Ivy Park at Simi Valley

Allegation investigated: Staff did not respond to resident's call button in a timely manner Resident sustained numerous falls due to staff neglect Staff does not ensure resident's toileting needs are being met

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 04/15/2026 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Galina Tovmasian. Entrance interview. During the initial visit on 04/15/2026, between 11:45 a.m. and 2:00 p.m., LPA Arroyo conducted interviews with three staff members and five residents, conducted a resident file review, and obtained copies of pertinent documents relevant to the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... **This report has been amended to include additional information that was not included in the original report. ** It was alleged that staff did not respond to resident’s call button in a timely manner and resident sustained numerous falls due to staff neglect. It was reported that Resident #1 (R1) attempts to transfer to the restroom or clean themselves after episodes of incontinence when staff do not respond in a timely manner. It was further reported that there are many instances in which staff do not respond promptly to R1’s calls for assistance, resulting in at least six (6) falls within the past six (6) months. Information gathered during the course of the investigation reflected that R1 sustained two (2) unwitnessed falls at the facility. The first unwitnessed fall occurred on 01/26/2026 and the second on 04/08/2026, R1, was sent out for medical evaluation and treatment for both cases. Interviews with staff reflected that R1 used a walker for mobility and was frequently reminded to use it. It was also revealed that R1 often attempted to independently use the restroom without requesting staff for assistance and did not use the walker. Moreover, following R1’s falls, staff communicated R1’s change in condition to R1’s POA/family and informed them that R1 would need increase in supervision. Record review of the facility’s Device Activity Report dated 04/01/2026 through 04/08/2026 further reflected that R1 pressed their call button fifty-nine (59) times. Of the total number of calls, only two (2) were answered after more than twenty (20) minutes. The remaining fifty-seven (57) calls were answered in under 15 minutes. Additionally, the report indicated that for all Assisted Living (AL), there were a total of five (5) call button requests that exceeded the twenty (20) minute response time. Further record review and interviews conducted revealed that the facility submitted reports for two (2) unwitnessed falls involving R1, during which R1 was sent out for medical evaluation and treatment. Interviews with staff revealed that all residents on the AL side are provided with a pendant upon admission. Staff further stated that caregivers attempt to respond to calls as quickly as possible and that medtechs also assist when needed. Additionally, per facility policy the expectation is that staff respond to pendant calls within 10 to 15 minutes. Staff further stated that residents identified as high fall risks are checked frequently, at least once every two (2) hours, totaling approximately three (3) to four (4) checks per staff member’s shift. During resident interviews, residents stated that staff generally respond promptly after pendants are activated and that staff check on them several times throughout the day. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Furthermore, residents did not express any concerns regarding facility staff or living conditions at the facility. Based on the information obtained and reviewed, although the allegation may have occurred or may be valid, there is insufficient evidence to determine whether the alleged violation did or did not occur. Therefore, allegations “staff did not respond to resident’s call button in a timely manner” and “resident sustained numerous falls due to staff neglect” are deemed Unsubstantiated at this time. It was also alleged that staff does not ensure resident’s toileting needs are being met. It was reported that R1 attempts to manage toileting independently due to delayed staff response and not assisting in a timely manner. Record review of R1’s Physician’s Report dated 04/28/2025 revealed that R1 requires assistance with bathing, dressing/grooming, and toileting needs. Although the report indicates that R1’s mental condition may include confusion and disorientation, R1 is able to follow instructions and communicate their needs. Additionally, according to the Resident Assessment dated 01/01/2026, R1 requires stand-by assistance with toileting. Interviews conducted with staff revealed that incontinent residents are generally checked every couple of hours unless the resident’s care plan requires more frequent monitoring. Staff stated that the frequency of resident checks is determined by the resident’s assessed level of care and individual needs. It was also noted that R1 tends to become antsy and wants everything done quickly. Furthermore, during resident interviews, residents reported observing staff assisting other residents to the restroom while in the dining room. Residents also did not express any concerns regarding facility staff or living conditions at the facility. Based on the information obtained and reviewed, although the allegation may have occurred or may be valid, there is insufficient evidence to determine whether the alleged violation did or did not occur. Therefore, allegation “staff does not ensure resident’s toileting needs are being met” is deemed Unsubstantiated at this time. No citations issued at this time. Exit interview. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 29, 2026 · control 29-AS-20260409150306

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Martha Arroyo and Brian Balisi conducted an unannounced annual inspection today at 09:15 a.m. Upon arrival, the LPAs met with Memory Care Director (MCD), Vana Dunn and explained the reason for the visit. The Executive Director (ED), Galina Tovmasian was unavailable during today’s inspection. Entrance interview. Starting at 09:55am, the LPAs along with the MCD and Maintenance Director, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Resident Rooms / Restrooms: The LPAs observed ten (10) resident rooms in the assisted living side and three (3) resident rooms in memory care. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:02 a.m., the hot water temperature was measured in ten (10) assisted living bathrooms and three (3) memory care bathrooms, and the temperature measured within the required range of 105 – 120 degrees Fahrenheit. Kitchen: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates. The LPAs observed an adequate amount of emergency food and water; properly stored. Report Continued on LIC 809C... Report Continued from LIC 809... Common Areas: The LPAs observed common areas to be clean and in good condition. There are games and/or activity supplies in the activity rooms as well as throughout the facility. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. Emergency exiting plans/sketch are posted throughout the facility. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 11/20/2025. There were no obstructions and/or tripping hazards throughout the facility. Outdoor Space: The LPAs observed the outdoor garden in Assisted Living and Memory Care which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. No bodies of water noted at the time of the visit. Record Review: The LPAs reviewed ten (10) resident records and ten (10) staff records starting at 11:20 a.m. Ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with negative TB results, consent for treatment forms, and current needs and services plan. All records were in order. Ten personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with negative TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were in order. Record review and interviews revealed that Staff #1 (S1) and Staff #2 (S2) had been working at the facility for at least 30 days but were subsequently disassociated on 01/01/2026. During today’s inspection, S1 and S2 were re-associated to the facility. Report Continued on LIC 809C... Report Continued from LIC 809C... Medication Review: The LPAs reviewed medications at approximately 11:25 a.m. The medications are centrally stored in a med room on the 1st floor near the dining room. Six (6) randomly selected resident’s medications and centrally stored medication & destruction records (CSMDR) were reviewed. Medications appear to be given as prescribed at the time of the visit. During today’s visit, the LPAs reviewed the facility's emergency disaster plan. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 03/08/2026. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $1,000. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 10, 2026

Allegation investigated: Due to Staff Neglect / Lack of Supervision: Staff did not prevent resident in care from being sexually abused at the facility

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA met with Executive Director (ED), Galina Tovmasian and Memory Care Director (MCD), Vana Dunn and explained the reason for the visit. Entrance interview. On 08/25/2025, the Department received a complaint alleging neglect/lack of care and supervision. The complaint alleges that staff did not prevent resident in care from being sexually abused at the facility. It was reported that Resident #2 (R2) has been physically aggressive with Resident #1 (R1) and R2 may have sexually assaulted R1 as R1 was seen to be bleeding and taken to the hospital for treatment. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... During the initial visit on 08/25/2025, between 2:25 p.m. and 3:50 p.m., LPA Arroyo conducted a physical plant tour with the Licensed Vocational Nurse (LVN) and requested and obtained copies of pertinent documents. On 10/14/2025, between 10:10 a.m. and 2:42 p.m., LPA Arroyo interviewed five staff and six residents. On 01/07/2026, between 09:45 a.m. and 1:30 p.m., LPA Arroyo observed residents in the common areas, conducted interviews with five staff members, conducted a resident file review, and obtained copies of pertinent documents. Additionally, during the course of the investigation, interviews with resident family members were conducted and police report was obtained. Records reviewed and interviews conducted revealed that R1 was admitted to the facility on 06/27/2023. According to R1’s physician’s report dated 02/26/2025, the primary diagnoses include Mild Cognitive Impairment (MCI), hypertension, and hyperlipidemia, with a secondary diagnosis of Chronic Kidney Disease stage 4 (CKD IV). The report indicated that R1 was not confused or disoriented and did not exhibit inappropriate, aggressive, wandering, or sundowning behaviors. It noted that R1 was able to follow instructions and communicate their needs. The report also described R1 as non-ambulatory and able to bathe, dress/groom, feed, and manage their own toileting needs. Additionally, R2 was admitted to the facility on 05/25/2023. Per the physician’s report dated 06/11/2024, R2 was also able to follow instructions and communicate their needs. R2’s primary diagnoses include dementia, Congestive Heart Failure (CHF), hypertension, Chronic Obstructive Pulmonary Disease (COPD), and depression. The report indicated that R2 was occasionally confused or disoriented and occasionally exhibited inappropriate, aggressive, wandering, or sundowning behaviors. It also described R2 as non-ambulatory and requiring assistance with Activities of Daily Living (ADLs), including bathing, dressing/grooming, feeding, and toileting. The investigation revealed that on 08/23/2025, R1 was sent to the hospital at the request of R1’s family. Although interviews indicated that R1 may have been experiencing bleeding, family members reported that R1 was taken to the hospital due to stomach problems which included pain and diarrhea. Report Continued on LIC 9099C... Report Continued from LIC 9099C... During the course of the investigation, it was further revealed that R1 and R2 spend much of their day sitting together in the main lobby and holding hands. Staff reported that they regularly check on both R1 and R2 throughout the day to ensure their well-being. R1 and R2 reside on the assisted living side of the facility and do not require continuous care; therefore, they are able to move freely throughout the facility. Staff stated that while they cannot prohibit R1 and R2 from seeing one another, boundaries have been established to ensure that the residents are not alone together in either resident’s room. Staff reported no concerns regarding R2 complying with staff instructions. Additionally, staff have encouraged R1 to participate in additional daily activities to help with engagement and reduce distractions. Additionally, while at the facility, the LPA observed R1 and R2 seated together in the main lobby as staff passed by every few minutes to monitor them. No issues or concerns were noted during these observations. During interviews, R1 denied being touched inappropriately by R2 at any time while residing at the facility. Both R1 and R2 separately stated that they enjoy spending time together. Furthermore, according to the Simi Valley Police Department report dated 08/23/2025, law enforcement indicated that R1 did not state at any point that they were a victim of a crime, and officers were unable to establish that a crime had occurred; therefore, the case was closed. Based on the information gathered during the course of the investigation, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, allegation “Due to Staff Neglect / Lack of Supervision: Staff did not prevent resident in care from being sexually abused at the facility” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided. Report Continued from LIC 9099... During the initial visit on 08/25/2025, between 2:25 p.m. and 3:50 p.m., LPA Arroyo conducted a physical plant tour with the Licensed Vocational Nurse (LVN) and requested and obtained copies of pertinent documents. On 10/14/2025, between 10:10 a.m. and 2:42 p.m., LPA Arroyo interviewed five staff and six residents. On 01/07/2026, between 09:45 a.m. and 1:30 p.m., LPA Arroyo observed residents in the common areas, conducted interviews with five (5) staff members, conducted a resident file review, and obtained copies of pertinent documents. Additionally, during the course of the investigation, interviews with resident family members were conducted. Records reviewed and interviews conducted revealed that R1 was admitted to the facility on 06/27/2023. According to R1’s physician’s report dated 02/26/2026, the primary diagnoses include Mild Cognitive Impairment (MCI), hypertension, and hyperlipidemia, with a secondary diagnosis of Chronic Kidney Disease stage 4 (CKD IV). The report indicated that R1 was not confused or disoriented and did not exhibit inappropriate, aggressive, wandering, or sundowning behaviors. It noted that R1 was able to follow instructions and communicate their needs. The report also described R1 as non-ambulatory and able to bathe, dress/groom, feed, and manage their own toileting needs. Additionally, R2 was admitted to the facility on 05/25/2023. Per the physician’s report dated 06/11/2024, R2 was also able to follow instructions and communicate their needs. R2’s primary diagnoses include dementia, Congestive Heart Failure (CHF), hypertension, Chronic Obstructive Pulmonary Disease (COPD), and depression. The report indicated that R2 was occasionally confused or disoriented and occasionally exhibited inappropriate, aggressive, wandering, or sundowning behaviors. It also described R2 as non-ambulatory and requiring assistance with Activities of Daily Living (ADLs), including bathing, dressing/grooming, feeding, and toileting. The investigation revealed that both R1 and R2 had lost their partners, who also resided at the facility, a few months prior. Due to R1’s diagnosis of MCI and R2’s diagnosis of dementia, staff interviews indicated that R2 may have confused R1 with their late spouse. Staff reported that at the beginning of R1 and R2’s relationship, R2 spoke to R1 in a stern manner, frequently questioned R1’s actions, and at times raised their voice when speaking to R1. These behaviors, along with other concerns, prompted facility staff to increase supervision of R1. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Staff further stated that, regardless of R2’s manner of speaking, R1 would seek out R2 daily, and R2 would likewise seek out R1. Staff reported that although they cannot prohibit R1 and R2 from seeing one another, boundaries have been established to ensure that the residents are not alone together and are not permitted to be in either resident’s room without supervision. Staff further reported that following a change in R2’s condition and adjustments to their medications, R2 no longer confuses R1 with their late spouse and, as a result, has not spoken inappropriately to R1 for several months. Furthermore, although both R1 and R2 denied the allegation, staff interviews corroborated that, at times, R2 did speak inappropriately to R1 during the early stages of their relationship. Based on the information gathered during the course of the investigation, the Department has sufficient evidence to say a violation occurred. Therefore, allegation “Due to Staff Neglect / Lack of Supervision: Staff did not prevent resident in care from being verbally abused at the facility” is deemed Substantiated at this time. Exit interview conducted. Report and appeal rights discussed and copy was provided.the state’s words, verbatim · CDSS document, Jan 23, 2026 · control 29-AS-20250825094140

