Ivy Park at Wood Ranch

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Incident report for the purpose of investigating a self reported incident report. Upon arrival LPA met with Operations Specialist Myla Belson and explained the reason for the visit. On 08/31/2026, the Regional Office received a self reported incident report and SOC 341 that stated on 08/24/2026, Resident #1 (R1) , reported that staff handled them roughly while receiving care. At approximately 10:00 a.m., LPA conducted a physical plant inspection, interviewed staff, resident's family members or responsible parties, and reviewed and obtained copies of documents relevant to the investigation. Based on interviews and records review no immediate or potential health and safety concerns were observed during the visit and no deficiencies cited at this time. LPA has determined should further investigation be warranted, LPA will return at a later date. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Martha Arroyo and Valeria Conway conducted an unannounced annual inspection today. Upon arrival, the LPAs were greeted by the front desk concierge and shortly after met with Executive Director (ED), Kellie Smith, and the reason for the visit was explained. Entrance interview. Starting at 09:55am, the LPAs along with ED 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 six (6) resident rooms in the Assisted Living (AL) side and two (2) resident rooms in Memory Care (MC). All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:10 a.m., the hot water temperature was measured in eight (8) total bathrooms in both AL and MC bathrooms. Four (4) out of eight (8) bathrooms measured between 120.6 and 128.7 degrees Fahrenheit which is above the required range of 105 – 120 degrees Fahrenheit. Staff adjusted the water temperature at the time of the visit. 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. 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. The LPAs observed several fireplaces throughout the facility; adequately covered. 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. At 10:07 a.m., the LPAs observed three (3) bottles of cleaning supplies including Lysol and disinfectant spray in the AL 2 unlocked and accessible to residents in care. Staff secured cleaning supplies at the time of the visit. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 11/11/2025. 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 nine (9) resident records and eight (8) staff records starting at 12:30 p.m. Nine 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. Eight 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. Medication Review: The LPAs reviewed medications at approximately 02:10 p.m. The medications are centrally stored in a medication room on the 2nd floor. Four (4) 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 the visit, the facility was advised that pre-pouring residents' medications is not permitted and must be discontinued moving forward. Report Continued on LIC 809C... Report Continued from LIC 809C... 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. The last fire safety inspection was completed on 06/05/2026 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 06/10/2026. 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. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 14, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Quoc Huynh arrived on 06/30/2026 at 10:20AM for an unannounced inspection to follow up on a substantiated complaint investigation. The LPA met with Executive Director Kellie Smith. Entrance interview conducted. Beginning at 10:25AM, the LPA and Executive Director toured the physical plant area, and no immediate concerns were observed. On 02/12/2026, the Department concluded a complaint investigation regarding the following allegation: Staff did not seek medical attention for resident in a timely manner. The licensee was cited for California Code of Regulations (CCR) 87469(c)(3) Advanced Directives and Requests Regarding Resuscitative Measures. An additional citation was also issued for Basic Services- 87464(f)(1) for inadequate care and supervision. At the time of the complaint visit on 02/12/2026, a Case Management - Deficiencies visit was also conducted. An immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). Report Continued on LIC 809-C The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing adequate care and supervision of Resident #1 (R1). R1 sustained multiple fractures of the right distal radius and distal ulna which resulted in hospitalization and severe physical pain. Today, 06/30/2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on 02/12/2026, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. The Executive Director Kellie Smith’s signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jun 30, 2026

