Hillcrest Royale

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced Case Management – Incident visit at 1:25 p.m., and was greeted by front desk receptionist and explained the reason for the visit. LPA met with Michelle Gubbay, Director of Resident Services and Mirian Rubinstein, Facility Designee and and the reason for the visit was explained. Entrance interview conducted. The Department received a self reported death report regarding Resident #1 (R1) on 09/23/2026 and a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). During today’s visit, LPA and staff conducted a physical plant tour to ensure there are no immediate health and safety concerns, conducted in-person interviews with the facility designee, Director of Resident Services, and Staff #1 (S1), a file and record review for R1 along with obtained copies of pertinent documents relevant to the incident. 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, Sep 24, 2026

Allegation investigated: Staff placed resident on hospice care without required diagnosis from a qualified physician Staff do not safeguard resident's cash resources Staff did not inform resident's responsible party of resident's change in condition Staff did not obtain medical care for resident in a timely manner

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegations. Upon arrival at approx.1:20 p.m. LPA was greeted by front door receptionst and explained the reason for the visit. The LPA met with Michale Sokolowski, Executive Director and Cherie Martin, Business Office Manager and reason for the visit was explained. Entrance interview conducted. On 06/22/2026, the Department received a complaint regarding the following allegations, Staff placed resident on hospice care without required diagnosis from a qualified physician, Staff do not safeguard resident's cash resources, Staff did not inform resident's responsible party of resident's change in condition and Staff did not obtain medical care for resident in a timely manner. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC-9099 Page 1... On 06/30/2026 LPA Mosley conducted the initial 10-day visit, toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Throughout the visit LPA conducted interviews with the DRS, ED and facility designee, along with a file review for Resident #1 (R1) and obtained copies of pertinent documents relevant to the investigation. On 07/09/2026 LPA Mosley conducted a subsequent visit, toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Starting at 10:10 a.m. and throughout the visit LPA Mosley conducted twelve (12) interviews, three (3) staff and nine (9) residents and obtained copies of pertinent documents relevant to the investigation. During today's visit LPA and staff toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations and obtained copies of pertinent documents relevant to the investigation. On the allegation, Staff placed resident on hospice care without required diagnosis from a qualified physician it is the concern of the Reporting Party (RP) that Resident #1 (R1) was placed on hospice without required diagnosis from a qualified physician. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, file and record review for R1 and obtained copies of pertinent documentation relevant to the investigation. LPA reviewed R1’s records including but not limited to hospice records, care plan, physician report and hospital records. Record review revealed that R1 was placed on hospice on 12/23/2025 and the election of hospice care benefits was approved by family on 12/23/2025 and by a licensed physician. On 07/09/2026 at 4:20 p.m. LPA conducted a medical board of California search for the physician listed on R1 hospice paperwork and found the physicians license to be active as of 03/30/2006 with the expiration date of 06/30/2027. On R1’s hospice paperwork lists cerebral infraction, unspecified with the effective date of 12/21/2025 to 03/20/2026. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff placed resident on hospice care without required diagnosis from a qualified physician is deemed unsubstantiated at this time. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC-9099 Page 2... On the allegation, Staff do not safeguard resident's cash resources it is the concern of the Reporting Party (RP) that Resident #1 (R1) had lost $150 dollars, or someone may have taken their money. To investigate this complaint, LPA conducted telephonic interviews, in person interviews, a file and record review and obtained copies of pertinent documentation relevant to the investigation. Interview with R1 revealed that sometime last month, on an unknown date, they had misplaced approximately $100. R1 stated that they reported the incident to the receptionist, who then had a staff assistant search for the money. R1 explained that the money was later found in their jacket pocket. R1 additionally stated, “At 89 and 90, you are not as sharp as you used to be.” Resident interviews indicated no concerns regarding the safeguarding of their property during their stay at the community. Residents reported no issues with the protection of their cash resources or personal belongings. Furthermore, residents did not express any additional concerns. Staff interviews revealed that when residents report personal belongings, including money, as missing, staff initially conduct a search with the residents to determine whether the items can be located. Staff stated that in the majority of cases—approximately 99%—the items are found. The incident is documented, and facility protocol is followed. Additionally, staff reported, “It has been a long time since something has gone missing or been reported missing and not found.” Records review, including but not limited to the admission agreement, theft and loss policy, and Client/Resident Personal Property and Valuables (LIC 621), indicated that R1 did not list any valuables, including money. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff do not safeguard resident's cash resources is deemed unsubstantiated at this time. On the allegation, Staff did not inform resident's responsible party of resident's change in condition and Staff did not obtain medical care for resident in a timely manner it is the concern of the Reporting Party (RP) that Resident #1 (R1) was experiencing cognitive impairment, and the facility staff did not notify the family or get them the proper medical care timely. To investigate this complaint, LPA conducted telephonic interviews in person interviews, a file and record review and obtained copies of pertinent documentation relevant to the investigation. Report continued on LIC 9099-C PAGE 4... (PAGE 4) Report continued from LIC-9099 Page 3... Interview with R1 revealed that they were not regularly monitoring their health, stating, “I am not on top of my health and did not check on it regularly.” R1 reported that while on hospice, they received their medications but felt as though their condition was not being actively monitored. R1 stated that they began feeling unlike themselves and experienced episodes of confusion, which they reported to staff. R1 added, “The nurse told me to go to the hospital, but I initially refused and fought it.” On 06/14/2026, R1 was out of the community with family and continued to feel confused and not like themselves. On 06/15/2026, R1 informed facility staff that they had hit their head. Staff contacted 911, and R1 was transported to the hospital. R1 stated they are fully independent, make their own decisions, and serve as their own responsible person. Interview with staff revealed that R1 had been encouraged on multiple occasions to go to the hospital due to observed cognitive concerns; however, R1 declined each time. Staff stated that R1 is independent and serves as their own responsible person, making their own decisions. Staff reported, “All we can do is encourage our residents to go to the hospital. If they choose not to go, that is their right.” Staff further indicated that once R1 was transported out of the community, the facility contacted R1’s family to inform them of the transfer to the hospital. Record review revealed that the facility submitted an incident report dated 06/15/2026 for R1, documenting that R1 had hit their head and, with staff encouragement, was transported to the hospital for evaluation. R1’s family was notified. The Department received the incident report on 06/19/2026, which is within the required reporting timeframe. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur. Therefore, the allegations of Staff did not inform resident's responsible party of resident's change in condition and Staff did not obtain medical care for resident in a timely manner are deemed unsubstantiated at this time. No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 29-AS-20260622123344