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1-3) · Plan of correction due date: Jan 30, 2026

Residents shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (3) To be free from abuse or other actions of a punitive nature. This requirement has not been met as evidenced by: Based on the investigation, the Licensee did not comply with the section cited above as R2 was observed speaking inappropriately to R1 on several occasions, which poses a potential health, safety, and/or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2026

Plan of correction: The Licensee has agreed to have staff training on residents’ personal rights and submit proof (training materials along with staff signatures) to CCL no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20250825094140). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation. During the course of the investigation, it was revealed that Resident #1 (R1) was not feeling well and had stomach issues. Per family’s request, R1 was sent out to the hospital to be evaluated and treated. Record review revealed that a written Unusual Incident/Injury Report (LIC 624) was not submitted to Community Care Licensing (CCL) within seven (7) days of the occurrence, as required by reporting regulations, for R1’s hospital visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 30, 2026

Each licensee shall furnish to the licensing agency such reports as the Department may require, including: Any incident which threatens the welfare, safety or health of any resident… This requirement has not been met as evidenced by: Based on record review, the licensee did not comply with the section cited above as the facility did not submit LIC 624 within seven (7) days of occurrence for R1’s hospital visit, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2026

Plan of correction: The Licensee has agreed to send LIC 624 for R1’s hospital visit to CCL no later than POC due date.

Allegation investigated: Staff do not communicate with responsible party regarding resident's care Staff did not allow resident to have visitors at the facility. Staff did not report an incident to responsible party

Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint visit to investigate the allegations noted above. Upon arrival, the LPA met with Executive Director (ED), Galina Tovmasian and the reason for the visit was explained. Entrance interview. During today’s visit, approximately between 12:25pm and 03:30pm, the LPA conducted interviews with three staff and seven residents, conducted a file review and obtained copies of pertinent documents relevant to the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff do not communicate with responsible party regarding resident's care. It was reported that Resident #1’s (R1’s) responsible person repeatedly contacted the facility requesting to speak with the ED regarding concerns about R1’s care and billing. Record review and interviews conducted revealed that R1 is renting a two-bedroom apartment; however, payment has been received for only one bedroom for the month of January. Staff interviews indicated that the Business Director (BD) is responsible for handling all billing-related matters. As this issue involved billing, the BD contacted R1’s responsible party and informed them that the rent was past due. Additionally, staff reported that R1’s care has not changed. R1 remains independent, and the only service currently provided by the facility is medication management. Therefore, no changes to R1’s care plan have been made. Based on the information obtained and reviewed, although the allegation may have occurred or may be valid, there is insufficient evidence to determine whether the alleged violation did or did not occur. Therefore, allegation “staff do not communicate with responsible party regarding resident’s care” is deemed Unsubstantiated at this time. It was also alleged that staff did not allow resident to have visitors at the facility. It was reported that R1’s visitor was not permitted to enter the facility to visit R1 on 12/17/2025. Record review and interviews conducted revealed that an incident occurred involving R1’s visitor and another resident. Staff reported that R1’s visitor was not denied access to the facility; however, the visitor was instructed not to walk through the facility searching for or disturbing other residents. Staff stated that visitors are permitted to visit residents at any time; however, all visitors are required to comply with the facility’s house rules while on the premises. According to the admissions agreement, page 12 under “House Rules,” it states: “Residents and their families or visitors must not be disruptive, create unsafe conditions, or be physically or verbally abusive to residents or community staff.” The incident was communicated to R1’s responsible person, who was informed that R1’s visitor would be permitted to visit provided the visit was limited to interacting with R1 only and not with other residents. The ED reported being away from the facility at the time of the incident but stated that staff communicated with them to ensure R1’s responsible person was informed. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Furthermore, during resident interviews, seven out of seven residents interviewed expressed no concerns regarding visitors at the facility and reported no concerns while living at the facility. Based on the information obtained and reviewed, although the allegation may have occurred or may be valid, there is insufficient evidence to determine whether the alleged violation did or did not occur. Therefore, allegation “staff did not allow resident to have visitors at the facility” is deemed Unsubstantiated at this time. It was further alleged that staff did not report an incident to responsible party. It was reported that R1 was not permitted to be inside Resident #2’s (R2’s) apartment and had been observed inside R2’s apartment. Records reviewed and interviews conducted revealed that on 12/16/2025, R1 was observed inside R2’s apartment; however, R2’s family members were also present in the apartment with both R1 and R2 at that time. Staff interviews indicated that the ED was not present at the facility during the incident but remained in communication with staff. Following the incident, R1’s visitor was informed that they would be permitted to enter the facility only for the purpose of visiting and interacting with R1 and not other residents. The ED directed facility staff to contact R1’s responsible party to communicate the incident involving R1, R2, and R1’s visitor. Although the ED was unable to personally contact R1’s responsible party, facility staff notified the incident to R1’s responsible party. Based on the information obtained and reviewed, although the allegation may have occurred or may be valid, there is insufficient evidence to determine whether the alleged violation did or did not occur. Therefore, allegation “staff did not report an incident to responsible party” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 29-AS-20260108123007

Allegation investigated: Facility staff do not meet resident’s hygiene needs. Facility staff did not provide adequate grooming to residents in care. Facility staff did not ensure resident clothing needs were being met.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 08/13/2025 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Regional Operational Specialist (ROS), Dina Davis. Entrance interview. During the initial visit on 08/13/2025, between 10:10 a.m. and 1:15 p.m., LPA Arroyo conducted a brief plant tour, interviewed four staff and Resident #1 (R1) personal companion, conducted a resident file review and obtained copies of pertinent documents relevant to the investigation. A telephonic interview was also conducted with R1’s family member at approximately 2:18 p.m. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that facility staff do not meet resident’s hygiene needs and facility staff did not provide adequate grooming to residents in care. It was reported that R1’s teeth were not being brushed, and old food particles were observed. Additionally, R1 was often seen with uncombed hair. A review of R1’s Physician’s Report dated 01/23/2025 revealed that R1 requires assistance with bathing, dressing/grooming, and toileting needs. Although the report states that R1’s mental condition may include confusion/disorientation, inappropriate behavior, aggressive behavior, and sundowning, R1 is still able to follow instructions and communicate their needs. According to the Resident Assessment dated 07/08/2025, R1 requires hands-on assistance with all grooming and hygiene tasks, assistance with dressing and undressing twice daily, observation and assistance during meals, routine medication management, as well as scheduled toileting and assistance to and from the bathroom. Record review and interviews conducted indicated that R1 is currently receiving hospice care, which provides 2–3 showers per week and ensures that R1’s hygiene needs are met. Staff interviews revealed that caregivers assist residents with grooming and hygiene based on their individualized care plans. Staff also stated that R1’s hair is brushed every morning before breakfast, and teeth are brushed both in the morning and before bedtime. Interviews with R1’s personal companion and family confirmed that hospice services come 2–3 times weekly to provide showers, and facility staff frequently check on R1 throughout the day. Furthermore, R1’s family did not express any concerns regarding R1’s grooming or hygiene needs not being met. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “facility staff do not meet the resident’s hygiene needs” and “facility staff did not provide adequate grooming to residents in care”. Therefore, these allegations are deemed Unsubstantiated at this time. It was also alleged that facility staff did not ensure resident clothing needs were being met. It was reported that R1 wore the same clothes for several days in a row. Interviews conducted with staff revealed that all residents’ clothes are changed daily, and laundry is done weekly. Additionally, staff stated that they change R1’s clothes every morning after waking up, before breakfast. Furthermore, an interview with R1’s personal companion confirmed that each morning upon arrival, R1 is observed to be clean and wearing different clothes than the previous day, confirming that facility staff change R1’s clothes at least once daily. Based on the information received, the Department has insufficient evidence to support the allegation of “facility staff did not ensure resident clothing needs were being met”. Therefore, this allegation is deemed Unsubstantiated at this time. No citations issued at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 29-AS-20250805081739

