Atria Santa Clarita

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management regarding an incident report received regarding resident # 1 (R1) who attempted to eloped from the memory care unit on Saturday 08/15/2026. During today's visit, LPA conducted interviews and obtained documentation pertaining to (R1) and the incident. Additional information maybe required for review. Exit interview and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Aug 18, 2026

Allegation investigated: Resident sustained multiple unstgeable pressure injuries due to staff neglect

Licensing Program Analyst, (LPA) Tuesday Cabiness conducted a subsequent visit to deliver final report for the above allegation. LPA spoke with the Administrator, and explained the reason for the visit . At 12:15pm, LPA inspected the facility; no health and safety hazard were noted. On 03/03/26, LPA Abeye Duguma conducted an initial visit to investigate the allegation, at which time, LPA conducted a brief facility well check and obtained records relevant to the investigation. To conclude the investigation Woodland Hils South RO was assisted by the CCLD Investigation Branch. During investigation on 3/10/26, between 10:35am to 12:17pm the department conducted interviews with witnesses that have knowledge about R1’s medical records and care and supervision in the facility. Between 1:30pm to 3:30pm, the Department representative spoke with four (4) facility staff and (Cont'd LIC9099C) Unsubstantiated three (03) residents from Atria Santa Clarita. Between 3:30pm to 4:00pm, the two (02) staff from the RCFE “Sunrise Studio City”, two (02) other witnesses including R1’s case managers/health care provider. and their responsible party were interviewed. R1 was interviewed at their current residence Mountain View Assisted Living on 03/10/26 around 4:30pm. In addition, on 06/01/26 at 1:00pm the department reviewed R1’s medical records previously requested from the Henry Mayo Hospital. It was alleged that resident #1 (R1) was observed sustaining unstageable pressure wounds due to staff neglect/lack of supervision. Information received revealed that R1 was residing at Atria Santa Clarita from 2021 until 11/30/25. On 11/30/25 R1 moved to Sunrise Studio City, admitted to the hospital on 01/24/26 and subsequently on 02/06/26, moved to Mountain View Assisted Living. Staff from Atria revealed that R1 resided at the facility for over 4 years and transferred out to Sunrise Senior Living on 11/30/25. During R1’s stay in the facility, R1 was assisted as needed. R1 was largely independent and ambulatory, requiring only standby shower assistance. During standby assistance, staff observed no skin breakdowns/pressure ulcers on R1's body; nor record of any staff witnessing skin ulcers during their residency at the facility. All residents interviewed at Atria revealed that they were satisfied with the care and supervision provided by staff. R1 confirmed that they sustained two pressure ulcers after R1 arrived at Sunrise Senior Living on 11/30/25 and that the ulcers worsened under Sunrise staff's care. R1 verified that while residing at the Atria, they did not require repositioning as R1 was able to do so on their own. Interviews with staff working for Sunrise Senior Living facility revealed the following: During R1's placement in the Sunrise facility as of 11/30/25, R1 lower body was not checked, and staff were unaware if R1 had any pressure ulcers. R1 received standby shower assistance by staff twice per week. Staff could not recall any pressure ulcers on R1 at any time during R1’s residency at Sunrise Senior Living. The two of R1’s Case Managers had knowledge of R1 unstageable pressure ulcers. They verified that between 11/30/25 and 01/24/26, R1 resided at Sunrise Senior Living. R1 went to the hospital on 01/24/26 and, subsequently placed at Mountain View from February 2026 to present. On 01/24/2026, R1 was transported to Henry Mayo Hospital from Sunrise Studio City for a fall, at which time, R1's medical assessment showed that R1 sustained several pressure ulcers described as unstageable and infected. A review of medical records from Henry Mayo Hospital verified that R1 was admitted on 1-24/26 and was found to have "sepsis due to bilateral gluteal pressure ulcers and cellulitis" and "...found to have MRSA bacteremia".....(Cont'd LIC9099C) Overall investigation concluded that although R1 sustained unstageable pressure injuries, there is no sufficient evidence to verify that a resident sustained unstageable pressure injuries while residing at the Atria Santa Clarita. Therefore, based on facility inspection, interviews and record review, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety hazards were noted during this visit. Exit Interview conducted, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 31-AS-20260227151826

Allegation investigated: Facility staff neglect resulted in resident sustaining a fracture

