Atria Hillcrest

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent Case Management – Incident visit at 10 a.m., The LPA met with Executive Director (ED), Remon Pagels and explained the reason for the visit. Entrance interview conducted. Community Care Licensing Division (CCLD) received two (2) self-reported incident reports and a subsequent incident death report regarding Resident #1 (R1) on 12/12/2025, 12/14/2025 and 01/08/2026. Incident report indicated that on 12/12/2025, Resident #1 (R1) experienced an unwitnessed fall and activated their pendant. Staff #1 (S1) found R1 on the floor. 911 was called, but the R1 refused transport. R1’s emergency contact (EC) and primary care physician (PCP) were notified. On 12/14/2025, the Department received a subsequent incident report stating the R1 continued to report pain in their left ribs and shortness of breath. Staff #2 (S2) called 911, and R1 was transported to the hospital. The EC and PCP were notified. On 01/07/2026, the EC informed the facility that the R1 passed away on 01/06/2026 at approximately 1:00 p.m. at a Skilled Nursing Facility (SNF) upon discharge from the hospital. On 01/08/2026, CCLD received the death report, and LPA Mosley requested the death certificate from the facility. On 02/03/2026, LPA received the death certificate and LPA Esther Cortez contacted the facility telephonically to request R1’s care plan and physician report. On 02/04/2026, LPA Mosley conducted the initial unannounced visit. During the visit LPA conducted a physical plant tour to ensure there were no immediate health and safety concerns, conducted an in-person interview with the ED, a file review for R1 along with obtained copies of pertinent documents relevant to the incident. CCLD’s Investigations Branch continued the investigation. The Department requested Ventura County Fire Department (VCFD) for the emergency medical service (EMS) report / medical records, 911 audio recording and call logs related to R1 on 12/11/2025 and 12/15/2025. Report continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809... The Department also requested records from Ventura County Sheriff’s Office (VCSO) for the death, police and incident report related to R1 and hospital records. On 04/09/2026 the facility Executive Director (ED) was interviewed. On 04/15/2026 and 04/16/2026, attempts were made to contact R1’s EC by telephone. On 04/17/2026 at 1:55 p.m., R1’s EC was interviewed by telephone. On 04/20/2026 beginning at 1:13 p.m., two (2) staff members were interviewed at the facility. Record review revealed that R1 had lived at the facility since 03/09/2014. R1 was on Level 2 level of care, with an assessment dated 02/06/2025. R1’s comprehensive assessment indicated a need for routine monitoring of ambulatory status to ensure evacuation needs were identified and met, and interventions to decrease identified fall risk including encouraging R1 to always use their cane. R1 required assistance with showering/bathing, supervision with clothing selection, and occasional assistance with the mechanics of dressing. R1 received assistance with medication management and required assistance to and from the bathroom for toileting needs. R1 needed occasional assistance with assistive/adaptive devices. R1 received housekeeping services and required standard weekly laundry services. R1 was able to leave the facility unassisted and did not have a history of falls. Hospital records revealed that R1 was admitted to the hospital on 12/14/2025 due to a fall. The primary diagnosis was listed as multiple fractures of the left ribs, with secondary diagnoses of a urinary tract infection (UTI) and sepsis. It was noted that R1 was brought to the hospital after a fall at home with worsening left-sided chest pain. Imaging revealed that R1 sustained “minimally displaced left posterior 6th and 7th rib fractures and a nondisplaced left posterior 8th rib fracture.” R1 was discharged on 12/22/2025 to a SNF. Death report revealed that on 01/06/2026, VCSO deputies responded to the SNF as fire department staff were conducting chest compressions on R1. R1 was pronounced deceased at 2:10 p.m. According to the medical examiner, R1’s death was due to accidental injury. Interviews with the ED revealed that R1 was described as very social and enjoyed living in the community. R1 was considered an advocate for the community and loved being part of the facility environment. It was noted that R1 was frequently out of their apartment and would ambulate around the community using either a cane or a walker. R1 was very active, out and about often, and attended all community activities. R1 was described as very independent and on minimal care. Report continued on LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... R1 changed their own briefs and required only reminder-level supervision regarding restroom use. It was also noted that facility staff conducted additional checks in R1’s apartment to ensure support was available if needed. Furthermore, it was reported that facility staff followed proper protocol when responding to R1’s fall. Staff interviews revealed that R1 was very social and often seen throughout the community. R1 frequently attended community activities and did not have a history of falls. R1 commonly ambulated with a cane or walker, and staff stated that R1’s mobility “had no limits.” It was noted that during the initial fall, staff encouraged R1 to go to the hospital when EMS arrived; however, R1 stated, “I’m fine,” and refused treatment against medical advice. Interview with the EC revealed that R1 “loved that place” and had no complaints regarding the care and supervision received while residing in the community. R1 had lived there for 12 years and had no difficulty voicing concerns. It was noted that R1 was “very stubborn.” The EC reported that R1 had “lost their balance” and fallen and added that R1 “suffered from vertigo.” The EC stated that the facility did a good job responding to R1’s fall and attempting to contact appropriate emergency services; however, they tried, but you can’t force somebody to go to the hospital. The EC confirmed R1 was in charge of their own decision making. No deficiencies are being cited at this time pertaining to this self-reported incident and death report. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility to conduct an unannounced continuation of the annual inspection that began on April 06, 2026 (04/06/2026). Upon arrival LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Ramon Pagels and the reason for the visit was explained. Entrance interview. During the annual inspection conducted on 04/06/2026, LPA Mosley completed a comprehensive physical plant tour. The tour included, but was not limited to, the common areas such as the mail room, living room, library, bistro, dining room, private dining room, activity room, theater, fitness center, salon, technology center, wellness center, laundry rooms, kitchen, and surrounding outdoor grounds. LPA also observed ongoing activities at the time of the visit. LPA Mosley inspected sixteen (16) randomly selected resident bedrooms, twelve (12) located in assisted living and four (4) in memory care, as well as resident restrooms and common/community restrooms. Additionally, LPA conducted a medication audit and obtained pertinent documentation. During today’s visit, starting at 10:15 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns, and facility is in compliance with Title 22 Regulations. The following was noted: The facility is a three-story building that consists of a secured memory care unit on the second floor and an assisted living unit. The facility is fire cleared for a capacity of 207 residents age 60 and over of which all may be non- ambulatory. Dementia wing rooms 240 to 258 approved for delayed egress. Hospice waiver for ten (10). LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 01/02/2026 and are inspected monthly by facility staff. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C... Records: Personnel Records were reviewed beginning at 11:13 a.m. Ten (10) Personnel files including the ED's file 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 in order. Resident Records were reviewed beginning at 12:42 p.m. Ten (10) 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, Home Health records, Hospice records, PRN authorization letters, and current needs and services plan. All records were in order. Facility Records: The facility uses Johnson Controls to conduct their annual fire alarm system inspection that was conducted on 04/03/2026 indicating a pass. LPA reviewed the quarterly inspections, testing and maintenance reports for the wet pipe and fire sprinkler system conducted on 03/04/2025, 05/27/2025, 08/25/2025 and 12/03/2025 indicating a pass in all areas. LPA reviewed smoke detector monthly test conducted the month of February 2026. The daily vehicle inspections, and annual Inspection report for both facility vehicles were reviewed. All records were in order. Infection Control / Emergency disaster planning: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The emergency disaster plan was observed to be updated and reviewed on 02/24/2026. The last emergency disaster drill took place on 03/28/2026 at 12:30 a.m. and conducted quarterly covering all shifts and areas of emergency disasters. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. Interviews: During the initial visit on 04/06/26 and throughout today’s visit, LPA Mosley conducted brief resident and staff interviews. LPA interviewed nine (9) staff members, who demonstrated knowledge of resident rights, the various forms of abuse, and appropriate reporting procedures. LPA also conducted eleven (11) resident interviews. Resident interviews revealed no concerns noted or expressed at the time of the visit. Residents reported that a variety of activities are offered and provided, and that food substitutions are available upon request. Report Continued on LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... Medication Audit: There are two (2) medication rooms / wellness centers in the facility. One on the first floor for assisted living and one on the second floor for memory care unit. Med Techs distribute medication at the appropriate times to residents in care. On the initial visit 04/06/2026 a Medication audit for ten (10) residents was conducted. Eight (8) in the Assisted Living Unit and two (2) in the Memory Care Unit. The following was observed. The medications were stored in the medication rooms in carts, both were locked and inaccessible to the residents. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed. During the medication review LPA observed four (4) out of ten (10) along with other residents with start dates missing on the centrally stored medication and destruction record which poses a potential health, safety, and personal rights risk to residents in care. LPA advised Resident Service Director (RSD) and Med Techs the importance of proper documentation to ensure medication audit and count is correct. RSD agreed to conduct an internal audit to ensure all records have the correct start date documented on the centrally stored medication and destruction record. During todays visit at 3:32 p.m. LPA conducted a brief medication audit and observed that the facility has began the internal audit of resident medications. Documents: Documents obtained during the visit include: Limited Liability insurance, Staff roster and a Resident roster. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies 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, Apr 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 10:00 a.m. Upon arrival LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Ramon Pagels and reason for the visit was explained. Entrance interview. Starting at 10:40 a.m. the LPA and 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 noted: The facility is a three-story building that consists of a secured memory care unit on the second floor and an assisted living unit. The facility is fire cleared for a capacity of 207 residents age 60 and over of which all may be non- ambulatory. Dementia wing rooms 240 to 258 approved for delayed egress. Hospice waiver for ten (10). LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 01/02/2026. LPA observed all the required postings in the Mail Room near the entrance and throughout the facility. The facility maintained a comfortable temperature throughout the visit. Common Areas: This includes the mail room, living room. library, bistro, dining room, private dining room, activity room, theater, fitness center, salon, technology center, wellness center and laundry rooms. Each floor has its own laundry room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. Facility elevators were operating properly. There are five (5) stairwells that all have emergency evacuation chairs on the third floor. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C... Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. LPA observed the facility generator adjacent to the entrance of the facility. LPA observed the facility main water and gas shut offs. LPA observed the designated smoking area, along with a putting green. Delayed egress doors checked and were operable at the time of visit. Activities: Planned activities are offered, and the activity schedule was posted, and is provided to the residents on a weekly basis. Activity rooms and common spaces appeared clean and in good repair. LPA observed residents engaged in both the Assisted living and in Memory care. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. The menu was posted and copies are available for residents. The menu is reviewed regularly by a dietician with the last review on 10/09/2025. The facility offers daily specials and a standard selection at every meal. Appliances appeared to be in operable condition. Snacks and beverages are available for residents in the Bistro. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. Bedrooms: There are one hundred thirty six (136) total apartments in the facility, one hundred seventeen (117) assisted living and nineteen (19) in memory care. There are resident rooms on all three (3) floors, units are designated for assisted living residents on all three (3) floors and a separate unit on the second floor is designated for residents in the memory care unit. There were no obstructions and/or tripping hazards observed. LPA observed sixteen (16) randomly selected resident bedrooms, of which twelve (12) in assisted living and four (4) in memory care. All resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. All passageways were observed to be clear of obstructions. Report Continued on LIC 809-C (PAGE 3) Report Continued from LIC 809-C PAGE 2... Restrooms: LPA observed resident restrooms along with common / community restrooms. Resident restrooms appeared clean, sanitary and in operating condition with grab bars and to be equipped with a slip resistant surface / mat. The restrooms were sufficiently stocked with supplies and paper towels. Towels and washcloths are not shared among the rooms. The hot water temperature was measured and ranged between 110.2 - 115.2 degrees Fahrenheit all within the required range. Medication Audit: There are two (2) medication rooms / wellness centers in the facility. One on the first floor for assisted living and one on the second floor for memory care unit. Med Techs distribute medication at the appropriate times to residents in care. Medication audit for ten (10) residents was conducted. Eight (8) in the Assisted Living Unit and two (2) in the Memory Care Unit. The following was observed. The medications were stored in the medication rooms in carts, both were locked and inaccessible to the residents. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed. During the medication review LPA observed four (4) out of ten (10) along with other residents with start dates missing on the centrally stored medication and destruction record. LPA advised Med Techs the importance of proper documentation to ensure medication audit and count it correct. Med Tech and supervisor agreed to conduct an internal audit to ensure all records have the start date document on the centrally stored medication and destruction record. DOCUMENTS: Documents obtained during the visit include: Staff roster and a Resident roster. Due to time constraints the LPA will return to complete the annual at a later date. Exit interview conducted. Copy of report reviewed and provided.the state’s words, verbatim · CDSS document, Apr 6, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced Case Management – Incident visit at 9:45 a.m., LPA met with Executive Director (ED), Remon Pagels and explained the reason for the visit. Entrance interview conducted. The Department received two (2) self reported incident reports and a subsequent incident death report regarding Resident #1 (R1) on 12/12/2025, 12/14/2025 and 01/06/2026. On 02/03/2026 a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB) and Investigator Veronica Padilla has been assigned to the incident investigation. During today’s visit, LPA and ED conducted a physical plant tour to ensure there are no immediate health and safety concerns, conducted a brief in-person interview with the ED, a file / record review for R1 along with obtained copies of pertinent documents relevant to the incidents. No immediate health and safety concerns were observed during today's visit. Further investigation is required. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Feb 4, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent Case Management – Incident visit at 9:55 a.m., The LPA met with Executive Director (ED), Remon Pagels and explained the reason for the visit. Entrance interview conducted. The Department received a self-reported incident report and a subsequent incident death report regarding Resident #1 (R1) on 05/12/2025 and 05/13/2025. Incident report indicated that on 05/11/2025 at approx. 9 a.m. Staff #1 (S1) called the front desk for assistance as they saw R1 on the floor in the parking lot on their way into work that morning. S1 and Staff #2 (S2) went to assist R1 and R1 was bleeding from the head and 911 was called. Paramedics informed staff to lay R1 on their back. At this time S1 and S2 noticed a firearm in between R1 legs / crotch area. Paramedics arrived on scene and transported R1 to the hospital. Police arrived on scene and conducted their investigation. Family and primary care physician notified. On 05/13/2025 LPA's Mosley and Kelly Dulek conducted the initial unannounced visit. During the visit LPAs conducted a physical plant tour to ensure there were no immediate health and safety concerns, conducted an in-person interview with the ED, a file review for R1 along with obtained copies of pertinent documents relevant to the incident. On 05/27/2025 LPA Mosley requested the related police report from Ventura County Sheriff’s Office (VCSO) and received the report on 06/05/2025. On 06/04/2025 LPAs Mosley and Dulek conducted a subsequent visit. During the visit LPAs conducted a physical plant tour to ensure there were no immediate health and safety concerns, conducted in-person interviews with the ED, six (6) staff, attempted three (3) resident interviews, conducted two (2) resident interviews along with obtained copies of pertinent documents relevant to the incident. Report continued on LIC 809-C PAGE 2 (PAGE 2) Report continued from LIC 809 Record review revealed that R1 had lived at the facility since 10/31/2024. R1 was on level 0 of level of care, indicating that at the time of move in R1’s comprehensive assessment indicated that R1 did not require personal care services offered by the facility. R1 was able to leave the facility unassisted. R1 did not have a history of suicide attempts/suicidal ideation. Interviews with the ED revealed that R1 was fully independent, still drove their personal vehicle, and had no changes in condition or care other than some recent falls. R1 would often sign themselves out and leave the community in their personal vehicle. The facility strictly prohibits firearms and there was no indication that R1 possessed a firearm. The resident had not exhibited signs of unhappiness or distress. When the ED spoke to R1 on 05/09/25 and 05/10/25 they appeared to be their usual self. R1 maintained a wide network of outside friends and was known to be friendly and communicative with staff. Interviews with staff revealed that R1 was highly independent and rarely needed help from staff. Staff were familiar with R1 but had limited direct interaction with R1 due to their high level of independence. Police report indicated that there was no evidence of foul play or suspicious activity, and the cause of death was suicide. No deficiencies are being cited at this time pertaining to this self-reported incident and death report. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Jul 25, 2025