Allegation investigated: Facility did not meet the needs of the resident in care.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. On today's visit, LPA Arroyo met with Regional Operational Specialist (ROS), Dina Davis. Entrance interview. On 06/10/2025, the Department received a complaint alleging facility did not meet the needs of Resident #1 (R1). It was reported that facility did not provide proper care to R1’s toe therefore, R1’s family had to hire an outside agency to provide care for R1. It was further stated that agency staff had to inform the facility staff to provide appropriate care for R1’s toe. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... A complaint was previously received by the department on 04/19/2024 (CC##29-AS-20240419134804), which alleged two allegations of Neglect/Lack of Care and Supervision: Resident #1 (R1) died due to facility neglect and staff did not provide medical attention to R1 in a timely manner resulting in sepsis. The complaint was referred to Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Seng at the time. On 09/30/2024, the Department unsubstantiated both allegations due to insufficient evidence. On 06/16/2025, LPA Arroyo conducted interviews with two staff and reviewed and obtained copies of pertinent documents relevant to the investigation. Additionally, the Department’s Investigation Report for complaint #29-AS-20240419134804 related to the 01/23/2024 incident included interviews, Adventist Health Hospital medical records, Ventura County Coroner’s Report #0134-24, Access TLC Home Health records, Performance Foot and Ankle medical records, and facility file documents, including staff training. The Department’s investigation revealed that on 01/23/2024, while R1 was being transferred from their bed to their wheelchair by facility staff, R1 became unresponsive, and 911 was called. Facility staff placed R1 on the floor and began performing compressions until paramedics arrived. R1 was then transported to the hospital and arrived at the emergency room (ER) in full cardiac arrest. According to the ER doctor who pronounced R1’s death, there was no obvious trauma or neglect associated with the death. According to the Access TLC home health nurses, they did not observe any signs of neglect and believed that the facility staff were providing adequate care for R1. R1’s podiatrist reported that R1 was diagnosed with hammertoe on 12/21/2023; however, the doctor stated it was unlikely that the toe became septic between 12/21/2023, and 01/23/2024, leading to R1’s death. Additionally, the ER physician indicated that R1 was likely septic, based on R1’s elevated white blood cell count; however, the physician suggested that the sepsis was more likely caused by a urinary tract infection (UTI) or pneumonia, rather than neglect. Furthermore, the facility’s logbook showed that staff checked on R1 daily. Based on the evidence obtained from complaint #29-AS-20240419134804, the Department has insufficient evidence to support the allegation that the facility failed to meet the needs of the resident in care. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 29-AS-20250610095737

Allegation investigated: Staff stole resident's personal items.

Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint investigation visit for the above allegation. Upon arrival, the LPA met with Regional Operational Specialist (ROS), Dina Davis and explained the reason for the visit. Entrance interview. During today's visit, between 10:10 a.m. and 1:25 p.m., the LPA interviewed five staff and six residents, conducted a resident file review and obtained copies of pertinent documents. It was alleged that staff stole resident’s personal items. It was reported that facility staff had been stealing from multiple residents, including pages from a bible and photographs belonging to Resident #1 (R1). Although this was reported to management, no action was taken regarding the matter. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... A review of R1’s personal property inventory list was conducted; however, the list was blank, as R1 chose not to document any personal belongings at the time of admission. Staff interviews revealed that R1 reported certain documents missing from their apartment, including a death certificate. Staff acknowledged R1’s concerns and suggested providing a locked file cabinet for securing personal items. However, R1 declined the facility’s offer. Further staff interviews indicated that staff do not enter resident rooms when the resident is not present. Staff stated that they knock and wait for a response before entering. Additionally, interviews with six out of six residents conducted today revealed no concerns about living in the facility and stated that they had no missing items to report. At this time, there is no evidence indicating that facility staff took any of the allegedly missing items from R1’s room. Based on the information gathered, the Department finds insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was review and copy issued.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 29-AS-20251007152514

Allegation investigated: Staff did not ensure that resident's grooming needs were met.

Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint investigation visit for the above allegation. Upon arrival, the LPA met with Executive Director (ED), Lea Bogoyevac and explained the reason for the visit. Entrance interview. During today's visit, between 10:10 a.m. and 11:00 a.m., the LPA conducted a brief plant tour, interviewed four staff and reviewed and obtained copies of pertinent documents relevant to the investigation. The LPA also interviewed two independent contractors during the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff did not ensure that resident’s grooming needs were met. It was reported that a beautician may be taking advantage of residents by sending them back to their rooms with soaking wet hair, causing their clothing to become wet, and exclusively accepting cash as payment. Record review and interviews conducted revealed that the individuals providing beauty salon services are considered "suppliers" who operate as independent contractors, not employees of the facility. Furthermore, each supplier has a signed Beauty Salon Services and Rental Agreement on file with the facility, which confirms that their services are contracted independently of the facility. The LPA also reviewed the facility’s most recent Personnel Report (LIC 500), which verifies that these contracted individuals are not listed as employees. Additionally, interviews with staff revealed that no residents or family members have reported any concerns regarding the care provided by the facility staff. Based on the information obtained through interviews and record review, the Department has insufficient evidence to say the alleged violation occurred. Therefore, allegation “staff did not ensure that resident’s grooming needs were met” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 29-AS-20250810215523

Allegation investigated: Due to neglect / lack of care and supervision, resident sustained unexplained bruises while in care. Staff do not ensure that a resident's incontinence needs are met. Staff do not ensure that a resident's dietary needs are met.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA met with Executive Director (ED), Lea Bogoyevac and explained the reason for the visit. Entrance interview. On 10/30/2024, the Department received a complaint regarding allegations of Neglect / Lack of Care and Supervision. The initial complaint visit was conducted on 10/31/2024 by LPA B. Balisi and a subsequent complaint visit was conducted on 04/22/2025 by LPA M. Arroyo. Report Continued on LIC 809C... Unsubstantiated Report Continued from LIC 809... During the initial visit on 10/31/2024, starting at approximately 11:15 a.m., LPA Balisi conducted a physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 04/22/2025, between 1:45 p.m. and 3:35 p.m., LPA Arroyo conducted interviews with three staff and eight residents and conducted a resident file review and obtained copies of pertinent documents. Records reviewed and interviews conducted revealed Resident #1 (R1) was admitted to the facility on 08/16/2024. R1’s physician’s report, dated 08/16/2024, listed R1’s primary diagnosis as cerebral atherosclerosis and dementia with a secondary diagnosis of insomnia, constipations, and hyperlipidemia. R1 was identified as being confused/disoriented yet able to follow simple instructions. The report also indicates R1 requires assistance with bathing, dressing / grooming, caring for toileting needs, and managing cash resources. However, R1 is able to feed themselves. Additionally, report stated R1’s ambulatory status is non-ambulatory. It was alleged that resident sustained unexplained bruises while in care. It was reported that R1 appeared to have a bite mark on the left hand, bruises on the legs, and a scratch on the right elbow. Records reviewed and interviews conducted revealed that R1's body is checked at least once per day, as outlined in the Resident Assessment dated 08/21/2024, which indicates that R1 has fragile skin and requires occasional skin checks. Additionally, according to R1’s Individualized Service Plan (ISP) dated 08/21/2024, R1 has experienced a fall within the past year and requires to be part of their fall management program. Staff interviews confirmed that each morning, while assisting R1, they assess R1’s skin and promptly report any changes to the medication technician or hospice staff. Staff reported that R1 tends to move frequently while lying in bed, which occasionally results in contact with the bed rails and self-inflicted scratches. However, staff denied observing any bruises on R1 that appeared intentional or caused by another person. They added that R1 is still adjusting to the bed and sometimes attempts to get up, which may contribute to the injuries. Correspondingly, Outside Provider Information (OPI) from hospice nurse visits dated 09/11/2024 documents that R1 had a skin tear on their right shin, for which the hospice nurse provided wound care. Report Continued on LIC 809C... Report Continued from LIC 809C... Additionally, the OPI dated 09/30/2024 notes that the hospice nurse observed multiple areas of skin discoloration on both shins and provided wound care for skin tears on R1’s right knee and left forearm. Furthermore, the OPI dated 10/23/2024 states that R1’s wounds were healing well, the hand skin tear was scabbing, and no open wounds were present on that day. An interview with R1’s power of attorney (POA) revealed that they frequently visit R1 and expressed no concerns regarding R1’s care as facility staff has been great. Additionally, during resident interviews, no concerns were reported regarding the care provided by the facility staff. Based on the information obtained and reviewed, the Department has insufficient evidence to support the resident sustained any injuries as a result of neglect or lack of supervision. Therefore, the allegation of “resident sustained unexplained bruises while in care” is deemed Unsubstantiated at this time. It was also alleged that staff do not ensure that a resident's incontinence needs are met. It was reported that R1 was left in a soiled diaper on 10/26/2024. Interviews conducted with staff revealed that residents are checked at least once every two (2) hours and changed as needed. Staff stated that incontinence checks are also conducted based on each resident’s level of care and individualized care plan. Residents who require full assistance are typically checked every two hours, while others are checked every two to three hours. According to Outside Provider Information (OPI) dated 08/29/2024 and 09/03/2024, a visiting hospice nurse noted that facility staff were applying prescribed skin barrier products to R1’s bottom to treat and prevent skin breakdown. Additionally, OPI dated 08/26/2024 documented that R1 verbalized to the hospice nurse that they wanted their brief changed, and facility staff were promptly called to assist. During an interview with R1’s Power of Attorney (POA), they stated that they had no concerns regarding staff changing R1 in a timely manner. In a resident interview, R1 confirmed that staff regularly check on them and reported that they are not left in wet briefs, as changes are made frequently. Other residents interviewed also did not express any concerns regarding staff appropriately addressing their incontinence needs. Furthermore, no concerns related to this issue were noted or reported on any dates, including 10/26/2024. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not ensure that a resident’s incontinence needs are met”. Therefore, this allegation is deemed Unsubstantiated at this time. Report Continued on LIC 809C... Report Continued from LIC 809C... It was further alleged that staff do not ensure that a resident's dietary needs are met. It was reported that R1 experienced weight loss due to staff serving food but not providing assistance with feeding. Record reviewed and interviews conducted revealed that staff assist R1 during mealtimes. A review of R1’s Individualized Service Plan (ISP) dated 08/21/2024 indicates that R1 requires assistance while eating. The care plan specifies that facility staff are to provide complete assistance to Resident 1 (R1), including opening containers, cutting food, and assisting or prompting R1 to eat. According to R1’s physician’s report, R1 weighed 90 pounds upon admission to the facility. Staff interviews indicated that R1 has never refused food while residing at the facility and consistently consumes Ensure drinks when provided. Staff also reported that R1 is able to pick up and eat food independently, provided it is cut into small pieces. Additionally, staff noted that while only a few residents require direct feeding assistance, most simply need encouragement or reminders to eat. Although there is no current recorded weight for R1, staff have not reported or documented any concerns or noticeable changes regarding R1’s weight. According to Outside Provider Information (OPI) from hospice nurse visits—including, but not limited to, visits on 09/03/2024 and 10/14/2024—the hospice nurse documented positive interactions between R1 and facility staff and observed staff feeding R1. Additionally, the OPI dated 10/23/2024 noted no significant changes in R1’s condition and indicated that R1 had consumed most of their meals during the visits. Interviews conducted with randomly selected residents revealed no concerns regarding the care provided by facility staff. Interviews conducted with random residents revealed no concerns regarding the care provided by facility staff. Furthermore, during an interview with R1’s POA, it was stated that they visit R1 frequently and have observed staff assisting R1 with feeding on multiple occasions. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not ensure that a resident’s dietary needs are met”. Therefore, this allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. Report was reviewed and copy provided.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 29-AS-20241030124951

