Almavia of Camarillo

Allegation investigated: Staff inappropriately touched resident.

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility at 8:45 A.M. to conduct a 10-day complaint investigation for the above allegation. Upon arrival LPA met with the Administrative Services Director, Sarah Stichler, Executive Director (ED), Michele Johnson, was unavailable during today's visit, however ASD is authorized to sign today's reports. Reason for the visit was explained. On 08/24/2026 the Department received a complaint alleging that staff inappropriately touched a resident. To investigate the allegation, the LPA obtained and reviewed pertinent facility records and conducted an interview with the ASD at approximately 9:00 A.M. The ASD identified themselves as the individual responsible for the facility’s Human Resources (HR) department. During the visit, ASD stated that no residents or staff members reported concerns related to the allegation. Continued on LIC 9099-C Unfounded Continued from LIC 9099-C The LPA reviewed the following records: the Personnel Report (LIC 500), the facility’s resident roster, and the Facility Personnel Report Summary extracted from the Guardian system. The documentation reviewed revealed that the resident identified in the complaint did not reside at this facility. Additionally, the staff members identified in the complaint were not employed by the facility and were not listed on the facility’s personnel roster or in the Guardian system. Based on the information obtained, the allegation is deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. No citations issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 29-AS-20260824101812

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Valeria Conway initiated an unannounced Case Management – Incident visit for an incident that was self-reported. Upon arrival LPA met with the Administrative Services Director (ASD), Sarah Stichler. Executive Director (ED), Michele Johnson, was unavailable during today's visit, however ASD is authorized to sign today's reports. Entrance interview conducted. The Woodland Hills Regional Office (RO) received an incident report via email on 07/30/2026 at 3:22 P.M. stating that on 07/27/2026, Resident #1 (R1) left the facility unassisted through the side exit egress door in the Memory Care unit. LPA Byrne, conducted a telephone call with the facility ED at 3:13 P.M. on 07/31/2026. During the telephone conversation, ED explained to the LPA that R1, who is a newer resident in the facility, was observed at approximately 8:45 P.M. walking around the unit. At approximately 9:00 P.M., after checking all common areas including R1’s room, staff realized that R1 was not present in the facility and that a secure egress door had been left unarmed. Interviews revealed that during the afternoon hours, Staff #1 (S1) accessed the Memory Care Unit using a key from the opposite side of the secured egress door, which activated the alarm system. Staff #2 (S2) responded to assist S1 and disengaged the alarm system. Further interviews revealed that S1 and S2 had not been trained on the proper procedure to fully re-arm and engage the secured egress door system after it was disengaged. As a result, R1 exited the facility unnoticed later that evening. 911 and POA were notified of the incident. A search was initiated and approximately 30 minutes later R1 was found safely by police near St. Jhon’s Hospital. ED reported R1 did not sustain any injuries as a result of the elopement incident. Continued on LIC 809-C Continued from LIC 809 During today's visit, LPA requested R1’s personal file. At 11:01 A.M., LPA discussed the incident with facility ED via telephone. R1’s Physician’s Report (LIC602A) indicates they are diagnosed with Alzheimer's Disease, have wandering behaviors and is not able to leave the facility unassisted. Service care plan report dated 07/02/2026 states under elopement risk "staff need to know where resident is at all times". After the incident, an in-service training was conducted on 07/28/2026, however S2 did not participate. Neither S1 nor S2 received disciplinary action following the incident. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D) Exit interview conducted, appeal rights discussed, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Aug 26, 2026

