Angels II

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

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced cased management – legal/non-compliance visit. LPA met with staff and explained the reason for the visit. Licensee Joann Trupiano arrived shortly after. The LPA focused today’s visit on ensuring there are no health and safety hazards and to ensure the facility is maintaining substantial compliance per Stipulation CDSS No. 6124211301-C , Subject ID No. 7501152976 ordered on 05/29/2026. At approx 10:30 a.m. conducted a walk through of the facility. Resident rooms were observed to be furnished appropriately with sufficient lighting. One (1) resident was eating watermelon at the dining table and another resident was in the living room with a family member. Resident bathrooms were sufficiently stocked with supplies and paper towels. Hot water temperature measured within 105- and 120-degrees Fahrenheit. Fire extinguishers were observed fully charged and last serviced on 06/09/2026. The facility has a sufficient supply of perishable and non-perishable food. No obstructions or hazards were observed inside or out. Facility was observed to be clean and in good repair. LPA reviewed four (4) resident records for appraisals, medical records, admissions agreement, consent forms. At approx 11:40 a.m., LPA resident records review of Resident #1's Physician's Report dated 07/24/2026 revealed that R1 has a prohibited health condition. R1 is not on hospice and no exception has been requested at this time. Four (4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training. All staff files were observed to be in order at this time. In addition the following was observed during the visit: Stipulations posted on bulletin board in dining area. Incident reports current and sent to regional office. Medications properly stored inaccessible to residents in care. Staff training's on facility protocols completed by staff and Administrators in May 2026. Mental Health Assessments Training completed by staff and Administrators on 06/24/2026 Medications Training completed by staff and Administrators on 06/27/2026. Alzheimer's Disease Training parts 1 - 5 completed by staff and Administrators between 07/20/2026 to 07/23/2026 Alzheimer's Disease Training part 6 completed by staff and Administrators on 08/12/2026 Additional required training's will be completed with Relias. Licensee / Administrator completed Administrator Qualifications and Duties between 06/04 - 06/22. 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.) Licensee was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were providedthe state’s words, verbatim · CDSS document, Aug 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(5) · Plan of correction due date: Aug 26, 2026

(a)Persons who require health services for or have a health condition including...(5)Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement is not met as evidenced by: Based on interview and record review, the facility did not comply with the above cited section, as R1 was retained in the facility with a prohibited health condition, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: Licensee agreed to work with R1's family on options to admit to hospice or apply for an exception. Licensee also agreed to review section cited and provide a written plan to ensure future compliance then send to LPA via email by POC date.

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. Licensee Joann Tripuano 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. 09:45 a.m. Knives and sharp objects are stored inaccessible in the garage. Cleaning supplies were observed kept inaccessible underneath the sink. 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. Staff room was located next to the kitchen. It was observed empty and inaccessible at this time. Dining area was observed to be clean and furniture appeared to be in good condition. LPA observed facility files and medication properly stored inaccessible in a cabinet next to the dining area. There is an attached garage. LPA observed garage to be inaccessible to residents in care. LPA observed additional freezer to store extra perishable food. LPA also observed additional non-perishable supplies, PPE, extra incontinent supplies, as well as additional furniture and medical equipment for facility use. Emergency food and emergency supplies were observed stored in (2) barrel containers. Laundry area was located in the garage as well. At the time of the visit, the common area furniture's were observed to be in good condition. A sufficient supply of clean linen and towels were observed stored in the hallway cabinets. 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 serviced 06/03/2025. LPA observed four (4) resident bedrooms total. Resident bedrooms were observed furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bathrooms were observed to be 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 between 105 - 120 degrees Fahrenheit. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings posted on a bulletin board in the dining area. The backyard has a covered outdoor area equipped with furniture including tables and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted at the time of the visit Records review four (4) 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. During review , at approx 11:10 a.m. LPA observed that Staff #1 (S1) has a criminal record clearance, but is not associated to the facility. 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. At approx 01:15 p.m. during review of Special Health Needs, LPA observed Resident #1 (R1) has full bed rails, but is not on hospice. 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 to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 02/27/2026. 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 or licensee. Smoke detectors and carbon monoxide detectors are tested monthly and were functional at the time of the visit. continued from 809-C LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the facility’s liability insurance. Interviews were conducted during the visit. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). Civil penalty in the amount of $500 is assessed today. The Licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, appeal rights and copy of report issued.the state’s words, verbatim · CDSS document, Mar 11, 2026