Allegation investigated: Staff did not provide medical attention to resident in a timely manner.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with Executive Director Lea Bogoyevac and explained the reason for the visit. On 05/30/2024, the initial complaint visit was conducted by LPA between approximately 09:45 a.m. - 03:30 p.m. During the visit, LPA’s conducted physical plant, interviewed residents, staff as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 09/30/2024, between approximately 09:45 a.m. – 03:00 p.m. LPA conducted a subsequent visit to interview staff as well as review and obtained additional pertinent documentation relevant to the investigation. On 01/30/2025, LPA conducted a subsequent visit to interview staff, families / responsible parties of residents in care as well as review and obtained copies of additional pertinent documentation relevant to the investigation. Today LPA interviewed staff and reviewed documentation pertinent to the investigation. It was reported that "Staff did not provide medical attention to resident in a timely manner" as it was alleged that a pain patch was not changed in a timely manner. Substantiated Interviews and a review of records showed that Resident 2 (R2) was prescribed a Fentanyl 50 mcg/hour transdermal patch, with instructions to apply one patch topically every 72 hours. Records indicate that the patch was applied on 05/07/2024 at 8:00 a.m., and again on 05/10/2024 , at 8:00 a.m. R2 was admitted to a local hospital on 05/12/2024, and returned to the facility at approximately 9:45 p.m. that same day. There is no documentation showing that the patch was replaced on 05/13/2024, as would have been scheduled based on the prescribed 72-hour cycle. However, records do indicate that the patch was replaced on 05/16, 05/19 and 05/22 each at 8:00 a.m. Staff interviews did not confirm whether the patch was replaced on 05/13/2024. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation above. Therefore, the allegation "Staff did not provide medical attention to resident in a timely manner" has been deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided. It was reported that "Resident sustained pressure injury while in care" and "Staff did not rotate and repositioned resident" as it was alleged that Resident #1 (R1) sustained pressure injuries due to staff neglect and failing to rotate and reposition R1. Interviews conducted and records review revealed R1 was admitted into the facility on 05/24/2023. LPA's records review of hospice records dated from 06/24/2023 - 01/26/2024, revealed R1 was serviced by Hospice at least two (2) times a week for routine services such as showering and to observe wound on left ankle. Records reviewed from 01/29/2024, revealed R1 was observed with Stage III pressure injury on coccyx. The records did not indicate any concerns for facility staff not repositioning R1 in a timely manner at this time. LPA's interview with six (6) staff who worked often with R1 confirmed R1 was checked on at least every (2) hours. When R1 was observed by staff it would typically involve, observing any bandages, ensuring they were dry, elevate their legs if necessary and address any concerns the R1 might express. Each staff did not express any concerns for staff not repositioning R1 in a timely manner at this time. LPA's interview with the spouse of R1, Resident #2 (R2), revealed that they have observed staff check on R1 throughout the day and reposition R1 in a timely manner. R2 did not express any concerns for staff not repositioning R1 in a timely manner at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Resident sustained pressure injury while in care" and "Staff did not rotate and repositioned resident" is deemed Unsubstantiated at this time. It was reported that "Lack of supervision resulting in resident falling causing injuries" as it was alleged that R2 was allowed to walk out of the facility without supervision resulting in a fall. LPA records review of R2's Physician’s Report dated 06/11/2024 indicated that R2 is able to leave the facility without assistance and does not require staff support for ambulation. LPA's interview with revealed that R2 requested to go outside, and there was no indication that R2 required staff assistance or was restricted from doing so. In an interview with R2, they stated they felt well enough to go outside for fresh air. R2 reported that while walking, they were not paying attention and tripped over the uneven space between the grass and the cement walkway. R2 recalled that bystanders and an off-duty employee assisted them in getting up. The off-duty employee then accompanied R2 back into the facility, where R2 received first aid. R2 did not express any concerns regarding staff supervision, noting that they exited the facility independently and the fall occurred due to their own inattention. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Lack of supervision resulting in resident falling causing injuries" is deemed Unsubstantiated at this time. It was reported that "Staff does not assist resident with daily needs" as it was alleged that staff refused to assist R2 with showering, dressing and overall care. Records review and interviews confirmed that R2 was admitted to the facility on 05/24/2023. According to R2’s Individualized Service Plan (ISP) dated 05/27/2024, R2 requires hands-on assistance with the following: Dressing and grooming – Caregivers are responsible for setting up grooming materials and assisting as needed, Bathing – Caregivers provide hands-on assistance for all showering/bathing needs, scheduled 1 to 2 times per week and Toileting – R2 is occasionally incontinent and may require staff assistance with toileting. LPA's interview with R2 revealed that staff consistently assist with their daily needs. R2 confirmed receiving showers at least twice weekly and stated that staff greet them each morning, help select clothing, and escort them to meals. R2 did not express any concerns regarding the level or timeliness of staff assistance. Additionally, a review of facility records and staff interviews confirmed that residents are provided care in accordance with their individual care plans. LPA also interviewed seven (7) residents currently residing in the facility. All residents interviewed stated they had no concerns about staff assistance with daily needs. Each resident also confirmed that staff respond to requests for help in a timely manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation "Staff does not assist resident with daily needs" is deemed Unsubstantiated at this time It was reported that "Staff not checking resident's blood pressure as required" as it was alleged that staff did not check R2's blood pressure twice daily as prescribed. Interviews conducted and records review revealed, on 04/16/2024, R2 received an order to "Check blood pressure twice a day through 05/08/2024 - keep log of readings" . LPA's records review revealed that from 04/16/2024 to 05/08/2024, R2's blood pressure was typically checked twice a day—once in the morning between 7:30 a.m. and 11:00 a.m., and once in the evening between 5:00 p.m. and 6:00 p.m. Additionally, on 05/20/2024, a prescription was issued for R2 to have their blood pressure checked daily. Records reviewed from 05/20/2024 to 06/02/2024, revealed R2’s blood pressure was generally checked around 8:00 a.m. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff not checking resident's blood pressure as required “ is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, May 19, 2025 · control 29-AS-20240524163713

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 20, 2025

The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as the facility staff could not provide confirmation that R2’s pain patch was replaced as prescribed, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 19, 2025

Plan of correction: Licensee agreed to review section cited and provide a statement of understanding along with a plan of how they will ensure future compliance then send to LPA via email by COB 05/20/2025.

Allegation investigated: Staff is chemically restraining the resident. Staff are administering the resident medication without a doctor’s prescription.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to continue investigation regarding above allegations. Upon arrival LPA met with the Health Services Director (HSD) Joseph Bautisita and later met with the Marketing Director Amy Curtis. The reason for the visit was explained. HSD contacted the Executive Director Lea Bogoyevac and LPA spoke with ED and discussed reason for LPA's visit. On 12/03/2024, Community Care Licensing Division received the above allegations. On 12/12/2024, LPA Brian Balisi conducted the initial complaint visit and met with Executive Director Lea Bogoyevac and reason for the visit was explained. Allegations were discussed. At approx. 2:13 p.m. LPA Balisi conducted a physical plant tour, interviewed staff and obtained copies of pertinent documentation relevant to the investigation. (Continue to LIC9099c). Unsubstantiated On 05/10/2025, from approximately 12:30pm -3pm LPA Chochian conducted additional interviews with three staff and reviewed former resident’s (R1) records including but not limited to medication and hospice records. At approximately 3pm, LPA toured the facility and conducted interview with randomly selected residents; LPA continued the tour with HCD and interviewed additional residents. Total eight (8) residents were interviewed. Also, during the tour at approximately 4pm, LPA toured the medication room and medication dispensing and recording procedures were reviewed with HCD. Following is a summary of the allegations and investigation finding: Allegations “Staff is chemically restraining the resident and Staff are administering the resident medication without a doctor’s prescription”. It was reported that resident #1 (R1) is being chemically restrained by the staff at the facility for financial gain. Additionally, it was reported, that on 11/17/2024 R1 was prescribed Lorazepam 3mg, and the physician was unaware of this medication change. A review of R1’s centrally stored medication record and medication administration records conducted revealed no discrepancies. Records review revealed R1 was on hospice and the prescription for Lorazepam was 0.5mg which was prescribed by the hospice physician. Staff interviewed denied the allegations. According to staff R1 was provided care and services according to plan of care by facility staff and hospice. According to the centrally stored medication records, medication administration log and physician orders R1 was prescribed 0.5mg Lorazepam and not 3mg of Lorazepam. Interview conducted with potential witnesses revealed that R1 was provided good care and had no issues with any of R1's medications being dispensed by facility staff or hospice nurse. Random residents interviewed expressed being satisfied with the care services and report no issues with medications dispensed. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff is chemically restraining the resident" and "Staff are administering the resident medication without a doctor’s prescription” are deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 10, 2025 · control 29-AS-20241203121926

