Arbor Victoria

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Administrator Richard Axtell. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, one (1) of whom may be bedridden in room #1 or #4 only. During today’s inspection there were five (5) residents in care. LPA and Administrator Richard Axtell toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Richard Axtell, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Richard Axtell to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 19, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified themselves to and discussed the purpose of the visit with Administrator Richard Axtell. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, one (1) of whom may be bedridden in room #1 or #4 only. During today’s inspection there were four (4) residents in care. LPA with Administrator Axtell toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Axtell, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Axtell to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 6, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Case Management visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Richard Axtell. Today's visit was in response to a self reported incident that occurred on 12/26/2024 regarding the death of Resident #1 (R1). [See LIC811 Confidential Names List.] During today’s visit LPA conducted a brief facility tour, observed residents in care, and interviewed relevant staff. No deficiencies were cited during today’s visit. An exit interview was conducted with Administrator Richard Axtell, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 2, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Ryan Fulton and Nacole Patterson conducted an unannounced Case Management visit to amend reports for a visit conducted on 3/19/24. LPAs identified themselves and discussed the purpose of the visit with Administrator Richard Axtell. During today’s visit, LPAs obtained signatures on the amended reports. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D). A Plan of Correction was jointly developed with the Administrator. An exit interview was conducted with Administrator Richard Axtell, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 3, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Apr 3, 2024

87555(b) "The following food service requirements shall apply: (8) All food shall be of good quality..." This requirement was not met, evidenced by: Expired canned goods were found in the pantry during the annual inspection visit on 3/19/24. This posed a potential health and safety risk to 6 of 6 persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2024

Plan of correction: Administrator agreed to immediagely discard all expired food items and regularly check food for expiration dates and discard or use by the expiration date.

Type of visit: Required - 1 Year

Licensing Program Analyst's (LPA) Ryan Fulton and Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and discussed the purpose of the visit to Caregiver Erika Garcia during the visit LPA's spoke to Licensee Richard Axtell over the phone and then in person later during the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, one (1) of whom may be bedridden in room #1 or #4 only. During today’s inspection there were six (6) residents in care. LPAs and Caregiver Erika Garcia toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per caregiver Yulissa Colon Ramirez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. First aid kit(s) were complete and readily accessible. Technical assistance and technical violations were provided regarding fire extinguisher checks, infection control, facility records, and required licensing postings. LPAs interviewed staff and clients, and reviewed client facility records. The files reviewed by LPAs contained required documents. Confidential records were stored in locked areas. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D). An exit interview was conducted with Licensee Richard Axtell, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. This is an amended report for facility visit conducted on 3/19/24.the state’s words, verbatim · CDSS document, Mar 19, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not ensure that medications were made inaccessible to residents