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors… (2) The licensee shall ensure...the fire clearance...staff on all shifts have access to, and know how to use… This requirement was not met as evidenced by: Based on an incident report and records review the ED did not comply with the regulation above as S1 and S2 were not properly trained to engage egrees door R1’s elopement.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: ASD will request ED to complete training with all MC staff, MedTechs and director on how to proper operate and re-arming of the secured egress door system. Training will be conducted by the Plant Operations Director.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced Case Management - Incident visit at the above facility in regards two self-reported incident reports received on 07/1/2026. Upon arrival LPA met with the Administrative Services Director (ASD), Sarah Stichler. Executive Director (ED), Michele Johnson, was unavailable during today's visit, however ASD is authorized to sign today's reports. Entrance interview conducted. Licensing received an incident report regarding Resident #1 (R1), in which R1’s friend reported several unauthorized charges on R1’s credit card statement. On the same day, Licensing received a separate incident report regarding Resident #2 (R2), who reported that a gold bracelet went missing on the night of 06/29/2026. Upon notification of both incidents, the ED contacted the Camarillo Police Department and Adult Protective Services (APS). The ED reported that law enforcement responded and completed reports regarding both incidents, however, they were not provided to the ED. Throughout the investigation, the LPA conducted interviews with the ED and the ASD and obtained available documentation related to the incidents. According to the ED, the facility has an established protocol for investigating allegations of theft and/or missing property and is currently conducting internal investigations related to both incidents. The ED further stated that the facility takes all allegations seriously. The ED reported that, after the unauthorized credit card charges were reported to the credit card company, the charges were refunded to R1, however, R2’s gold bracelet was not found. Pending internal investigation report and Camarillo PD report. A supplemental report will be issued, if warranted. Exit interview held and copy of report provided.the state’s words, verbatim · CDSS document, Aug 25, 2026

Allegation investigated: Staff do not ensure residents have TB test results prior to admission Staff do not ensure that resident appraisals/care plans are being completed

Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced initial complaint visit to investigate the allegations noted above. Upon arrival, the LPA was greeted by the front desk concierge and shortly after met with Executive Director (ED), Michele Johnson and the reason for the visit was explained. Entrance interview. During today's visit, between 09:30 a.m. and 11:45 a.m., the LPA interviewed the ED, conducted a resident file review of five (5) newly admitted residents, and obtained copies of pertinent documents relevant to the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff do not ensure residents have TB test results prior to admission. It is the complainant’s concern that residents are being admitted to the facility before receiving a negative TB test result. Record review of five (5) newly admitted residents revealed that all five residents had undergone TB testing prior to admission to the facility. The LPA reviewed each resident's file and verified documentation of a negative TB test result. An interview with the ED confirmed that all residents are required to obtain a negative TB test result before admission and is a requirement for acceptance into the facility. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not ensure residents have TB test results prior to admission”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff do not ensure that resident appraisals/care plans are being completed. It is the complainant’s concern that residents are not being properly assessed and may not be receiving the care they need. Record review of five (5) newly admitted residents revealed that each resident received a pre-admission appraisal prior to admission to the facility. In addition, the facility conducted an interview with each resident and developed an individualized service plan that identifies the resident's care needs and outlines how the facility will meet those needs. An interview with the ED confirmed that an appraisal and individualized care plan are completed for each resident and maintained in the resident's chart, which is stored in the medication technician's office. The ED further stated that all care staff have access to residents' files and may review each resident's care plan as needed to ensure appropriate care is provided. The care plan is reviewed and updated at least once every six (6) months to ensure its accuracy and reflect the resident's current care needs. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not ensure that resident appraisals/care plan is being completed”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview. No citations issued. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 29-AS-20260804111544