Allegation investigated: Facility staff did not meet hygiene needs of residents. Facility staff did not ensure residents had clean clothing. Facility staff did not dispense medications to residents as prescribed. Facility staff did not respond to resident's call in a timely manner. Facility staff did not check resident’s blood pressure as required. Facility staff did not meet resident's incontinence care needs.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegations. On today’s visit, the LPA met with Executive Director (ED) Lea Bogoyevac and explained the reason for the visit. Entrance interview. The initial visit was conducted on 08/15/2024 and a subsequent visit was conducted on 04/22/2025, both by LPA M. Arroyo. On 08/15/2024, the LPA conducted interviews with the ED and two staff members between 10:25 a.m. and 1:15 p.m., conducted a file review at 11:30 a.m., conducted a medication review of two randomly selected residents 1:30 p.m., and obtained copies of pertinent documents. On 04/22/2025, the LPA conducted interviews with three staff and eight residents, conducted a medication review, conducted a resident file review and obtained copies of pertinent documents between 1:45 p.m. and 3:35 p.m. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... Records review and interviews conducted revealed Resident #1 (R1) was admitted to the facility on 10/28/2017. Per R1’s physician’s report dated 04/25/2022, it lists R1’s primary diagnosis as mild cognitive impairment (MCI), is able to follow instructions and communicate needs. The report indicates R1 is able to bathe, dress/groom, feed self, care for own toileting needs, and manage own cash resources. Additionally, per doctor’s orders, R1’s blood pressure is checked every other day scheduled for Monday, Wednesday, and Friday at 9:00 a.m. Also, Resident #2 (R2) was admitted to the facility on 05/25/2023 and per physician’s report dated 05/27/2024, R2 is able to follow instructions and communicate needs. Review of R2’s assessment dated 05/27/2024 states R2 requires assistance setting up grooming tools, hands on assistance with dressing / undressing, escorting to meals and activities, showering / bathing 1-2 times a week, occasional incontinent assistance, is a high fall risk, and requires vital sign checks 1 time a day, per physician’s order. It was alleged that facility staff did not meet hygiene needs of residents and facility staff did not ensure residents had clean clothing. It was reported that residents are not getting their showers and clothes were dirty and appeared to not have been changed for several days. Records reviewed and interviews with staff revealed that housekeeping is done daily, and each resident’s laundry is scheduled to be done once a week. However, caregivers will use washers and dryers that are located throughout the facility to do small loads if for any reason a resident requires clean clothes or linens. Additionally, staff stated that residents are assisted with all activities of daily living (ADLs) depending on their care plan. If a resident is not able to shower / bathe or dress / groom themselves, the staff will assist the resident to ensure the resident is getting their needs met. Additionally, R1 is able to shower / bathe themselves without needed assistance from staff and R2 is on a shower rotation indicating R2 is currently getting assistance with showers / bathing on the evenings of Monday’s, Wednesday’s, and Saturday’s. Furthermore, interviews conducted with residents revealed that staff will assist them at any time when they request assistance and reported no concerns living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegations of “facility staff did not meet hygiene needs of residents” and “facility staff did not ensure residents had clean clothing.” Therefore, this allegation is deemed Unsubstantiated at this time. Report Continued on LIC 9099C... Report Continued from LIC 9099C... It was also alleged that facility staff did not dispense medications to residents as prescribed. It was reported that staff have administered medications to the wrong residents and have occasionally failed to administer medications. Medication reviews conducted on 08/15/2024 and 04/22/2025 revealed that medications were properly documented on the Centrally Stored Medication and Destruction Records (CSMDR) and appeared to be administered as prescribed at the time of inspection. Interviews with staff indicated that med-techs assist residents with medication administration. Med-techs either bring medications to residents in their rooms or meet them in common areas where they are known to be at the scheduled time. Additionally, many ambulatory and fully alert residents independently go to the medication room to receive their medications. Furthermore, interviews conducted with residents confirmed that they receive their medications daily as prescribed and reported no concerns regarding their medication administration. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “facility staff did not dispense medications to residents as prescribed”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that facility staff did not respond to resident's call in a timely manner and facility staff did not check resident’s blood pressure as required. It was reported that facility staff did not respond to a resident’s request for assistance in taking their blood pressure when they were not feeling well. Records reviewed and interviews conducted revealed that certain residents have doctors' orders to monitor their blood pressure regularly. According to the electronic medication administration records (eMAR) for Residents R1 and R2, both residents had their blood pressure monitored in accordance with their respective physician’s orders. R1's blood pressure was checked every other day, while R2's was checked every morning. Additionally, interviews with R1 and R2 confirmed that staff assist them with blood pressure monitoring as needed, and both residents stated they have no issues requesting help from staff. R1 also added that they had asked staff to take their blood pressure on several occasions, and staff never refused. Interviews with randomly selected residents further revealed that they frequently use their call pendants to request assistance and reported no issues with staff response times. Residents also noted that staff are consistently willing to help and routinely check on them throughout the day to ensure their well-being. Furthermore, residents expressed no concerns regarding staff responsiveness, or the assistance provided. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “facility staff did not respond to resident’s call in a timely manner” and “facility staff did not check resident’s blood pressure as required”. Therefore, these allegations are deemed Unsubstantiated at this time. It was further alleged that facility staff did not meet resident's incontinence care needs. It was reported that residents are left soaking wet for hours, especially during the nighttime. Interviews conducted with staff revealed that residents are checked for incontinence based on their level of care and care plan. Full-assist residents are typically checked at least once every two hours, while others are checked every two to three hours. Staff stated that residents are separated into sections, and each staff member is assigned specific areas to check and assist residents with their incontinence needs. Additionally, staff members emphasized that they ensure all residents are changed promptly, as they aim to prevent urinary tract infections (UTIs) and the development of pressure sores. Interviews conducted with residents revealed that staff frequently check on them, and residents reported that they are not left in soiled diapers. Staff members consistently ensure that residents stay dry throughout the day. Furthermore, residents did not express any concerns about staff meeting their incontinence needs. Based on interviews conducted with staff and residents, the Department has in sufficient evidence to support the allegation of “facility staff did not meet the resident’s incontinence care needs”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy provided. Report Continued from LIC 9099... It was alleged that facility staff yelled in the presence of residents. It was reported that a staff member was observed screaming and cursing at another staff member on the evening 08/12/ 2024, while residents were present. Interviews conducted with staff revealed that medication technicians are placed in charge when management is not present in the facility. Staff reported that an altercation occurred between the medication technician and a caregiver, during which one staff member verbally attacked the other. Interviews further revealed that confrontation between staff was observed by a resident’s bedroom with the resident present, in the common areas by the dining room, and outside in the parking lot. Furthermore, a family member was entering the facility at the time, and several residents lounging in the lobby witnessed the verbal altercation between the staff members. Based on the information obtained during the course of the investigation, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation of “facility staff yelled in the presence of residents” is deemed Substantiated at this time. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 8, 2025 · control 29-AS-20240813132042

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 12, 2025

87468.1(a)(1) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on information obtained and reviewed, including interviews, the Licensee did not comply with the section cited above as facility staff were observed yelling in the presence of residents, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: The Licensee has agreed to have a staff training on resident’s personal rights and submit proof to CCL no later than POC due date. POC has been met.

Allegation investigated: Facility staff are providing medications to resident without physician's orders.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. Upon arrival, LPA Arroyo met with Executive Director (ED), Lea Bogoyevac. Entrance interview. The initial visit and subsequent visit were conducted by LPA Arroyo on 11/14/2024 and 04/22/2025. On 11/14/2024, LPA Arroyo conducted interviews with the ED and two staff between 2:15PM and 3:40PM, conducted a file review starting at 2:30PM and obtained copies of pertinent documents. On 04/22/2025, LPA Arroyo conducted interviews with three staff and eight residents, conducted a medication review, and conducted a file review and obtained copies of pertinent documents between 1:45PM and 3:35PM. On 11/15/2024, LPA Arroyo conducted a collateral visit at a day program and interviewed one staff starting at 9:25AM and conducted a file review at approximately 9:40AM and obtained copies of pertinent documents. Hospital records were also obtained and reviewed. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that facility staff are providing medication to resident without physician’s order. It was reported that Resident #1 (R1) had been given prescription medications at the facility against the orders of R1’s physician and without a valid prescription. Additionally,it was reported that facility staff administered medication to R1 without a doctor’s order in an attempt to chemically sedate the resident. These medications were said to cause R1 mental distress and behavioral changes. Records reviewed and interviews conducted revealed that R1 had become more disruptive than usual and harder to redirect while attending the day program around April–May 2024. According R1’s physician's report dated 08/11/2022, R1’s primary diagnosis were autism spectrum disorder and mild cognitive impairment. The report also indicated that R1 experienced confusion, disorientation, and exhibited inappropriate and aggressive behaviors. However, the resident did not have any medications prescribed by their physician. Staff interviews revealed that R1’s family was informed of the resident’s behavioral changes, which included signs of sundowning in the afternoons and what appeared to be panic attacks. Staff stated that both R1’s family and paramedics were contacted during these episodes; however, either R1 or R1’s family declined hospital transfer. As an alternative, staff suggested hiring a personal companion, which the family agreed to try in hopes of alleviating R1’s symptoms. Staff interviews further revealed that all medications are administered strictly according to doctors’ orders and staff denied giving medication to any resident without a valid prescription on file. On 11/09/2024, during a behavioral episode, 911 was called and R1 was transported to the hospital for evaluation. While hospitalized, R1 underwent testing for the presence of any drugs or substances in their system; all test results came back negative. Furthermore, interviews with other residents indicated that they were receiving their prescribed medications without issue and reported no concerns about living in the facility. Based on the information obtained during the course of the investigation, the Department has insufficient evidence to support the allegation of “facility staff are providing medications to resident without physician’s orders”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 8, 2025 · control 29-AS-20241105134333