Licensing Program Analyst (LPA) Mark Mandel conducted an unannounced visit to follow-up on a complaint investigation regarding the above-mentioned allegation. LPA identified himself to, was granted entry by and met with Administrator, Richard Axtell. LPA stated the purpose of the visit and discussed the elements of the complaint with Administrator Axtell. LPA delivered the findings of the investigation that was initiated on 12/18/2023 to Adminstrator Axtell. On 12/11/2023, the Department received a complaint alledging that facility staff did not ensure that medications were made inaccessible to residents. The Department's investigation consisted of facility visits, record reviews and interviews with residents, staff and outside sources. During the initial visit conducted on 12/18/2023, LPA Mark Mandel and Licensing Program Manager (LPM) Simon Jacob toured the facility and interviewed staff. During the tour of the facility, LPA and LPM observed that medications for residents were kept on the second floor in a locked cabinet and the residents all lived on the first floor. Interviews revealed that Staff 1 (S1) never saw Resident 1 (R1) take any pills, but then heard R1 say that they wanted to die. LPA and LPM also observed R1 in their room lying in their bed on 12/18/2023 and their Phsycians Report confirmed that they are nonambulatory. (Cont. on LIC9099) Unsubstantiated (Cont. from LIC9099) A review of the Discharge Summary from Scripps Memorial Hospital Encinitas- where R1 was taken on 12/10/2023 for 5150WI after admitting to the Carlsbad Fire Department Medics that she tried to kill herself by ingesting 2000 mg of Tylenol - states Outside Source 1 (OS1) said R1 stays in bed unless assisted by staff and can walk short distances to her bathroom, or transfer to a wheelchair, which, along with their non ambulatory status, further demonstrates R1's inability to access medication at the facility. The report also states that OS1 alleges that R1 had some Tylenol pills in a small container that was holding R1's rosary either from hoarding pills that facility staff had administered to R1 or possibly from the pills having been placed in the container prior to R1 moving into the facility. Also, the Physian's Report for R1 states they had difficulty walking, muscle weakness and were non ambulatory, which, again, points to R1's inability to access medication at the facility. An interview with Outside Source 1 (OS1) revealed that a female caregiver- whose name they did not remember- at the facility told him by phone on 12/10/2023 that R1 had told the caregiver that they had taken 3-4 Tylenol pills. OS1 said the caregiver also told him that she saw two pills left inside of a small box that she concluded were Tylenol pills, which prompted the caregiver to call 911 in case the Tylenol R1 said they had taken would affect R1 adversely. Two or three days after the incident, OS1 visited R1 at the facility and viewed the small box where the facility caregiver said she had found the Tylenol pills and confirmed he had seen the box previously, but did not think it ever contained any medication and he had never opened it. OS1 said the box was white in color and had a religious picture on it and had a rosary inside of it. He said the box was really for religious items and R1 is "pretty religious". OS1 said he did not bring any medication to R1 at the facility and that R1 has no opportunity to access medication when he takes them to the doctors or from anywhere, but said the Tylenol pills could have been in the box prior to the date R1 moved into the facility and maybe for years, or R1 may have been hoarding pills given to them by staff. OS1 said R1 was living in their own home as recently as August 2023, but then they fell and went to the hospital. Once R1 left the hospital they went to Vista Life Care for two to three weeks and then they were admitted to Arbor Victoria in September 2023. He added that R1's medication is kept in another room at the facility in a drawer or cabinet and it is administered to R1 by staff who put it in R1's hand, while giving R1 a cup of water to drink with their medication. (Cont. on LIC9099) (Cont. from LIC9099) Also, Carlsbad Police Department Report No. 2307923.1 states that the facility administrator told the responding officer that R1 had been hiding a stash of Tylenol in their room, which corroborates a similar statement made by OS1 to the doctor at Scripps Memorial Hospital Encinitas that discharged R1 on 12/12/2023, and one made to LPA Mandel by OS1. LPA also reviewed the House Rules staging it is not appropriate for residents to refuse to store prescribed and over-the-counter medications in a secured locked central location. The form was signed by OS1. During today's visit, LPA toured the facility, reviewed records, observed residents in care and interviewed staff, residents and outside sources. S1 stated he spoke to OS2 on 12/24/2023 and she told him she did give R1 Tylenol pills that OS2 bought at Costco when R1 was her neighbor in Oceanside and also told S1 that R1 kept the Tylenol pills in a pill box designed to hold a rosary. LPA also spoke to OS2 and she confirmed that she gave R1 Tylenol pills when R1 lived in Oceanside that OS2 had bought as Costco. OS2 said R1 kept the Tylennol in a pill box the was round and gold in color and held six pills. OS2 said she never gave any pills to R1 during anytime she visited R1 at the facility, which she said is 3-4 times weekly. OS2 said it is possible that R1 brought the pills OS2 gave her when they both were neighbors in Oceanside to the facility, but she was not aware of it if she did. She added that R1 doesn't have access to medication and can't get up to get in any drawers. LPA confirmed daily medication is locked up in a drawer in the kitchen and that a storage of medication for the month is kept locked in a desk upstairs. Based on the interviews conducted and records obtained and reviewed, the allegation that facility staff did not ensure that medications were made inaccessible to residents is Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with Administrator, Richard Axtell, and a copy of this report was provided to Administrator Axtell.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 08-AS-20231211165614