Allegation investigated: Staff are mistreating a resident in care

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival at approx 12:20 p.m. LPA met with Executive Director Kellie Smith and explained the reason for the visit. At approx 12:30 p.m. LPA conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. It was reported that "Staff are mistreating a resident in care" as it was alleged that staff purposefully placed ketchup on Resident #1 (R1)'s clothing , body and personal items to persuade R1 to get out of bed and change their clothes. Interviews and record reviews revealed that Staff #1 (S1) admitted to placing ketchup on R1's body, clothing, bedding, and personal belongings in an effort to encourage R1 to change clothes and prepare for the day. Substantiated S1 stated that, upon reflection, they exercised poor judgment in using this method. S1 further stated that they used this method on one other occasion with R1 but could not recall the exact date. S1 reported that they did not use this method with any other residents in care and they did not inform their direct supervisor or management. Interviews and record reviews further revealed that Staff #2 (S2) was aware that S1 was using ketchup with R1 for this purpose. LPA's interview with Executive Director stated they had spoken with R1's family member/responsible party, who reported being aware that staff were using this method because R1 had previously refused multiple attempts by staff to assist with changing clothes. According to the Executive Director , the family member/responsible party stated they did not believe staff had malicious intent and had previously discussed the method with staff. Executive Director further stated they were not aware of any prior discussions between S1 and the family member/responsible party regarding the use of ketchup. In addition, the Executive Director informed the family member/responsible party that alternative redirection and intervention techniques could have been utilized instead of intentionally soiling R1's clothing. LPA interviewed three staff members who regularly work in the area where R1 resides. These staff members stated they had not observed other residents being intentionally soiled with food or otherwise treated in an inappropriate manner. Based on the information obtained during the investigation, the allegation of "Staff are mistreating a resident in care" has been 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.) Executive Director 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 providedthe state’s words, verbatim · CDSS document, Jun 9, 2026 · control 29-AS-20260608101601

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jun 19, 2026

To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. 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 intentionally placed ketchup on R1's body and personal belongings to encourage a clothing change, which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 9, 2026

Plan of correction: Licensee representative stated that staff had been suspended and written up, then returned to work after internal investigation had completed. Additionaly Licensee rep agreed to review section cited and provide a written plan to ensure future compliance then send to LPA via email by COB POC date.

Allegation investigated: NEGLECT/LACK OF CARE AND SUPERVISION – A facility resident was found to have toxic levels of a medication in their system by doctors

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegations listed above. Upon arrival, LPA met with Executive Director Kellie Smith and explained the reason for the visit. On 05/15/2025, the Regional Office (RO) received a complaint alleging the neglect / lack of care and supervision of a resident. It was reported that Resident #1 (R1) was sent to the Emergency Room (ER) for rash / blisters. It was reported that, while at the hospital, it was discovered that “Depakote” medication in which R1 was taking was found to be at toxic levels in R1’s system. On 05/16/2025, the RO referred the case to Community Care Licensing Divisions (CCLDs) Investigations Branch (IB). On 05/16/2025 between 10:00 a.m. to 03:30 p.m., LPA Balisi conducted the initial 10- day complaint visit. At approx. 10:00 a.m. LPA conducted physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. Substantiated Continued from 9099 On 06/11/2025, medical records from Adventists Health – Simi Valley were reviewed. Between 07/07/25 and 09/15/25, The Department interviewed current and former facility staff, R1’s Responsible Party (RP) and other relevant parties. R1’s charting notes covering periods from 01/28/25 through 07/06/25 were also reviewed. On 11/26/2025 between 09:30 a.m. to 12:30 p.m., LPA Balisi conducted a subsequent complaint visit. At approx. 09:45 a.m. LPA conducted physical plant tour, interviewed staff and reviewed and obtained additional copies of pertinent documentation relevant to the investigation. It was reported that due to neglect/ lack of care and supervision R1 had toxic levels of a prescribed medication identified by medical providers. Interviews conducted and records review revealed that R1 was transported to the hospital on 04/21/2025 for evaluation of a skin rash and blistering. During that hospitalization, medical staff identified toxic levels of the prescribed medication Depakote in R1’s system. Hospital discharge instructions directed that Depakote be held, pending follow-up with R1’s primary care provider. Upon R1’s return to the facility, the discharge instructions were provided to facility staff by R1’s family and private caregiver, and staff were verbally informed of the medication hold. On 05/14/2025, R1 was again transported to the hospital, at which time laboratory results showed Depakote levels that were higher than those recorded on 04/21/2025. A review of facility medication records indicated that on 04/28/2025, staff began administering a newly prescribed medication, Keppra, but did not discontinue Depakote as directed in the hospital discharge instructions. As a result, from 04/28/2025 through 05/14/2025, R1 received both Depakote and Keppra. Based on the information obtained during the investigation, the allegation of neglect / lack of care and supervision, related to the continued administration of a medication that had been ordered to be held, 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.) Executive Director 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 “Due to lack of supervision, resident fell resulting in a bruise” as It was alleged that Resident 1 (R1) sustained a bruise to the abdomen as a result of a fall. Interviews conducted and records reviewed reflected that that R1 experienced a fall on 04/27/2025. On 05/09/2025, staff observed a bruise on the right side of R1’s abdomen. No fall involving R1 was documented on 05/09/2025, and R1 was unable to identify how the bruise occurred. A review of facility records indicated that no additional falls involving R1 were documented between 04/27/2025 and 05/09/2025.LPA’s interview with Staff revealed that, based on the circumstances of the fall on 04/27/2025, the observed bruise did not appear consistent with that fall. Staff reported that following the fall, R1 were found lying on their back with their head on a pillow and were not positioned against or in contact with any object at the time they were found. It was further revealed that R1 uses a scooter and has been observed leaning forward onto the scooter handles. Staff also stated that the bruise may have resulted from contact with two exposed metal poles on an attachable bed rail when the rail is in the lowered position. Staff explained that the poles are exposed when the bed rail is lowered. A review of R1’s charting notes indicated that since 01/28/2025, R1 has experienced a total of five unwitnessed falls. No significant injuries were reported as a result of these falls. Following R1’s first three falls, charting notes dated 05/01/2025 indicated that Home Health recommended R1 receive assistance with all upright activities due to increased fall risk. Records further revealed that R1 experienced two additional unwitnessed falls on 06/05/2025 and 06/10/2025. Both incidents occurred in R1’s room. 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 “Due to lack of supervision, resident fell resulting in a bruise” is deemed Unsubstantiated at this time. It was reported that “Staff did not notify authorized representative of bruise on resident”, as It was alleged that R1’s responsible party was not notified in a timely manner of a bruise observed on R1. Interviews were conducted and records reviewed reflected that on 05/09/2025, Staff #1 (S1) observed a bruise on the right side of R1’s abdomen. According to charting notes, S1 informed R1’s private caregiver of the observed bruise. The private caregiver is listed in R1’s records as Emergency Contact #2. The charting notes further indicated that the private caregiver requested Tylenol for R1 and stated they would notify R1’s Power of Attorney (POA) of the bruise. LPA’s interview with S1 revealed, S1 stated that they asked R1’s private caregiver, who was present in R1’s room at the time, to send a text message to R1’s POA regarding the bruise. Continued from 9099-C S1 further stated that after assessing R1, they also directly contacted R1’s POA to report the observed bruise. Interviews with R1’s POA and R1’s private caregiver revealed that both individuals stated they did not recall being notified of the bruise. Interviews were conducted with seven (7) facility staff. All seven staff stated that when a bruise or change in condition is observed, the med tech or appropriate staff are notified immediately, the resident is assessed, and notifications are made to the resident’s family or responsible party, the primary care physician, and any involved home health agencies. None of the staff interviewed reported concerns regarding untimely notification to required parties when a bruise or change in condition is observed. 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 did not notify authorized representative of bruise on resident” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 29-AS-20250515145455