Type of visit: POC

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a case management – plan of correction (POC) visit at 10:30 AM. LPA was greeted by front desk receptionist and explained the reason for the visit. LPA met with Michelle Gubbay, Director of Resident Services, Mirian Rubinstein, Facility Designee, and Michael Sokolowski, Executive Director (ED) and the reason for the visit was explained. Entrance interview conducted. The purpose of this visit is to follow up on the plan of corrections that was not submitted by the POC due date of 06/18/2026. On 06/17/2026 LPA Kelly Dulek conducted the annual inspection and the facility was cited for one (1) staff not being finger print cleared and seven (7) staff not being associated to the facility. During todays visit LPA was informed that two staff no longer work at the facility and it was an error on their end for not removing them from the LIC 500 - Facility roster. During todays visit LPA was informed that the facility does not have access to the email that is associated with their Guardian account and are in the process of regaining access. During the visit LPA informed the facility that they can submit the LIC 9182 Criminal background clearance transfer request form and submit it to the Regional Office if they are unable to associate the staff on Guardian. At the time of the visit the ED stated they would be submit the required documentation today 06/30/2026.LPA informed the ED that because the facility did not correct the deficiency within the given time frame a civil penalty in the amount of $1,200 is being assessed on today’s date for the failure to correct HSC 1569.605 by 06/18/2026. The penalty amount of $1,200 is calculated as $100/day past the due date of the POC (12 days x $100/day= $1,200). LPA informed the ED that penalties in the amount of $100/day will continue to be assessed until the Department receives the LIC 9182 forms for the six (6) staff. Pursuant to HSC, the following civil penalty was assessed (refer to LIC 421FC): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 01:26 p.m. Upon arrival, LPA was greeted by the front desk receptionist and explained the reason for the visit. LPA met with Facility Designee Marian Rubinstein and the reason for visit was explained. Entrance interview conducted. Records: Resident Records and Personnel records were reviewed beginning at 02:31 p.m. Eight (8) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training. LPA observed eight (8) staff did not have criminal record clearances associated with this facility location (Staff #1 - S1, Staff #2 - S2, Staff #3 - S3, Staff #4 - S4, Staff #5 - S5, Staff #6 - S6, Staff #7 - S7, and Staff #8 - S8). Four (4) staff (S1, S2, S3, S4) did not have a completed health screening, and three (3) staff did not have tuberculosis test results (S2, S3, S4). Five (5) 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, and current needs and services plan. All resident files were in order at the time of the visit. Physical Plant: Beginning at 05:04 p.m., LPA and Facility Designee briefly toured the common areas of the physical plant inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. All passageways were observed to be clear and no immediate health and safety hazards were identified. A complete physical plant tour will be completed during the annual continuation visit. Report continued on LIC809-C PAGE 2... (PAGE 2) REPORT CONTINUED FROM LIC 809... Interviews: During today's visit, LPA interviewed one (1) resident and one (1) staff. No concerns were noted. Infection Control / Emergency disaster planning: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control and emergency planning are satisfactory at this time. Both documents were observed to be complete, however, not signed or dated annually as required. Medication Audit: Will be conducted during the annual continuation visit. LPA obtained the following documents – Census, LIC 500 - Personnel Report Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) During today's visit, a $4000 civil penalty was assessed. Facility designee was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeal rights discussed and a copy of today's report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 17, 2026