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA’s) Erica Mosley and Kelly Dulek conducted an unannounced Case Management – Incident visit at 11:00 a.m., The LPA’s met with Executive Director (ED), Remon Pagels and explained the reason for the visit. Entrance interview conducted. The Department received a self reported incident report and a subsequent incident death report regarding Resident #1 (R1) on 05/12/2025 and 05/13/2025. During today’s visit, LPA's conducted a physical plant tour to ensure there are no immediate health and safety concerns, conducted in-person interviews with the Executive Director (ED), six (6) staff members, attempted three (3) resident interviews, conducted two (2) resident interviews along with obtained copies of pertinent documents relevant to the incident. If further investigation is needed the LPA will return at a later date. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Staff are not assisting residents with feeding

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegation listed above. LPA arrived at the facility at 09:28AM and met with Executive Director (ED) Remon Pagels. Entrance interview conducted. During an unrelated visit conducted on 04/24/2025, LPA interviewed ED throughout the visit and reviewed and obtained copies of additional relevant documents. During an initial complaint visit conducted on 11/13/2024, LPA interviewed ED at 09:55AM, reviewed resident records beginning at 10:32AM, toured the facility at 11:38AM, interviewed resident's family member at 11:44AM, and conducted staff interviews from 11:59AM to 1:10PM. LPA also obtained copies of pertinent documents. Throughout the course of the investigation, LPA reviewed all documents obtained and telephonically interviewed other relevant parties. The following was then determined: Report Continued on LIC 9099-C Substantiated It was alleged that staff are prohibited from assisting residents with feeding, including Resident #1 (R1) and Resident #2 (R2) who reside in the facility’s memory care unit and are receiving hospice care services. During the initial complaint visit, LPA interviewed multiple staff, Administrator and Corporate office representative. All employees interviewed indicated this facility does not assist residents with feeding. ED indicated all families are aware of the Atria policy and the facility’s Admission Agreement indicates Atria does not provide these services. Review of Acceptance and Retention criteria revealed that residents “must have the ability to feed him or herself.” LPA reviewed the Admission Agreement signed by R1’s representative, which does include the attachment referenced, however, the Admission Agreement that was submitted to Community Care Licensing Division (CCLD) upon licensure does not include this Attachment nor any policy indicating residents must be able to feed themselves. LPA confirmed with ED that the facility’s Admission Agreement and current related policies have not been sent to nor approved by CCLD. Interview with ED and corporate representative revealed that the facility is not staffed to assist with feeding residents and residents in the facility need to be able to feed themselves or have a private caregiver or family member to assist with resident’s feeding. ED reiterated that facility staff do not assist residents with feeding. Corporate representative stated that if a resident declines and requires any of the services Atria does not offer, as outlined in the Acceptance and Retention Criteria (such as puree food, thickened liquids, or feeding assistance) that the facility staff may assist the resident for up to 30 days while an eviction notice is served to the resident. However, interviews conducted during the initial complaint visit revealed that staff have been instructed not to assist with feeding, as it is against policy. None of the care staff interviewed mentioned they are able to assist with feeding temporarily while a resident is relocated. Instead, all care staff interviewed stated they have been instructed that assisting residents with feeding is against policy. As far as R1, ED stated that R1 passed away under hospice care, but near the end R1 had a private companion to assist in feeding R1. Record review revealed that in a fax dated 09/20/2024, facility staff communicated to R1’s hospice care provider “[R1] needs to be fed by care staff or else [R1] won’t eat.” However, interview revealed care staff are not allowed to assist residents with feeding. In the case of R2, ED stated that R2’s family member is present for 2 (two) meals a day 6 (six) days a week and when R2’s family member isn’t present, R2 will still pick at their food. Interview with R2’s family member revealed that they assume the staff are spoon feeding R2 when the family member is not present at the facility. R2’s family member appeared to be unaware of Atria’s policy related to feeding. Staff did state R2 will sometimes feed Report Continued on LIC 9099-C themselves if the food is placed in their hand, but staff have been reminded this is not allowed per Atria policy. Review of Atria plan of operation revealed that “the community must provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself…The community must provide this assistance and cannot delegate this care to family members, private duty personnel, outside agencies, etc.,” which is consistent with Title 22 Regulation. Both ED and corporate representative interviews revealed the facility is delegating ADL care such as feeding to private duty aides and family members, contrary to the facility policy. ED also stated that per ED's conversation with corporate, that changes to both the Admission Agreement and facility’s policies related to feeding and care services offered were not submitted to CCLD for approval. Based on interview and record review, the preponderance of evidence standard has been met, therefore, the allegation “staff are not assisting residents with feeding” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 29-AS-20241106103236

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Jun 6, 2025

87208 (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility...significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval... This requirement is not met as evidenced by: Based on interview and record review, the facility has changed it's policies and Admission Agreement as it relates to care services offered to residents, however no approval was obtained from the Department, which poses a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Executive Director agreed to contact corporate to amend and submit the facility's plan of operation and related documents to CCL for approval by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted a case management visit with the purpose of continuing the investigation into a self-reported incident/death report. LPA arrived at the facility at 09:28AM and was greeted by front desk staff. LPA met with Executive Director (ED) Remon Pagels shortly after the visit began. Entrance interview conducted. An incident report and separate death report were received at the Woodland Hills Regional Office on 12/16/2024. Incident report indicated that on 12/15/2024, resident’s family member called the front desk asking for staff to check on Resident #1 (R1). Caregiver went to check on R1 and found R1 “passed away by taking [R1's] own life.” Caregiver called med techs, 9-1-1 was called and ED was contacted. LPA called ED and requested relevant facility documents for R1, including care plan and physician’s report. LPA requested the related police report from Ventura County Sheriff’s Office (VCSO.) LPA received the facility documents on 12/17/2024. The death investigation was referred to Community Care Licensing Division (CCLD)’s Investigation Branch (IB) and was assigned to Investigator Dennis Douglas. Investigator Douglas obtained relevant medical records for R1 and conducted both in person and telephonic interviews with staff, residents, and other relevant parties on the following dates: 01/03/2025, 02/07/2025, 02/18/2025, and 02/19/2025. LPA Dulek then reviewed all documents provided by the facility and IB Investigator. The following was then determined: Record review revealed that R1 had lived in the facility since 07/28/2018. According to facility staff, R1 served as a “facility ambassador” and was typically very social amongst the facility residents and potential new residents. R1 was described by ED as “independent;” incident report indicates R1 was not on care plan, medication management, or status check. Physician’s report signed on 06/14/2019 indicates R1 was able to Report Continued on LIC 809-C store and administer their own prescription and PRN medications and able to care for their own activities of daily living (ADLs.) Diagnoses listed as of 06/14/2019 include but are not limited to: anxiety disorder due to another medical condition and major depressive disorder, recurrent episode. Atria’s Resident Functional Needs Service Plan dated 10/21/2024 also lists these diagnoses and indicates R1 able to self-manage medications and does not require assistance with ADL care. However, on 12/02/2024, R1 was treated for a urinary tract infection (UTI) and was given antibiotics, a catheter, Buspar and Zoloft because R1 was anxious about urinating. R1 returned to the facility. After returning to the facility, staff noted R1 to be staying in their room more often and ordering tray service rather than eating meals in the common dining room. Documents reviewed revealed that Atria staff knew R1 was “having medical issues and depression because of these medical issues.” Staff knew that for about 2-3 weeks R1 did not leave their room for meals and for 2-3 days prior to R1’s death that R1 refused to eat some of their meals. Interview with R1’s family member revealed that R1 was reacting to the medication prescribed and R1 was experiencing increased anxiety. R1’s physician discontinued use of this particular medication on 12/09/2024. Physician explained to R1 and their family member that R1 would continue to experience the effects (bouts of depression) as the medication cycled out of R1’s system over several days. R1’s family member stated they did not directly inform the facility staff of the change in medication, the effect the medication had on R1 nor that R1 expressed suicidal ideations. On 12/15/2024, R1’s family member was unable to reach R1 by telephone and requested the facility staff conduct a status check. Staff found R1 in their room, apparently deceased and called 9-1-1. Responding police deemed R1’s death a suicide and R1’s death certificate indicated manner of death was suicide, cause of death listed as smothering asphyxia. Staff and ED interview revealed that R1 was “independent” and R1’s care plan dated 10/21/2024 does not indicate R1 required status checks, so facility staff stated they did not conduct regular status checks on R1. Executive Director provided LPA with documentation indicating a care task was added on 12/09/2024 directing care staff to “monitor for signs of anxiety” 7 days a week at 08:00AM, 01:00PM and 06:00PM through 12/23/2024. However, the facility did not provide documentation of status checks being completed and staff working on the date of R1’s death stated they checked on R1 due to the call from R1's family member and/or due to R1 not arriving in the dining room for breakfast. Staff did not mention status checks as a regularly scheduled task for R1. Additionally, no reassessment was completed following R1’s change in condition (UTI diagnosis and insertion of an indwelling catheter and increasing anxiety/depression.) And although R1 had previously been socially engaged at the facility, when staff noticed R1 was not leaving their room, no new care plan was initiated for R1. Report Continued on LIC 809-C Additionally, R1’s physician’s report signed on 06/14/2019 indicates R1 was able to store and administer their own medications, so leading up to R1’s death, facility staff was not assisting R1 with medications. However, no new physician’s report was completed due to R1’s change in condition. R1’s family member stated they did not directly inform the facility staff of R1’s change in medications. It should be noted that Atria policy on file with the Department states that all residents, including those who store and manage their own medications, are required to keep a current medication list on file with the facility. ED stated that this policy is no longer in effect, however Atria did not inform the Department of the change in policy. The medication list on file for R1 was dated 07/05/2018, therefore was not updated with the medications prescribed for the UTI on 12/02/2024. Even though the facility did not complete a reassessment nor obtain a new physician’s report or medication list following a change in condition, it is unclear whether these were contributory factors in R1’s suicide. The investigation did not provide sufficient evidence to prove a lack of care and/or supervision led to R1’s death. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC809-D). ED was informed that failure to correct the deficiency 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, May 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jun 6, 2025