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 10, 2026

87465(a)(4) Incidental Medical&Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility… (4) The licensee shall assist residents with self-administered medications as needed. 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 continued to administer a medication to R1 that was discontinued by R1’s PCP which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Licensee agreed to conduct medication inservice review section cited and create a written plan to ensure future compliance then send to LPA via email by COB POC date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Brian Balisi conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20250515145455). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation unrelated to the complaint. Upon arrival, LPA met with Executive Director Kellie Smith and explained the reason for the visit. During the investigation between 07/07/25 and 09/15/25, The Department reviewed Resident #1(R1s) charting notes covering the period from 01/28/25 through 07/06/25. Charting notes revealed that since 01/28/25, R1 experienced a total of four (4) unwitnessed falls on 03/11/2025 at 11:00 a.m., and 01:59 p.m., on 04/12/2025 at 01:25 p.m., on 04/27/2025 at 04:42 p.m. On 05/01/25, Home Health recommended that R1 receive assistance with all upright activities due to fall risk. After Home health’s recommendation R1 experienced additional falls on 06/05/2025 at 04:22 a.m. and on 06/10/2025 at 04:10 p.m. LPA’s records review of incident reports (LIC 624) revealed the Regional Office (RO) only received an incident report for the fall on 06/10/2025. LPA’s records review of R1’s file revealed there was no reappraisal on file after home health’s recommendation that R1 receive assistance with all upright activities due to fall risk on 05/01/2025. The following deficiencies were cited from the Title 22 California Code of Regulations. (See LIC 809-D). The Executive Director was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report was providedthe state’s words, verbatim · CDSS document, Apr 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 17, 2026

A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days... and disposition of the case. This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as incident reports (LIC 624) for multiple falls for R1 were not sent to the RO in a timely manner which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Licensee agreed to review reg cited and submit a written plan on how they will ensure future compliance then submit to CCL via email by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(i) · Plan of correction due date: Apr 17, 2026

When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first...as specified in Section 87467, Resident Participation in Decision Making.This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as no updated reappraisals were observed in R1’s file after R1 experienced multiple falls, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Licensee agreed to review reg cited and submit a written plan on how they will ensure future compliance then submit to CCL via email by POC date.