Allegation investigated: Staff does not ensure resident is kept clean and dry at all times Staff does not ensure resident is kept free of mal odors

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegations. The purpose of this visit is to deliver findings for the above listed allegations. Upon arrival at approx. 10:25 a.m. LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Michelle Gubbay, Director of Services (DOS) and the reason for the visit was explained. Entrance interview conducted. On 12/16/2025, the Department received a complaint regarding the following allegations, Staff does not ensure resident is kept clean and dry at all times and Staff does not ensure resident is kept free of mal odors. On 12/19/2025 starting at 10:20 a.m. LPA and staff briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards. Starting at 10:33 a.m. and throughout the visit LPA conducted six (6) in-person interviews with three (3) staff, two (2) residents, and one (1) family visitor, at 11:45 a.m. conducted a file and record review for Resident #1 (R1), starting at 12:09 p.m. attempted two (2) telephonic interviews with R1 and emergency contact #2. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC 9099... At 12:13 p.m. conducted one (1) telephonic interview with the Power of Attorney (POA) for R1 and obtained copies of pertinent documentation relevant to the investigation. On 01/13/2026 at 1:42 p.m. conducted a telephonic interview with the facility DOS. At 2:25 p.m. and 4:00 p.m. attempted a telephonic interview with R1. At 2:28 p.m. and 4:40 p.m., attempted a telephonic interview with POA of R1. During today's visit LPA and DOS briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and obtained copies of pertinent documentation relevant to the investigation. On the allegations, Staff does not ensure resident is kept clean and dry at all times, and Staff does not ensure resident is kept free of mal odors it is the concern of the Reporting Party (RP) that R1 was covered in urine, had poor hygiene, and smelled foul. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Interviews with POA revealed that R1 is considered independent living by receiving minimal assistance / basic services from the facility at the time. They have no concerns related to the care or hygiene of R1. POA stated that they believe the facility may no longer be the best place for R1’s care noting that they do not have additional funds to cover extra services and believe R1 may be declining due to age. They are in the process of relocating R1 to their hometown and do not see R1 returning to the facility after their current hospitalization. Interviews with DOS revealed that on 12/13/2025 R1 was transported to the hospital via ambulance due to congestion and shortness of breath. As of 12/19/2025 R1 has not returned to the facility. R1 does not receive hands-on services from the facility, noting that the family is aware of R1’s level of independence and capabilities. R1 always appeared presentable and did not smell of a mal odor. They had no prior issues related to R1. To their knowledge and observation R1 upkept themselves. R1 would occasionally participate in activities but generally kept to themselves. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099... Interviews with the Administrator revealed that R1 is independent requiring little to no assistance from the facility. R1 was always well put together, and they had no concerns regarding R1’s capabilities including hygiene. The Administrator stated that residents are always kept clean and dry noting that even residents who are not formally receiving services are supported. If grooming is needed staff address residents promptly. Additionally, the facility is responsible for ensuring residents are cared for appropriately. Interview with Staff #1 (S1) revealed that on 12/13/2025 R1 had a meal tray delivered to their room. R1 was congested, not breathing well and their oxygen level was at 88. 911 was called. R1 was seated in a recliner chair. R1 was not soiled and remained dry throughout the incident and upon leaving the facility. R1 did not smell of mal odor. Interviews with residents revealed that they are assisted by facility staff. To their knowledge they have not experienced or witnessed other residents being unkept, soiled, or smell of mal odor. Interview with family visitor revealed that for the past four (4) months they have visited the facility regularly, unannounced at different times during the day. They have never had any problems or concerns with the quality of care. They have not experienced or witnessed residents being unkept, soiled, or smell of mal odor. Record review revealed that R1 moved into the facility on 07/01/2025. R1 physician report dated 06/27/2025 indicated that R1 was diagnosed with Mild Cognitive Impairment (MCI), R1 does not have any bowel or bladder impairments, R1 is able to communicate needs, and R1 has the capacity for self-care. R1’s LIC 9172 – Functional Capability Assessment indicates that R1 can conduct Activities of Daily Living (ADL’s) on their own with no assistance. Additionally, R1’s care plan indicates R1 is fully independent. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur. Therefore, the allegations of Staff does not ensure resident is kept clean and dry at all times, and Staff does not ensure resident is kept free of mal odors are deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 29-AS-20251216094744

