Alta Vista Simi #2

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Administrator Emil Siapno arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area at approx. 10:00 a.m. Knives and sharp objects are stored in a locked drawer to the right of the stove. No cleaning supplies were observed stored in the kitchen area. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Office area located in the kitchen. At the time of the visit, the common area furniture's were observed to be in good condition. Medications and a sufficient supply of PPE and toiletries were observed stored inaccessible to residents in care in a closet at the entry way. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last purchased in 05/01/2025. The LPA observed four (4) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. LPA observed hallway cabinets to store various electronic equipment, flashlights and other supplies for emergency use. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care. LPA observed garage to have an additional fridge to store extra perishable food. LPA also observed a laundry area, a sufficient supply of clean linen and towels, laundry supplies securely stored, extra incontinent supplies, PPE , canned goods, emergency food supply as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction. There were no bodies of water over 3ft noted at the time of the visit. LPA observed a storage shed behind a locked gate that stored extra furniture and equipment for facility use. LPA also observed a small tool shed behind the locked gate that stored various gardening tools. At 10:51am staff was observed mopping floors. Records review, six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. Medication review, medications for all residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Infection control / Emergency Disaster plan: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 08/03/2026 The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. Smoke detectors and carbon monoxide detectors were tested, all alarms were functional at the time of the visit. During today’s visit LPA updated the facility mailing address, Administrator and telephone number. LPA also obtained a copy of the facility’s LIC 500, resident roster and Limited Liability insurance. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 1, 2026

Allegation investigated: Facility staff did not assist resident with ambulating Facility staff spoke inappropriately to resident Staff did not provide adequate food service for residents

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to investigation the allegations listed above. Upon arrival LPA met Administrator Emiliano C Siapno and explained the reason for the visit. On 11/07/2025, LPA conducted an initial 10-day complaint visit to investigate the allegations listed above. At approximately 10:00 a.m. LPA conducted physical plant, interviewed staff, residents, families / responsible parties of residents in care and reviewed and obtained copies of pertinent documentation relevant to the investigation. Today LPA conducted physical plant, interviewed staff, residents, families / responsible parties of residents in care. It was reported that “Facility staff did not assist resident ambulating” as it was alleged that staff are not assisting Resident #1 (R1) with using the restroom. LPA’s interview with six (6) residents during the investigation reflected that none of the (6) residents reported concerns about staff failing to assist them with toileting or incontinence care. All (6) residents stated they have not been left in soiled diapers or clothing for an extended period of time. Unsubstantiated LPA was unable to effectively communicate with one (1) resident. LPA interviewed four (4) staff members. Staff reported that residents are typically asked if they need to use the restroom or have their diapers checked before each shift, before and after meals, before and after snacks, and before going to bed. Staff stated that R1 is encouraged to request assistance with using the restroom; however, at times when R1 requested assistance they already had urinated or had a bowel movement. LPA also interviewed five (5) residents’ family members or responsible parties. None of the (5) individuals did not report any concerns about staff failing to assist residents with toileting or incontinence care in a timely manner. 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 violations did or did not occur, therefore the above allegations "Facility staff did not assist resident with ambulating " has been deemed Unsubstantiated at this time. It was reported that “Facility staff spoke inappropriately to resident” It was alleged that staff told R1 to “shut up.” LPA’s interview six (6) residents during the investigation revealed one (1) resident stated they were not comfortable ringing a bell to request assistance, however when they do request assistance by other means staff attend to them in a timely manner. All (6) residents also reported they have not observed staff speak inappropriately to residents and did not express any concerns about staff speaking inappropriately or discouraging residents from requesting assistance. LPA was unable to effectively communicate with one (1) resident. LPA’s interview with four (4) staff members revealed all (4) Staff reported they have not observed any staff speak inappropriately to residents and have not observed staff deny assistance to residents when requested. LPA also interviewed five (5) residents’ family members or responsible parties. None of the (5) individuals expressed concerns about staff speaking inappropriately to residents in care. 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 violations did or did not occur, therefore the above allegations " Facility staff spoke inappropriately to resident” has been deemed Unsubstantiated at this time. It was reported that “Meals are not provided in a timely manner” as It was alleged that meals are not provided to residents at typical meal times. LPA interviewed six (6) residents during the investigation. One (1) resident stated they receive their meals "long after" typical meal times, but also indicated they can't recall what time the meals were served or when this occurred. Continued from 809-C The other (5) residents reported they have not experienced delays in meal service and did not express concerns about meals being provided at inconsistent times. LPA was unable to effectively communicate with one (1) resident. LPA interviewed four (4) staff members. Staff stated that meals are typically served at approximately 7:30 a.m., 12:00 p.m., and 5:30 p.m., with snacks offered between meals. Staff reported that residents are asked if they would like to eat when meals are offered and that some residents occasionally choose to eat later than the scheduled meal time depending on how much they ate during their previous meal time. LPA also interviewed five (5) residents’ family members or responsible parties. None of the (5) individuals expressed concerns regarding residents not receiving meals in a timely manner. 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 violations did or did not occur, therefore the above allegations " Meals are not provided in a timely manner”” has been deemed Unsubstantiated at this time. During the visit Administrator Emiliano C Siapno stated they had leave to attend to an urgent matter, but stated staff can sign in their place. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 29-AS-20251106115359

