Aegis Living Granada Hills

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the Health Service Director (HSD), Yolanda Ramirez, and explained the reason for the visit. Administrator, Mauricio Flores was out ill for today. At approximately 8:45am, a tour of the physical plant was conducted. The facility has three (3) floors. The fire clearance is for one hundred (100) non-ambulatory residents, of which ten (10) may be bedridden. Bedridden clearance only for the ground floor. Third floor is only allowed a total of six (6) non-ambulatory residents. Hospice waiver is for ten (10) residents. Delayed egress is approved for Dementia Unit (Italy & France). There is a fifteen second delay, or combination required for doors to open. The facility's smoke alarms are hard wired. Last testing, which includes the sprinklers, fire door, alarms and exit light was completed on 08/18/25. Fire/earthquake and emergency evacuation drill was last conducted on 07/18/26. The fire extinguishers throughout the facility hallways are on all three (3) floors, all extinguishers were last serviced on August 20, 2026. Kitchen: The kitchen is clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food properly sealed. Listing for residents that require a special diet is posted on the kitchen wall. Food deliveries from US foods are made twice a week. There were no pesticides or poisons observed near any food areas. Kitchen/food service staff observed with gloves and proper hair cover. Bedrooms: Personal accommodations in resident bedrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Emergency push button was tested for proper function. Bathrooms: Resident bathrooms were properly supplied and had functional fixtures, grab bars and non-skid mats. Hot water temperature in resident bathrooms on all three floors were checked and measured at a range of 108°F to 110°F. Common Areas: Common areas, including the lobby, activity rooms, movie theater, dining rooms, salon and library was clean properly furnished. There is a coffee/hot beverage station at the front entrance. Surrounding Grounds: Entry/exits were free of obstruction. There are evacuation chairs stationed at each stairwells on either the second or third floor. The outdoor/patio areas for both the assisted living and dementia wing is clean and free of hazards. There is no swimming pool or any other bodies of water. Laundry: Both dementia wings have it's own designated laundry area in the dining/activity section of the dementia wing. The assisted living laundry room is located on the first floor, across the kitchen. All three laundry areas were locked during the day of the visit. Staff Office/Work Station: Administrator's office is located on the first floor, by the entrance. Medication room and HSD office on the second floor. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: There are medication carts stationed at both dementia wings, and on each floor. There is a refrigerator, with lock, in the medication room to store medicine that requires cooler temperature. Medication room is locked at all times. Medication and medication records were reviewed for proper storage and documentation. There is a First aid kit on each medication cart. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.the state’s words, verbatim · CDSS document, Aug 28, 2026

Allegation investigated: . Staff do not ensure that residents are provided a comfortable accomodations 2. Staff do not treat residents with dignity and respect

Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director Rhodora Escobar to inform her the reason of the visit, which was address the allegations mentioned above. The following information was provided during the visit: Allegation # 1: Concerns were expressed staff do not ensure that residents are provided with comfortable accommodations. To investigate the allegation, during today’s visit, from 845am to 130pm, LPA interviewed (2) staff, (8) out of (8) residents, and other witnesses pertaining to the allegation. According to the complaint, the facility provided a Mother’s Day brunch for residents and families. Due to the large number of people who were going to participate, the facility decided to divide the brunch into (2) sessions to accommodate family and residents, and residents who were not participating with family. The concern was the residents who were not participating, versus the residents who were participating in the brunch. It was alleged they were treated differently and did not provide the same food as the participants who were with family. (Cont'd LIC9099C) Unsubstantiated Administration reported to LPA that everyone was served the same food, except the non-participants food was plated and served by kitchen staff. Administration also revealed to LPA that residents were provided constant reminders regarding the luncheon. Although the Administration did state, there could have been a better way of organizing the event, but overall, there was only (1) complaint from the residents, and others reported they were happy and enjoyed the luncheon put together by the facility. Interviews by residents reported to LPA, some did not participate due to being with their family, and others reported the luncheon was nice and they appreciated the efforts by the facility. Administration held a resident’s council meeting, to ensure they accommodate all residents uniformly. Overall, residents had a good time, and enjoyed the festivities provided by facility staff. Therefore, based on interviews, there is insufficient evidence to prove residents were not provided comfortable accommodations, and the allegation is Unsubstantiated at this time. Allegation #2: Concerns were expressed that facility staff do not treat residents with dignity and respect. To investigate the allegation, during today's visit from 8:45 a.m. to 1:30 p.m., (LPA) interviewed two (2) staff members, eight (8) out of eight (8) residents, and other relevant witnesses. According to the complaint, the facility hosted a Mother's Day brunch for residents and their families. It was alleged that residents who participated in the family luncheon appeared to receive preferential treatment, while residents who did not participate were treated without dignity and respect. Specifically, concerns were raised that the dining area designated for participating residents was esthetically pleasing, well decorated, and organized, whereas the area designated for non-participating residents appeared plain and lacked comparable decorations. Administration reported that the event was divided into separate sessions to accommodate the anticipated number of residents and family members attending. Administration acknowledged that the event could have been organized more effectively; however, they stated that only one resident expressed dissatisfaction with the event. Administration further reported that the event was intended to celebrate all residents and was not designed to exclude or diminish any residents’ experience. Interviews conducted with residents revealed that some residents did not participate because they chose to spend time with family members, while others reported attending the luncheon and enjoying the event. Residents interviewed generally stated that they appreciated the efforts made by facility staff and enjoyed the Mother's Day festivities. None of the residents interviewed reported being treated disrespectfully by staff during the event. (Con'td LIC9099C) Based on interviews conducted and information obtained during the investigation, there is insufficient evidence to support the allegation that facility staff treated residents without dignity and respect. differently in a manner that compromised their dignity. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided to the ED.the state’s words, verbatim · CDSS document, Jun 5, 2026 · control 31-AS-20260528105630