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

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced cased management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with staff and explained the reason for the visit. Licensee Joann Trupiano arrived shortly after. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At approx 01:45pm conducted a walk through of the facility. Resident rooms were observed to be furnished appropriately with sufficient lighting. Three (3) residents was observed to be sleeping during the visit and the other two (2) residents were relaxing in their room. Resident bathrooms were sufficiently stocked with supplies and paper towels. Hot water temperature was measured. Water temperature measured within 105- and 120-degrees Fahrenheit. Fire extinguishers were observed fully charged and last serviced on 06/03/2025. The facility has a sufficient supply of perishable and non-perishable food. No obstructions or hazards were observed inside or out. LPA observed a cleaning company arrive to deep clean the floors. LPA’s reviewed five (5) resident records for appraisals, medical records, admissions agreement, consent forms. All records were observed to be in order at this time. No deficiencies issued. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, Feb 3, 2026

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

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced cased management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with staff and explained the reason for the visit. Joann Trupiano was contacted, but could not be onsite during the visit. They stated Rolando could sign the report for them. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At approx 12:18pm conducted a walk through of the facility. Resident rooms were observed to be furnished appropriately with sufficient lighting. Four (4) residents were observed to be sleeping during the visit. One (1) resident was watching television and (1) resident was relaxing in their room. Resident bathrooms were sufficiently stocked with supplies and paper towels. Hot water temperature was measured. Water temperature measured within 105- and 120-degrees Fahrenheit. Fire extinguishers were observed fully charged and last serviced on 06/03/2025. The facility has a sufficient supply of perishable and non-perishable food. No obstructions or hazards were observed inside or out. LPA observed a cleaning company arrive to deep clean the floors. LPA’s reviewed staff Records at 12:40 p.m. 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 records were observed to be in order at this time. No deficiencies issued. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, Jul 1, 2025

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. Licensee Joann Tripuano and Administrator Tony Tripuano arrived during the visit. 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. 09:45 a.m. Knives and sharp objects are stored inaccessible in a cabinet underneath the sink. Cleaning supplies were observed kept inaccessible underneath the sink as well. 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. Staff room was located next to the kitchen. It was observed empty and inaccessible at this time. Dining area was observed to be clean and furniture appeared to be in good condition. LPA observed facility files and medication properly stored inaccessible in a cabinet next to the dining area. There is an attached garage. LPA observed garage to be inaccessible to residents in care. LPA observed additional freezer to store extra perishable food. LPA also observed additional non-perishable supplies, canned goods, PPE, extra incontinent supplies, as well as additional furniture and medical equipment for facility use. Laundry area was located in the garage as well. At the time of the visit, the common area furniture's were observed to be in good condition. A sufficient supply of clean linen and towels were observed stored in the hallway cabinets. 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 serviced 04/08/2024. LPA observed four (4) resident bedrooms total. Resident bedrooms were observed furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bathrooms were observed to be 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 between 105 - 120 degrees Fahrenheit. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings posted on a bulletin board in the dining area. The backyard has a covered outdoor area equipped with furniture including tables and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted at the time of the visit. Records review began at approx. 10:00 a.m. Six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. At approx. 10:45 a.m. 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 records were observed to be in order at this time. Medications review began at approx. 12:45 p.m. All medications including PRNs were labeled, properly stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time. At approx. 01:30pm, LPA discussed 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 at this time. The LPA brought a copy of Accusation /CDSS No 6124211301 / CDSS no 6124211301B / CDSS no 6124211301C / CDSS no 6124211301D and reviewed the contents alongside Licensee and staff. The LPA also provided information pertaining to Health and Safety Code 1569.38 regarding posting and notification requirements. The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the facility’s liability insurance. Interviews were conducted during the visit. Exit interview conducted, discussed and copy of report issued.the state’s words, verbatim · CDSS document, Mar 21, 2025