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Martha Arroyo and Brian Balisi conducted an unannounced annual inspection today. Upon arrival, the LPAs met with Memory Care Director (MCD), Vana Dunn and explained the reason for the visit. The Executive Director (ED) Lea Bogoyevac arrived shortly after. Entrance interview. Starting at 10:30am, the LPAs along with the Executive Director and Maintenance Director, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: RESIDENT ROOMS/RESTROOMS: The LPAs observed seven (7) resident rooms in the assisted living side and four (4) resident rooms in memory care. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:38am, the hot water temperature was measured in seven (7) assisted living bathrooms and four (4) memory care bathrooms, and the temperature measured between 107 – 115.8 degrees Fahrenheit. KITCHEN: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. Report Continued on LIC 809C... Report Continued from LIC 809... COMMON AREAS: The LPAs observed common areas to be clean and in good condition. There are games and/or activity supplies in the activity rooms as well as throughout the facility. There was sufficient space to accommodate both indoor and outdoor activities. An adequate amount of emergency food and water was observed; properly stored. Night lights were maintained in hallways and passageways. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 11/06/2024. OUTDOOR SPACE: The LPAs observed the outdoor garden in Assisted Living and Memory Care which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. No bodies of water noted at the time of the visit. RECORD REVIEW: The LPAs reviewed ten (10) resident records and ten (10) staff records starting at 11:52pm. Ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Ten personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were in order. During today’s visit, the LPAs conducted interviews with six (6) staff and five (5) residents. No concerns were noted. Report Continued on LIC 809C... Report Continued from LIC 809C... MEDICATION REVIEW: The LPAs reviewed medications at approximately 1:15pm. The medications are centrally stored in a med room on the 1st floor near the dining room. Medications appear to be given as prescribed at the time of the visit. During today’s visit, the LPAs reviewed the facility's infection control policy as well as their emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. The last fire safety inspection was completed on 04/23/2024 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 02/05/2025. No citations issued. Exit interview conducted. Report was reviewed and copy provided.the state’s words, verbatim · CDSS document, Apr 10, 2025

Allegation investigated: Staff are not practicing proper hand hygiene. Staff does not ensure kitchen is clean.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 03/14/2025 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED) Lea Bogoyevac. Entrance interview. During the initial visit on 03/14/2025, the LPA conducted a plant tour starting at 2:56 p.m. and observed the kitchen/food service area and dining room, conducted interviews with four staff between 3:10 p.m. and 3:40 p.m., and obtained copies of pertinent documents. Report Continued on LIC 809C... Unsubstantiated Report Continued from LIC 809... It was alleged that staff are not practicing proper hand hygiene. It was reported that facility staff are not washing their hands after eating or handling other items. Records reviewed and interviews conducted revealed that all kitchen staff are required to complete and pass food handler training. In addition to the required training, in-service sessions are conducted monthly, focusing on specific topics. Interviews with staff indicated that the first thing they do when beginning their shift is wash their hands. Staff also mentioned that, while not everyone washes their hands as frequently as they do, they do observe other staff members washing their hands at appropriate times. Additionally, staff stated that when wearing gloves, the protocol is to wash their hands each time before putting on a new pair of gloves. Based on the information obtained and reviewed through records and interviews, the Department has insufficient evidence to support the allegation of “staff are not practicing proper hand hygiene”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff does not ensure kitchen is clean. It was reported that staff were not cleaning the kitchen and dining room areas after each meal service. During the plant tour on 03/14/2025, the LPA inspected the kitchen/food service area and observed that the kitchen was clean and sanitary, with no toxic substances in sight. The LPA noted staff present in the kitchen cooking upon arrival to the facility; however, the kitchen was clean. Staff interviews indicated that after each meal service, they clean the dining room area to prepare for the next meal service. Staff also stated that cleaning duties are assigned to each person to complete every day. These tasks include vacuuming the dining room, cleaning and setting up the tables for the next meal service, and maintaining the server's station in a clean state at all times. Based on observations and information obtained, the Department has insufficient evidence to support the allegation of “staff does not ensure kitchen is clean”. Therefore, this allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 29-AS-20250312151818

Allegation investigated: Staff handled resident in a rough manner resulting in resident's injury.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 12/20/2024 by LPA M. Arroyo. During today's visit, the LPA met with Executive Director (ED), Lea Bogoyevac. Entrance interview. During the initial visit on 12/20/2024, LPA Arroyo conducted interviews with six staff and six residents, and conducted a file review and obtained copies of pertinent documents between 11:05 a.m. and 2:20 p.m. It was alleged that staff handled resident in a rough manner resulting in resident’s injury. It was reported that staff has long nails and while bathing Resident #1 (R1), staff was aggressive and scratched R1. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... Interviews conducted with staff revealed that R1 had reported to facility staff that it hurt when they were being cleaned. However, R1 did not indicate that staff had been aggressive or rough during the assistance. After the report, R1 was assessed and tested, which resulted in a diagnosis of a urinary tract infection (UTI). No cuts, scratches, or bruising were observed on R1’s body. Additionally, the interviews with staff revealed that they follow proper hygiene protocols, such as wearing gloves and ensuring that they are gentle and patient while assisting residents. During resident interviews, residents denied any instances of staff being aggressive or rough. Furthermore, residents described the staff as nice and reported having no concerns about staff or living at the facility. Based on interviews conducted with facility staff and residents, the Department does not have sufficient evidence to support the allegation of “staff handled resident in a rough manner resulting in resident’s injury”. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Jan 28, 2025 · control 29-AS-20241218153517

Allegation investigated: Staff did not ensure facility was free from pests.

Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint investigation visit for the above allegation. Upon arrival, the LPA met with Executive Director (ED), Lea Bogoyevac and explained the reason for the visit. Entrance interview conducted. During today's visit, between 11:05 a.m. and 2:45 p.m., the LPA conducted interviews with six staff, seven residents, and one private companion, observed Resident #1’s (R1’s) apartment, and conducted a file review and obtained copies of pertinent documents. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff did not ensure facility was free from pests. It was reported that R1’s is being bitten by earwigs in their room. During the visit, the LPA conducted a walkthrough inside R1's apartment and did not observe any signs of bugs. Record reviews and interviews revealed that R1 had reported seeing earwigs inside their apartment. Staff stated that R1’s room had been inspected by several facility staff members to ensure there were no bugs or earwigs present. A record review of staff communication, dated 12/09/2024, indicated that the maintenance director had also inspected R1’s room and reported no bugs of any kind. Additional records show that the facility receives monthly pest control services from Ecolab to maintain a bug-free environment. Interviews further revealed that R1 has been consistently mentioning bugs, specifically earwigs, over the past couple of weeks, although staff have attempted to redirect R1, as they have not observed any bugs in R1’s bedroom. Furthermore, five out of five residents interviewed denied seeing any bugs while living at the facility and reported no concerns regarding pests. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not ensure facility was free from pests”. Therefore, this allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 29-AS-20241217102437

Allegation investigated: Licensee did not provide responsible party with a refund.

Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint investigation visit for the above allegation. Upon arrival, the LPA met with Executive Director (ED), Lea Bogoyevac. Entrance interview conducted. During today's visit, the LPA conducted an interview with the ED at 9:20 a.m. and obtained copies of pertinent documents. It was alleged that licensee did not provide responsible party with a refund. It was reported that the Responsible Party (RP) had toured the facility with the intentions of possibly admitting a family member into the facility. Records review and interview conducted revealed that RP had paid the facility the preadmission fee of $3,500 on 09/26/2024. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... On 10/04/2024, the RP contacted the facility and informed them that they no longer wished to proceed with the process and had canceled. A review of the Community Fee Receipt indicates that all applicable refunds will be processed within 60 business days. Although the refund check for the RP was not fully approved until six (6) weeks after the RP communicated the cancellation, the RP was issued a refund check for the preadmission fee on 11/20/2024. Furthermore, the RP received the refund of the preadmission fee within the 60 days as initially agreed upon and as stated in the Community Fee Receipt. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “licensee did not provide responsible party with a refund”. Therefore, this allegation is deemed Unsubstantiated at this time. No citations issued at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 29-AS-20241119083142

Allegation investigated: Staff handled resident in a rough manner.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial complaint visit was conducted on 10/17/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Lea Bogoyevac. Entrance interview. During the initial visit on 10/17/2024, LPA Arroyo conducted interviews with three staff and one resident between 2:15 p.m. and 3:55 p.m., conducted a file review at approximately 4:00 p.m., and obtained copies of pertinent documents. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff handled resident in a rough manner. It is the complainant’s concerns that two (2) caregivers were rough with Resident #1 (R1) resulting in R1 having bruises on their arms. Record review of R1’s physician’s report dated, 06/06/2024 lists R1’s primary diagnosis as osteoarthritis and mild cognitive impairment (MCI). Additionally, per R1’s preplacement appraisal information dated 04/24/2024 indicates under mental condition that R1’s short term memory is not really good. Interviews conducted with facility staff revealed that R1 has had a personal companion 24 hours a day for at least two (2) months. Staff stated that R1’s family hired a personal companion for R1 to ensure R1 was getting taken care of at all times as R1 has been alleging staff mistreatment. Additionally, per Los Robles occupational therapy evaluation dated 09/27/2024, it states “patient very verbose and requires frequent redirection”. During separate interviews conducted with R1, the LPA and complainant did not observe any bruising on R1’s arms. Furthermore, R1 was asked about the incident; however, due to R1’s inconsistency with their statements, the information obtained did not include evidence sufficient to corroborate the allegation. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff handled resident is a rough manner”. Therefore, this allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. Report was reviewed and a copy issued.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 29-AS-20241014190246