87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary...to note significant changes in condition...and to keep the appraisal accurate...updated pre-admission appraisal shall be referred to as reappraisal This requirement is not met as evidenced by: Based on interview and record review, R1 had a change of condition on or around 12/02/2024 (hospitalization, UTI, catheter, medication change and increased anxiety/depression) however, the facility did not conduct a reappraisal, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Executive Director indicated the facility has already begun using a document to be used upon hospital discharge to indicate whether the resident has had a change in condition. Inservice training was conducted on resident change in condition. POC cleared.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA’s) Erica Mosley and Kelly Dulek conducted an unannounced Case Management – Incident visit at 11:45 a.m., The LPA’s met with Executive Director (ED), Remon Pagels and explained the reason for the visit. Entrance interview conducted. The Department received a self reported incident report and a subsequent incident death report regarding Resident #1 (R1) on 05/12/2025 and 05/13/2025 a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). During today’s visit, LPA's conducted a physical plant tour to ensure there are no immediate health and safety concerns, conducted an in-person interview with the Executive Director (ED), a file review for R1 along with obtained copies of pertinent documents relevant to the incident. If further investigation is needed the LPA will return at a later date. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, May 13, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a required annual visit. The LPA met with Executive Director (ED) Remon Pagels and reason for the visit was explained. Beginning at 10:45AM, the LPA and Maintenance Director Hector Arjon toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The following was observed: Common Areas: The facility is a three-story building. Facility elevators were operating properly. There are three stairwells that all have emergency evacuation chairs on the third floor. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors and a separate unit on the second floor is designated for residents in the memory care unit. There were no obstructions and/or tripping hazards observed. The facility maintained a comfortable temperature throughout the visit. The fire extinguishers were charged and last serviced 01/06/2025. Various rooms' smoke detectors and common area carbon monoxide detectors were tested during today's visit; all tested were functional. The facility uses Johnson Controls to inspect their fire suppression system with the last annual inspection completed 06/06/2024; 5-year inspection was completed on 10/11/2021. A fire and life safety inspection was conducted by Ventura County Fire Department on 07/23/2024 and no violations were noted. Required postings were observed on the first floor. Activities: Planned activities are offered, and the activity schedule was posted, and is provided to the residents on a weekly basis. Activity rooms and common spaces appeared clean and in good repair. There is a movie theater, hair salon and exercise/therapy room for residents use. Report Continued on LIC 809-C Kitchen: At the time of the visit, there was a sufficient supply of perishable and nonperishable food. The facility also has an emergency supply of food and water. The menu was posted and copies are available for residents. The menu is reviewed regularly by a dietician with the last review 10/03/2024. The facility offers daily specials and a standard selection at every meal. Appliances appeared to be in operable condition. Resident Rooms: The LPA toured 12 (twelve) randomly selected resident rooms (both the memory care and assisted living unit). Rooms appeared well kept, with sufficient lighting and appropriately furnished. Restrooms: Resident restrooms observed to be fully stocked with supplies; grab bars and slip resistant surfaces. The water temperature was tested on all floors in various resident rooms and water temperature ranged from 107.7 to 115.2 degrees Fahrenheit. Outside Areas: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There was an enclosed patio for residents whom reside in the memory care unit on the second floor. Delayed egress doors checked and were operable at the time of visit. Interviews: LPA interviewed 6 (six) residents and 3 (three) staff during the visit. No concerns were noted. Record Review: Record review began at 01:13PM. The LPA reviewed 5 (five) resident files for, but not limited to: admissions agreements, medical assessment, updated appraisals. Resident records reviewed were in order at this time. The LPA reviewed 5 (five) staff files for items including but not limited to: health assessments, TB results, criminal record statements and clearances, first aid/CPR certification. Staff files reviewed were in compliance with regulation at this time. Medication: Medications review began at 02:50PM in Assisted Living and 03:45PM in Memory Care. The LPA reviewed medications for 2 (two) residents. Medications are maintained locked inaccessible to residents in medication carts in the Medication Room. Resident medications reviewed were documented and stored in compliance with regulation at this time. Infection Control/Emergency Disaster Plan: LPA reviewed the facility's infection control plan and Emergency Disaster plan. Both documents were observed to be completed and updated annually as required. Facility conducts emergency disaster drills as required with the last documented drill 03/01/2025. No deficiencies cited at this time. Exit interview conducted. Copy of today's report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2025

Allegation investigated: Resident was confined by staff Staff did not safeguard resident's funds Staff are attempting to poison resident Staff mismanaged resident's medication

A subsequent complaint visit was conducted today to deliver final findings for the above allegations. During this visit, LPA met with Gudalupe Ambriz, Community Business Director and explained the reason for the visit. Following is a summary of the allegations and investigation finding: Regarding allegation - Resident was confined by staff – Information was provided that resident #1 did not feel safe at the facility - no supporting information was provided (no specific incident, no names, date or time). On 05/31/2024, LPA Cortez initiated the investigation and discussed allegation with the facility representative. On 03/27/2025, LPA Chochian conducted a subsequent visit and reviewed records from 11:30 a.m. – 12:30 p.m.; LPA conducted interview with three (3) staff and eight random residents from approximately 1:30 p.m. – to 4 p.m. Staff reported that no resident was mistreated or confined by any staff. Random resident interviews expressed that they feel safe at the facility and have not been mistreated in anyway. Potential witnesses interviewed revealed that the staff are kind and attentive to all residents; no mistreatment observed. (Continue to LIC9099c). Unsubstantiated Staff denied ever confining R1 or any resident of the facility. According to staff and other potential witnesses interviewed, R1 was provided with appropriate care services. Based on the above information gathered, although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Resident was confined by staff” is deemed unsubstantiated at this time. Regarding allegation - Staff did not safeguard resident's funds – It was reported that staff are stealing money from R1. On 03/27/2025, LPA reviewed records from 11:30 a.m. – 12:30 p.m . LPA also conducted interview with three (3) staff and eight random residents from approximately 1:30 p.m. – to 4 p.m. Staff reported that resident funds are not handled by facility staff. Staff denied stealing monies for resident. Random resident interviews did not reveal any financial abuse. Potential witnesses interviewed revealed that R1’s finances were handled by R1's responsible person. Interviews revealed no evidence of any financial abuse. Based on the above information gathered, although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, allegation “Staff did not safeguard resident's funds” is deemed unsubstantiated at this time. Regarding allegations - Staff are attempting to poison resident and Staff mismanaged resident’s medication – It was reported that R1’s was refusing to take medications due to fear of facility "trying to poison R1”. No specifics or identifying information was provided for the allegations. On 05/31/2024 and 03/27/2025, staff were interviewed and denied the allegation. Staff reported that R1 was not consistent with taking medications (amlodipine and Seroquel). Review of R1’s medication records revealed/confirmed that R1 was consistently refusing to take medications; physician and family were aware. Staff and potential witnesses interviewed reported that due to R1 being non-compliant with medications, R1 showed increasing signs of paranoia, delusions and had high blood pressure; resulting in hospitalization (9/2024); later discharged to a Skilled Nursing Facility where R1 passed away in 11/2024. Based on the above information gathered, although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, allegations “Staff are attempting to poison resident and Staff mismanaged resident's medication” are deemed unsubstantiated at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 7, 2025 · control 29-AS-20240529165126

Allegation investigated: Licensee did not issue accurate refund Staff did not provide care services agreed upon

Licensing Program Analyst (LPA) Zabel Chochian met with Gudalupe Ambriz to issue final findings on the allegations above. During the investigation, Licensing Program Analyst (LPA) Zabel Chochian conducted an initial complaint visit to the facility above on 5/21/24. LPA Chochian met with the Executive Director, Remon Pagels and explained the reason for the visit. During the visit LPA Chochian interviewed eight residents and two visitors from 12:45pm to 4:15pm, and collected relevant documents. LPA Erika Miller conducted additional review of documents, and interviewed Resident 1 (R1’s) representative via phone and email. Allegation: Facility failed to issue an accurate refund. It was alleged that R1 was charged a New Resident Service Fee of $2,895.00, which did not include monthly rent. RP alleges that a portion of the rent was refunded, but the New Resident Service Fee has not been addressed. (Continue to LIC 9099c) Unsubstantiated LPA Miller reviewed the Admission Agreement executed on 11/9/23. Section 7, states in part, “We will refund to you 80% of the amount (“the Excess”) of the New Resident Services Fee that exceeds $500.00 and we will retain $500.00 plus 20% of the Excess if (A) we have conducted a preadmission appraisal of your condition and you do not move into the Community, or (B) you move into the Community and stay for less than one month.” R1 had a preadmission appraisal and stayed for less than one month. The facility retained only $500.00 of the New Resident Services Fee and did not hold the additional 20% as stipulated in the agreement. A review of the facility financial statements reflect that an accurate refund was issued to R1 and calculated as follows: 80% of $2,895.00 Community Fees = $2,316.00. less $500.00, as outlined in the admission agreement, being $1,816.00. The facility further deducted 1) $309.47 Pro-rated December rent 2) $120.38 Late Fee 3) $350.14 for December Level 5 Care, and 4) $57.21 December Med Lev 1 Care. ($1,816.00 - $309.60 - $120.38 - 350.14 - 57.21 = $978.80, being the balance refunded to R1. LPA Erika Miller interviewed R1’s representative on 1/7/2025, and R1’s representative indicated they did not have an issue with the refund that was provided. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not provide care services agreed upon. It was alleged that staff did not provide care services as agreed upon in the admission agreement, as the facility did not provide two-person transfer assistance to R1. LPA reviewed Physician’s Report dated 11/14/23, which states R1 is ambulatory, but needs assistance in self-care. LPA reviewed 11/20/23 Functional Needs Assessment, which states R1 is non-ambulatory and uses a walker and wheelchair. Based on the results of the assessment, it was determined that R1 required Level 5 Care, providing up to 17.5 hours of care per week and Med Level 1 Care, that provided for up to two medication passes per day. Facility classified R1’s fall risk as a Stand-By/Remind level of assistance. R1 required limited assistance in bathing/showering, and dressing. R1 also required minimal level of assistance in transfers and escorting. No documents in R1’s file indicate they required two-person transfer assistance. Interview with R1’s representative revealed after R1 moved in, they were informed the facility is not “licensed” to provide a two-person transfer. R1’s representative stated R1 was very weak when they first moved in from the hospital and needed a two-person assist for several days. R1’s representative stated staff “dropped” R1 on the floor three separate times during a wheelchair to bed transfer, but only reported one fall. LPA reviewed files for Unusual Incident Reports on R1 and found no incidents reported during R1’s stay at the facility. Staff confirmed that they were unaware of any falls R1 sustained while at the facility. There was insufficient evidence to support that facility was unable to or failed to provide care as stipulated in the Admission Agreement. The facility is not required to have a specialized license to perform a 2-person assist. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. An exit interview conducted, and a copy of this report issued.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 29-AS-20240515135218

