Haven Oasis Senior Living

Allegation investigated: Resident developed multiple pressure injuries in care due to staff neglect

This report is a correct version of report dated 5/23/2026 to add an additional deficiency and additional information on the LIC9099. Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent visit to this facility to deliver findings. LPA met with staff (S1), Aldin Martinez, who granted access to the facility. On 2/19/2026, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding above allegation. Initial investigation was conducted by LPA on 2/20/2026. LPA requested the following documents: staff roster (LIC 500); resident roster (LIC 9020), residents’ physician’s report, admissions agreement, appraisal needs and service plan, hospice care plan, and other documents. Continue to LIC 9099-C. Substantiated LPA interviewed five (5) out of five (5) residents, staff designee and three (3) staff from 1:14 PM until 2:12 PM. LPA reviewed resident’s records from 2:14 PM until 3:45 PM. LPA took a tour of the physical plant with the assistance of the administrator at 1:13PM. On 3/9/2026, LPA requested R1’s hospital medical records. Regarding allegation: Resident developed multiple pressure injuries in care due to staff neglect. It is alleged that on 2/17/2026 R1 had an appointment with their Geriatrician and R1 has several stage 3 wounds. R1 was admitted to the facility on 5/23/2025, record review, appraisal needs and service plan and preplacement appraisal (LIC 603), revealed that R1 did have an unstageable wound on their coccyx. All of the residents interviewed during the investigation did not address any concerns regarding their care at the facility. Hospital medical records reviewed reveal R1 had developed pressure injuries on their coccyx, sacral, and bilateral heel. Wound started developing on 4/14/2025 before R1 was admitted to the facility. An interview with staff revealed repositioning assistance was provided to avoid and give relief to pressure injuries by staff. Interview with R1’s responsible party revealed that they are happy with the care given by the facility and were not aware that R1 required higher level of care or were clear regarding the care hospice will provide. Records reviewed reveal that all of the staff are trained by the administrator and were following home health instructions on how to care for R1’s wounds. A review of hospital medical records revealed R1 was admitted to home health on 5/29/2025. On 5/29/2025 sacral wound stage 3 was noted to measure 1.5 cm x 1 cm x 0.2 cm. On 8.7.2025 medical records noted coccyx wound was noted as stage 2. On 5/21/2026, LPA called and spoke to R1 family revealed that they refused to admit R1 to hospice. On 11/3/2025, additional wounds were noted to the right heel (full thickness skin loss) stage 3 measuring 2.25 cm x 2.5 cm x 0.2 cm. Family eventually agreed for R1 was to be admitted to hospice on 11/3/2025. On 2/5/2026, it was noted that R1 had stage 3 wounds on their right (R) heel measuring 2.25 cm x 2.5 cm x 0.2 cm. On 2/18/2026 right heel was noted as unstageable. Continue to LIC 9099-C. Although R1 was receiving home health care and hospice care, staff were providing required assistance, pressure injuries were not healing and developed into unstageable wounds. Facility staff admitted R1 on 5/23/2025 with stage 3 wound and upon development of new stage 3 wounds from 5/29/26 to 2/20/2026 R1 was retained at the facility. Therefore, the allegation is substantiated. Based on observation, interviews, and record review, there is sufficient evidence. Therefore, the allegation is deemed substantiated California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. An immediate Civil Penalty of $500.00 will be issued during this visit due to neglect/lack of care by providing care to R1 with a prohibited health condition. An additional civil penalty may be assessed at a later time based on Health and Safety Code 1569.49. Deficiency noted on 4/23/26 remains the same. An exit interview was conducted. Appeal rights, a copy of the report, LIC 9099D, were provided.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 31-AS-20260219085327