Allegation investigated: Staff did not treat residents with dignity and respect

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced subsequent complaint visit to deliver findings for the allegation listed above. Upon arrival LPA met with the Executive Director (ED), Michele Johnson, and explained the reason for the visit. Entrance interview. During previous visits conducted on 09/25/2025 and 05/15/2026, the LPA toured the physical plant, interviewed staff members and residents, and obtained pertinent documents relevant to the investigation. Throughout the course of the investigation, the LPA reviewed all documents obtained and conducted additional telephonic interviews. The following was then determined: Continued on LIC 9099-C Substantiated Continued from LIC 9099 Regarding allegation of “Staff did not treat residents with dignity and respect” it was reported that afternoon (P.M.) shift staff made rude comments toward Memory Care (MC) residents and that when staff became aggravated with residents, staff would limit and/or refuse food to them. Interviews conducted with staff and residents did not reveal any observations or reports of P.M. staff refusing or limiting food portions to residents. Staff and residents interviewed stated that the facility always maintains an adequate supply of food and snacks available to residents, and residents are provided with additional servings upon request. However, staff interviews did reveal concerns regarding inappropriate comments and behaviors made by Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3). Staff #4 (S4) witnessed S1, S2 and S3 making “gagging” gestures, noises, and rude or condescending comments while assisting Resident #1 (R1) who had experienced and incontinent episode. S4 expressed concern for the residents’ well-being, stating that the resident repeatedly apologized to staff for causing a “mess” during the incident. Additionally, other staff interviewed reported hearing P.M. staff make inappropriate and rude comments toward the residents during care. According to interviews conducted, these comments and gestures were occasionally made in the presence of residents and other staff members. Staff interviewed also indicated concerns that S1, S2 and S3 communicated with residents in an unprofessional and disrespectful manner. Staff reported that the residents were spoken to in a raised tone of voice and inappropriate for a caregiving setting, rather than with the respect and professionalism expected when providing care and supervision to residents. Several staff members also expressed concerns regarding reporting issues to the former ED and/or upper management due to fear of favoritism and potential retaliation. Records reviewed and interviews conducted revealed that management provided in-service training to MC staff on 03/28/2026, regarding appropriate communication and interaction with residents, on 12/27/2025, regarding respecting residents’ rights; and on 06/27/2025 reminding staff to avoid or “stay away” from words like “No”, “Stop” and, “Don’t Do That” when interacting with residents. Based on interview and record review, the allegation 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. Continued on LIC 9099 Regarding allegation of “Staff handled resident in a rough manner” it was it was reported that Memory Care unit staff were yanking residents when being transferred from their chair. Interviews conducted with staff members, including the former Executive Director, denied the allegation and stated that residents are not being mistreated, and they have not seen any staff handle residents in a rough manner. Staff interviews revealed that when a resident becomes agitated or noncompliant, staff are trained to utilize redirection techniques and, when appropriate, temporarily step away and revisit the situation at a later time to allow the resident an opportunity to de-escalate and comply with care. LPA attempted to conduct random resident interviews within the Memory Care Unit; however, multiple residents were unable to participate due to loss of cognitive ability. One resident who was interviewed did not indicate that staff had been aggressive or rough, adding that staff are “nice and kind”. A private caregiver interviewed stated that the morning (A.M.) staff are very helpful and efficient. 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. The Department does not have sufficient evidence to support the allegation of “staff handled resident in a rough manner”. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. No deficiencies issued. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, May 28, 2026 · control 29-AS-20250917145319

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a) · Plan of correction due date: May 29, 2026

87468(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) 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 and record review, the Administrator did not comply with the section cited above as S1, S2, and S3 were observed making rude comments and speaking inappropriately to Memory Care residents which poses an immediate personal rights risk for persons in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: ED agreed to submit a statement of understanding on regulation 87468(a) and get all staff (including all shifts) trained on personal rigths and Elder Abuse. ED will submit memo provided to all staff regarding the training by POC due date.Training log will be sent to LPA by 6/5/2026.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Valeria Conway conducted a Case Management - Incident visit regarding a self-reported incident. At 1:00 P.M., LPA met with Executive Director (ED), Michele Johnson, and explained the reason for the visit. Entrance interview conducted. On 04/30/2026, the Woodland Hills North Adult and Senior Care Regional Office (RO) received an incident report regarding Resident #1 (R1). The self-reported Unusual Incident/Injury Report (LIC 624) indicated that on 04/25/2026, R1 was unable to transfer or bear weight and was observed with increased swelling on their left leg. R1 was subsequently transported to the hospital on 04/25/2026, where they were treated for a left hip fracture. Interviews conducted with staff revealed that while R1 was in the activities area "rotunda", R1 reportedly slipped from their wheelchair. Staff stated that by the time staff attempted to prevent the fall, R1 was already on the ground. Staff further reported that while paramedics were assisting R1, R1’s Power of Attorney (POA) arrived at the facility and refused transportation of R1 to the hospital. LPA did not receive a LIC 624 form regarding the unwitnessed fall that reportedly occurred on 4/24/2026. Information pertaining to the circumstances surrounding R1’s injuries was not provided to the Department within the required 7-day time frame and only because the LPA emailed the Resident Care Director, Erika Miller, on 05/26/2026, requesting additional information. LPA also discussed hospice reporting requirements with he ED. During today’s visit the LPA explained the importance of reporting to CCLD within the required time frame. Based on the information obtained, the facility is cited for late reporting. Exit interview, report given, deficiency cited on 809-D, appeal rights given.the state’s words, verbatim · CDSS document, May 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 11, 2026