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Administrator Brenda Siapno arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area at approx. 09:40 a.m. Knives and sharp objects are stored in a locked drawer to the right of the stove. No cleaning supplies were observed stored in the kitchen area. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Office area located in the kitchen. At the time of the visit, the common area furniture's were observed to be in good condition. Medications and a sufficient supply of PPE and toiletries were observed stored inaccessible to residents in care in a closet at the entry way. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last purchased in 05/01/2025. The LPA observed four (4) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. LPA observed hallway cabinets to store various electronic equipment, flashlights and other supplies for emergency use. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care. LPA observed garage to store an additional fridge to store extra perishable food. LPA also observed a laundry area, a sufficient supply of clean linen and towels, laundry supplies securely stored, extra incontinent supplies, PPE , canned goods, emergency food supply as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction. There were no bodies of water over 3ft noted at the time of the visit. LPA observed a storage shed behind a locked gate that stored extra furniture and equipment for facility use. LPA also observed a small tool shed behind the locked gate that stored various gardening tools. Records review began: six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Four (4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time . Medications review: medications are centrally stored and locked inside an entry way closet. All medications including PRNs were labeled, stored and locked inaccessible to individuals. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during medications review at this time. During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Smoke detectors were tested and all functional at the time of the visit. Carbon monoxide detectors are wired and operational at the time of the visit. Emergency disaster drills conducted quarterly as per regulation; the last one conducted was a fire drill on 08/05/2025. LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, and facility’s liability insurance Interview conducted during the visit. Exit interview conducted. A copy of the report was provided to the Administratorthe state’s words, verbatim · CDSS document, Sep 25, 2025

Allegation investigated: Staff left a resident unattended outside during inclement weather

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with House Manager Trish Talastas and explained the reason for the visit. On 03/27/2025, the initial complaint visit was conducted by LPA between approximately 10:00 a.m. - 12:30 p.m. During the visit, LPA’s conducted physical plant, interviewed staff as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. Today LPA interviewed staff. It was reported that " Staff left a resident unattended outside during inclement weather" as it was alleged that staff brought Resident #1 (R1) to sit outside and did not bring R1 back inside the home in a timely manner when it was raining and windy. Interviews and record reviews showed that part of R1’s daily routine was to sit outside under the gazebo from about 1:00 p.m. to 4:00 p.m. The only time R1 did not want to go outside during this period was on Sundays during football season. Unsubstantiated Continued from 9099 On February 13, 2025, at around 1:00 p.m., R1 asked staff to take them outside to the gazebo, even though it was observed to be a light rain. R1 kept asking to go outside, and at approx 02:10 p.m. staff eventually agreed to take R1 outside. Staff said R1 was wearing a fleece jacket, UGG slippers, and a blanket. A family member / responsible party of R1 stated that R1 attempted to contact them at approx. 01:30 p.m. but they missed R1’s call. Between approx 03:15 a.m. - 3:30 p.m., a family member of R1 came to the facility and told staff that R1 had contacted them wanting to come inside. The family member saw R1 sitting under the gazebo and asked staff to bring R1 back inside. At that time the rain and wind were observed to be getting worse. In an interview with R1, they confirmed they had asked staff to bring them outside under the gazebo despite the weather. R1 said they felt properly dressed for the weather in their fleece jacket and other warm clothes but didn’t remember having a blanket. R1 also explained that they usually use their bell to ask staff for help, but they didn’t ring it while they were outside. R1 also stated they do not recall if staff checked on them during that time. When interviewed, staff said they checked on R1 at approx 02:15 p.m. and 02:30 p.m. In addition, staff also stated they observed R1 from the living room window and waited for R1 to ring their bell for assistance. 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 violations did or did not occur, therefore the above allegation, “Staff left a resident unattended outside during inclement weather" is deemed Unsubstantiated at this time Exit interview conducted and a copy of report issuedthe state’s words, verbatim · CDSS document, Apr 24, 2025 · control 29-AS-20250320140155

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Administrator Emiliano C Siapno arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area at approx. 12:05 p.m. Knives and sharp objects are stored in a locked box in a locked drawer to the right of the stove. No cleaning supplies were observed stored in the kitchen area. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Office area located in the kitchen. At the time of the visit, the common area furniture's were observed to be in good condition. Medications and a sufficient supply of PPE and toiletries were observed stored inaccessible to residents in care in a closet at the entry way. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last purchased in July of 2024. The LPA observed four (4) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. LPA observed hallway cabinets to store various electronic equipment, flashlights and other supplies for emergency use. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care. LPA observed garage to store an additional fridge to store extra perishable food. LPA also observed a laundry area, a sufficient supply of clean linen and towels, laundry supplies securely stored, extra incontinent supplies, PPE , canned goods, emergency food supply as well as additional furniture and medical equipment for facility use. Continued from 809 The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction. There were no bodies of water over 3ft noted at the time of the visit. LPA observed a storage shed behind a locked gate that stored extra furniture and equipment for facility use. LPA also observed a small tool shed behind the locked gate that stored various gardening tools. Records review began at approx. 12:30 p.m. , six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Three (3) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time . Last emergency disaster drill was conducted on August 5, 2024 Medications review began at approx. 01:30 p.m. All medications including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time. Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. Interviews were conducted during the visit. Exit interview conducted. A copy of the report was provided to the Administratorthe state’s words, verbatim · CDSS document, Sep 11, 2024