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 8, 2026

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on observation, interviews, and medical records reviewed licensee did not ensure to obtain proper medical care for R1 upon observation of stage 3 wounds which poses an immediate health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Administrator will create a plan that will identify pre-placement assessment process, retention or seeking medical care upon evaluation of wounds, will certify in writing that understands regulation sections 87609, 87615, and 87616 and will submit a copy of both to the department by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff, Cristina Poole, and explained the reason for the visit. Approximately, around 10:35 AM administrator, Hananiah Pramono, arrived and was explained for the reason of the visit. At 10:50 AM, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. At 11:27 AM the smoke alarms were tested and are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 1.27.2026. During the visit the facility is at 71 degrees Fahrenheit. The facility is fire cleared six (06) non-ambulatory clients and one (1) bedridden in bedroom #1. Hospice waiver for six (6). Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the garage. Bedrooms: There were four (4) bedrooms designated for residents' use. Bedroom #1, bedroom #3, bedroom #4 are for private used. Bedroom #2 is shared. Bedroom that are in used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C Bathrooms: There are two (2) bathroom designated for residents' and staff use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.6 degrees Fahrenheit for bathroom #1 located inside bedroom #1. Bathroom #2 is beside bedroom #3. Hot water temperature was measured at 105.4 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway. Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a body of water (jacuzzi), it was observe to be close and blocked off. The garage is attached and is observed to be locked and used for storage and laundry. Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area. Laundry area and is located in the lock attached garage. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Medications: Medication and Medication Records (MMR) were review for all residents for proper documentation. Resident records were reviewed for requirements and legibility: Planned activities are offered. Facility is within CA code of Regulations Title 22 or Health and Safety Code. Deficiencies were found, exit interview conducted, copy of report has been issued and discussed.the state’s words, verbatim · CDSS document, May 23, 2026

Allegation investigated: Resident developed multiple pressure injuries in care due to staff neglect

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent visit to this facility to deliver findings. LPA met with staff (S5), Jesse Valdez, who granted access to the facility. On 2.19.2026, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding above allegation. Initial investigation was conducted by LPA on 2.20.2026. LPA requested the following documents: staff roster (LIC 500); resident roster (LIC 9020), residents’ physician’s report, admissions agreement, appraisal needs and service plan, hospice care plan, and other documents. LPA interviewed five (5) out of five (5) residents, staff designee and three (3) staff from 1:14 PM until 2:12 PM. LPA reviewed resident’s records from 2:14 PM until 3:45 PM. LPA took a tour of the physical plant with the assistance of the administrator at 1:13PM. On 1.9.2026, LPA requested R1’s hospital medical records. Continue to LIC 9099-C Substantiated Regarding allegation: Resident developed multiple pressure injuries in care due to staff neglect. It is alleged that on 2.17.2026 R1 had an appointment with their Geriatrician and R1 has several stage 3 wounds. R1 was admitted to the facility on 5.23.2025, record review, appraisal needs and service plan and preplacement appraisal (LIC 603), revealed that R1 did have an unstageable wound on their coccyx. All of the residents interviewed during the investigation did not address any concerns regarding their care at the facility. Hospital medical records reviewed reveal R1 had developed pressure injuries on their coccyx, sacral, and bilateral heel. Wound started developing on 4.14.2025 before R1 was admitted to the facility. An interview with staff revealed repositioning assistance was provided to avoid and give relief to pressure injuries by staff. Interview with R1’s family revealed that they are happy with the care given by the facility and were not aware that R1 required higher level of care. Records reviewed reveal that all of the staff are trained and were following home health instructions on how to care for R1’s wounds. A review of hospital medical records revealed R1 was admitted to home health on 5.29.2025. On 5.29.2025 sacral wound stage 3 was noted measuring 1.5 cm x 1 cm x 0.2 cm. On 8.7.2025 medical records noted coccyx wound was noted as stage 2. Family refused to admit R1 to hospice. On 11.3.2025, additional wounds were noted to the right heel (full thickness skin loss) stage 3 measuring 2.25 cm x 2.5 cm x 0.2 cm; R1 was then admitted to hospice on 11.3.2025. On 2.5.2026, it was noted that R1 had stage 3 wounds on their right (R) heel measuring 2.25 cm x 2.5 cm x 0.2 cm. On 2.18.2026 right heel was noted as unstageable. Although R1 was receiving home health care and hospice care, staff were providing required assistance, pressure injuries were not healing and developed into unstageable wounds. Facility staff retained and accepted R1 from 5.23.2025 to 2.20.2026 with a stage 3 wound. Therefore, the allegation is substantiated. Based on observation, interviews, and record review, there is sufficient evidence. Therefore, the allegation is deemed substantiated California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. An immediate Civil Penalty of $500.00 will be issued during this visit due to neglect/lack of care by providing care to R1 with a prohibited health condition. An additional civil penalty may be assessed at a later time based on Health and Safety Code 1569.49. An exit interview was conducted. Appeal rights, a copy of the report, LIC 9099D, were provided.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 31-AS-20260219085327