Type of visit: Case Management - Other

On 12/12/2024, Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management visit to issue a civil penalty per Health and Safety Code §1569.49(e). Upon arrival LPA met with staff Honorata Perla Avestro and explained the reason for the visit. Administrator Joann Trupiano was contacted and stated they were unable to be on site for the visit, but stated Honorata Perla Avestro could sign in their place. On May 4, 2023, the Department received a complaint alleging failure to seek timely medical attention and questionable death. Resident #1 (R1) sustained an unwitnessed fall at the facility and staff delayed contacting emergency services. R1 was transported to the hospital and died the next day. The Department initiated the complaint investigation on May 5, 2023. On April 18, 2024, the allegations were substantiated, and the licensee was cited for violating California Health and Safety Code Section 1569.312(a) Basic Services Requirements as it was determined facility staff did not properly supervise R1. The improper supervision of R1 resulted in R1 falling and sustaining a traumatic subdural hematoma, resulting in death. The licensee was also cited under California Code of Regulations (CCR) Title 22, Section 87465(g) Incidental Medical and Dental Care, as it was determined facility staff did not seek timely medical attention when R1 fell and sustained facial and head injuries; yet was put to bed. The investigation revealed that R1 was admitted to Angels II on April 19, 2022, after discharge from a skilled nursing facility. The discharge summary indicated that R1 needs assistance with activities of daily living, supervision/assistance during meals, ambulation, and transfer. Since admission, R1 suffered a total of four unwitnessed falls. On January 17, 2023, R1 was brought to a local hospital by the Sheriff’s with a chief complaint of hip pain. Facility staff left R1 at the facility’s backyard unsupervised and R1 wandered off into the community. On April 12, 2023, R1 suffered a second unwitnessed fall, staff noticed a bump on their forehead and bruising started to appear around their left eye. Continued from 809 R1 was asked to start using their walker. Licensee had identified that R1 “has severe dementia and memory issues, trying to encourage R1 to use a walker is difficult. Caregivers are using standby assistance when R1 is ambulating around the house. R1 is very dependent and has to be observed at all times”. On April 22, 2023, R1 informed responsible person that they fell overnight, this incident was not reported to the Department or the responsible person. At around 9 a.m. on April 25, 2023, information obtained revealed that R1 suffered another unwitnessed fall. Facility staff informed home health agency and was advised to contact 9-1-1 immediately at around 9:30 a.m. The unusual incident sent to the Department identified the fall to occur at around 10:30 a.m. The Electronic Patient Care Report confirmed "dispatch notified" occurred at 10:52 a.m. on April 25, 2023, when R1 was sent to a local hospital. It was notated on hospital records that the reason of the visit was an unspecified intracranial injury. R1 was found unresponsive at the facility. Staff did not follow directions of home health to contact 9-1-1 immediately until R1’s responsible person arrived and observed that R1 was unconscious. The licensee/administrator and staff admitted that calling 9-1-1 was applicable only after a non-medically trained staff conducted an evaluation of a resident’s visible or non-visible injuries. Facility staff also informed the responsible person that 9-1-1 was not called as the cost is not covered by “social security”. The medical staff at the hospital documented that R1 "did not regain consciousness" while at the emergency department. R1 was discharged to "Hospice" on April 26, 2023, early in the day before passing away on that same day. Per the Ventura County Medical Examiner Autopsy Report, the cause of death was listed as subdural hematoma due to blunt force head trauma. At the time of the case management visit on April 18, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in the death of R1 due to lack of care and supervision. This is evidenced by the licensee’s failure to address R1’s increased care needs which resulted in the multiple falls of R1, which ultimately led to the death of R1. Continued from 809-C Today, 12/12/2024, the Department is issuing a civil penalty per Health and Safety Code §1569.49(e) in the amount of $15,000 for a violation that the Department determined resulted in the death of R1. However, since an immediate civil penalty of $500 was previously issued on April 18, 2024, the amount of the civil penalty issued is reduced to $14,500. A copy of the LIC 421D was given to the Honorata Perla Avestro and originals were signed. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Honorata Perla Avestro signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Dec 12, 2024

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

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with staff "Perla" Avestro and explained the reason for the visit. Joann was contacted, but could not be onsite during the visit. They stated Perla could sign the report for them. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At approx 2:15pm LPA conducted a walk through of the facility. LPA inspected three (3) resident bedrooms. Resident rooms were observed to be furnished appropriately with sufficient lighting. Resident bathrooms were sufficiently stocked with supplies and paper towels. Hot water temperature was measured. Water temperature measured within 105- and 120-degrees Fahrenheit. Fire extinguishers was observed fully charged and last serviced on 04/08/2024. The facility has a sufficient supply of perishable and non-perishable food. No obstructions or hazards were observed inside or out. LPA reviewed Resident Records at 02:30 p.m. Three (3) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order at this time. No deficiencies issued. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, Dec 10, 2024

Allegation investigated: Questionable death. Facility staff failed to seek medical attention for resident in a timely manner. Resident sustained unknown injury while in care. Resident left the facility unassisted.