Allegation investigated: Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 9:57AM and met with Executive Director (ED) Kellie Smith. Entrance interview conducted. On 05/16/2025, LPA Brian Balisi conducted an initial visit and met with former ED Lilit Mnatsakanyan. LPA Balisi conducted a physical plant tour, interviewed the ED and five (5) staff, and reviewed and obtained pertinent documents. On 07/16/2025, LPA Huynh conducted a subsequent visit and met with ED Kellie Smith. Between 9:16AM and 11:58AM, the LPA interviewed the ED and two (2) staff, reviewed and obtained additional documents, and conducted a physical plant tour. Report Continued on LIC 9099-C Substantiated On 09/10/2025, the investigation was referred to Community Care Licensing Division’s (CCLD) Program Clinical Consultant (PCC) and assigned to Lorena Kho. PCC Kho reviewed documents including facility files, hospice records, and hospital records. During today’s visit, LPA Huynh and the ED conducted a physical plant tour at 10:03AM and no immediate concerns were observed. The following was then determined: Allegation: “Staff did not seek medical attention for resident in a timely manner” It was reported that Resident #1 (R1) sustained a fall that resulted in wrist fractures, and the facility did not send R1 to the hospital for evaluation. R1’s Physician Report dated 02/27/2025 documented diagnoses of acute chronic diastolic heart failure, shortness of breath, and mild cognitive impairment. R1 was receiving Hospice services for heart failure and treatment for cellulitis in both legs, with secondary diagnoses including muscle weakness and a disorder of bone density and structure. Although disoriented and forgetful, R1 was able to follow instructions and communicate their needs. They required assistance with bathing, grooming, and toileting and ambulated with a cane and walker. Per R1’s Facility Assessment Summary dated 02/05/2025 with an effective date of 05/01/2025, R1 required standby assistance and cues for transfers and was identified as high risk for fractures due to osteopenia. Hospice visit notes dated 05/06/2025 documented R1 reporting an unwitnessed fall that occurred on the evening of 05/05/2025. Facility Charting Notes also referenced an unwitnessed fall disclosed during a care plan meeting, though no date or time was documented. This fall reportedly caused bruising and swelling to R1’s right shoulder. The Hospice nurse observed that R1 was unable to move their arm and requested a shoulder x-ray, which returned normal. Beginning on 05/07/2025, facility caregivers documented extensive bruising to R1’s right upper arm, shoulder, and upper chest, along with ongoing complaints of pain. Hospice was notified and advised as needed (PRN) medications. Report Continued on LIC 9099-C Later on 05/07/2025, R1 sustained a second fall in the evening while attempting to reach for a snack, landing on the floor in a seated position. Over the following days, R1 continued to report severe pain, and staff documented worsening bruising, swelling, and redness. On 05/11/2025, staff noted that R1’s “[right] hand is so swollen and [their] arm is just hanging down [their] recliner, looks like something pulling it down.” On 05/12/2025, staff documented that R1’s “arm is extremely purple and swollen” and that redness remained present on the arm, hip, and legs. On the evening of 05/12/2025, R1 sustained a third unwitnessed fall near the fireplace, resulting in a skin laceration on the right dorsal forearm. First aid was administered, Hospice was notified, and it was further documented that R1 was “in too much pain.” On 05/13/2025, Charting Notes indicated that R1 was “screaming in pain” and refused to allow staff to reposition their hand. A second x-ray was then ordered on the arm, revealing multiple fractures of the distal radius and distal ulna with soft tissue swelling. Later that evening and at the family’s request, R1 was discharged from Hospice and transferred to the hospital for further treatment. Staff interviews revealed that the facility protocol for unwitnessed falls is to notify the med-tech, who then assesses the resident to determine if a hospital transfer is warranted. The med-tech reportedly conducts a skin assessment, evaluates for major injuries, observes range of motion, and provides the resident with verbal cues. Staff stated that emergency services are contacted immediately if the resident is in pain, has limited mobility, grimacing, hits their head, is bleeding, or sustains a skin laceration. If the resident is on Hospice, the facility notifies the Hospice agency and follows their orders. Staff #1 (S1) expressed that R1 should have been transferred to the hospital immediately after the first fall and again after the final fall resulted in a skin laceration; however, the facility followed the Hospice reporting procedures. The ED also expressed uncertainty regarding whether facility protocols were followed prior to new management. Staff reported conducting daily skin checks but were unable to specify what occurred after reporting abnormal findings, and inconsistencies were noted in how staff monitored residents for injuries. Report Continued on LIC 9099-C Based on interviews and record review, R1 experienced three (3) falls and although staff notified Hospice after each incident, R1’s falls were not related to their condition of acute chronic diastolic heart failure. R1 was not sent for medical evaluation after their falls, reports of pain, decline in physical condition, or following the skin laceration they sustained. The preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 29-AS-20250514091509

