 inside R1’s bedroom. LPAs did not observe any residents attempting to enter other residents’ rooms during today’s visit. No other health and safety issues observed during today’s visit. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not address a resident's behavior that posed a risk to other residents in care” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, Oct 14, 2024 · control 29-AS-20240807114227

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs), Valeria Conway and Kelly Dulek, conducted an unannounced Case Management – Incident visit. The purpose of the visit is to investigate self-reported incident report submitted to the Department on 10/07/2024. Upon arrival, LPAs met with front desk staff. Administrator, Monica Reyes, was called via phone. At 11:35 a.m., Administrator arrived at the facility. Reason for the visit was explained. Entrance interview. The Incident report submitted noted that on 10/06/2024 at 1:30 p.m., a staff member noticed Resident #1 (R1) walking in the Memory Care (MC) garden area. Per incident report, “R1 was doing activities and they had just seen him walk in, and then after five (5) minutes they (staff members) looked again and R1 was no longer there”. Staff members then called the Administrator and the Sheriff Department. At 1:45 p.m., R1 was found across the street walking around the park. On 10/10/2024, LPA Conway, conducted a phone interview with facility Administrator Monica Reyes between 10:35 a.m. and 10:47 a.m. During the interview Administrator stated that Resident 1 (R1) have been triggering the emergency alarms frequently since R1 was admitted on 10/04/2024. Administrator confirmed that R1 eloped from the facility by jumping a fence surrounding the Memory Care (MC) garden. No injuries were reported, and family members were informed. Continued on LIC 809-C Continued from LIC 809-C During today's visit the LPAs conducted a tour of the Memory Care unit at 12:30 p.m. LPAs interviewed Administrator and random staff members between 10:30 a.m. and 2:30 p.m. LPAs also reviewed facility records and obtained pertinent copies. During the record review, LPA Conway reviewed the pre-admission appraisal for R1, physician’s report, dated on 09/24/2024, and the Care Assessment and Service Plan. Documentation indicates that R1 is confused/disoriented and has wandering behavior confirming the resident’s tendency to wander. According to the Administrator, following R1’s elopement, staff are providing close supervision while the resident is in the garden. Furthermore, administrator’s recommendation to R1’s responsible party is to hire a private caregiver to help prevent R1 from leaving the facility. LPA’s attempted to interview R1, however R1 was unable to communicate in English. LPA’s asked Administrator to demonstrate that the delay egress side gates were functioning properly during the visit. Between 1:10 p.m. - 1:15 p.m. both gates were tested, and the alarm was triggered when the bars were pushed. Pursuant to Title 22 of the CA Code of Regulations and Health and Safety Code, the following deficiencies were cited (refer to LIC 809-Ds): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.312(a) · Plan of correction due date: Oct 15, 2024

1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services:(a) Care and supervision as defined in Section 1569.2. Based on record review and interview Facility staff did not ensure to provide the necessary care and supervision to Resident #1 which allowed Resident #1 to elope from the facility unassisted, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2024

Plan of correction: The licensee will submit a written plan describing how staff will ensure protocols for residents who require additional supervision while in care. Additionally, in-service training in the memory care unit about how to prevent an elopment of a resident. Submit proof to CCL by POC due date. Training by 10/28/24

Allegation investigated: Facilty staff did not administer medications to resident as prescribed The licensee did not provide assistance needed to meet the resident's home health needs Licensee did not allow resident's chosen third-party provider to provide services to the resident Facility is understaffed

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Allegation investigated: Resident is left soiled for an extended period of time Resident has missed meals due to staff neglect Staff do not clean resident's room timely Staff do not put resident's call button in a place accessible to resident

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Allegation investigated: Staff did not give resident medication as prescribed Staff did not address a change in residents’ condition

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Allegation investigated: Staff prohibiting resident from leaving the facility for visits Facility restricted visitation

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Allegation investigated: Staff did not prevent residents from wandering away from the facility Staff do not respond to residents call for assistance in a timely manner Staff do not ensure that residents are adequately fed

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Allegation investigated: Staff are making inappropriate comments towards residents

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Allegation investigated: Staff did not treat resident with dignity or respect.

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Allegation investigated: Neglect/Lack of Care and Supervision - the facility staff did not ensure Resident #1 (R1) had oxygen resulting in brain injury.

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Allegation investigated: Facility did not assist resident with obtaining medical care Facility staff did not assist resident with administering medications as prescribed

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Type of visit: Case Management - Deficiencies

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Allegation investigated: Staff are not ensuring that resident is provided with a comfortable mattress. Staff are not addressing resident's burn injury

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Allegation investigated: Licensee did not provide resident's records as requested

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Allegation investigated: Staff neglect resulted in a resident leaving the facility unsupervised.

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Type of visit: Case Management - Deficiencies

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Allegation investigated: Licensee issued an unlawful eviction notice to resident in care

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