This report is an addendum to the Licensing Report previously delivered to the facility on October 30, 2025. The report has been amended to correct the investigative findings and the citation issued to the facility. Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Tracey Paulk and explained the purpose of the visit. As a result of the second-level appeal process, the Department conducted a comprehensive review of the available information. Upon further review, it was determined that revisions were necessary to clarify the factual basis supporting the investigative findings. Therefore, today's visit was conducted to amend the investigative report and correct the citation previously issued on October 30, 2025. On January 24, 2025, the Woodland Hills South Adult and Senior Care Regional Office received a complaint alleging that facility staff neglect resulted in Resident #1 (R1) sustaining a fracture. (Cont'd LIC9099C) Substantiated That same day, the complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Sonia Torre. The initial investigation was conducted by LPA Tuesday Cabiness on February 24, 2025, from 12:45 p.m. to 2:30 p.m. During the visit, LPA obtained facility and resident records, including Special Incident Reports (SIRs), the admission agreement, move-in documentation, fire department records, physician's reports, and resident assessments. Between January 25, 2025, and April 26, 2025, IB Investigator Torre conducted interviews with residents, staff, and witnesses, and reviewed additional resident records, medical records, and incident reports involving R1. Allegation: Facility staff neglect resulted in Resident #1 sustaining a fracture. It was alleged that between September 15, 2024, and December 6, 2024, Resident #1 (R1) experienced six reported falls. The final fall, which occurred on December 6, 2024, resulted in a fractured femur. According to the IB investigation and a review of the 911 audio recording, staff reported that R1 was unable to support their own weight, did not want to be changed while in bed, and required a higher level of assistance than previously identified. Interviews with the Executive Director (ED) and the Residential Services Director (RSD) revealed that, due to R1's frequent falls, administration intended to reassess R1 in September 2024 to determine the appropriate level of care. However, the reassessment and implementation of an updated care plan were delayed because R1's responsible party was unavailable to participate in the meeting. The RSD stated that although staff provided two-person assistance with transfers when deemed necessary, this practice was temporary and not formally incorporated into R1's care plan because it was inconsistent with facility policy. Interviews with direct care staff consistently identified R1 as a high fall risk whose condition had progressively declined. Staff acknowledged that R1 increasingly required two-person assistance with transfers due to recurrent falls and declining mobility; however, this increased level of assistance was never formally documented or incorporated into R1's service plan. (Cont'd LIC9099C - page 2) A review of facility records, including reassessments and internal incident reports, revealed that R1's last annual assessment was completed on August 13, 2024, and identified the need for an increased level of care. Following that assessment, R1 experienced six documented falls on September 15, September 20, September 23, October 1, November 13, and December 6, 2024. Incident reports consistently documented that R1's legs gave out while being transferred by a single staff member. The investigation further revealed that facility administration, including the Executive Director, Residential Services Director, and other responsible personnel, were aware of R1's significant decline in condition and repeated falls. Despite this knowledge, the facility failed to timely reassess R1, revise the care plan, or implement appropriate interventions, including a documented requirement for two-person assistance during transfers. The facility's failure to reassess R1 and address the resident's increased care needs placed R1's health and safety at immediate risk and contributed to the circumstances that resulted in R1 sustaining a fractured femur. Therefore, based on interviews, record reviews, the allegation that facility staff neglect resulted in resident #1 sustaining a fracture while in the care, will remain SUBSTANTIATED. Under Title 22, Division 6, Chapter 8, the following citations are issued and recorded on LIC9099D. In addition, a $500.00 immediate civil penalty is being assessed today due to violation of the Title 22 Regulations posing immediate danger to the resident’s health and safety. The ED was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Citations issued, appeal rights provided, exit interview conducted and copy of report provided to ED. (LIC9099C-page 3)the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 31-AS-20250122155506

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(h)(5) · Plan of correction due date: Jul 17, 2026

Administrator - Qualifications and Duties...(h) The administrator shall...(5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, …and Reappraisal. This requirement is not met as evidenced by; The Executive Director failed to take responsibility to ensure provision of services to R1 and to provide appropriate services identifies in R1’s appraisal/reappraisal. This poses an immediate risk to residents health and safety.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: The Administrator will read Title 22 regulations, 87405 - Administrator Qualifications and Duties and submit to LPA in writing the regulations were read and understood.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(a)(g) · Plan of correction due date: Jul 17, 2026