Allegation investigated: Staff does not ensure facility is free of bed bugs.

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. LPA met with the Executive Director (ED) Lance Shenk, and advised him of the complaint. It's being reported that the facility has at least 14 rooms affected with bed bugs and nothing has been done to address the issue. Today's investigaiont consisted of interviews with the ED, Staff, and residents. LPA also conducted a record review and a physical plant inspection to insure the health and safety of the residents in care. Prior to this investigation, LPA ran a file review of the facility's Incident Reports (IR) and observed about four IRs that were submitted by the licensee for July, September and October 2025 indicating insects in resident apartments. There were approximately four resident apartments that were affected. Included in the reports was an immediate action taken by the licensee to have the pest control company service the facility. Unsubstantiated Interviews conducted with the ED and staff were made between 9:00am to 11:00am confirm that approximately four resident apartments were affected by insects in July, September and October 2025, but were treated immediately by a pest control company. Since October, there were no additional issues with insects at the facility. Between 11:00am to 12:00pm, interviews with ten (10) of ten residents do not corroborate with the allegation that the licensee not insuring the facility is free from bed bugs, as some resident state that there is a pest control company that comes often to service the facility. Between 12:00pm and 1:00pm, LPA conducted a record review of facility invoice and records from the pest control company. Record review reveal that Western Exterminator Company was hired for service. Record review also reveal the type of treatment made by the pest control company and dates of service. From 1:00pm to 2:00pm, LPA conducted a physical plant tour. Although there is some information that the facility was affected by some insects for the months of July, September, and October 2025, based on the information obtained, there was insufficient evidence to corroborate with the allegation that the licensee did not ensure facility is free of bed bugs as there is proof that a pest control company is hired monthly to provide service. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 31-AS-20251114105110