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 10:15 a.m. Upon arrival LPA was greeted by the front desk receptionist and explained the reason for the visit. LPA met with Administrator (AD) Miriam Rubinstein, and the reason for visit was explained. Entrance interview conducted. LPA Mosley and the AD 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. Common Areas: At approx 11:07 a.m., the LPA and AD began the physical plant tour. The common areas include the following on the first floor two (2) dining rooms, library and lounge. On the second and third floor LPA observed two (2) lounge areas. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced on 02/14/2025. The LPA observed required postings throughout the common space. There is a dedicated area for the posting of required documents directly by the main entrance and hallway. The LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. The LPA observed an adequate supply of emergency food and water. The last fire inspection was completed on 06/10/25 and was found to be in compliance with Fire Code Regulations at the time of inspection. Emergency disaster drills conducted quarterly as per regulation; with the last one conducted on 06/24/25. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. All records were in order. Report continued on LIC809-C PAGE 2... (PAGE 2) REPORT CONTINUED FROM LIC 809... Interviews: From approx. 11:15 a.m. - 12:34 p.m. LPA conducted random interviews with eight (8) residents, ten (10) staff, and one (1) family visitor. Resident interviews revealed that no concerns were noted at the time of the visit. Staff interviews revealed that staff are knowledgeable in their job description, resident rights, different forms of abuse, and reporting procedures. Family visitor interview revealed that no concerns were noted at the time of the visit. Infection Control / Emergency disaster planning: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control and emergency planning are satisfactory at this time. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of a communicable disease. Bedrooms: Starting at 11:13 a.m. LPA inspected ten (10) randomly selected bedrooms throughout the (3) floors. The resident bedrooms were properly furnished with a bed, nightstand, and sufficient lighting. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Restrooms: The resident restrooms appeared clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water was measured in all ten (10) randomly selected rooms and ranged from 114.1 – 117.7 degrees Fahrenheit all within the required range. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors. Kitchen: The LPA inspected the kitchen/food service area at 12:20 p.m. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Dining room furniture was observed to be in good condition and appeared to be relatively clean. LPA observed resident having lunch in the dining room. Report continued on LIC809-C PAGE 3... (PAGE 3) REPORT CONTINUED FROM LIC 809-C PAGE 2... Medication Audit: LPA conducted a medication review on six (6) randomly selected residents at approx. 12:38 p.m., The medications are centrally stored in the Medication Room located on the first floor. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. No errors observed during review. Records: Resident Records and Personnel records were reviewed starting at approx. 1:02 p.m., eight (8) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files in order at the time of the visit. Nine (9) 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, and current needs and services plan. All files in order at the time of the visit. LPA obtained the following documents – Census, Staff schedule, and updated Limited Liability insurance. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 26, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kelly Dulek made an unannounced case management visit to check the health and safety of residents in care following a reported smoke/fire incident at the facility that occurred yesterday 02/13/2025. LPA initially met with facility staff and explained the reason for today’s visit. Facility Designee Michelle Gubbay was contacted via telephone and arrived at 09:40AM, followed shortly thereafter by Designee Marian Rubenstein. Entrance interview conducted. Yesterday, 02/13/2025 around 05:15PM, LPA was informed that there had been an incident at approximately 12:45PM involving a fire at the facility. LPA called the facility at 05:20PM on 02/13/2025 and gathered additional information from the Facility Designee. During today’s visit, LPA spoke with 2 (two) facility managers related to the incident. Management reported that the resident whose room was affected was not present at the facility at the time of the incident. Most residents were eating lunch in the facility dining rooms or otherwise out of their rooms. Incident report reviewed states that at approximately 01:00PM, the facility fire emergency system was activated by smoke from a resident’s apartment. Sprinkler system engaged and residents were evacuated from the building, following the facility’s emergency protocol. Management indicated that Ventura County Fire Department (VCFD) was contacted and arrived at the facility promptly. VCFD inspector informed the facility that the fire appeared to be electrical in nature and no foul play was suspected. Per interview with the facility management, only the 1 (one) resident was relocated to a vacant room. All other rooms were inspected by VCFD and cleared for resident use. Management indicated that water from the sprinkler system did affect the management office below, but no additional residents were affected. During today’s visit at 10:08AM, LPA, along with Facility Designee, conducted a health and safety check tour of the facility and no concerns were observed. During the visit, fire alarm system representative was present inspecting the damage and observing the building electrical units to ensure safety of all residents in care. Facility management indicated the plan is to have all electrical inspected by a skilled professional to ensure there are no further incidents. A hard copy of the written incident report was provided to LPA during the visit. No citations issued. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 14, 2025