Reappraisals...(a)The pre-admission appraisal…shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, and to keep the appraisal accurate. The resident appraisal as frequently as necessary to ensure (g) The licensee shall ensure corresponding changes are made in the care and supervision provided to resident. This requirement is not met as evidenced by; staff failed to update changes are made in care and supervision as required. This poses an immediate health and safety risk to residents in care,the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: ED will discuss with corporate and legal regarding the plan of corrections for the citation issued. LPA informed ED, that by 07/30/2026, a definitive plan needs to be submitted in writing to LPA, the facility's intervention plan for residents involving reappraisals for high fall risks and two person assist will be created and implemented. A copy of the plan needs to be submitted to LPA. If additional time is needed, the Administrator will email LPA for more time.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual inspection. LPA met with Executive Director Tracy Paulk who was present during inspection. The entire facility has (3) floors, which (67) residents may be bedridden on the 1st and 2nd floor of villas 1 & 2. There is a hospice waiver for (13), and fire clearance approved for delayed egress for the Memory Care, located in villa 2. The current census is 103. Facility license/sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, rights of resident council, discrimination notice, theft and loss policy, activity schedule, and evacuation plan visibly posted. Common areas: The first floor, identified the front entrance lounge with a hospitality station that serves coffee, water, and tea. The Administration offices, beauty salon, resident’s rooms, and laundry were also observed. All areas were clean and appropriately furnished for resident’s comfort. Passageways were free from obstruction, and inside temperature was comfortable. The second and third floor consists of resident rooms, dining room, activity, fitness, snack room, mail room, and personal laundry equipment for residents. The third floor also has movie and game room, and library. Dining Room and Kitchen: Passageways were free from obstruction, with adequate lighting. There is a daily menu placed on the table, with chairs and table were comfortable and clean. There are a variety a healthy foods. Coffee, tea, and water is available throughout the day, as well as a variety of snacks. LPA inspected the food supply and kitchen area where food is stored and prepared. LPA observed licensing requirements of (2) day perishable and (7) day non-perishable. Kitchen area was clean and food was stored and wrapped in a safe and health manner. Due to time constraints, LPA was not able to complete the annual inspection and will return at a later date and time to complete. Exit interview and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Apr 24, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit regarding an incident report submitted to Licensing concerning Resident #1 (R1) being observed leaving the facility unassisted. According to the incident report, staff observed R1 walking on the sidewalk outside of the community. Staff escorted R1 back to the facility. The report further stated that R1 exited the facility through the back gate and was not immediately observed by staff. During today’s visit, LPA met with Resident Care Director Venca Avivi, who confirmed that R1 left the facility. Venca reported that R1 is physically capable of leaving the facility; however, per physician’s orders, R1 is not permitted to leave unassisted due to physical limitations, not cognitive impairment. Venca stated that R1 was taken to urgent care by R1’s daughter and was diagnosed with a urinary tract infection (UTI), which may have contributed to the incident. Facility staff reported there are currently no concerns regarding R1. The facility will continue to monitor R1 closely and document any changes in condition. LPA obtained and reviewed R1’s current physician’s report. At this time, no further review is required. During the visit, LPA also identified concerns regarding the facility Administrator on record, Eden Tolentino. According to Eden, her designated back-up Administrator is Chad Jones, who resides in Kentucky when Eden is not present at the facility. LPA spoke with Eden via telephone. Eden reported she has not been physically present at the facility since January 05, 2026, and stated that Chad Jones has been present full time. (See LIC809C) LPA requested submission of an updated LIC 308 (Designation of Administrative Responsibility) and LIC 501 (Personnel Report), reflecting the days and hours the Administrator is working at the facility. At this time, there is no full-time Administrator physically present at the facility. Eden reported she is fulfilling the Administrator licensing requirements. LPA will follow up with Eden and Chad regarding the requested documentation. An exit interview was conducted, and a copy of this report was provided to Venca Avivi.the state’s words, verbatim · CDSS document, Jan 22, 2026

Allegation investigated: Staff did not follow proper rate increase procedures with resident in care

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility, met with Venca Avivi, and explained the reason for the visit. --- Staff did not follow proper rate increase procedures with resident in care It was alleged that Resident #1 (R1) received a monthly rate increase notice on 12/24 without a proper assessment. To investigate the allegation, on 01/07/2026/ LPA requested documents at around 11:00a.m. and interviewed one staff from 12:00p.m. – 12:30p.m. A review of R1’s Medical Assessment dated 10/18/2025 states R1 is able to bathe self with proper devices, e.g. handrail, chair and shower wand. The reassessment dated 12/09/2025 state R1 requires assistance twice a week with preparing all bathing supplies, escorting in and out of the shower/tub, washing and drying body while maintaining dignity. (CONT on LIC 9099-C) Substantiated A review of the Admissions Agreement states , “…we will reassess your needs to determine whether your condition has changed, work with you to update your service plan, if necessary, and review it with you”. During interviews, staff stated facility will meet with R1 or their responsible party on 01/08/2026 to discuss the details and changes in the level of care and the increased fees associated with such changes. Based on interviews and record review, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 31-AS-20251231084726

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jan 9, 2026

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidenced by; Based on interviews and record review, facility did not meet with R1 or RP to discuss the details behind the most recent rate increase which poses a potential health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: Licensee will meet with R1 or their responsible party to discuss the recent changes. Licensee will review regulation and submit a written letter stating they have conducted their meeting and reviewed regulations.