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the Health Service Director (HSD), Yolanda Ramirez, and explained the reason for the visit. The administrator, Lance Shenk, is currently at the Ventura Facility and unable to join. With the assistance of the HSD, a tour of the physical plant was made. The facility has three (3) floors. The fire clearance is for one hundred (100) non-ambulatory residents, of which ten (10) may be bedridden. Hospice waiver is for ten (10) residents. Delayed egress is approved for Dementia Unit (Italy & France). There is a fifteen second delay, or combination code to open the door. The facility's smoke alarms are hard wired. Last testing, which includes the sprinklers, fire door, alarms and exit light was completed on 05/31/25. Fire/earthquake and emergency evacuation drill was last conducted on May 10, 2025. The fire extinguishers throughout the facility hallways are on all three (3) floors, all extinguishers were last serviced on August 1, 2024. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen. Listing for residents that require a special diet is posted on the kitchen wall. Food deliveries from US foods are made twice a week. There were no pesticides or poisons observed near any food areas. Kitchen/food service staff observed with gloves and proper hair cover. Bedrooms: Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Emergency push button was tested for proper function. Bathrooms: Resident bathrooms were properly supplied and had functional fixtures. Hot water temperature in random resident bathrooms on all three floors were checked and measured at a range of 111°F to 114°F. Common Areas: Common areas, including the lobby, activity rooms, movie theater, dining rooms, and library appeared clean and were properly furnished. There is a coffee/hot beverage station at the front entrance. Salon was closed and locked during the day of the visit. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor/patio areas for both the assisted living and dementia wing was clean and free of hazards. Gates for the dementia wing is locked to prevent residents from wandering out. Sufficient staffing was also observed at both dementia wings. Laundry: Both dementia wings have it's own designated laundry area in the dining/activity section of the dementia wing. The assisted living laundry room is located on the first floor, across the kitchen. All three laundry areas were locked during the day of the visit. Staff Office/Work Station: Administrator's office is located on the first floor, by the entrance. Medication room and HSD office on the second floor. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: There are medication carts stationed at both dementia wings, and on each floor. There is a refrigerator, with lock, in the medication room to store medicine that requires cooler temperature. Medicaiton room is also locked at all times. Medication documentation and implementation appeared to be complete. There is a First aid kit on each medication cart. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.the state’s words, verbatim · CDSS document, Jul 23, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20211004100524. LPA met with the Administrator and explained the reason for the visit. The purpose of the visit is to issue an amended version of the original report created 06-14-2022 after review of a second level appeal which changed the finding of the complaint. New, amended report had been created and previously issued LIC9099-D (deficiency) page will be removed. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 2, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit to the facility to follow up on an Incident Report received on 12/14/24, pertaining to R1's personal rights. LPA met with the administrator, Lance Shenk, and advised him of the visit. Today's CM visit consisted of interviews with the administrator, staff and Resident 1 (R1). LPA also made a physical plant inspection and conducted a record review. According to the IR, the incident occurred on or around 12/14/24, at approximately 8:10am. R1 was interviewed by administrator and Health Service Director (HSD). Law Enforcement (LE) was also notified and a Battery Report (#24096208) was taken. LE indicated that they will not be conducting any further investigation based on their conversation with R1. Today, interviews made with administrator and Wellness Nurse. Administrator confirms no further interviews from LE based on their initial investigation. R1 is still at the facility. Facility made an internal investigation, which was deemed Inconclusive. R1 was sent immediately to the hospital after the alleged incident on or around 12/14/24. R1 was diagnosed with UTI, which caused some confusion. New orders prescribed at discharge. R1 is back at the facility. Family notified, and no concerns made. Based on the information obtained, it does not appear R1's personal rights were violated. No citations issued as the licensee satisfied their reporting requirements. Administrator was advised and a copy of this report issued.the state’s words, verbatim · CDSS document, Jan 10, 2025

Allegation investigated: Staff left resident at the hospital unattended Staff left resident in soiled diapers/clothing

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the Regional Care Director (RCD), Ticarra Boyd, and advised her of the allegations. Executive Director (ED), Lance Shenk joined shortly after. Today's investigation consisted of interviews witht the RCD, staff, residents. LPA also conducted a physical plant inspection and conducted a record review. Staff left resident at the hospital unattended: In regards to the allegation, it was reported that Resident 1 (R1) was sent to the hospital on or around 11/27/24, and left unattended by staff. R1 is unable to speak or communicate their needs. Interviews with the wellness and care director, Staff 1 (S1) and Staff 2 (S2) deny the allegation, stating they would never leave a resident unattended when taken out into the community. In regards to R1, both S1 and S2 stated R1 was taken to the hospital under doctor's orders for kidney injury. R1's family made arrangements with a Unsubstantiated private ambulance company to transport R1 to the hospital, and gave specific instructions for the driver to stay with R1 until admission at the hospital. LPA interviewed R1's family, and they confirmed that the private ambulance company was given specific instructions to stay with R1 until staff at the hospital admits R1. R1's family stated this incident is at no fault of the facility, because of the arrangements made with the ambulance company. Moreover, family stated the driver from the ambulance company not only left R1 unattended, but dropped R1 at the wrong entrance at the hospital. LPA also conducted interviews with residents who do not corroborate with the allegation of ever being left unattended by staff during their medical appointments. Based on the information obtained, there was insufficient evidence to prove that facility staff left R1 unattended at the hospital. Therefore, the allegation is deemed Unsubstantiated at this time. Staff left resident in soiled diapers/clothing: In regards to the allegation, it was reported that when R1 was transported to the hospital, R1 was soiled or covered in their urine. The reporting party (RP) was unable to confirm if R1 left the facility dry, and had an accident while waiting for admission in the hospital, or if R1 had urinated on self in route to the hospital. There were no witnessed provided by the RP to corroborate if the facility staff allowed for R1 to leave the facility soiled in their clothes, in route to the hospital. Interviews with facility staff deny the allegation, stating, when R1 was picked up by the ambulance for hospitalization on 11/27/24, they were dry and not soiled in their clothing. R1 was assessed prior to departure to the hospital. Based on the information obtained, there wasn't enough evidence to prove that staff left R1 soiled in the diapers or clothing. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 31-AS-20241202110854