87211(a)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement was not met as evidenced by: Based on record review, the licensee did not ensure that an incident report regarding R1’s unwitnessed fall, which resulted in a diagnosis of a hip fracture, was submitted to the Department within the required seven-day (7) reporting timeframe which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: The Executive Director (ED) agreed to review Regulation 87211 and submitted a Statement of Understanding detailing how the facility and all employees responsible for reporting incidents will maintain ongoing compliance with reporting requirements. Submit statement no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA)s Valeria Conway and Martha Arroyo arrived at the facility at 9:30 A.M., for an unannounced annual inspection. Upon arrival, LPAs met with Administrator Michael O’Neill and explained the reason for the visit. Entrance interview conducted. Beginning at 10:28 A.M., the LPAs along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: 5-Year fire sprinkler inspection was completed on 09/15/2023, with an annual fire alarm test and inspection record conducted on 06/03/2025. As of today, all deficiencies have been cleared. Fire extinguishers throughout the building were observed to be fully charged and last serviced on 08/20/2025. At 11:54 A.M., carbon monoxide alarm was tested and properly functioned at the time of the visit. ASSISTING LIVING ROOMS: There are 60 Assisted Living units and can be found on the first and second floors of the building. Assisted Living units are equipped with a refrigerator, sink, and microwave and contain private restrooms. A random selection of 4 (four) resident rooms were observed. Residents’ rooms were observed to be furnished appropriately and contained appropriate bedding/linens. Bathrooms were observed to be safe and sanitary with grab bars and slip-resistant flooring. Hot water temperature was measured in four (4) bathrooms. All four (4) bathrooms inspected in the Assisted Living unit measured above the required range of 105 to 120 degrees Fahrenheit. Continued on LIC 809-C Continued from LIC 809 MEMORY CARE ROOMS: Memory Care is located on the first floor and has 18 (eighteen) rooms. Resident bedrooms are single and double occupancy with private bathrooms. A random sample of four (4) resident rooms were observed to be furnished appropriately. Bathrooms were observed to be safe and sanitary with grab bars and slip-resistant flooring. Hot water temperature was measured in four (4) bathrooms. Two (2) out of four (4) bathrooms inspected in the Memory Care unit measured above the required range of 105 to 120 degrees Fahrenheit. Medications for the memory care unit are centrally stored and locked in the medication room. The indoor and outdoor areas of the memory unit are secured with a delayed egress system, which functioned properly during the visit. There are two outdoor gated courtyards designated for Memory Care. COMMON AREAS: The facility is a two-story building. The facility contains multiple common areas, which were all observed to be clean, furnished appropriately and in good condition at the time of the visit. There were no obstructions and/or tripping hazards throughout the facility. All required postings were observed in the common areas on the first floor. The LPAs toured the outside areas of the facility. The Assisted Living and Memory Care unit contained 2 (two) courtyards for resident use. During today’s visit the LPAs observed two operational water fountains, one the promises. One fountain is located in the assisted living area, and the other is situated withing the memory care unit. The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use. The facility maintained a comfortable temperature of 73 degrees. LPAs observed cameras throughout the common areas only. Facility provides sufficient space to accommodate both indoor and outdoor activities. Several fireplaces were observed throughout the facility adequately screened. The LPAs observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed clean at the time of visit. KITCHEN: The main kitchen and dining room are located on the 1st floor. Food is prepared in the main kitchen and delivered to the dining area and the Memory Care dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPAs observed a minimum of two (2) days perishable and seven (7) days non-perishable foods. LPAs inspected refrigerator and pantry for expiration dates. LPAs observed a sufficient supply of emergency food and water. Continued on LIC 809-C Continued from LIC 809-C RECORD REVIEW: Between 12:00 P.M and 1:14 P.M., LPAs reviewed six (6) staff files and six (6) resident files. Files were reviewed for, but not limited to: Physician's Reports, Personal Rights, Admission Agreements, staff training records, health screenings, TB tests, and background clearance. All files reviewed were observed to be in compliance with regulation. MEDICATIONS: Medication review began at 2:40 P.M. LPAs observed medications for six (six) residents. All medications observed were stored and recorded in compliance with regulation. LPAs also reviewed the facility's Emergency Disaster Plan, which was observed to be complete and updated annually as required. Emergency Disaster drills are conducted monthly, with the last drill documented on 10/10/2025. During today’s visit LPAs obtained a copy of the facility’s LIC 500, resident roster, last emergency drill and current liability insurance. 