Allegation investigated: Neglect/Lack of Care and Supervision: Facility Resident #1 (R1) died as a result of facility neglect. Neglect/Lack of Care and Supervision: Staff did not provide medical attention to resident in a timely manner resulting in sepsis.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA met with Executive Director Lea Bogoyevac and explained the reason for the visit. On 04/19/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint of two allegations of Neglect/Lack of Care and Supervision: Facility Resident #1 (R1) died due to facility neglect and staff did not provide medical attention to R1 in a timely manner resulting in sepsis. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Seng. On 04/22/2024, from 3:50 p.m. to 5:00 p.m., LPA Balisi conducted an unannounced complaint visit for the allegations listed above. At approximately 3:50 p.m., the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation. Unsubstantiated Continued from 9099 On 07/08/2024, at approximately 4:05 p.m., Investigator Seng conducted interviews with R1’s resident representative; on 07/19/2024, from approximately 11:48 a.m. to 3:35 p.m., with Resident #2 (R2), Access TLC home health nurses and social worker, facility Executive Director/Administrator, Resident Care Coordinator, Memory Care Director, and med tech; on 08/17/2024, at approximately 4:50 p.m., with R1’s Podiatrist; on 08/30/2024, from approximately 2:48 p.m. to 3:31 p.m., with Resident Care Coordinator and med tech; on 09/03/2024, from approximately 4:21 p.m. to 4:40 p.m., with former Health Services Director and med tech; on 09/05/2024, at approximately 12:52 p.m., with Adventist Health Hospital ER physician; and on 09/06/2024, from approximately 12:52 p.m. to 12:57 p.m., with facility staff and the Long-Term Care Ombudsman (LTCO). In addition, the investigator reviewed Adventist Health Hospital medical records, Ventura County Coroner’s Report #0134-24, Access TLC Home Health records, Performance Foot and Ankle medical records, and facility file documents, including staff training in ostomy care, related to the investigation. A review of R1’s Physician’s Report, dated 09/29/2023, listed R1’s primary diagnosis as dementia, with secondary diagnoses of ataxia. R1 was noted as having an ileostomy The Performance Foot and Ankle medical records revealed on 10/12/2023 at 2:45 p.m., the Podiatrist conducted an exam of R1’s foot. The diagnosis was listed as musculoskeletal hammertoe deformity. R1 was to return to the office in 10 weeks for at-risk foot care. Per the Department’s interview with the Podiatrist, they stated that they were responsible for assessing R1’s hammertoe and added that the odds of R1’s hammertoe leading to sepsis was unlikely. R1 had a wound on their toe that was discovered on an examination on 12/21/2023 which exposed the bone. The doctor considered amputation of R1’s toe as an option; however, decided to try and save the toe with wound care treatment. The main priority was to focus on keeping the toe from getting infected. Orders to treat the toe included covering the foot with bandages and avoiding rubbing of it against any shoes R1 would wear. The doctor stated that they were unaware of what happened after the examination; however, stated it was unlikely for R1’s toe to become septic from 12/21/2023 to the day of death on 01/23/2024. Continued from 9099-C The doctor based this on their examination, as they did not believe R1’s toe condition was serious and that a wound on R1’s toe would not progress to sepsis in a month due to the poor blood supply in that area of R1’s foot. The doctor added that they had no additional concerns with the facility or R1’s condition. According to the review of the facility logbook, on 01/23/2024 at 8:21 a.m., Resident #2 (R2) called staff to transport R1 to the bathroom. The staff attempted to move R1; however, R1 declined, as R1 preferred to remain in bed. Staff left R1 alone in their bed. At 9:13 a.m., R2 called staff and they returned to transport R1 to the toilet, and they emptied R1’s ostomy bag. The staff gave R1 water as R1 was thirsty. The staff transferred R1 to their recliner and noticed R1 appeared pale. The staff called for a med tech to come and assess R1. 911 was called and R1 was transferred to Adventist Health Hospital in Simi Valley. According to the Adventist Health Hospital records, on 01/23/2024 at approximately 10:46 a.m., R1 was admitted for treatment for cardiac arrest. R1 was unresponsive upon arrival; per the report, R1 was transported from their bed to chair and R1’s body went limp and collapsed. The paramedics performed CPR for approximately 20 minutes prior to R1’s arrival. R1 arrived at the ER in full cardiac arrest and was pronounced dead at 10:55 a.m.. Based on the labs, R1 may have been septic, which caused R1’s cardiac arrest. The Ventura County Coroner’s report noted there was no trauma or neglect associated with the death. On the allegation “Neglect/Lack of Care and Supervision: Facility Resident #1 (R1) died as a result of facility neglect” - Based on records review and interviews conducted, there was insufficient evidence to prove that the facility was responsible for R1’s death. Per R1’s Podiatrist, R1 sustained a hammertoe diagnosis on 12/21/2023; however, the doctor stated it was unlikely for R1’s toe to become septic from 12/21/2023 to 01/23/2024 which would lead to R1’s death. Continued from 9099-C Based on the examination, the doctor did not believe R1’s toe condition was serious and added that the likelihood for R1’s toe to become septic in such a short timeline would be unlikely. The ER Physician stated that they believed R1 was septic. The physician based this on R1’s white blood cell count; however, stated that this would likely be from a UTI or pneumonia instead of neglect. The facility logbook showed that staff would check on R1 daily. They would also empty R1’s bag and change it as needed. The Coroner’s Report stated that they did not believe there was any sign of obvious trauma or neglect associated with R1’s death. Per the Access TLC home health nurses, they trained staff on how to manage R1’s ostomy bags. They did not witness any signs of neglect and believed the facility staff were adequately caring for R1. Based on the evidence received from the Coroner’s Report, ER Physician, Podiatrist, Access TLC home health nurses and their medical records, the Department did not find sufficient evidence that the facility neglected the care of R1 leading to R1’s death. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation “Neglect/Lack of Care and Supervision: Staff did not provide medical attention to resident in a timely manner resulting in sepsis.” - Based on records review and interviews conducted, there was insufficient evidence to prove that the facility was responsible for R1’s developing sepsis and passing away at the hospital due to the facility’s failure to obtain medical attention for R1. Per the med techs and direct care staff, they did not notice any change in condition with R1 in the week prior to R1’s death. The facility logs showed that staff would check on R1’s bag daily and address any bag drainages or changes as needed. Access TLC home health nurses both added they did not witness any signs of neglect when they would conduct follow up appointments with R1 to treat R1’s bag. Based on the evidence received from the facility staff, Access TLC home health nurses, and the facility logs, the Department did not find sufficient evidence that the facility was responsible for neglect leading to failure to provide proper medical attention leading to R1 getting sepsis and passing away. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Sep 30, 2024 · control 29-AS-20240419134804

Allegation investigated: Staff did not meet residents’ toileting needs. Staff do not ensure that resident is adequately fed.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility today. The purpose of the visit is to issue findings for the above allegations. The initial visit was conducted by LPA M. Arroyo on 11/08/2023 and subsequent visits were conducted by LPA’s M. Arroyo and B. Balisi on 04/15/2024, and on 07/29/2024 by LPA M. Arroyo. During today's visit, LPA met with Executive Director (ED), Lea Bogoyevac. Entrance interview. During the initial visit on 11/08/2023, LPA Arroyo conducted a tour of the facility to ensure there are no health and safety concerns at 2:15 p.m., conducted an interview with the Memory Care Director (MCD) at 2:35 p.m., conducted a resident file review at 2:50 p.m., and obtained copies of pertinent documents relevant to the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... On 04/15/2024, LPA’s Arroyo and Balisi conducted interviews with five (5) staff between 12:10 p.m. and 2:00 p.m., conducted a medication review of six (6) randomly selected residents at approximately 2:00 p.m., and obtained copies of pertinent documents. On 07/29/2024, LPA Arroyo conducted interviews with two (2) staff and nine (9) residents between 1:22 p.m. and 3:35 p.m., conducted a medication review of three (3) randomly selected residents at approximately 2:50 p.m., and obtained copies of pertinent documents. Home Health Records and Hospital Records were also obtained and reviewed. It was alleged that staff did not meet resident’s toileting needs. It was reported that Resident #1 (R1) had multiple Urinary Tract Infections (UTI’s) and had been hospitalized due to lack of care from staff. Records review and interviews conducted revealed R1 moved into the facility on 09/30/2023. R1’s physician report, dated 09/29/2023, listed R1’s primary diagnosis as dementia and second diagnosis as ataxia. R1 was identified as being confused/disoriented with inappropriate, aggressive, wandering, and sundowning behaviors and was able to follow instructions; however, R1 was not able to communicate their needs. The report indicated R1 was not able to bathe, dress/groom, or take care of their toileting needs without having someone to assist. Home Health records reviewed revealed that R1 was admitted to the hospital on 10/13/2023 due to altered mental status. After tests conducted, it was revealed that R1’s agitation was due to a urinary tract infection (UTI) and later on discharged back into the facility on 10/17/2023. Further records reviewed revealed R1 had also been admitted to the hospital on 11/01/2023 and 11/14/2023; however, diagnosis for these two (2) visits did not include UTI as a cause. Interviews conducted with staff revealed that status checks are conducted on incontinent residents every two (2) hours unless they need it more often. Additionally, staff stated that they check on the residents assigned to them at the start of their shift and about three (3) times during their entre shift. Per resident notes, it indicates that staff was checking in on R1 and Resident #2 (R2) every morning to assist with dressing and then help escort to the dining room. Interviews with residents revealed that staff often check on them throughout the day and reported having no concerns while living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to supports the allegation. Therefore, this allegation is being deemed Unsubstantiated at this time. Report Continued on LIC 9099C... Report Continued from LIC 9099C... It was also alleged that staff do not ensure that resident is adequately fed. It was reported that R1 suffers from dementia, refuses food, and staff does not ensure that R1 is eating. Records review of R1’s physician’s report, dated 09/29/2023, indicated R1 is capable of feeding themselves and is on a soft foods diet. Interviews conducted with staff revealed that residents that require assistance with their activities of daily living (ADL’s) are dressed and brought down to the dining room for breakfast every morning. Additionally, per resident notes, it indicated that staff was checking in on R1 and R2 every morning to assist with dressing and then help escort to the dining room. Additionally, staff are noted to assist residents with mealtimes, offering food multiple times if resident initially refuses to eat or drink. Records reviewed revealed that R1 was re-admitted to the hospital on 10/26/2023. Hospital records from 11/01/2023 indicated that R1 was consuming a fair amount of a pureed diet and meeting estimated nutritional needs with supplemental intake. Furthermore, interviews also revealed that both staff and R2 were consistently assisting and helping R1 to eat and drink throughout the day. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation. Therefore, this allegation is being deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy issued. Report Continued from LIC 9099... On 04/15/2024, LPA’s Arroyo and Balisi conducted interviews with five (5) staff between 12:10 p.m. and 2:00 p.m., conducted a medication review of six (6) randomly selected residents at approximately 2:00 p.m., and obtained copies of pertinent documents. On 07/29/2024, LPA Arroyo conducted interviews with two (2) staff and nine (9) residents between 1:22 p.m. and 3:35 p.m., conducted a medication review of three (3) randomly selected residents at approximately 2:50 p.m., and obtained copies of pertinent documents. Home Health Records were also obtained and reviewed. It was alleged that staff mismanaged resident’s medication. It was reported that staff provided an incorrect list of medications list to medical providers. Records review of R2’s centrally stored medication and destruction record (CSMDR) it listed all medications the facility obtained when R2 was admitted to the facility. Per R2’s medication clarification, the facility did not have a doctor’s order for medication Carbidopa-Levodopa 25 – 100mg; therefore, the facility faxed R2’s Primary Care Physician (PCP) requesting to review the medications list and clarify the dosage and frequency of medication. Although the facility reached out to R2’s PCP regarding R2’s medications on 10/05/2023, the facility did not update R2’s medications list before providing it to the hospital after R2 was sent out a week later. Furthermore, per medication of three (3) randomly selected residents it was revealed that facility is receiving resident’s medication; however, the staff are not documenting the medication on the CSMDR when it is received. Staff interviews revealed that personnel in charge of medications continuously changes which may be the reason why medications are not being properly documented on resident’s CSMDR. Additionally, two (2) out of three (3) CSMDR reviewed did not have medication information such as filled date and start dates up to date. Based on the information obtained during the course of the investigation, the Department has sufficient evidence to say, “staff mismanaged resident’s medication”. Therefore, this allegation is being deemed Substantiated at this time. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 29-AS-20231103120219

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 30, 2024

87465 (a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as medications are not being properly documented on the CSMDR once received, which posed an immediate health and safety concern to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: The Licensee will review Regulation and have staff training on how to properly document medication on the CSMDR and submit proof to CCL on or before POC due date.