Licensing Program Analyst (LPA) conducted a subsequent complaint visit to deliver findings for the above allegation. Upon arrival LPA met with staff. Staff contacted Licensee/Administrator Joann Trupiano. LPA spoke with Mrs. Trupiano and explained the reason for the visit. Report was reviewed with Mrs. Trupiano. Mrs. Trupiano stated that staff may sign for the report as she could not make it to the facility. On 05/04/2023, the Department received a complaint alleging the facility failed to seek timely medical attention and questionable death of Resident #1 (R1). R1 sustained an unwitnessed fall at the facility and staff delayed contacting emergency services. R1 was transported to the hospital and died the next day from the injuries sustained from the fall. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Edward Hector. The case was also referred to and reviewed by the Departments Program Clinical Consultant (PCC) Paul Chua. On 05/05/2023, from 11:45 a.m. to 1:10 p.m., LPA Emily Peraldi conducted an unannounced 10-day initial complaint visit at the facility. (Continue to LIC9099c) Substantiated At 11:45 a.m. LPA Peraldi met with facility staff and explained the reason for the visit. Between 11:51 a.m. and 12:25 p.m. the LPA interviewed three (3) out of five (5) residents and one (1) staff. At 11:55 a.m., the LPA conducted a telephonic interview with the licensee/administrator. At 12:15pm the LPA obtained copies of pertinent documents. No immediate health and safety concerns were observed during the inspection. On 07/18/2023, from 3:12 p.m. to 5:57 p.m., Investigator Hector conducted interviews with R1’s resident representatives, staff, Simi Valley Police Department Detective, and the licensee/administrator; and on 08/29/2023, at 1:55 p.m., with the home health case manager. In addition, Investigator Hector reviewed Simi Valley Police Department (SVPD) report, Reliance Home Health report, and Los Robles Regional Medical Center report, Ventura County Medical Examiner Autopsy report, photos of R1’s injuries, and other facility file documents related to R1. The investigation revealed that R1 was a fall risk and had a history of falls. According to the medical records, R1 was transported via ambulance to the Los Robles Regional Medical Center and admitted on April 25, 2023, at 11:25 a.m. R1’s "reason for visit" diagnosis documented an unspecified intracranial injury. The admitting diagnosis included Dementia, Hypertension, and an "unwitnessed ground level fall." The chief complaint listed an unknown reason for fall, face injury, head injury, and loss of consciousness. The Electronic Patient Care Report confirmed "dispatch notified" occurred at 10:52 a.m. on April 25, 2023. The medical records stated R1 was found unresponsive at residential care facility. In addition, R1 had a "fall about 3 days prior with facial bruising but was not brought into the hospital at that time." Moreover, R1 had been, "having more frequent falls lately." R1 had a DNR/DNI with comfort measures only. The medical staff documented that R1 "did not regain consciousness" while at the emergency department. R1 was discharged to "Hospice" on April 26, 2023, early in the day before passing away on that same day. Per the Ventura County Medical Examiner Autopsy Report, the cause of death was listed as subdural hematoma due to blunt force head trauma. Contributing: Unspecified Dementia. Manner of Death: Accident. According to the SVPD report, R1’s resident representative reported that on 04/25/2023, at approximately 9:58am, R1’s other resident representative, received a phone call from facility Staff #1 (S1). S1 advised that R1 had slipped from their walker and fallen. (Continue to LIC9099c.) R1 suffered an injury to their lip as well as a bloody nose. At approximately 10:30am, R1’s resident representative was able to respond to the facility to check on R1, who was in bed. R1 was unconscious and unresponsive. 911 was called and R1 was transported to the hospital by ambulance. While at the hospital, it was discovered R1 was suffering from a brain bleed. R1 ultimately passed away on 4/26/2023 at approximately 8:30am while receiving treatment at the hospital. R1’s resident representative recalled seeing a pink towel in R1’s room that was saturated with blood. Furthermore, R1’s resident representative stated no one at the facility called 911 prior to R1’s resident representative asking staff to do so. No one was monitoring R1 after R1 had fallen and suffered a head injury. According to the Reliance Home Health Care Coordination report, S1 called the home health case manager to inform that R1 sustained a "witnessed fall" around 9:00 a.m. on April 25, 2023. S1 also reported that R1 had "nosebleeds which S1 was able to stop." The report confirms that "the clinician supervisor instructed S1 to call 911 emergency services immediately." The "Date and Time of Orders" was listed as "4/25/23 9:30 a.m." On the allegation “Questionable death”. R1 had an unwitnessed fall at the facility, was transported to the hospital, and died the next day from the injuries sustained from the fall. The medical records and coroner's report confirm that the cause of death was directly linked to the injuries suffered by R1 while at the facility. Moreover, R1 had a history of unwitnessed falls that the facility failed to address by increasing R1’s level of supervision. The Department found sufficient evidence to support the allegation of a lack of supervision resulted in the death of R1. Therefore, the allegation is deemed Substantiated at this time. On the allegation “Facility staff failed to seek medical attention for resident in a timely manner”. The investigation noted discrepancies related to the time of the fall and some staff statements were contradictory. All the information obtained during interviews revealed that there was a delay in staff initially responding to R1 who had taken a fall, there was no immediate call for emergency services, there was no call for emergency services after observing injuries related to R1’s head, and staff only called once R1’s resident representative arrived and observed the condition of R1. Moreover, the licensee/administrator and staff admitted that calling 911 was applicable only after a non-medically trained staff conducted an evaluation of a resident’s visible or non-visible injuries. The Department found sufficient evidence to support the allegation “Facility staff failed to seek medical attention for resident in a timely manner”. Therefore, the allegation is deemed Substantiated at this time. (Continue to LIC9099c.) On the allegation “Resident sustained unknown injury while in care”. The investigation noted that R1 had a history of unwitnessed falls that the facility failed to address by increasing R1’s level of supervision. R1 had a fall about 3 days prior to the 04/25/2023 fall incident with facial bruising but was not brought into the hospital at that time. The Department found sufficient evidence to support the allegation “Resident sustained unknown injury while in care”. Therefore, the allegation is deemed Substantiated at this time. On the allegation “Resident left the facility unassisted”. The investigation noted that R1 did leave the facility unassisted on 01/17/2023. R1 was left in the backyard unassisted, where R1 was able to walk out the side gate and wandered away from the facility undetected. Staff went looking for R1 and were unable to find R1. R1 was located by law enforcement and transferred to the hospital for evaluation. The Department found sufficient evidence to support the allegation “Resident left the facility unassisted”. Therefore, the allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Licensee/Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 29-AS-20230504133547