Allegation investigated: Staff did not provide resident's records to authorized representative

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver an amended report regarding above allegation. On 10/25/2024, an unsubstantiated finding was issued for the above allegation in error. During today’s visit, LPA Chochian met with Executive Director (ED) Remon Pagels and explained the reason for the visit. On the allegation Staff did not provide resident's records to authorized representative. It was alleged that the facility had failed to produce R1’s records for over 2 months to the authorized records company making the request on behalf R1/Responsible person. A timeline record was provided outlining numerous attempts made by the record company to obtain records on behalf of R1/Responsible person. Staff #2 (S2) was interviewed and stated that there was a records request via email for R1 earlier this year (05/24/2024) and the email was forwarded to the facility’s Legal Department. Timeline record reviewed showed that the facility was contacted by the record company beginning 3/22/2024 to 6/28/2024. (Continue to LIC9099c) Substantiated Staff #2 provided a copy of an email confirmation (dated 6/28/2024) showing the records company confirming that the facility’s Legal Department provided records. Per regulation: 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19)To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. Based on interviews and records review, there is sufficient evidence to support the allegation, therefore, the allegation “Staff did not provide resident's records to authorized representative” is deemed Substantiated at this time. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. Copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 18, 2024 · control 29-AS-20240524095925

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Nov 22, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19)To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.the state’s words, verbatim · CDSS document, Nov 18, 2024

Plan of correction: Executive Director agreed to submit a self-certification letter regarding their plan on ensuring future compliance with section cited.

Allegation investigated: Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care to Resident #1 (R1) which resulted in R1 developing sepsis from a urinary tract infection while in quarantine for COVID-19. Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care to Resident #1 (R1) resulting in R1 becoming malnourished while in quarantine for COVID-19. Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care to Resident #1 (R1) resulting in R1 becoming dehydrated while in quarantine for COVID-19.

This report has been amended to remove allegation "Staff did not provide resident's records to authorized representative." Please refer to report dated 11/18/2024 for supplemental report. Licensing Program Analyst (LPA) Angela Barutyan conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Barutyan met with Business Director Guadalupe “Lupe” Ambriz and Executive Director (ED) Remon Pagels and explained the reason for the visit. On 05/24/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding neglect/lack of care. The complaint alleged staff neglected or failed to provide an adequate level of care to Resident #1 (R1) resulting in R1 developing sepsis from a urinary tract infection and becoming malnourished and dehydrated while in quarantine for COVID-19. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Christine Ferris. Report Continued on LIC 9099-C. Unsubstantiated On 05/28/2024, from 11:11 a.m. to 2:30 p.m., LPA Z. Chochian conducted an initial 10-day complaint visit for the above allegations. Upon arrival, LPA Chochian met with the Executive Director (ED), Remon Pagels and explained the reason for the visit. During the visit, the LPA reviewed resident files and gathered information pertinent to the case. On 06/19/2024, from approximately 12:15 p.m. to 2:45 p.m., Investigator Ferris conducted interviews with the Executive Director (ED), staff and residents; on 07/15/2024, from approximately 12:45 p.m. to 3:30 p.m., with R1’s resident representative, attempted an interview with R1, and staff; and on 07/30/2024, at approximately 2:30 p.m., with R1’s Primary Care Physician (PCP) nurse. In addition, the investigator reviewed Los Robles Regional Medical Center hospital records, Affinity Home Health Resources records, and facility file documents related to R1 and the investigation. According to R1’s Physician’s Report, dated 09/19/2023, diagnoses included dementia with confusion and disorientation, aortic stenosis, and urinary incontinence with the ability to follow instructions, communicate needs, and was ambulatory, but unable to bathe self, dress or groom self, or care for own toileting needs. R1 was not prescribed any medications. A review of the Unusual Incident/Injury Report (SIR) dated 02/05/2024, noted R1 tested positive for COVID-19 and placed on 5-day quarantine in apartment. The SIR dated 02/10/2024, noted R1 was sent to the hospital for weakness and that R1 had not eaten in two days or drank any fluids. (During interviews, Staff #1 (S1) denied R1 stopped eating and drinking completely but clarified R1’s intake of food and liquids lessened after R1’s COVID-19 diagnosis and that was what was meant by their statement on the SIR dated 02/10/2024). The SIR dated 02/16/2024, noted R1 was transported to the hospital for confusion. A review of the facility meal attendance reports showed R1 ate on 02/05/2024, (02/06/2024 meal attendance report could not be located), 02/07/2024, 02/08/2024, 02/09/2024, (R1 was hospitalized on 02/10/2024 and returned on 02/15/2024) and was hospitalized again on 02/16/2024 without returning to the facility. The shower/bath log for February 2024, showed R1 was showered on 02/02/2024, 02/06/2024, 02/09/2024, and 02/16/2024. Report Continued on LIC 9099-C. The Los Robles Regional Medical Center (LRRMC) records documented, on 02/10/2024, R1 was brought in by ambulance from Atria Hillcrest for evaluation of generalized weakness and increased darkness of urine, onset two days ago. The notes documented R1 had advanced dementia who presented to the emergency department with a recent COVID-19 diagnosis. R1 was admitted for severe sepsis and complicated urinary tract infection (UTI). A malnutrition screen was conducted on 02/12/2024, noting in summary, the nutrition problem was inadequate oral intake and etiology was acute illness and chronic disease with no notations or concerns of neglect and/or lack of care. On 02/15/2024, R1’s Primary Care Physician (PCP) discharged R1 back to the facility. On 02/16/2024, R1 was re-admitted to the LRRMC hospital due to the chief complaint of mental status changes. The hospital notes document “Patient with dementia recent admission post COVID-19 with hypernatremia, AKI, and UTI who presents to the emergency room after discharge. Likely toxic metabolic encephalopathy from UTI and recent hospitalization in setting of advance dementia. Urinalysis is still positive, started Cefepime. Oral intake is adequate, and labs are stable.” On 02/20/2024, R1 was discharged to a skilled nursing facility with a discharge diagnosis of dementia, acute encephalopathy, altered mental status, and history of COVID-19. On the allegation Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care to Resident #1 (R1) which resulted in R1 developing sepsis from a urinary tract infection while in quarantine for COVID-19. The Department’s investigation did not provide sufficient evidence to substantiate neglect/lack of care. Staff interviewed stated R1’s adult diaper was changed on a regular basis and R1 was checked every two hours. Staff also stated R1’s urine had a strong odor, and R1 was tested for a urinary tract infection with negative results, but they were unable to provide documentation to confirm this information. Affinity Home Health Resources medical records had no notations for concerns of neglect and/or lack of care. Los Robles Regional Medical Center (LRRMC) Hospital medical records had no notations concerning neglect and/or lack of care. Per R1’s resident representative there were no concerns with R1’s care prior to R1’s COVID-19 diagnosis and all issues resulted after R1’s diagnosis and while R1 had COVID-19. Per R1’s Primary Care Physician (PCP), it is possible COVID-19 was a causative factor of the sepsis diagnosis and no concerns of neglect and/or lack of care were reported. There is no evidence to conclusively determine the cause of sepsis, R1 was diagnosed with comorbidities including COVID-19, and there was insufficient evidence to support the allegation, therefore it is deemed Unsubstantiated at this time. Continued on LIC 9099-C. On the allegation Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care to Resident #1 (R1) resulting in R1 becoming malnourished while in quarantine for COVID-19. The Department’s investigation did not provide sufficient evidence to substantiate neglect/lack of care. Daily meal records showed R1 was provided three meals on a daily basis and per the Executive Director (ED), R1 consumed the food due to no notations made on the meal records that stated otherwise. Staff interviewed stated R1 consumed the food R1 was provided and at no time was R1 denied access to food. Staff stated R1 was less hungry and thirsty during the quarantine but did eat and drink. No notations or concerns of neglect and/or lack of care were noted on the Affinity Home Health Resources medical records. According to LRRMC medical records, a malnutrition screen was conducted on 02/12/2024, noting in summary, the nutrition problem was inadequate oral intake and etiology was acute illness and chronic disease with no notations or concerns of neglect and/or lack of care. Per R1’s resident representative, there were no concerns with R1’s care prior to R1’s COVID-19 diagnosis and all issues resulted after R1’s diagnosis and during R1’s term with COVID-19. Per R1’s PCP, it is possible COVID-19 was a causative factor of the malnutrition diagnosis and no concerns of neglect and/or lack of care were reported. There is no evidence to conclusively determine the cause of malnutrition, R1 was diagnosed with comorbidities including COVID-19, and there was insufficient evidence to support the allegation, therefore it is deemed Unsubstantiated at this time. On the allegation Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care to Resident #1 (R1) resulting in R1 becoming dehydrated while in quarantine for COVID-19. The Department’s investigation did not provide sufficient evidence to substantiate neglect/lack of care. Staff interviewed stated R1 consumed the fluids R1 was provided and at no time was R1 denied access to fluids. Staff stated R1 was less hungry and thirsty during the quarantine but did eat and drink. Affinity Home Health Resources medical records had no notations of concerns for neglect and/or lack of care. No notations were made concerning neglect and/or lack of care on R1’s LRRMC medical records. Per R1’s resident representative, there were no concerns with R1’s care prior to R1’s COVID-19 diagnosis and all issues resulted after R1’s diagnosis and while R1 had COVID-19. Per R1’s PCP, it is possible COVID-19 was a causative factor of the dehydration diagnosis and no concerns of neglect and/or lack of care were reported. There is no evidence to conclusively determine the cause of dehydration, R1 was diagnosed with comorbidities including COVID-19, and there was insufficient evidence to support the allegation, therefore it is deemed Unsubstantiated at this time. Continued on LIC 9099-C. This report has been amended to remove allegation "Staff did not provide resident's records to authorized representative." Please refer to report dated 11/18/2024 for supplemental report. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 29-AS-20240524095925