Allegation investigated: Facility staff neglect resulted in resident sustaining a fracture

Licensing Program Analyst (LPA) Tuesday Cabiness met with Venci Avivi, Resident Service Coordinator and informed her of the purpose of the visit. Executive Director April Princessa, arrived shortly after and was also informed of the visit. LPA delivered the final findings of the complaint investigation. On January 24, 2025, the Woodland Hills South Adult and Senior Care Regional Office received a complaint for the following allegation: “Facility staff neglect resulted in resident sustaining a fracture”. The same day, the complaint was referred to the Community Care Licensing Division’s (CCLD’s) Investigations Branch (IB), and assigned to Investigator, Sonia Torre. The following investigation and fact finding was determined: The initial investigation visit was conducted by LPA Tuesday Cabiness on 02/24/2025 from 1245pm to 230pm to obtain resident and facility documents: special incident reports (SIRs), resident agreement, move-in information, fire department records, physician report and resident assessment model. Between 01/25/2025 and 04/26/2025 IB Investigator Torre conducted interviews with residents, staff, witnesses, and reviewed, resident records, Substantiated SIRs, and medical records involving resident #1 (R1). “Facility staff neglect resulted in resident sustaining a fracture”. It was alleged that between 09/15/24 and 12/06/24 residents #1 (R1) had six (06) reported falls. The last fall incident occurred on 12/06/25 resulting in sustaining a broken femur. According to the investigation conducted by IB investigator Torre, and the review of the 911 audio call, it was revealed that the resident was very heavy, did not want to be changed in bed and was unable to “hold themselves.” According to the interview by the Residential Services Director (RSD), who confirmed the facility planned to reassess R1 in September 2024 due to the falls to determine the next appropriate level of care but failed to do so because the facility was unable to contact the responsible party. The facility preferred to first meet with R1’s responsible party before implementing a new care plan. The RSD stated two person assists for transfers were utilized at the discretion of staff and only offered on a temporary basis because it was against the facility’s policy. The interviews with staff revealed R1’s health continued to decline. R1 was considered a fall risk, and no new corrective action and/or care plan was implemented to address the recurrent falls. The review of the facility records including internal incident reports revealed the last (annual) assessment completed on R1 was on 08/13/2024 which resulted in an increase in care level. Subsequently, after the assessment, R1 sustained multiple falls (09/15/2024, 09/20/2024, 09/23/2024 10/01/2024, 11/13/2024 and 12/06/2024) where R1 legs reportedly continued to give out while being transferred by a single staff. Therefore, based on interviews and record review, the allegation of “facility staff neglect resulted in resident sustaining a fracture, while in care of the facility”, is Substantiated. This is a health and safety risk to residents in care. A $500 immediate civil penalty is assessed today for a violation posing immediate danger to the resident’s health and safety. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f), or 1548(e) or (f), 1568.0822(f). Exit interview, appeal rights, civil penalty, and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 31-AS-20250122155506

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 31, 2025

Additional Personal Rights of Residents in Privately Operated Facilities: (a)...residents in privately operated residential care facilities for the elderly shall have …the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers qualifications, and competency ...This requirement was not met, evidenced by, based on the investigator Torre, R1 was considered a fall risk, and no new corrective action and/or care plan was implemented to address the recurrent falls.This a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Executive Director will discuss with corporate and legal team in regards to training for staff and the Resident Services Director. The ED will notify LPA by the COB 10/31/2025, the exact specifics of training, and date and time.If further time is needed to accomplish the POC, the ED will remain in communication with LPA. Submit training documents of the topics, and staff attending.

Allegation investigated: Questionable death

Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director April Francessa and informed her of the purpose of the visit, which was to deliver the final findings of the complaint investigation. On January 24, 2025, the Woodland Hills Regional Office (South Adult and Senior Care Program) received a complaint alleging “Questionable Death.” On the same day, the complaint was referred to the Community Care Licensing Division’s (CCLD) Investigations Branch (IB) and assigned to Investigator Sonia Torre. The initial investigation visit was conducted by LPA Cabiness on February 24, 2025, from 12:45 p.m. to 2:30 p.m. During this visit, the LPA obtained facility and resident documents, including Special Incident Reports (SIRs), the resident agreement, move-in information, fire department records, the physician’s report, and the resident’s assessment. Between January 25, 2025, and April 26, 2025, IB Investigator Torre conducted interviews with residents, staff, and witnesses, and reviewed resident records SIRs, and medical documentation related to Resident #1 (R1). Unsubstantiated The complaint alleged that R1 expired after sustaining a serious injury due to the fall while in care. According to the IB investigation, fire department records confirmed that on 12/06/2024, staff called 911 to request medical assistance for R1, who sustained a fall while being assisted in the bathroom. Staff interviews indicated they followed facility protocols for falls, including assessing R1, requesting medical attention, and monitoring R1 until emergency services arrived. On December 6, 2024, R1 was admitted to the hospital and diagnosed with a displaced distal femur fracture from a mechanical ground-level fall, which required surgery. R1 was discharged from the hospital on December 17, 2024, in stable condition and transferred to a skilled nursing facility (SNF). IB Investigator Torre’s review of R1’s death certificate indicated that R1 expired on January 22, 2025, while under care at the SNF. The immediate cause of death was listed as cardiopulmonary arrest (within minutes), with contributing conditions of Alzheimer’s dementia (within years) and cancer. Based on the investigation conducted by the IB Investigator and review of the medical records, there is insufficient evidence to support the allegation that R1’s death was the result of a serious injury sustained while in care at the facility. Therefore, the allegation “Questionable Death” is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 31-AS-20250122155506

