Camden Senior Living

Allegation investigated: Facility staff did not address fall risk prevention when resident had a fall at the facility.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Administrator, Allan Jay Pacis and stated the purpose of today’s visit. On 02/24/2026, the Department received a complaint with the above allegations. On 02/25/2026, the Department conducted an initial investigation at the facility. It was alleged that the resident (R1) fell on 02/19/2026 and 02/21/2026 and the facility staff did not address fall risk prevention for R1. On 02/25/2026, LPA Rai interviewed 3 staff (S1-S3). Three out of three staff stated there has been a change of condition for R1, wherein R1 started falling at the facility in February 2026. They stated R1 has been restless at night, and not sleeping throughout the night, which has increased the number of falls. They stated R1 has had 3 falls on 02/19/2026, 02/21/2026 and 02/22/2026. Continuation on LIC 9099-C, Page 1 of 2. Unsubstantiated Page 2 of 2. Three staff stated the staff called R1's doctor after the first fall and the other 2 falls resulted in R1 being transported to the hospital. Three out of three staff stated there are fall prevention measures in place which were established when R1 moved into the facility. All three staff stated R1's fall prevention which is also documented on R1's Appraisal/Needs and Services Plan are increasing supervision by staff, at least every 2 hour status check and checking on R1 whenever the facility staff pass R1’s room in the hallway, placing a commode in resident’s room to increase R1's independence and safety, using a bed alarm as a secondary alert to notify staff and encouraging resident to come out to the common areas to interact with other residents. They stated R1’s authorized representative is working with hospital staff for physician to assess the resident since R1 had 3 falls in 4 days and no new orders have been given to the facility staff. Based on review of R1’s Appraisal/Needs and Services Plan of 12/08/2024, 03/27/2025 and 02/05/2026, facility staff documented R1’s objective and plan for risk of fall which was signed by both facility’s representatives and resident’s authorized representatives. The plan addressed fall risk prevention which included providing a safe, barrier-free environment that encourages independent activity, keeping care area uncluttered, keeping needed items within reach (eg. call light, personal items), promoting regular intentional rounding to assess for position change, pain assessment, personal needs, set/activate auditory alerts, ensure equipment is functioning appropriately, providing adaptive/assistive devices(eg. commode, raised toilet seat, cane, walker), providing appropriate bed/furniture choice for diagnosis/activity, utilize bed rails appropriately, providing stabile/heightened seating and maintaining bed in lowest position with brakes locked. Based on review of R1's Incident Reports, on 02/19/2026, R1 had a fall and facility staff contacted R1’s doctor after resident did not complain of any pain. On 02/21/2026, R1 had a fall and facility staff called Kaiser nurse hotline which advised staff to call 911. R1 was taken to the hospital and returned the same day in the evening. On 02/22/2026, R1 had a fall and facility staff called Kaiser nurse hotline which advised staff to call 911 to transport R1 to the hospital. Based on the interviews conducted with staff and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Allan Jay Pacis and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 19, 2026 · control 26-AS-20260224170312

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with James Equing Azarel, Administrator. LPA announced the purpose of the visit, LPA observed 2 staff and 6 residents. During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature displayed on the refrigerator was 44 degrees F and freezer is -14 degrees F. LPA toured 6 resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. ADM tested the smoke detector in the hallway and found smoke detector to function properly when tested. LPA toured 4 resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 105.2 - 109.7 F. LPA observed a designated laundry room for laundry not accessible to residents in care. LPA observed a staff bedroom. The facility has a ramp leading to the front door with hand rails and another ramp leading to backyard from bedroom #4. Page 1 of 2 LPA toured the outside area and found the exits to be clear of obstructions. LPA observed a locked shed in back yard used as storage and not as living quarters. LPA observed fire extinguisher was last serviced on 07/25/25. The facility has a pull alarm fire alarm that was last serviced on 07/25/25 by a third party. LPA reviewed Fire and Earthquake log. The last disaster drill was conducted on 07/19/25. LPA reviewed resident records for 3 residents. LPA reviewed 3 staff records. ADM and LPA reviewed Centrally Stored Medication Record for 3 residents. No deficiency were cited as per California Code of Regulations Title 22. This report was reviewed with James Equing Azarel, Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Licensee, Irish Ladwig and Administrator, Azarel James Equing and stated the purpose of today's visit. LPA Rai observed 2 staff and 5 residents at the facility. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 1 storage shed which was locked and inaccessible. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured 6 resident bedrooms. 6 Out of 6 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 106.5 degrees F - 107.6 degrees F. Fire extinguisher was observed and inspected on 03/23/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills were conducted on 04/19/2024 and 07/27/2024. LPA Rai reviewed facility records for 2 staff and 2 residents. No deficiencies were cited per California Code of Regulations, Title 22. Technical Violation as provided. This report was reviewed with Licensee, Irish Ladwig and Administrator, Azarel James Equing and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 25, 2024