Allegation investigated: Facility is understaffed. Due to facility staff neglect, incontinent residents are being left in soiled diapers for extended periods of time. Unqualified staff are attending to residents.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 02/12/2024 and a subsequent complaint visit was conducted on 10/07/2024, both by LPA M. Arroyo. On today's visit, LPA Arroyo met with Business Office Manager, Guadalupe Ambriz. Entrance interview. During the initial visit on 02/12/2024, LPA Arroyo conducted a plant tour at 2:02pm, toured the memory care unit at 2:04 p.m., conducted interviews with the ED and four (4) staff between 1:52 p.m. and 4:25 p.m., and obtained copies of pertinent documents. On 10/07/2024, LPA Arroyo conducted interviews with three (3) staff, six (6) residents, and one (1) family member between 10:55am and 12:05pm, conducted a file review at 10:30am, and obtained copies of pertinent documents. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that facility is understaffed and unqualified staff are attending residents. It is the complainant’s concern that the memory care unit has been understaffed during the evening shifts leaving one (1) staff member to attend all residents. Additionally, the staff that is being placed in memory care, do not have the training or experience to assist the residents. Record review and interviews conducted revealed that the memory care unit typically has two (2) or three (3) staff which includes caregivers and a medication technician. Per staff schedule, dated January 2024, it confirms that there are at least two (2) staff in the memory care unit for the AM and PM shifts. Additional staff interviews revealed that although staff calls out at times, there is other staff that is able to assist. Staff stated that caregivers from the assisted living side and even outside agency staff are used at times when necessary. Staff added that the front desk clerk and kitchen staff were also used to assist in memory care; however, during interviews it was revealed that staff used from different departments only assisted by escorting residents to and from their rooms before and after meals times. Furthermore, record review of three (3) randomly selected staff hired in February 2024 revealed that staff complete all necessary training through Atria University which is an online based training. Correspondingly, randomly selected staff has completed online training as well as shadowing peers for all the required hours per regulations. And although each department requires different training, all facility staff are first aid trained upon hiring. Based on the information obtained through record review and interviews conducted, the Department does not have sufficient evidence to support the allegations of “facility is understaffed” and “underqualified staff are attending to residents”. Therefore, these allegations are deemed Unsubstantiated at this time. It was also alleged that due to facility staff neglect, incontinent residents are being left in soiled diapers for extended periods of time. It is the complainant’s concern that staff is double briefing residents to limit the times residents are being changed. Interviews conducted with staff revealed that incontinent residents are changed every two (2) to three (3) hours. Staff stated that some residents require changing more often than others and are checked more often to ensure they are not left in soiled diapers. Staff added that they are aware of which residents require more changing as it is placed in the resident’s care plan. Interviews conducted with residents revealed that staff often check on them throughout the day and assist with their toileting needs when requested. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Residents stated that they use their pendants to request for staff assistance and staff usually arrives at a decent time after the request. Furthermore, residents did not report any concerns while living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “due to facility staff neglect, incontinent residents are being left in soiled diapers for extended periods of time”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 29-AS-20240205142728

Allegation investigated: Facility staff not meeting the incontinence needs of the resident(s) in care. Facility staff have inadequate training.

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct subsequent complaint visit to address the allegations listed above. LPA met with Executive Director/Administrator (ED) Remon Pagels upon arrival. Entrance interview conducted. During today's visit, LPA reviewed training records for various staff who were employed at the time the complaint was received, toured the facility with ED at 11:31AM, interviewed staff and residents from 12:02PM to 02:34PM. During an initial complaint visit, conducted by LPA Elsie Campos on 10/12/2023, LPA Campos conducted interviews and reviewed pertinent documents relevant to the investigation. Throughout the course of the investigation, LPA Dulek reviewed pertinent documents. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: "Facility staff not meeting the incontinence needs of the resident(s) in care:" LPAs interviewed both residents and staff in regards to this allegation. Staff interviewed indicated that the facility uses ipods to track the care needs of residents. All residents' care needs are entered into the computer system, then each care staff does carry an ipod that indicates what tasks are assigned for the day. Staff then check off the tasks for each resident as they are completed. Staff interview revealed that they check residents approximately every 2 (two) hours and change residents as needed. If a resident is observed to be wet or soiled, they are changed additional times as needed. During the facility tour in both initial complaint visit and the subsequent visit, no incontinence odors were noted. Care staff interviewed indicated that sometimes residents refuse incontinence care, which is also documented on the ipod as well as reported to management. Residents interviewed felt their incontinence needs are being met and did not note any concerns with the care they receive at the facility. Based on interview and observation, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "facility staff not meeting the incontinence needs of the resident(s) in care is deemed UNSUBSTANTIATED at this time. Allegation "Facility staff have inadequate training:" LPA Dulek reviewed facility staff records and conducted interviews related to this allegation. Record review revealed that prior to 2023, all training records were documented and recorded on paper copy. Beginning in 2023, staff began completing some initial and ongoing training on the facility's computer system. LPA reviewed both paper documents and printouts from the electronic training system. All staff files reviewed did contain adequate initial and ongoing documented training. Interviews revealed that upon staff hire, staff complete 2 days of computer training, including orientation and training in line with Title 22 regulation. After the 2-days, the staff are then directed to the Department head to schedule additional training, shadowing, and hands on training with seasoned staff prior to beginning work with residents. Based on interview and record review, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "facility staff have inadequate training" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Oct 15, 2024 · control 29-AS-20231006100424

Allegation investigated: Staff left resident in soiled clothing and diapers for a period of time. Staff not keeping resident’s room free from odor. Staff does not maintain residents hygiene.

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct subsequent complaint visit to address the allegations listed above. LPA met with Executive Director/Administrator (ED) Remon Pagels upon arrival. Entrance interview conducted. During today's visit, LPA toured the facility with ED at 11:31AM, interviewed staff and residents from 12:02PM to 02:34PM. Additionally, LPA observed residents throughout the visit. During an initial complaint visit, conducted by LPA Elsie Campos on 11/21/2023, LPA Campos collected pertinent documents relevant to the investigation and conducted a physical plant tour with Memory Care Director of resident rooms in Memory Care at 12:05PM and conducted resident observations at 12:30PM. Throughout the investigation, LPA Dulek reviewed all documents. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation "Staff left resident in soiled clothing and diapers for a period of time:" The complaint alleges that Resident #1 (R1) who resides in the facility's Memory Care unit, is not being provided clean clothing daily and that the resident is being left in soiled incontinence briefs. During both the initial and subsequent complaint visit, both LPAs observed residents to be wearing clean clothing, and with no obvious signs of soiled incontinence briefs. Residents interviewed indicated the staff are nice and they are assisted with toileting and changing clothes daily. Staff interviews revealed that residents are provided incontinence care at least every 2 hours or more frequently as needed. Memory Care staff do launder residents' clothing and bedding at a minimum weekly, or more often if needed. Staff interviewed stated that in Memory Care there are 2 care levels and residents are assessed to ensure their care needs are being met. Staff do carry ipods that track the care needs of the residents and as tasks are completed for a resident, staff indicate completion on the ipod. Staff interviewed denied the allegation, stating they have never seen residents left in soiled clothing and/or diapers. Based on interview and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "staff left resident in soiled clothing and diapers for a period of time" is deemed UNSUBSTANTIATED at this time. Allegation "Staff not keeping resident room free from odor:" The complaint alleges that R1's room smells of urine and is not cleaned adequately to meet the needs of the resident. Both LPAs during the initial and subsequent complaint visit, observed resident rooms for incontinence odors, including R1's room. No odors were observed in Memory Care during either visit. Additionally, LPA reviewed copies of carpet cleaning invoices and work orders from the period of time the complaint was received. Record review revealed that R1's room and the hallway R1's room is located in did have the carpets cleaned regularly. Staff interviewed indicate if they notice an odor from a resident's room, they will immediately report to maintenance staff to ensure the room is cleaned as soon as possible. Staff also stated that following incontinence care, staff remove all soiled items from a resident's room to ensure odors are kept to a minimum. Based on observation and interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "staff not keeping resident room free from odor" is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C Allegation "Staff does not maintain residents hygiene:" The complaint alleges that R1's hygiene is not up kept, however no additional information was provided. During both the initial and subsequent complaints, LPAs observed residents to be clean, properly groomed and no concerns with hygiene were noted. Staff interviewed indicated that some residents do refuse hygiene care occasionally, but that this is documented and communicated with residents' physician and family. Most residents are compliant in meeting hygiene needs with staff assistance. R1 was observed in both the initial and subsequent complaint visits to be properly groomed and clean. Residents interviewed stated they are independent with their hygiene needs, but that the care staff are wonderful and make sure they are taken care of. Staff interviews revealed that there are daily tasks assigned to each caregiver for each resident they are responsible for. Staff stated there are enough staff present to meet resident needs and if a resident has an unmet need or refuse care with a particular caregiver, they ask each other for assistance and usually a change of care staff will encourage residents to allow care to be provided. Based on observation and interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "staff does not maintain residents hygiene" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Oct 15, 2024 · control 29-AS-20231115151656