Allegation investigated: Facility staff did not follow resident's admission agreement

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit and met with Resident Services Director Venca Avivi and informed her the reason of the visit. Executive Director April Princessa was not present during the initial visit, but came shortly after. The following was determined during today's visit: It was alleged that facility staff did not follow resident's admission agreement. To investigate the allegation, (LPA) conducted visits on 02/24/2025 and today, between approximately 9:30 a.m. and 2:30 p.m. During today's visit, LPA conducted additional interviews and reviewed facility and resident records. The admission agreement, which was reviewed and signed by R1, did not contain any specific provisions indicating that R1 required two-person assistance. Although it was reported that R1’s family privately compensated the facility for additional care, LPA was not provided with any supporting documentation to verify this arrangement. Multiple requests for such evidence were made but were unsuccessful. LPA reviewed R1’s records, which showed that upon admission, R1 required minimal assistance and was independent. Unsubstantiated Over time, however, R1’s health declined, and R1 became a fall risk. Facility staff appropriately documented this decline and implemented preventative measures in collaboration with R1’s medical providers. Based on the available documentation and lack of corroborating evidence, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided to Executive Director.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 31-AS-20250122155506

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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced annual inspection. LPA was greeted by front the receptionist. Executive Director (ED) April Princesa was not present during the initial inspection, but came shortly after. The entire facility has (3) floors, which is licensed for (160) non-ambulatory, of which (67) may be bedridden on the 1st and 2nd floor of villas 1 & 2. There is a hospice waiver for (13), and fire clearance approved for delayed egress for the Memory Care, located in villa 2. The current census is 123. Facility license/sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, rights of resident council, discrimination notice, theft and loss policy, activity schedule, and evacuation plan visibly posted. Common areas: The first floor, identified the front entrance lounge with a hospitality station that serves coffee, water, and tea. The Administration offices, beauty salon, resident’s rooms, and laundry were also observed. All areas were clean and appropriately furnished for resident’s comfort. Passageways were free from obstruction, and inside temperature was comfortable. The second and third floor consists of resident rooms, dining room, activity, fitness, snack room, mail room, and personal laundry equipment for residents. The third floor also has movie and game room, and library. Dining Room: Passageways were free from obstruction, with adequate lighting. There is a daily menu placed on the table, with chairs and table were comfortable and clean. LPA observed residents eating a variety and healthy food for lunch. Coffee, tea, and water is available throughout the day, as well as a variety of snacks. Resident Rooms: All apartments are provided with a microwave and refrigerator purchased by the facility. Rooms, floors, walls, and carpet areas were clean in good repair. Residents are allowed pets. Inside temperature was cool, and each resident has there own thermostat to regulate. Bathrooms: All were clean, with grab bars, non-skid mats, and shower chairs. There are emergency pull cords located by the toilet for emergency purposes. Residents also have emergency pendants. Due to time constraints, the annual was not able to be completed. LPA will continue inspection at another date and time; reviewing staff, resident, training and medication records and the memory care unit. Exit interview and copy of report provided to ED.the state’s words, verbatim · CDSS document, Feb 24, 2025

Allegation investigated: . Resident sustained multiple falls while in care 2. Staff failed to provide resident's authorized representative with incident reports

Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director April Princesa, Venca Avivi, Residential Services Director, and Michelle Lagoy, Life Guidance Director. Everyone was notified the reason of the visit, which was to deliver the final findings of the allegations mentioned above. Allegation # 1: It was alleged resident sustained multiple falls while in care. During the initial investigation, on June 06/07/2023, from 1130am to 2pm, LPA conducted interviews and obtained resident records, as well reviewed facility documents. During today’s visit, from 930am to 230pm, LPA conducted additional interviews and re-reviewed documents. From the information obtained, the initial assessment revealed resident # 1 (R1) did not have any falls for over a year. (R1) was admitted to the facility in January 2023, and in March 2023, there was a change in condition with (R1’s) health and mobility. (R1) began using a wheelchair, which caused (R1) to fall. The facility re-assessed (R1) and implemented changes. Although, it was documented (R1) had several falls, it was due to (R1’s) change in mobility. LPA interviewed (R1’s) family, who reported the facility did the best they could with (R1) due to change of condition, and there was no neglect from the facility. Unsubstantiated Therefore, based on documentation and interviews, the allegation is Unsubstantiated at this time. Allegation # 2: It was alleged staff failed to provide resident's authorized representative with incident reports. During the initial investigation, on June 06/07/2023, from 1130am to 2pm, LPA conducted interviews and obtained resident records, as well reviewed facility documents. During today’s visit, from 930am to 230pm, LPA conducted additional interviews and re-reviewed documents. It was reported to LPA by the family, that they requested incident reports of (R1) falling at the facility. LPA interviewed staff, who denied there was a request of any documentation for (R1). It was revealed to LPA, that the former Life Guidance Director was no longer working at the facility, and the request could have been directed to her. The family could not specifically identify who they requested the documents to. Therefore, based on interviews, LPA does not have enough evidence to prove the allegation, and it’s Unsubstantiated at this time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 31-AS-20230606104724

Allegation investigated: . Staff do not ensure resident's are showered 2. Staff do not provide daily activities for residents

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a complaint visit and met with the Executive Director (ED) April Princesa, who was explained the reason of the visit. Allegation # 1: It was alleged staff do not ensure residents are showered. During today’s visit, from 930am to 245pm, LPA conducted a physical plant inspection, reviewed facility documents and interviewed staff and residents. From the information obtained, residents are showered twice a week, and as needed. Therefore, based on interviews, the allegation is Unsubstantiated at this time. Allegation # 2: It was alleged staff do not provide daily activities for residents. During today’s visit, from 930am to 245pm, LPA conducted a physical plant inspection, reviewed facility documents and interviewed staff and residents. From the information obtained, the staff follow the activity schedule that is created by facility staff for the assisted living and memory care unit. LPA also observed residents participating in arts and crafts during the visit, and reviewed the activity schedule. Therefore, based on observations and interviews, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 21, 2024 · control 31-AS-20240812193250

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Aug 22, 2024

Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well being This requirement is not met as evidenced by: based on interviews during today's visit, (R1) walked out the front door of the memory care unit without staff awrare. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: Administrator and Supervisor from the memory care unit, will conduct an in-service training to all staff regarding how to safeguard residents from eloping from memory care. POC cleared during the visit, training was already conducted.

Allegation investigated: Staff are illegally evicting resident Staff obtained & billed resident for services not agreed upon Staff did not provide requested records to resident's authorized representative

This is an amended copy of the report previously issued on 8/16/2024 and 5/30/2023. This report supersedes reports previously issued. The findings for this complaint remain the same. On 8/14/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Resident Services Director, Venca Avivi who stated the Administrator would be arriving to the facility. LPA was greeted by the Executive Director, April Princesa at 11:20 am. LPA explained the purpose of this visit was to present the findings. The investigation consisted of the following: On 5/30/2023 LPA Spaeth initiated a complaint investigation for the allegation(s) listed above. LPA Spaeth requested the resident roster and copies of residents’ files. During the visit, LPA received the documentation. Continued on 9099C Unsubstantiated Regarding the allegation: Staff are illegally evicting resident: it’s being alleged that R1 was given a 30-day notice to pay or quit due to failure to pay their rent since January, 2023. LPA Spaeth received a copy of the 30-day notice to pay or quit letter issued to R1 on 5/04/2023. The letter clearly stated R1’s account is past due in the amount of $25,833.95, which represents a past due balance for the months of January through May, 2023. LPA Spaeth interviewed R1 on 5/30/2023 at 11:00 am who stated they did not remember receiving an eviction notice and could not remember if they were up to date with their payments. LPA Spaeth interviewed R1 today, 8/16/2024 at 11:00 am who stated they have made all their payments to the facility. LPA Spaeth spoke to the Business Director, Wendy Rose on 8/12/2024 at 4:00 pm who stated R1 has made all their outstanding payments. Based upon interviews and record review, the allegation is unsubstantiated. Regarding the allegation: Staff obtained & billed a resident for services not agreed upon: it’s being alleged that the facility told R1 they require supervision when leaving the facility and there would be a monthly additional charge. It’s also being alleged R1 was given a letter stating R1 requires this service and there would be an additional monthly charge for the service each month. LPA reviewed R1’s Admissions Agreement. R1 moved into the facility as of July, 2022. The Admissions Agreement states “Assessment of Your Needs which states a rate change will occur when the change in service occurs due to a resident’s need for a service change. Facility will then review the assessment with the resident.” LPA Spaeth reviewed the physician’s report (LIC 605C) which reveals R1 will need assistance when leaving the facility. LPA interviewed the Resident Services Director (S1) who stated they conducted the yearly assessment for R1 and reviewed the assessment with R1 each year. S1 confirmed R1 was aware they needed assistance when leaving the facility and also told R1 the charge would be indicated on their bill as a “private duty personnel” charge. LPA Spaeth spoke to R1 at 11:00 am who stated they were aware they would be charged for staff assistance when they left the facility. LPA Spaeth interviewed R2 – R10 who confirmed they have never been charged for services they have not agreed upon. Based upon record review, staff and residents’ interviews, the allegation is unsubstantiated. Continued on 9099C Regarding the allegation: Staff did not provide requested records to resident's authorized representative. It’s being alleged that a resident's authorized representative requested copies of the resident’s records and did not receive them. LPA Spaeth was informed the records requested have been received by the requester. Therefore, the allegation is unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 31-AS-20230524170317