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Apr 19, 2024

§1569.312(a) Basic services requirements. Basic services shall at a minimum include:(a)Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff did not supervise R1 which resulted in R1’s fall, sustaining traumatic subdural hematoma, resulting in death, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2024

Plan of correction: Licensee will submit a plan how you will ensure appropriate care and supervision to residents. Submit to CCL by due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Apr 19, 2024

Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff did not seek timely medical care when R1 fell and sustained facial and head injuries, yet was put to bed, which posed an immediate health and safety risk to resident in carethe state’s words, verbatim · CDSS document, Apr 18, 2024

Plan of correction: Licensee will submit a plan how you will ensure residents receive timely medical care. Submit to CCL by due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(5) · Plan of correction due date: Apr 19, 2024

(f) Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c (5) Regular observation of the resident's physical and mental condition..... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above.Facility staff failed to assess R1 completely for fall prevention and develop a service plan as R1 had a history of falls with visible injuries noted, which posed an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Apr 18, 2024

Plan of correction: Licensee will submit a plan how they will ensure appropriate care and supervision to residents. Submit to CCL by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 19, 2024

Additional Personal Rights of Residents in Privately Operated Facilities.Residents shall have all of the following....: To care, supervision, and services that meet their individual needs........ This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 was not properly supervised which led to an elopement, which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2024