Allegation investigated: Staff did not distribute resident's medication as prescribed Staff did not ensure that resident was hydrated Staff did not monitor resident for change in condition Staff did not meet resident's dietary needs

At 10:10 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent complaint inspection regarding the above allegations. The LPA met with Business Director Lupe Ambriz and explained the reason for the visit. Senior Executive Director (ED) Brian Larios arrived shortly thereafter. On 11/10/2022, LPA Lopez between 12:55 PM and 3:45 PM reviewed facility records, conducted staff and resident interviews, and obtained copies of pertinent records. On 05/02/2024, LPA Cortez between 1:00 PM and 4:25 PM, reviewed interviews conducted, and facility records collected during the initial 10-day complaint visit and conducted staff interviews, and obtained copies of pertinent records. During today’s visit, LPA Cortez conducted, one (1) resident, and three (3) staff interviews, observed lunch and obtained copies of pertinent documents. Report will continue on LIC9099-C. (2ND PAGE) Unsubstantiated On the allegation Staff did not distribute resident's medication as prescribed it is the reporting parties (RP) concern that in or about August 2022 staff only distributed half of Resident#1 (R1) Covid medication, while R1 was quarantined. RP also reported that R1’s Covid medicine was in R1’s kitchen counter. To investigate the allegation, file review and interviews were conducted. File review revealed that R1 could manage their own medication. Furthermore, file review reflected that R1 had been assessed on 11/25/21 to determine their ability to self-manage medications. R1 was able to tell time/day/month, could explain signs/symptoms which would require PRN medication use, demonstrated ability to correctly verbalize time and routes of all medications, demonstrated ability to document, order medication and could call refills in a timely manner as well as demonstrated the ability to self-administer all medications prescribed by physician. Staff interviewed revealed that R1 was independent and was not receiving care or part of the medication program. Staff also revealed that staff cannot administer medications to residents who are not on the medication program and residents’ family would have to notify the facility if the resident could no longer manage their medication and needed to be placed on the medication program. While residing at the facility, R1 tested positive for Covid in or about August 2022, however staff revealed that they were unaware if the resident was taking their medication since they were independent and not on the medication program. Based on interview and record review, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that " Staff did not distribute resident's medication as prescribed"and "is deemed UNSUBSTANTIATED at this time. On the allegations that Staff did not ensure that resident was hydrated, and that Staff did not monitor resident for change in condition it is the reporting parties concern that on 9/1/2022, R1 was observed to be curled up in bed and not feeling well, and afterwards R1’s physician diagnosed R1 with dehydration. To investigate the allegation, interviews and file review was conducted. Staff interviews revealed that R1 tested positive for Covid in or about August of 2022. Staff noted that residents are not being reassessed, when they get COVID, staff checks on them but no actual paper assessment is done. That if there is a significant change in condition then the resident will get sent to the hospital. Staff interviews also revealed that residents are assessed yearly or when there is a change of condition. On 11/10/22 Senior Executive Director (ED) Brian Larios stated that the nurses were responsible for doing the assessments on the residents. ED Larios also noted that before his time, the previous Executive Director spoke with the family regarding concerns with R1 regarding having dementia and they wanted to move up the date for the resident's medical assessment due to their concerns. REPORT WILL CONTINUE ON LIC9099-C (3RD PAGE). Furthermore, file review reflected that on 08/31/22, the facility’s Divisional Nurse spoke with R1’s son regarding R1’s increased confusion and disorganization and discussed possible transition to memory care, however R1’s son did not feel R1 was ready for memory care. File review further revealed that a request was sent to R1’s physician for an updated LIC602 due to change in condition, and additional tasks for status checks and escorts to meals were entered for two weeks. In addition, file review reflected that facility staff was in communication with R1’s physician. On 7/19/22 a “Notification of Incident or Change of Condition” was sent to R1’s physician informing them that R1 had experienced confusion and difficulty with their speech and R1 was taken to the hospital. R1’s physician did not issue any new orders. On 08/29//22 and additional “Notification of Incident or Change of Condition” was sent to facility staff by the Physician regarding concern for dehydration for R1. R1’s physician provided new orders. Lastly, staff interviews revealed that residents are provided water with every meal, however they can only encourage residents to drink water but cannot force residents. It was also revealed that water is provided throughout the facility, as they have water dispensers throughout the community and residents can go to the bistro, and the dining room and get water bottles at any time. Based on interview and record review, at this time there is insufficient evidence to support the allegations or that a violation occurred, therefore, the allegations that "Staff did not ensure that resident was hydrated, and Staff did not monitor resident for change in condition" are deemed UNSUBSTANTIATED at this time. On the allegation that Staff did not meet resident's dietary needs, it is the reporting parties concern that on 8/29/2022, staff delivered R1 a meal that contained sausage and a bottle cap in the food. To investigate the allegation, interviews, file review and observations were conducted. Staff and resident interviews revealed that in 2022 R1 tested positive for Covid on 08/16/22 and when residents test positive for Covid staff would deliver meals to the residents in their rooms. It was also revealed that by 08/26/22 R1’s Covid had resolved. Staff interviews revealed that staff are unaware of any staff delivering a meal with sausage and a bottle cap to any resident. Staff revealed that R1’s family made them aware of the meal tray, however it is unknown who placed the meal in front of the resident’s bedroom. Interviews also revealed that if a resident was mistakenly delivered the wrong meal they could call the front desk and request something different. REPORT WILL CONTINUE ON LIC9099-C (4TH PAGE). Furthermore, file review of the meal attendance report reflected that R1 was accounted for at the dining room during breakfast, lunch, and dinner on 8/29/22, however it is unclear if R1 went down to the dining room or received their food in their room since the facility was still experiencing a Covid outbreak. Facility’s menu obtained by LPA Lopez in 2022 reflected that the facility provided a variety of food options including Vegan and Vegetarian options in 2022. Menu options included vegetarian minestrone, veggie quesadilla served with guacamole and salsa, salads, eggplant parmesan served with garlic bread stick, among other options. Lastly, during today’s visit the LPA observed resident’s eating a variety of foods in the dining room and was able to interview a resident who is Vegan. Interview conducted with the resident revealed that there have always been food options for them during the 10 years that they have lived at the facility. Based on interview and record review, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that " Staff did not meet resident's dietary needs." is deemed UNSUBSTANTIATED at this time. Exit interview was conducted, and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 31, 2024 · control 29-AS-20221107143915

Allegation investigated: Staff did not prevent resident's room from having plubming issues

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint unannounced visit to investigate the allegation listed above. The LPA met with Executive Director (ED) Remon Pagels and explained the reason for the visit. On 11/08/2023, LPA Campos conducted an initial 10-day complaint and met with Memory Care Director,Cassandra Sadowsky. During the visit, LPA Campos interviewed staff at 11:42 a.m. and 11:50 a.m. and collected pertinent documents relevant to the investigation. On 11/28/2023 LPA interviewed one (1) resident. During today's visit, between 10:50 a.m. and 1:00 p.m. the LPA Cortez toured the facility with the ED, interviewed one (1) staff and reviewed interviews and documents collected during the initial 10-Day Visit. Report will continue on LIC9099C. Unsubstantiated On the allegation that Staff did not prevent resident's room from having plumbing issues, the reporting parties concern is that Resident#1’s (R1’s) room had plumbing issues three (3) times in six (6) months during 2023. To investigate the allegation, the LPA reviewed interviews conducted and documents collected during the initial 10-day visit and conducted interviews. Interviews and documents revealed that the facility did have plumbing issues in 2023, however they had services done to fix the issues and moved R1 to a new unit. Based on the documents review, the above allegation is deemed Unsubstantiated at this time. Exit interview was conducted, and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 2, 2024 · control 29-AS-20231106122246