Allegation investigated: Due to lack of care and/or supervision, residents engaged in a physical altercation, resulting in injury

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegation. LPA met with Executive Director (ED) Michael Sokolowski and explained the reason for the visit. Entrance interview conducted. During an initial complaint visit conducted on 12/10/2024, LPA interviewed management at 03:10PM related to recent incident reports submitted to the Department. LPA, along with Executive Director, conducted a health and safety check tour of the facility at 03:40PM. No immediate health and safety hazards were observed during facility tour. LPA obtained copies of pertinent documents. LPA informed facility management that the allegation was referred to Community Care Licensing Division (CCLD)'s Investigations Branch (IB). IB Investigator Veronica Padilla interviewed Resident #1 (R1) and Resident #2 (R2) on 12/27/2024. During a subsequent complaint visit conducted on 01/29/2025, LPA interviewed ED at 01:40PM and conducted staff Report Continued on LIC 9099-C Unsubstantiated interviews at 02:00PM, 02:14PM and 02:42PM. LPA reviewed and obtained copies of documents relevant to the investigation, including the police report related to the incident that occurred on 12/07/2024. The following was then determined: On 12/07/2024 in the early afternoon hours, there was an altercation between R1 and R2 on the outdoor patio of R1’s room. Neither resident could recall what started the altercation, but both were aware of the physical altercation that resulted. The residents indicated they were friends and would spend time in R1’s room often. On the date of the incident, R2 had gone to R1’s room and they were both out on the patio of R1’s room when a verbal altercation escalated into a physical altercation. Review of documents for both R1 and R2 revealed that both residents are independent, with the exception of both requiring assistance with medication management. Neither resident requires 1:1 supervision and both residents are able to leave the facility unassisted, according to their physician’s reports. Staff interviewed indicated that R1 tended to remain in their own private room most of the time, but that R2 would visit R1 from time to time. Staff stated that residents are free to move about the facility as they wish and it is common for residents to visit with other residents in their private rooms. On the date of the incident, the Maintenance Director heard yelling, looked outside and down towards where the sound was coming from and saw R1 and R2 on the outdoor patio of R1’s room. Maintenance Director responded to R1’s room, while calling for care staff and medication technician to respond to the room as well. Medication Technician called 9-1-1. In total, 5 (five) staff responded to assist with the incident. Staff were able to separate the residents and started assessing both residents for injury. Both police and paramedics responded to the facility promptly and assisted both residents before taking both residents from the facility. Staff interviewed stated both residents are back in the facility currently. Following the incident, they now stay away from each other and do not interact. Interviews and documents reviewed do indicate the incident occurred, which resulted in injury to both residents. However, document review revealed that both residents are independent and did not require constant care and supervision. Both residents admitted they chose to enter R1’s private room and engaged in conduct which violated the facility’s documented house rules. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No deficiencies cited during this visit. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 29-AS-20241209134414