Allegation investigated: Staff did not prevent covid outbreak.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 12/12/2023 by LPA M. Arroyo, and subsequent complaint visits were conducted on 04/15/2024 by LPAs M. Arroyo and B. Balisi and on 04/15/2024 and 07/29/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Lea Bogoyevac. Entrance interview. During the initial visit on 12/12/2023, LPA Arroyo conducted interviews with the ED at 2:25pm and one staff at 2:30pm, conducted a file review at 2:55pm, and obtained copies of pertinent documents relevant to the investigation. On 04/14/2024, LPAs Arroyo and Balisi conducted five staff interviews between 12:10pm and 2:00pm and obtained copies of pertinent documents. On 07/29/2024, LPA Arroyo conducted interviews with two staff and nine residents between 1:22pm and 3:35pm and obtained copies of pertinent documents. Report Continued on LIC 9099... Unsubstantiated Report Continued on LIC 9099C... It was alleged that staff did not prevent covid outbreak. It was reported that there was a covid outbreak at the facility, but it was not disclosed to family members until after 12/07/2023. Records review and interviews conducted revealed the facility had their first resident test positive for covid on 12/02/2023. Following the first positive case, the facility began testing residents that reported not feeling well or displaying signs of weakness. In December 2023, the facility reported about forty (40) residents that had tested positive not including facility staff. Records review further revealed that facility had started reporting the positive cases to Ventura Public Health (VPH) on 12/03/2023. Personal Protection Equipment (PPE) carts were being placed in residents front doors and staff were monitoring residents and doing frequent checks. Interviews conducted with staff revealed that residents were encouraged and provided PPE when coming outside of their bedrooms and into common areas. Furthermore, although the facility had a covid outbreak, the facility was reporting to the proper agencies and family members as well as taking the necessary precautions to minimize the spreading. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not prevent covid outbreak”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy was issued. Report Continued from LIC 9099... It was alleged that staff neglected to check on resident resulting in multiple injuries and staff did not assist resident in a timely manner. It was reported that although Resident #1 (R1) is fairly independent, staff did not check on R1 for at least two (2) days. Additionally, R1 sustained bruises, sores, and scabs after falling due to R1 experiencing a fall. Furthermore, R1 called out for assistance but no one came. Information obtained during the course of the investigation revealed that R1 was admitted to the facility on 08/24/2023. Per R1’s physician report, dated 08/23/2024, it listed R1’s primary diagnosis as spinal stenosis and indicated R1 was able to follow instructions and communicate needs; however, required assistance with certain activities of daily living (ADL’s) such as bathing, dressing/grooming, and caring for toileting needs. Interviews conducted with staff revealed that all residents residing in assisted living have status checks conducted at least once per day. Staff stated that caregivers are assigned a “block” which is a list of residents that they are in charge of caring and making sure their needs are met for the duration of their shift. Staff interviews further revealed that residents that did not require assistance with ADL’s, had not had any recent falls or change in condition did not receive status checks, but were still checked on once a day. Additionally, staff stated that dining room staff usually report to caregivers if they did not see a particular resident during mealtimes. However, during December 2023, the facility had a covid outbreak which resulted staff to be understaffed, working double shifts, and they did not notice R1 had not been down at the dining room during meals. Additionally, per incident report submitted by the facility on 12/08/2023, it stated that on 12/06/2023, at approximately 2:00pm, staff was doing rounds and R1 was observed on the floor in their room, in pain and with a skin tear with discoloration to their left arm. Furthermore, during staff interviews, staff were unable to say or determine if R1 had been checked on a daily basis two (2) days prior to the unwitnessed fall incident. Based on the information obtained and reviewed, the allegation of “staff neglected to check on resident resulting in multiple injuries” in being deemed Substantiated at this time. It was also alleged that staff did not ensure resident’s call button was working. It was reported that R1 pushed their call button pendant, but the pendant did not work. Records review and interviews conducted revealed that R1’s pendant did not activate requesting assistance prior to being checked on by staff on 12/06/2023. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Interviews conducted with staff revealed that R1 was independent and did not require assistance with ADL’s or medication management. Staff stated that residents are given a pendant which they carry at all times; as well as having a call button / pull chord available in their bathrooms. Staff also reported that periodically pendants will go out and facility will either replace batteries or entire pendant. Furthermore, staff stated that R1 had reported pressing the call button calling for help after suffering the fall. Additional records review of Device Activity Report, dated 11/30/2023 to 12/07/2023, lists the resident name and room number in which a pendant was activated and the time it took staff to respond to the call. Per report dated 12/06/2023, it took approximately two (2) hours for facility staff to report that the pendant was functioning correctly as the pendant for R1 was not tested or activated until 3:59pm on 12/06/2023. According to incident report dated 12/06/2023, R1 was found on the floor at approximately 2:00pm. Based on the information obtained and reviewed, the allegation of “staff did not ensure resident’s call button was working” is being deemed Substantiated at this time. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 29-AS-20231208092110

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Sep 30, 2024

1569.312(a) Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as staff did not check on R1 in a timely manner resulting in R1 sustaining multiple injuries, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee agreed to submit a plan on how they will ensure appropriate care and supervision to meet the needs of residents and submit to CCL on or before POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 30, 2024

87468.1(a)(2) Personal Rights of Residents in All facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as facility staff did not ensure that resident’s call pendant for assistance was functioning properly, which posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee agreed to have an in-service with staff regarding answering call pendants / pull chords in a timely manner and submit proof to CCL on or before POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20231208092110). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation. During the visit on 12/12/2023, interviews conducted with staff revealed that Resident #1 (R1) was independent and did not require assistance of daily living (ADL’s) and managed their own medications. Staff stated that R1 had their personal vehicle while living at the facility which R1 used when leaving the facility unassisted. Record review of R1’s physician report dated, 08/23/2023, indicated R1 is able to follow instructions and communicate their needs. However, physician report also indicated that R1 was not able to leave the facility unassisted and required assistance with ADL’s including but not limited to bathing, dressing/grooming self, and with toileting needs. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Although this is a basic services violation, it has already been cited under the Complaint Control # 29-AS-20231208092110. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 24, 2024

Allegation investigated: Staff does not prevent resident's room from having bed bugs.

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegations listed above. Upon arrival LPA met with Lea Bogoyevac and explained the reason for the visit. At approx 9:15 a.m. LPA conducted a physical plant, interviewed staff, residents and reviewed and obtained copies of pertinent documentation relevant to the investigation. It was reported that staff does not prevent resident's room from having bed bugs as it was alleged, that a residents' room has had ongoing issues with bed bugs for the past (3) months. Interviews conducted and records reviewed reflected that on 03/04/2024, housekeeping staff were conducting a weekly cleaning in Resident #1 (R1)s apartment when they observed evidence of bed bugs. On 03/05/2024, the facilities pest control company Ecolab conducted a visit to treat R1's bedroom for bed bug infestation. On 03/06/2024, a follow up visit was conducted on R1's bedroom to apply additional treatment and inspect surrounding units and common areas. Unsubstantiated Continued from 9099 No pest activity was observed during that visit. On 04/22/2024, housekeeping staff were conducting a weekly cleaning on R1's room and observed evidence of bed bugs. R1 was relocated to a different unit and the room was treated on 04/25/2024. The facility has scheduled another company to conduct a heat treatment on R1's bedroom on 05/01/2024. After the heat treatment the facility will clean and sanitize the room then R1 will be moved back. Records review further revealed, during Ecolab's scheduled monthly visits conducted on 01/18/2024, 02/16/2024, 03/07/2024 and 04/04/2024 their inspection report notated that there were no evidence of pest activity found during those visits. LPA's interview conducted with R1 revealed they have only left the facility with a family member to be taken to medical appointments at a local hospital, but continued to state their family member has not observed any bed bug activity in their own home. Also R1 did not express any potential or immediate concerns that this was an ongoing issue or that the facility staff does not do enough to prevent bed bugs. In addition, LPA's interview conducted with six (6) residents revealed that all (6) have not observed bed bugs or other bug infestations in the facility. Two (2) out of the six (6) residents interviewed were aware that R1's room was being treated for bed bugs and in addition all (6) residents interviewed did not express any potential or immediate concerns that there was an ongoing issue of bed bugs or that the facility staff does not do enough to prevent resident's rooms from having bed bugs. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff does not prevent resident's room from having bed bugs ", is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 29-AS-20240423112621

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:40am. Upon arrival LPAs met with Executive Director Lea Bogoyevac and explained the reason for the visit. The LPAs 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. At approximately 10:28am, LPAs inspected (10) randomly selected bedrooms in memory care and assisted living. 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. All exits in Memory care have functioning auditory devices and were operational at the time of the visit. The LPAs observed required postings throughout the common spaces. The common areas were appropriately furnished, and the lighting was adequate. There are games and/or activity supplies in the activity rooms as well as throughout the facility. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non private bathrooms. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. Continued from 809 The LPAs began the inspection in the kitchen/food service area at 11:07am Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Records review began at 12:00 PM, ten (10) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Records review revealed on 4/30/2023, Resident 1 (R1) was admitted into the facility and physician's report dated 04/28/2023, lists R1 as having no capacity for self-care which is a prohibited health condition. The licensee did not submit an exception request to admit and retain the resident with a prohibited health condition. Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. Last emergency disaster drill was conducted 03/15/2024. All records were observed to be in order at this time. The first aid supplies were complete , including a thermometer and a current version of a first aid manual. First aid was observed stored inaccessible in the medication cabinet as well. Medications review began at approximately 02:00pm The medications are centrally stored in a med room on the 1st floor near the dining room. Medications are properly documented on the centrally stored medications and destruction record. 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 COVID. 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 COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Continued from 809-C During the visit the LPAs interviewed (5) staff and (5) residents. LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Apr 15, 2024