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian arrived unannounced to conduct a required annual visit. The LPA met with Executive Director Remon Pagels and reason for the visit was explained. At approximately 1:45pm, the LPA, Executive Director Remon Pagels and Maintenance Director Hector Arjon toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Common Areas: The facility is a three-story building. Facility elevators were operating properly. There are three stairwells that all have emergency evacuation chairs on the third floor. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors and a separate unit on the second floor is designated for residents in the memory care unit. There is a central entry point for universal screening. There was hands-free hand sanitizer interspersed throughout the common areas. There were no obstructions and/or tripping hazards observed. The facility maintains a comfortable temperature at 71 degrees Fahrenheit. The fire extinguishers were charged and last serviced 1/3/2024. Smoke detectors and carbon monoxide detectors are tested yearly - The facility uses Johnson Controls to inspect their fire suppression system with the last inspections being conducted on July 11, 2023 through July 12, 2023. According to Maintenance Director the facility maintenance staff conducts monthly inspections of all smoke and carbon monoxide detectors with the last inspection being conducted in March 2024. Required postings observed on the first floor. Activities: Planned activities are offered, and the activity schedule was posted, and is provided to the residents on a weekly basis. Activity rooms and common spaces appeared clean and in good repair. There is a movie theater, hair salon and exercise/therapy room for residents use. Kitchen: At the time of the visit, there was a sufficient supply of perishable and nonperishable food. The facility also has an emergency supply of food and water. The menu was posted and copies are available near the elevators for residents to take. The facility offers daily specials and a standard selection at every meal. Appliances appeared to be in operable condition. (Continue to LIC809c). Resident Rooms: The LPA toured eight (8) randomly selected resident rooms (both the memory care and assisted living unit). Rooms appeared well kept, with sufficient lighting and appropriately furnished. Restrooms: Resident restrooms observed fully stocked with supplies; grab bars and non skid mat/floor surface. The water temperature was tested on all floors and water temperature ranged from 114-115 degrees Fahrenheit. Interviews: LPA interviewed five residents during the tour and no concerns were noted. Outside areas: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There was an enclosed patio for residents whom reside in the memory care unit on the second floor. Delayed egress doors checked and were operable at the time of visit. Due to time constraints, the annual inspection will be completed on a follow-up visit. No deficiencies cited at this time. Exit interview conducted. Cope of report provided.the state’s words, verbatim · CDSS document, Apr 17, 2024

Allegation investigated: Facility is trying to persuade resident and or their responsibly parties to change physicians or home agency to one’s preferred by administration.

Licensing Program Analyst (LPA), Elsie Campos conducted unannounced subsequent complaint investigation for the above allegation. LPA met with Executive Director, Adam Syncheff and explained the reason for the visit. On initial complaint visit conducted 6/21/23, LPA conducted interviews with the Executive Director and Resident Services Directo at 1:50 p.m. and 2:30 p.m., obtained resident records and other pertinent documents relevant to the investigation. On subsequent complaint visit conducted 8/7/23, LPA conducted resident interview at 2:30 p.m. and reviewed pertinent documents relevant to the investigation. On subsequent visit conducted 10/12/23, LPA conducted interviews and reviewed pertinent documents relevant to the investigation. During today's subsequent complaint visit, LPA conducted interviews with staff and residents between 11:00 a.m. and 12:35 p.m., reviewed pertinent documents relevant to the investigation and issued findings. **Continued on LIC 9099-C** Unsubstantiated Regarding the allegation: Facility is trying to persuade resident and or their responsible parties to change physicians or home agency to one’s preferred by administration. It was alleged that the facility is trying to persuade residents and or their responsible parties to change physicians or home agency to one’s preferred by administration for financial gain. It was communicated that some residents have lived at the facility for an extended period of time and due to individual health conditions and care plans, were recommended to receive home health services by their primary care physician. Staff confirmed that they are unable to refer a resident to receive home health services from a specific agency or refer a resident to use an in-house physician, as they are not medical professionals and that decision is to be made in collaboration with the resident’s responsible party, the resident and/or the prescribing medical professional providing care for the resident. Staff and in -house physician further indicated that they offer recommendations for various home health agencies based on experience and services available for the resident however, it is not inferred to use any home health agency over another as that choice is ultimately left to the resident and their responsible parties. In addition the choice to use an in-house doctor is by personal choice of the resident and responsible parties, if they choose to use an in-house doctor it is based on preference,ease of access to care and resident on resident recommendations and that is a personal choice. Interviews with residents who receive home health services confirmed that the resident was referred to home health by either the resident’s primary care physician or admitting physician in the hospital, and that it was not the decision of the facility administration on who they chose. Interviews with residents who use in-house physician confirmed that it was not the decision of the facility administration on using them as it was a matter of convenience and accessibility. This facility uses various home health agencies. However, further review confirmed that facility provides family members and residents with a choice of agencies if requested, which is a list of available local home health agencies to aid in the family’s choice in choosing the best fit for the resident in question. Family interviews confirmed that they were never persuaded or forced to choose the facility’s internal home health agency or in-house physician. A review of the resident roster confirmed that there are currently at least six (6) different home health agencies providing home health services to residents in this facility. Based on the information obtained, there is insufficient evidence to support the claim that the facility is inappropriately referring residents to change physicians or use a preferred home health agency. This allegation is Unsubstantiated at this time. No deficiencies observed. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 28, 2023 · control 29-AS-20230619082021

Allegation investigated: Staff force residents to do activities of daily living

Licensing Program Analyst (LPA), Elsie Campos conducted unannounced initial complaint investigation for the above allegations. LPA met with Executive Director, Adam Syncheff and explained the reason for the visit. On 6/26/2023 LPA Campos conduted and intial 10 day comaplint visit in which interviews and record review were conducted. During today's complaint visit, LPA conducted interviews, reviewed pertinent documents and delivered findings. Continued on LIC 9099-C Unsubstantiated Staff force residents to do activities of daily living. Complainant alleges that staff are instructed to force residents to participate and engage in activities of daily living. Interviews with staff and residents denied claims that they are forced to do activities of daily living. Interviews with residents confirmed that they are allowed to make their own decisions and participate at their leisure. Staff interviews indicated that although some residents may have specific care instructions they are never forced to bathe or change against their will. Staff will always attempt to work with the resident and with management in addressing the residents care needs and concerns with non-compliance. Resident interviews denied claims that they are forced to do any forms of activities of daily living and will only be encouraged or given the option to participate if they wish. Based on interviews, there is insufficient evidence to support the allegation that the “staff force residents to do activities of daily living”. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 29-AS-20230626105737

Allegation investigated: Facility is charging for services not provided. Facility does not provide special diets to resident(s) as prescribed. Facility staff do not have criminal record clearance.

Licensing Program Analyst (LPA), Elsie Campos conducted unannounced initial complaint investigation for the above allegations. LPA met with Executive Director, Adam Syncheff and explained the reason for the visit. During today's complaint visit, LPA conducted interviews and reviewed pertinent documents relevant to the investigation. Continued on LIC 9099-C Unsubstantiated Allegation: Facility is charging for services not provided. Complainant alleges that the facility charges the residents and/or responsible parties for weekly maintenance including housekeeping, laundry, changing linens, and cleaning the facility further alleging that these services are not being completed by the facility while still accepting money from residents regularly. Upon arrival to the facility LPA observed that the facility was conducting a regular carpet cleaning of the facility. LPA further observed housekeeping conducting cleaning services throughout the facility. Interview with Administrator confirmed that services rendered at the facility are part of the general cost of living and all services such as housekeeping, laundry, changing linens and cleaning the facility are provided to all residents either daily or weekly depending on their personal plan of action. In addition,the facility does maintain regular and daily cleaning protocols and maintenance. Interviews with staff and residents did not express concerns with charges administered for services not rendered or with services not being completed. Interviews with residents expressed that the services are great and no issues with housekeeping. Based on interviews and LPA observation, there is insufficient evidence to support the allegation that the “facility is charging for services no provided”. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Facility does not provide special diets to resident(s) as prescribed. Complainant alleges that the facility does not provide special diets to residents in care who have documented dietary requirements, which has led residents to become ill while in care. Interview with administrator revealed that special diets are comprised of low sodium, low sugar, or no sugar. Residents in care are not on diets that require special textures such as blended or chopped. All residents who require a special diet are in charge of managing what they consume. The facility will provide specialized options for residents to choose from within the parameters of the resident’s diet however, ultimately the choice of what the resident decides to eat is left up to them. Interviews with residents confirmed that they are provided options based on their special dietary needs and will opt in for them however,they do have the option to choose something else. Based on interviews, there is insufficient evidence to support the allegation that the “facility does not provide special diets to resident’s as prescribed”. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Facility staff do not have criminal record clearance. Complainant alleges that Staff members employed in the facility are not associated to the facility, do not have a criminal record background check, and have not gone through the fingerprinting process prior to beginning employment at the facility. Record review conducted by LPA confirmed that all staff scheduled and on the staff roster are associated to the facility. Based on record review, there is insufficient evidence to support the allegation that the “facility staff do not have criminal record clearance”. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 29-AS-20231006100424

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.