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87469(c)(3) · Plan of correction due date: Feb 13, 2026

(c) If a resident who has an advance directive and/or request regarding resuscitative measures… experiences a medical emergency… (3) Specifically for a terminally ill resident that is receiving hospice services... For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement was not met as evidenced by: Based on interviews and record review, the Licensee did not comply with the above cited section in facility staff did not seek medical attention for R1 in a timely manner which poses/posed an immediate health, safety, and person rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: The Licensee will conduct an in-service training with all staff to address Hospice and CCLD procedures and will provide CCLD proof by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit in conjunction with Complaint #29-AS-20250514091509. The LPA arrived at 9:57AM and met with Executive Director (ED) Kellie Smith. Entrance interview conducted. On 09/10/2025, the Complaint investigation was referred to Community Care Licensing Division’s (CCLD) Program Clinical Consultant (PCC) and assigned to Lorena Kho. PCC Kho reviewed documents including facility files, hospice records, and hospital records. During today’s visit, LPA Huynh and the ED conducted a physical plant tour at 10:03AM and no immediate concerns were observed. The following was revealed during the Complaint investigation: Between 05/05/2025 and 05/12/2025, Resident #1 (R1) sustained three (3) falls resulting in wrist fractures, a skin laceration, and significant physical pain. On the morning of 05/06/2025, R1 informed their Hospice nurse of an unwitnessed fall that occurred the evening of 05/05/2025. According to Hospice notes, facility staff denied the fall due to the absence of documentation. Later that same day, during a care plan meeting with R1’s family, the facility disclosed an unwitnessed fall that caused bruising and swelling to R1’s right shoulder, though no specific date or time was provided. The facility did not provide any additional information or documentation regarding the care plan meeting. Report Continued on LIC 809-C On 05/07/2025, R1 sustained a second fall in the dining room, landing in a seated position on the floor while attempting to reach for a snack. On 05/12/2025, R1 was left unattended near a fireplace and was found on the floor with a skin laceration. Staff interviews revealed that R1 had been left unsupervised while staff attended to another resident, and R1 was later discovered by a staff passing by. R1 began reporting pain and limited mobility in their arm on 05/06/2025. The facility notified Hospice who recommended as needed (PRN) medications, increased dosages, and provided new medication orders. In the following days, R1 continued to report severe pain and was unable to move their arm. Facility staff and the Hospice nurse observed extensive bruising and swelling extending from R1’s right shoulder to the right arm and upper right chest. Staff documentation included observations such as: “moaning in pain and [their] arm is extremely swollen and bruised,” “redness and swelling continues to worsen,” and “right hand is so swollen and [their] arm just hanging down [their] recliner.” The Facility Assessment Summary documented R1’s last assessment on 02/05/2025 with an effective date of 05/01/2025. The Assessment indicated R1 required standby assistance and cueing for transfers and showering, did not require assistance with repositioning, and was able to ambulate to the dining room and participate in activities without assistance. R1 was identified as a high fall risk and at high risk for fractures due to osteopenia. The Assessment instructed staff to “provide personalized interventions, per fall management protocol,” but did not specify active transfer or ambulation assistance or other safety measures to prevent falls or fractures. The facility did not complete an updated assessment or implement additional safety interventions following R1’s initial falls, further increasing R1’s risk for subsequent falls and injury. Report Continued on LIC 809-C On 05/25/2025 CCLD received an Incident Report stating that R1 experienced a “slip/fall” on 05/12/2025 resulting in a skin laceration and was hospitalized on 05/13/2025 when fractures were discovered. The Incident Report also referenced an unwitnessed fall on 05/06/2025 “which didn’t result in any serious injuries except slight complaints of discomfort… noted by light bruise on the clavicle.” However, the report did not disclose R1’s second fall on 05/07/2025. Interviews with R1’s family revealed that the facility did not communicate or disclose the seriousness of R1’s condition, aside from receiving notification of the first and last falls. Based on interviews and record review, the facility failed to provide adequate care and supervision to R1, resulting in fractures of the distal radius and distal ulna with soft tissue swelling, as well as a skin laceration. The facility also failed to provide timely and adequate notification to R1’s family and did not submit required notification to CCLD within seven (7) days of the occurrences, as required by reporting regulations. An immediate civil penalty in the amount of $500 was assessed today (Refer to LIC421M). The ED was informed that additional civil penalties may be assessed based on Health and Safety code Section 1569.49. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Feb 12, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 13, 2026