Plan of correction: Licensee will submit a plan how they will ensure appropriate care and supervision to residents. Submit to CCL by due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management - Deficiencies visit due to deficiencies observed during the investigation related to complaint control 29-AS-20230504133547. Licensee/Administrator did not comply with reporting requirements when resident #1 (R1) eloped from facility on 01/17/2023. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency were cited (refer to LIC 809-D): Exit interview conducted. Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 18, 2024

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

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.. This requirement was not met as evidenced by: Based on records review, R1 eloped from the facility on 01/17/2023, however this incident was not reported to CCL timely, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2024

Plan of correction: Licensee will submit a plan how they will ensure reporting requirements are met. Submit to CCL by due date

Allegation investigated: Staff are not providing responsible party with access to resident's records

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Reason for visit was explained. Administrator was contacted however was not feeling well therefore could not come to the facility and asked that staff sign for the report. Investigation into the above allegation consist of interview with Mrs. JoAnn Trupiano on 11/08/2023 and interview with reporting party on 10/30/2023 and 11/09/2023. On 11/08/2023, Mrs. Trupiano stated that she sent everything via email to the requestor. After review of the records it was revealed that records were sent to a wrong email and Mrs. Trupiano never followed up or returned any of the requestor's calls. Mrs. Trupiano confirmed that she did not follow up with the requestor or return their call due to a pending litigation. Interview with reporting party confirmed that Mrs. Trupiano did not return any of their calls or responded to the many request sent for copies of records pertaining to former resident (R1). Based on interviews conducted and records reviewed allegation "Staff are not providing responsible party with access to resident's records" is substantiated at this time. Citation issued (see attached LIC 9099-D). Exit interview conducted. Copy of report and appeal rights issued. Substantiatedthe state’s words, verbatim · CDSS document, Mar 21, 2024 · control 29-AS-20231030170141

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Mar 21, 2024

Personal Rights of Residents in All facilities (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidence by: Based on interview with Licensee/ administrator, licensee did not comply with the above regulation. Licensee did not communicate or provide records to former resident's family representative despite the several attempts made by requestor/family representative.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Licensee/Administrator eventually sent records to the requestor and informed LPA that due to the pending litigation her attorney advised her not to communicate with requestor. Requestor confirmed receipt of former resident's records POC cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff Honorata Perla Avestro and Magdalena Guansing. LPA explained the reason for the visit. Staff contacted Licensee JoAnn Trupiano. LPA spoke with Mrs. Trupiano who stated that she is not feeling well therefore, unable to meet LPA at the facility today. Mrs. Trupiano stated that staff can review and sign the report on her behalf. At approximately 10:40am, LPA and staff 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. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was last serviced 04/12/2023. KITCHEN: Knives were found in an unlocked drawer. Other knives and cleaning supplies are stored in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At approximately (approx) 10:45 a bottle of Tylenol on the kitchen table. BEDROOMS: The LPA observed four (4) bedrooms two single-occupancy resident bedrooms and two shared bedrooms which were furnished with appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms observed clean and sanitary and in operating condition. Cleaning items are stored in locked cabinets. At approx. 10:30am, LPA observed medications belonging to staff accessible to others in an unlocked cabinet in the hallway. COMMON SPACES: The living room, family room and dining room furniture were observed to be in good condition. The patio is equipped with furniture for resident use. No bodies of water. Resident records reviewed at approx. 11:15am - Resident files were reviewed for updated Needs and Services plans, medical assessments, admission agreements, and all other pertinent documents in their files. Administrator did not have a current Needs and services plan for resident #3. (Continue to LIC809C). Staff records reviewed at approx. 12:45pm - Staff records were reviewed and noted to be complete for first aid certification, health screening documentation, employee rights and criminal record clearance. However no current training records found for the staff. Last training records observed for the required annual 20hrs was conducted in 2020. Medications reviewed at approx. 2:30pm - Four (4) out of 5 residents centrally stored medication records were not updated with all prescribed/non-prescribed medications on hand. Staff admit that the centrally stored record is not up to date with medication on hand for the four residents. Throughout the visit, LPA also conducted interviews with two staff and four (4) residents. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Today's report was discussed and issued.the state’s words, verbatim · CDSS document, Mar 21, 2024

The state marks this report as 12 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.