Allegation investigated: Staff does not provide a comfortable room temperature for resident.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit for the purpose of continuing the investigation for the above allegation. Upon arrival, LPA met with the Director of Services, Michelle Gubbay and the reason for the visit was explained. Entrance interview conducted. During the initial visit on 04/26/2024, LPA Arroyo conducted a plant tour to ensure there were no health and safety concerns at 2:42 p.m., conducted interviews with two (2) staff members between 2:35 p.m. and 3:30 p.m., and obtained a copy of the resident roster. During today’s visit, LPA Arroyo conducted interviews with one (1) staff and nine (9) residents starting at 11:15 a.m. and obtained copies of pertinent documents. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff does not provide a comfortable room temperature for resident. It was the complainant’s concern that the facility’s heater has been in disrepair for a couple months and the resident rooms were getting cold. Records reviewed and interviews conducted revealed that the facility began renovation to install a new air conditioner and heating system; however, residents and family members were notified prior to the company hired coming out to the facility and begin working. Notices were also posted in common areas to inform the residents of the facility’s upgrades. Staff interviews revealed that upon completion, several rooms did not have a functioning air system; however, the facility provided all residents that were affected a portable air conditioner and a small room heater. Interviews conducted with resident revealed that a heater was provided by the facility when the heating system malfunctioned, which helped keep their rooms warm during the cold season. Also, residents reported receiving a portable air conditioner from the facility without requesting. Furthermore, nine (9) out of nine (9) residents interviewed did not report having any concerns living at the facility or with the temperature in their bedrooms. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff does not provide a comfortable room temperature for the resident”. Therefore, this allegation is being deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. Report was reviewed and a copy issued.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 29-AS-20240419133829

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 12:00 p.m. Upon arrival LPAs met with Miriam Rubinstein. LPA 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. LPA began the inspection in the kitchen/food service area at 12:30p.m. Knives are kept inaccessible to residents in care. Kitchen appliances were appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored. Dining room furniture were observed to be in good condition and appeared to be relatively clean. LPA observed resident having lunch in the dining room. LPA inspected the common areas throughout the facility. The common areas include the following on the first floor (2) dining rooms, library and lounge. On the second and third floor LPA observed (2) lounge areas. All the rooms have been appropriately furnished. There is a dedicated area for the posting of required documents directly by the main entrance and hallway. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced 11/28/2023 LPAs inspected eight (8) randomly selected bedrooms throughout the (3) floors. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms in each resident bedroom were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. At approx. 12:45 p.m. LPA did not observe any emergency evac chairs in the stairwells. Executive Director stated they had recently placed an order for new evac chairs in each stairwell, which are scheduled to arrive by approx July 1st. Records review began at 01:30 pm, eight (8) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. At approx. 01:50 p.m. (7) out of (8) staff files reviewed do not have a valid first aid / CPR certification on file. Eight (8) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were observed to be in order at this time. Medications review began at approximately 03:30pm The medications are centrally stored in a med room on the third floor inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time. LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance. Between 12pm - 05:00pm the LPAs interviewed staff and residents. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $500.00 Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 24, 2024