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, Nov 13, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA)s Valeria Conway and Martha Arroyo arrived at the facility at 9:00 A.M., for an unannounced annual inspection. Upon arrival, LPAs met with Business Office Manager, Sarah Stichler and Resident Care Director, Erika Miller. Administrator Michael O’Neill was unable to be present during today’s visit and authorized Business Office Manager to review and sign the report. Entrance interview conducted. Beginning at 9:15 A.M., the LPAs along with both staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: 5-Year fire sprinkler inspection was completed on 09/15/2023. No safety concerns were noted at that time. Fire extinguishers throughout the building were observed to be fully charged and last serviced on 08/30/2024. At 9:58 A.M., carbon monoxide alarm was tested and properly functioned at the time of the visit. ASSISTING LIVING ROOMS: There are 60 Assisted Living units and can be found on the first and second floors of the building. Assisted Living units are equipped with a refrigerator, sink, and microwave and contain private restrooms. A random selection of 6 (six) resident rooms were observed. Residents’ rooms were observed to be furnished appropriately and contained appropriate bedding/linens. Bathrooms were observed to be safe and sanitary with grab bars and non-skid mats. Hot water temperature was checked in multiple randomly selected rooms in the Assisted Living unit and measured within the required range of 105 to 120 degrees Fahrenheit. Continued on LIC 809 Continued from LIC 809-C MEMORY CARE ROOMS: Memory Care is located on the first floor and has 18 (eighteen) rooms. Resident bedrooms are single and double occupancy with private bathrooms. A random sampling of 2 (two) resident rooms were observed to be furnished appropriately. Bathrooms were observed to be safe and sanitary with grab bars and non-skid mats. Hot water was measured in a sample of observed resident rooms and tested within the required range of 105 to 120 degrees Fahrenheit. Medications for the memory care unit are centrally stored and locked in the medication room. The indoor and outdoor areas of the memory unit are secured with a delayed egress system, which functioned properly during the visit. There are two outdoor gated courtyards designated for Memory Care. COMMON AREAS: The facility is a two story building. The facility contains multiple common areas, which were all observed to be clean, furnished appropriately and in good condition at the time of the visit. There were no obstructions and/or tripping hazards throughout the facility. All required postings were observed in the common areas on the first floor. The LPAs and staff toured the outside areas of the facility. The Assisted Living and Memory Care, contained 2 (two) courtyards for resident use. During today’s visit the LPAs observed two operational water fountains, one the promises. One fountain is located in the assisted living area and the other is situated withing the memory care unit. The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use. The facility maintained a comfortable temperature of 73 degrees. LPAs observed cameras throughout the common areas only. Facility provides sufficient space to accommodate both indoor and outdoor activities. Several fireplaces were observed throughout the facility adequately screened. KITCHEN: The main kitchen and dining room are located on the 1st floor. Food is prepared in the main kitchen and delivered to the dining area and the Memory Care dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPAs observed a minimum of two (2) days perishable and seven (7) days non-perishable foods. LPAs inspected refrigerator and pantry for expiration dates. LPAs observed a sufficient supply of emergency food and water. Continued on LIC 809-C Continued from LIC 809-C LPAs also reviewed the facility's Emergency Disaster Plan, which was observed to be complete and updated annually as required. Emergency Disaster drills are conducted monthly, with the last drill documented on 10/28/2024. During today’s visit LPAs obtained a copy of the facility’s LIC 500, resident roster and last emergency drill. RECORD REVIEW: Between 11:38 A.M and 1:14 P.M., LPAs reviewed 7 (seven) staff files and 7 (seven) resident files. Files were reviewed for, but not limited to: Physician's Reports, Personal Rights, Admission Agreements, staff training records, health screenings, TB tests, and background clearance. All files reviewed were observed to be in compliance with regulation. MEDICATIONS: Medication review began at 1:50 P.M. LPAs observed medications for 7 (seven) residents. All medications observed were stored and recorded in compliance with regulation. INTERVIEWS: Throughout today's visit, LPAs interviewed 5 (five) residents and 4 (four) staff members. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Nov 5, 2024