Allegation investigated: Neglect by facility staff resulted in severe dehydration to resident. Facility staff did not follow admission agreement. Facility staff did not properly notify resident's responsible person of rate changes. Facility staff did not answer communications from resident's responsible person.

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. The ten day visit was made by LPAs Ray Comer and Michael Cava on 02/29/24. LPA met with the Administrator, Lance Shenk, and Health Service Director, Adriana Sais, and advised them of the complaint. During the course of the investigation, interviews and record review were made. A physical plant inspection also conducted to insure compliance with regulation. Neglect by facility staff resulted in severe dehydration to resident: In regards to the allegation, it was reported that on or around 10/3/23 Resident 1 (R1) was sent to the hospital, and was admitted for being disoriented, unbalanced, unable to walk and speak. The hospital found that the symptoms were due to a severe Urinary Tract Infection (UTI) and severe dehydration sustained while at the facility because of staff neglect. R1 was diagnosed with hypernatremia and required two IV bags. After returning to the facility, R1 never regained the ability to ambulate. Unsubstantiated Interviews with facility staff, and record review reveal that at admission to the facility, R1 already has an impairment and diagnosis causing for them not to keep hydrated and drink enough water, resulting into the UTI and dehydration. Additional information received from these interviews and record review, also reveal that at admission, R1 already had a history of UTI and kidney stones. R1’s responsible person always had to push for R1 to drink fluids to stay hydrated. Despite the facility’s care plan in addressing R1’s inability to keep hydrated, R1 still showed resistance to drinking and keeping fluids down, due to their mental condition. On or around October 3, 2023, there is documentation of a fall, resulting in medical treatment for dehydration. R1 was discharged and returned to facility 10/05/23, with instructions to encourage frequent hydration. Regarding R1 never regaining the ability to ambulate, interviews made with facility staff and record review reveal that R1 was already non-ambulatory when admitted into the facility, requiring the use of a wheelchair at times. Moreover, R1 was admitted with their own wheelchair. Based on the information obtained, although there was record of a fall caused by possible dehydration, there wasn’t enough evidence to prove that neglect by facility staff caused for R1 to become dehydrated. Therefore, the allegation is deemed Unsubstantiated at this time. Facility staff did not follow admission agreement/ Facility staff did not properly notify resident's responsible person of rate changes. In regards to the allegation, it was reported that since hospice staff have taken over certain responsibilities, the licensee is finding new things to charge for, such as “hospice interface” and continuing to charge for showers on non-hospice days. Moreover, staff are not logging showers to prove showers are being provided to R1. Interviews with facility staff reveal that that on or around January 31, 2024, due to the progression of R1’s condition and diagnosis, their primary physician ordered hospice care. Hospice care plan was initiated for once a week, of which, assistance with showers is included. Although some services, such as incontinence services were dropped from service points on the facility’s care system, there was a hospice collaboration points added to the admission agreement. Hospice and home health collaboration is always explained to the resident, and their responsible person, prior to admission. Moreover, assistance with bathing, which R1 did require, was still in the admission agreement, scheduled for two times per week, which was already agreed upon. Facility did maintain a shower log, as proof assistance with showers were provided and as agreed. Copies of these logs were provided to the responsible person. Copies also obtained by LPA during the investigation. R1’s responsible person was explained of these charges and new charges for both the addition and subtraction for services. R1's responsible person acknowledged, agreed and signed the documentation for the charges. Staff stated that without the responsible persons agreement to the new services and their signatures, hospice service would not have started. Based on the information obtained, there was insufficient evidence to prove that staff did not follow R1’s admission agreement, or the licensee did not notify R1’s responsible person of rate changes. Therefore, the allegation is deemed Unsubstantiated at this time. Facility staff did not answer communications from resident's responsible person. In regards to the allegation, it was reported that R1’s responsible person has attempted to call and email the licensee, trying to get clarification on the facility charges received on a statement dated 2/23/24 for the hospice interface and additional showers, but no response by the licensee was made. These charges were back dated to about 02/01/24. Interviews with facility staff and record review (copies of email interaction) confirm that there was communication between the facility business office, and R1’s responsible person to discuss the order placed by R1’s physician to initiate hospice service, the hospice care plan, changes to R1’s care, and rate charges and subtractions to R1’s admission agreement for services to be provided by the facility. R1’s responsible person acknowledged these changes and services, and the initiation for the hospice care., which they agreed and signed on for these services to start. Without the responsible person’s agreement and signature, hospice services would not have initiated. Based on the information obtained, there was insufficient evidence to prove that staff did not communicate with R1’s responsible person regarding clarification on their hospice service. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 11, 2024 · control 31-AS-20240228094940