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility at 9:30am to conduct Annual inspection. LPA was greeted by front the receptionist, who notified the Executive Director (ED) April Princesa, and who was informed the reason of the visit. The entire facility has (3) floors, which is licensed for (160) non-ambulatory, of which (67) may be bedridden on the 1st and 2nd floor of villas 1 & 2. There is a hospice waiver for (13), and fire clearance approved for delayed egress for the Memory Care, located in villa 2. The current census is 132. Facility license/sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, rights of resident council, discrimination notice, theft and loss policy, activity schedule, and evacuation plan visibly posted. Common areas: LPA conducted a physical plant tour with (ED) April, and inspected the first floor, which identifies front entrance lounge with a hospitality station with coffee, water, and tea. The Administration offices, beauty salon, resident’s rooms, and laundry were also observed. All areas were clean and appropriately furnished for resident’s comfort. Passageways were free from obstruction, and inside temperature was comfortable. The second and third floor consists of resident rooms, activity, fitness, snack room, mail room, and personal laundry equipment for residents. The third floor also has movie and game room, and library. Dining Room: Passageways were free from obstruction, with adequate lighting. There is a daily menu placed on the table, with chairs and table were comfortable and clean. LPA observed residents eating a variety and healthy food for lunch. Coffee, tea, and water is available throughout the day, as well as a variety of snacks. Resident Rooms: All apartments are provided with a microwave and refrigerator purchased by the facility. Rooms, floors, walls, and carpet areas were clean in good repair. Residents can have pets, and during inspection, LPA observed cats and dogs signs posted on resident's doors. Thermostat, smoke alarms, and carbon monoxide detectors were being tested during the inspection, hired by Johnson Control Inc, (JCI) company. Bathrooms: All were clean, with grab bars, non-skid mats, and shower chairs. There are emergency pull cords located by the toilet for emergency purposes. Residents also have emergency pendants. Water temperature was measured in several of the rooms. Memory Care Unit: Is located adjacent to the Assisted Living facility. It has (3) floors, with a delayed egress front door and keypad lock located outside the facility. The current census is (38). Rooms are either private or separated, with (1) shared bathroom. All common areas were clean and in good repair. Passageways were free from obstruction, and furnishings were appropriate for residents. There is a dining room, kitchen, and activity room for resident’s entertainment and comfort. Snacks, water, and tea are available throughout the day. Meals are prepared by the main kitchen and delivered to the unit. Smoke alarm and carbon monoxide detectors are in each resident room. . Record Review: Medication room was locked and inaccessible to residents. There is a complete first aid kit at the facility. Residents and staff records were reviewed. LPA reviewed files of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed. Residents files appear to be complete and updated. Staff present files were also reviewed, staff files appear to be complete and updated training is computerized. First aid and medication training current. No health and safety hazards noted during the visit. **Note, inspection tool questions for staff and residents did not populate and LPA was not able to complete them. Exit interview conducted and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jun 18, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced case management visit pertaining to a resident eloping from the facility. LPA met with Venca Avivi Resident Services Director and Executive Director April Princesa, who was informed the reason of the visit. LPA received (3) incident reports, pertaining to resident #1 (R1) eloping from the facility. (R1) physically moved in the facility on 05/03/2024. On 05/05/2024, (R1) was found wandering in the front parking lot of the facility, and was returned to the community. The second elopement was dated on 05/18/2024, and the 3rd was on 05/24/2024. LPA contacted the ED on 05/24/2024, to obtain further information regarding the incident. During today's visit, LPA conducted interviews and reviewed (R1s) records. (R1) is diagnosed with dementia and was currently residing on the AL (Assisted Living) side until an opening for the memory care unit was available. It was also reported to LPA that (R1's) family recently hired private companion/caregiver to accompany (R1) until (R1) could be admitted to the memory care unit. LPA was informed that (R1) will be admitted either on 05/31/2024 or 06/01/2024. (R1) is not allowed to leave the facility unassisted. LPA discussed with both the Resident Services Director & Executive Director, regarding the concerns of staffing during dining room hours and residents who are diagnosed with dementia and residing on the assisting living (AL) side of the facility, that cannot leave the facility unassisted. LPA has cited the facility for a previous incident that dealt with the same issue, dated 03/14/2024. During this visit, a citation will be issued and a civil penalty will be assessed. The ED has been informed by the LPA, that the plan of correction (POC) for today's citation will be discussed with there legal team, and ED will contact LPA on 05/31/2024 by 5pm with confirmation on the plan to correct citation. This is an immediate health and safety risk to residents in care. Citation issued, civil penalty, appeal rights, exit interview, and copy of report provided.the state’s words, verbatim · CDSS document, May 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: May 31, 2024