Allegation investigated: Staff hit resident(s)

Licensing Program Analyst (LPA), Valeria Conway conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. Upon arrival, LPA met with Administrator, Michael O’Neill, and the reason for the visit was explained. Entrance interview conducted. It was alleged that staff hit residents. The Reporting Party (RP) further stated that on 09/17/2024, Staff #1 (S1) swatted Resident #1 (R1) twice on R1s wrist while assisting R1 from the toilet to the wheelchair and that REsident #2 (R2) was swatted on the butt cheek after changing their diaper. Continued on LI 9099-C Unsubstantiated Continued from LIC 9099 On 09/27/2024, a Case Management – Incident visit was conducted by LPA Conway to follow up on two (2) separate self-reported Incident Reports (SIRs) submitted to the Department by the facility. It was reported that on 09/17/2024, S1 was observed swatting the wrist of R1 twice while assisting R1 from the toilet to the wheelchair. In a separate incident, S1 was observed swatting Resident #2 (R2) on the butt cheek after changing their diaper. During the visit, LPA Conway along with staff conducted a plant tour to ensure there were no health and safety concerns, conducted an interview with the Administrator at 12:00 P.M., conducted a resident file review starting at 1:15 P.M., and obtained copies of pertinent documents. On 10/02/2024, LPA Conway conducted an initial 10-day complaint visit. During the visit, LPA conducted interviews with two (2) staff members and attempted to interview S3. LPA was unable to get S3 statement During the visit, LPA was informed that Ventura County Sheriffs (VCS) office responded to the facility on 09/23/2024 to investigate the incidents. On 10/04/2024, LPA obtained and reviewed police reports received from VCS. Information gathered during the course of the investigation revealed that on 09/17/2024, S2 was being trained by S1. During that day, S2 observed S1 swatting two (2) dementia residents. S2 reported both incidents to Resident Care Director (RCD) on 09/22/2024. Facility self-reported these two (2) separate incidents to Community Care Licensing (CCL) on 09/23/2024. Both incidents identified S1 as the alleged aggressor. No injuries were noted on R1 or R2. R1 and R2 responsible parties were contacted. A review of the records and interviews conducted revealed that facility has a camera system in the memory care common areas. No cameras are installed inside residents’ rooms. On 09/17/2024, video recordings shows that three (3) staff members were inside R2’s room. S2 was the only eyewitness to come forward about these incidents. Administrator provided written statement by S2 to LPA. On 09/24/2024, LPA interviewed S1. S1 denied hitting residents and explained that caregiving is their passion and that they would never put hands on any residents. However, S3 provided a statement to facility’s Administrator and denies being in R2’s room with S1 and S2 during the incident. Continued on LIC 9099-C Continued from LIC 9099-C Further record review and interviews conducted revealed that facility’s Administrator and Human Resources staff conducted an internal investigation, including reviewing of video footage and interviews to caregivers. On the recording shows that S1, S2 and S3 entering and exiting R2’s room. No recording on allegations were captured. Review of police report revealed that local police responded to a called by facility’s Administrator on 09/23/2024 regarding a possible elder abuse incident. During police investigation, officer conducted interviews with Administrator and staff members. Due to lack of evidence, injuries and information during interviews conducted, officer did not believe that the crime of elder abuse took place during either incident. Based on the information gathered during the course of the investigation, the Department does not have sufficient evidence to determine that S1 swatted R1 and R2. Although the allegations may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time. No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was issued.the state’s words, verbatim · CDSS document, Oct 15, 2024 · control 29-AS-20240930113535

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced Case Management – Incident visit at 11:50 A.M. for the purpose of investigating self-reported incident reports. Upon arrival, LPA met with Executive Director (ED), Michael O’Niell, and explained the reason for the visit. Entrance interview conducted. The purpose of today's inspection is to follow up on two (2) self-reported incident reports that were submitted to the Woodland Hills Regional Office late on 09/23/2024. According to the reports, on 09/22/2024, Staff #1 (S1) reported to Staff #2 (S2) that they witnessed Staff #3 (S3) swatting Resident #1 (R1) on their wrist while transferring them from the toilet to their wheelchair. Additionally, it was also reported that S3 allegedly swatted Resident #2 (R2) on the bottom while assisting with a diaper change. During today's visit, the LPA toured the facility with ED, conducted interviews and gathered copies of pertinent documents and police report number. ED stated that police report is expected to be delivered in a few days. No immediate health and safety concerns were noted during today's facility tour. Further investigation is required at this time. An additional report may follow, if warranted. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 27, 2024

Allegation investigated: Staff did not provide assistance to resident in a timely manner