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Gary Tan and Michael Cava arrived to this facility today to conduct a One (1) Year Required inspection of the facility. LPAs met with Business Office Manager Andrea Hernandez and explained the reason for the visit. The facility is fire cleared for one hundred (100) non-ambulatory residents, of which ten (10) may be bedridden. Hospice waiver for ten (10) residents. Delayed egress is approved for Dementia Unit (Italy & France). Executive Director Lance Shenk called and designated Ms. Hernandez to sign the report. There is only one entrance being utilized at the facility, the front main entrance door. Screening area is located immediately upon entrance. There is also a sign in sheet, hand sanitizer, gloves and masks available. The facility had submitted and approved Mitigation and Infection plan. There are hand sanitizing stations all over the facility. There are signs of Covid 19 prevention protocol posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in common bathrooms, and the other common areas of the facility. The facility have multiple designated visitors' area in the front entrance and backyard. The facility has sufficient stock of PPE in the storage room. LPA conducted physical plant tour of the facility with Ms. Hernandez, residents' bedrooms on the first, second and third floors were inspected. Common areas, including the activity rooms, movie theater, dining rooms and library appeared clean and were properly furnished. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen, dangerous items are properly stored and inaccessible to residents. The facility menu appears to meet the daily dietary needs of the residents. (continued on LIC 809-C) (continued from LIC 809) There were no pesticides or poisons observed near any food areas. Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. The medications were locked in the medication carts, properly labeled and stored. Medication documentation and implementation appeared to be complete. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked and measured a range of 114.6°F to 118.7°F and within the required range. LPAs observed fire extinguishers throughout the facility hallways on all three (3) floors, all extinguishers were last inspected on 06/06/24. There is a First aid kit on each medication cart stored/parked in the medication room located in the second floor. The facility's smoke alarms are hard wired as back up and tests are done in house on a monthly basis. Facility emergency disaster plan was reviewed. Facility disaster drills are conducted monthly and was last conducted on 07/10/24. A fire protection equipment performance certification was completed on 07/31/24. In addition to the physical plant inspection, residents and staff records were reviewed. LPAs reviewed files of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed. Residents files appear to be complete and updated. Staff present files were also reviewed, staff files appear to be complete and updated. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Jul 27, 2024

Allegation investigated: Facility staff restrained resident.

Licensing Program Analysts (LPAs) Ray Comer and Michael Cava conducted a complaint visit to the facility to investigate the above allegation. It was reported that facility staff had “sandwiched" Resident 1 (R1) between a wall and the table intentionally to keep them from falling over. This was observed several times during facility visits. Photos were obtained prior to investigation. LPAs met with the administrator, Matthew La Vine, and advised him of the complaint. Todays investigations consisted of interviews with staff, record review, and a physical plant inspection. Although, during the day's investigation, both LPAs Comer and Cava did not observe R1 "sandwiched" between the wall and table, the LPA interviews with staff confirm that caregivers would bring the table close to R1 to assist in feeding and restrict movement to minimize R1 from pushing their wheelchair over. Substantiated Pursuant to title 22, division 6, chapter 8, "Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. Therefore, based on the information obtained, the allegation of resident being restrained is Substantiated. Citation issued on the 9099D. Copy of this report and appeal rights given.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 31-AS-20240228094940

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(1) · Plan of correction due date: Feb 29, 2024

Postural Support: Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement was not met as evidenced by: Staff admission during interviews.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: As POC, the administrator will hold staff training to address this section of the regulation. As proof training was held, administrator will submit a copy of the training log and staff sign in sheet to the licensing agency by March 7, 2024

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.