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Apr 24, 2026

Prohibited Health Condition: Persons who require health services for or have a health condition, including, but not limited to, Stage 3 and 4 pressure injuries, shall not be admitted or retained in a residential care facility for the elderly. This requirement was not met, as evidenced by: Based on observation medical records received and interviews with staff, R1 was noted with multiple stage 3 wounds on 5.23.25 and remained at the facility until 2.20.26 which poses an immediate health, safety, or personal rights to the people in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: The administrator will provide written plan of action explaining steps they will take to avoid similar issues from happening again. Written statement should verify that a Licensed consultant will be hired to provide additional training to address this section of the regulation. A copy of the training log, the training topic, and attendance shall be submitted to the Licensing agency by POC.

Type of visit: Prelicensing

On 2/20/25 at 10:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection with the facility Administrator Pramono Hananiah. Upon arrival, LPA introduced herself by showing her badge. This is a single story house which will be operating as Residential Care Facility for Elderly (RCFE). The Application to operate the RCFE was received by Community Care Licensing (CCL) on November 15th, 2024. A fire clearance was approved on January 9th, 2025, for six (6) Non-Ambulatory residents of which one (1) may be Bedridden for bedroom #1. The smoke alarms and carbon monoxide detectors are hard wired and inter-connected, they were tested and are operational. The facility has one (1) fire extinguisher that was purchased on 12/21/2024 and is located on the wall next to the kitchen cabinet. A tour of the physical plant was initiated at approximately 10:45am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave oven and sink. There were adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food, dining ware to accommodate a maximum capacity of six (6) residents. Knives and other sharps were observed locked inside kitchen cabinet next to the refrigerator and chemicals observed stored inside locked cabinet under the kitchen sink. Kitchen area is open plan facing both dining and living areas. BEDROOMS: The facility has four (4) bedrooms and all bedrooms are designated for residents' use. All residents' bedrooms observed to be nicely furnished with beds, night stands, lamps, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and a closet space. Additional linen is available inside each bedroom’s closet and inside the linen cabinet located in the hallway. BATHROOMS: The facility has two (2) bathrooms, both designated for residents’ and staff use. All bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids, paper towels and washing hands signs. The hot water delivered in the bathrooms measured at 11:10am to be at 115 degrees. Continue On LIC809-C COMMON AREAS: These include living room and a dining room. The living room was equipped with new furniture, a television, and chairs. There is an electric fireplace in the living room area. The dining area has a dining table to accommodate six (6) clients. There were no visible immediate hazards. The facility has comfortable temperature which was measured at 11:15am to be at 69 degrees F. Office/Activity room: Facility has separate activity/resting room located next to the kitchen. LPA observed a cabinet with various activity supplies nicely stored and ready for residents' use. The office area is furnished with office desk, cabinets, printer and other required office supplies. GARAGE: The garage is currently being used as storage for facility equipment, supplies and water. Garage is attached to the facility and has access from the dining area. LAUNDRY ROOM: The washer and dryer is located in a garage. Laundry chemicals are also kept in the laundry area which is always locked and under supervision. MEDICATIONS: Medications will be kept inside locked cabinet located in the office which is next to the activity room area. First Aid and the new manual is also locked in the cabinet. LPA observed the First-aid has all proper items and is current. Licensee/ Administrator might move and store medications in the kitchen area inside locked cabinet. Client/Staff Files: All files and documents will be kept locked in the office area. SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a patio and backyard furniture to accommodate six (6) clients. LPA observed locked Spa located in the backyard. Administrator confirmed it will always stay locked and under supervision. LPA observed the facility is clean, safe and sanitary. All window screens were in good repair. Auditory signals were installed on exit doors. All passageways were free of obstruction. In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised. An emergency exit plan/sketch along with other posting requirements were available and posted on the wall. No deficiency cited on today’s visit. Exit interview conducted and copy of this report signed and delivered to the Administrator.the state’s words, verbatim · CDSS document, Feb 20, 2025