Licensing Program Analyst (LPA) Kelly Dulek conducted subsequent complaint investigation with the purpose of delivering findings for the allegation listed above. LPA arrived at the facility at 12:50PM and met with Executive Director (ED) Mike O’Neill. Entrance interview conducted. During the initial complaint visit, conducted on 01/17/2023, LPA interviewed ED Matthew Hathway at 02:55PM, toured the facility with ED Hathway at 03:32PM, conducted resident interview at 03:40PM, and LPA gathered copies of pertinent documents. No immediate health and safety hazards were identified during facility tour. Throughout the course of the investigation, LPA spoke both in person and telephonically with facility staff related to the complaint allegation, as well as other relevant parties. The following was then determined: Report Continued on LIC 9099-C Substantiated It was alleged that Resident #1 (R1) was escorted to their room after dinner and left in their wheelchair for a lengthy period of time, even when R1 verbally requested transfer assistance. Record review revealed that R1 does require transfer assistance and escorts. Needs and service appraisal and interview indicate that staff utilize a Hoyer lift, as well as a 2-person assist for all of R1’s transfers. In-service training records reflect that facility staff did receive training in using R1’s Hoyer lift, as well as training for R1’s service plan, which included additional status checks and transfer assistance. Interview with staff revealed that due to a personality complaint/conflict, Staff #1 (S1) was removed from R1’s direct care prior to receipt of the complaint. At the time of the alleged incident, there were 3 staff working – 1 (one) medication technician and 2 (two) care staff, including S1. As R1 is a 2-person assist, the other 2 (two) staff present were needed to assist R1 with their transfer out of their wheelchair following dinner. Interview revealed that the medication technician escorted R1 back to their room around 06:30PM, but there was no second staff available to assist with R1’s transfer at that time. R1 and staff indicated that no one returned to R1’s room until around 08:00PM, when the medication technician arrived to assist R1 with their scheduled medication. At that time again, only 1 (one) staff was present, so R1 was unable to be transferred. At approximately 08:30PM, R1’s family member arrived at the facility to discover that R1 had been transferred to their bed, instead of their recliner chair as requested. Interview with then-ED revealed that “we did blow it…per [R1]’s routine, [R1] should have been transferred back when [R1] was brought back to her room after dinner. The staff didn’t follow up after that to get her transferred.” Based on interview and record review, there is sufficient evidence to support the allegation, therefore the allegation that “staff did not provide assistance to resident in a timely manner” 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. 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, May 1, 2024 · control 29-AS-20230109102247

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: May 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...as specified in Section 87608, Postural Supports. 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 was not provided timely transfer assistance, which posed a potential health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 1, 2024

Plan of correction: During today's visit, LPA confirmed that training has been completed in basic services for care staff since the allegation. POC cleared.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 12:50PM for an unannounced annual continuation visit. Upon arrival, LPA was greeted by front desk staff. Shortly after arrival, LPA met with Executive Director (ED) Mike O'Neill. Entrance interview conducted. As a full facility tour was conducted during the initial annual inspection, during today's visit, LPA along with ED conducted a brief physical plant tour beginning at 01:29PM. The following was observed during today's visit: RECORD REVIEW: LPA reviewed 5 (five) staff files and 5 (five) resident files. Files were reviewed for, but not limited to: Physician's Reports, Personal Rights, Admission Agreements, staff training records, health screenings, TB tests, and background clearance. All files reviewed were observed to be in compliance with regulation. MEDICATIONS: Medication review began at 02:39PM. LPA observed medications for 3 (three) residents. All medications observed were stored and recorded in compliance with regulation. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, May 1, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 10:10AM for an unannounced annual inspection. Upon arrival, LPA met with Interim Executive Director (ED) Justine Ortiz. Entrance interview conducted. Beginning at 10:35AM, the LPA along with Interim ED, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: 5-Year fire sprinkler inspection was completed on 09/15/2023. No safety concerns were noted at that time. Fire extinguishers throughout the building were observed to be fully charged and last serviced on 09/15/2023. MEMORY CARE: Memory Care is located on the first floor and has 18 (eighteen) rooms. Resident bedrooms are single and double occupancy with private bathrooms. A random sampling of 3 (three) resident rooms were observed to be furnished appropriately. Bathrooms were observed to be safe and sanitary with grab bars and non-skid mats. Hot water was measured in a sample of observed resident rooms and tested within the required range of 105 to 120 degrees Fahrenheit. Medications for the memory care unit are centrally stored and locked in the medication room. The indoor and outdoor areas of the memory unit are secured with a delayed egress system, which functioned properly during the visit. There are two outdoor gated courtyards designated for Memory Care. LPA observed sufficient outdoor furnishings and shaded outdoor space. KITCHEN: The main kitchen and dining room are located on the 1st floor. Food is prepared in the main kitchen and delivered to the dining area and the Memory Care dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPA observed Report Continued on LIC 809-C sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day emergency supply of food and water. COMMON AREAS: The facility is a two story building. The facility contains multiple common areas, which were all observed to be clean, furnished appropriately and in good condition at the time of the visit. There were no obstructions and/or tripping hazards throughout the facility. All required postings were observed in the common areas on the first floor. Carbon monoxide detectors were tested throughout the building and all functioned properly. The LPA and Interim ED toured the outside area of the Assisted Living, which contains 2 (two) courtyards for resident use. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. RESIDENT ROOMS: There are 60 Assisted Living units and can be found on the first and second floors of the building. Assisted Living units are equipped with a refrigerator, sink, and microwave and contain private restrooms. A random selection of 7 (seven) resident rooms were observed. Residents rooms were observed to be furnished appropriately and contained appropriate bedding/linens. Bathrooms were observed to be safe and sanitary with grab bars and non-skid mats. Water temperature was checked in multiple randomly selected rooms in the Assisted Living unit and measured within the required range of 105 to 120 degrees Fahrenheit. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's Emergency Disaster Plan, which was observed to be complete and updated annually as required. Emergency Disaster drills are conducted monthly, with the last drill documented on 10/15/2023. RECORD REVIEW: Will be completed during the annual continuation. MEDICATIONS: Will be reviewed during the annual continuation. INTERVIEWS: Throughout today's visit, LPA interviewed 4 (four) residents. Exit interview conducted with Interim ED. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Nov 9, 2023