Care of Persons with Dementia: (j)The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met, evidenced by; based on interviews and information obtained R1 is diagnosed with dementia, and eloped from the facility on (3) different occasions. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: The Executive Director, will email LPA by 5pm on 05/31/2024, informing LPA that she has contacted there legal team regarding the plan of correction that is required for today's citation and civil penalty. The ED will have (2) weeks from 05/31/2024, to submit the POC to LPA regarding's today's citation.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced case management visit pertaining to a resident eloping from the facility. LPA met with Wendy Rose, the Community Business Director; who was informed the reason of the visit. The Executive Director April Princesa was not available or at the community. During today's visit, LPA conducted a physical plant inspection of the entire facility, including all exit doors and interviewed staff. The following was revealed: On 03/09/2024, resident #1 (R1) eloped from the facility, and was returned back to the community by the local police department. It was revealed to LPA, that R1 is diagnosed with dementia and was currently residing on the AL (Assisted Living) side until an opening for the memory care unit was available. It was also reported to LPA that R1 has a private companion/caregiver that works in the evenings with R1. The companion did not report to the facility to work with R1, the evening of the incident. R1 is not allowed to leave the facility unassisted. The day of the incident, R1 left the facility approximately around 415pm, and staff was not made aware R1 was missing until a phone call received by a bystander who contacted the facility and spoke to the front desk receptionist, who reported, they saw R1 walking down the street from the facility. The bystander contacted the police, who picked up R1 by the freeway and returned to the community. R1 was not aware that R1 eloped and was returned. Staff contacted the Executive Director and family was notified. Therefore, based on interviews, LPA determined there was a lack of care and supervision for R1, which caused R1 to elope and wander. This is an immediate health and safety risk to residents in care. At the end of the visit, LPA spoke to the ED and regarding the visit and citation that was issued. Citation issued, appeal rights, exit interview, and copy of report provided.the state’s words, verbatim · CDSS document, Mar 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Mar 15, 2024

Care of Persons with Dementia: (j)The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met, evidenced by; based on interviews and information obtained R1 is diagnosed with dementia, and eloped from the facility and returned by the police. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Executive Director will contact LPA by 5pm on 03/15/2024, to discuss a plan of action on how they will prevent R1 from eloping again and other residents who are diagnosed with dementia and living in assisted living.

Allegation investigated: Residents safety pendents are inoperable

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced complaint visit and met with the Executive Director (ED) April Princesa, who was informed the reason of the visit. The following was determined: It was alleged the resident's safety pendents were not operable. During today's visit, from 945am to 1230pm, LPA conducted a physical plant inspection, interviewed residents and staff, and reviewed facility documents. On 01/19/2024, the ED and facility staff were notified by residents that there pendants were not working. The alarm was tested, and it was determined by the IT Support team the computer system had crashed, and needed to be replaced. The ED reported to LPA, it took (4) days to repair, and on 01/22/2024, the system was operating properly. LPA verified the system was operating, by having staff do a test check. Residents were notified the system was not working and when it was repaired. LPA confirmed that during interviews with residents. Also LPA obtained facility document that was provided to all residents. LPA also reviewed incident reports; there were no health and safety concerns. Therefore, the allegation is Substantiated and POC was cleared during visit. Substantiatedthe state’s words, verbatim · CDSS document, Jan 23, 2024 · control 31-AS-20240122091521

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 23, 2024

Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met evidenced by, based on today's interviews, it was reported the resident's pendents were not working for (4) days. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: POC cleared -- documentation was provided the computer system was replaced.