Allegation investigated: Staff failed to supervise resident resulting in falls and injuries Facility is overcharging for care

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 10:22AM and met with Interim Executive Director (ED) Justine Ortiz. Entrance interview conducted. During today's visit, LPA toured the facility with ED at 11:02AM. LPA obtained copies of pertinent records and conducted an interview with staff at 11:38AM. Previously, during an intial complaint visit conducted on 11/12/2021, LPA toured Memory Care with Executive Director and Memory Care Director Julie Downs. LPA conducted staff and third party care provider interviews between 2:30PM and 3:40PM, and obtained copies of documents pertinent to the investigation. Throughout the course of the investigation, LPA reviewed all relevant documents. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: "Staff failed to supervise resident resulting in falls and injuries:" It was alleged that Resident #1 (R1) was not provided proper supervision, resulting in a fall. R1 had been residing at the facility since 2017. Review of records prior to R1's fall revealed that R1 did require frequent checks during the PM shift and used a walker to ambulate. R1 required assistance with most ADL care, as well as escort services to meals and activities. R1's needs and service appraisal indicated R1 required frequent reminders. On 10/17/2021, at approximately 06:30PM, R1 called for help. When staff entered R1's room, they found R1 on the floor near their restroom, but with their walker next to their bed. R1 sustained a fracture to their left ankle and was hospitalized. Staff interviews revealed that R1 was on a 2-hour check and had been last observed when they were escorted back to their room following dinner. R1 is typically escorted back to their room between 05:30PM and 06:00PM, so staff would return to check on R1 between 07:30 and 08:00PM. R1's fall occurred at 06:30PM, between scheduled checks. Staff interviewed indicated that R1 does require a walker to ambulate, but R1 would frequently forget to use the walker and forget to request staff assistance. R1's needs and service appraisal, as well as physician's report did not indicate R1 required constant supervision, only "two hour checks throughout the night." Therefore, based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation that "staff failed to supervise resident resulting in falls and injuries" is deemed UNSUBSTANTIATED at this time. Allegation: "Facility is overcharging for care:" The complaint alleges that following R1's fall that R1 required additional care and supervision through a private caregiver and R1 and their responsible party must pay the cost for this service. R1's physician's report indicating R1's status post-fall indicates R1 requires a 24-hour caregiver. According to the facility's admission agreement "if you require one-on-one supervision because you are a danger to yourself or others, we may require that you obtain such supervision at your own expense." The facility assisted R1's responsible party in obtaining outside supervision services for R1. Interviews revealed that the private help was only there to supervise R1 to ensure R1 remained non-weight bearing for the duration of R1's recovery. The facility staff still met all of R1's ADL care needs as outlined in R1's needs and service appraisal. Staff interviewed indicated that the additional one-to-one was there only for reminders. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that "facility is overcharging for care" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 29-AS-20211104135846