(f) Basic services shall at minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews and record review, the Licensee did not comply with the above cited section in that R1 did not receive adequate care and supervision resulting in bodily injuries which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: The Licensee will conduct in-service training with all care staff on care and supervision as well as ensuring Appraisals are current/maintained and will provide CCLD proof by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Feb 13, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)… This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section in CCLD and R1's family were not adequately notified of R1's incidents in a timely manner which poses/posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: The Licensee will review reporting requirements with all Directors and submit a signed statement of understanding and provide it to CCLD by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Martha Arroyo and Brian Balisi conducted an unannounced annual inspection today. At approx 09:50 a.m. LPAs met with Executive Director (ED) Kellie Smith and explained the reason for the visit. At approx 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: 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. LPAs observed ten (10) resident rooms total six (6) 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, between 109 – 117.4 degrees Fahrenheit. The common areas on the first floor consists of the bistro, 2 separate dining areas, a living room, movie room, and multiple activity rooms. Also, on the first floor were observed several offices, staff lounge, a copy room, and a supply room. The second-floor common areas consists of the beauty salon, dining room, leisure/lounge room, offices, and multiple other activity rooms. LPA's 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. The common areas were appropriately furnished, and the lighting was adequate. Smoke alarms, carbon monoxide detectors, sprinklers and fire extinguishers were observed throughout the facility. The emergency exiting plans/sketch are posted throughout the hallways. The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. There is a functioning telephone on the premises. Emergency evacuation chairs were present in all stairways. The facility has approved delayed egress systems in the Memory Care unit. There is a secured patio area with tables and chairs for residents within the Memory Care unit. There is also a large outdoor space with shaded areas and adequate furniture for resident use throughout the facility. All passageways, walkways, driveways, steps and patios are free from obstructions and hazards at this time. Several fire extinguisher were observed throughout the facility to be fully charged and last serviced on 12/18/2024. LPAs reviewed ten (10) resident records and ten (10) personnel records starting at 11:50am. 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. (10) 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 appeared to be in order during the visit. LPAs reviewed medications at approximately 1:30pm. The medications are centrally stored in a med rooms on the 2nd floor. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record. Medications appeared 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 05/6/2025 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 06/26/2025. No citations issued. Exit interview conducted. Report was reviewed and copy provided.the state’s words, verbatim · CDSS document, Jul 8, 2025

Allegation investigated: Staff did not keep the facility free of bedbugs.

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA met with Executive Director Lilit Mnatsakanyanand explained the reason for the visit. At approx 09:50 a.m. LPA conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. It was reported that "Staff did not keep the facility free of bedbugs" as it was alleged that there continues to be a recurring bed bug problem in multiple rooms. On 05/12/2025, LPA conducted an investigation on control # 29-AS-20250509152429, for the allegation "Staff does not keep resident’s room free from bed bugs", it was confirmed that there was an occurrence of bed bugs, however that allegation was found to be Unsubstantiated due to information received stating that the occurrence had been contained to one room and the facility demonstrated a proactive preventative approach by having Ecolab conduct additional visits outside of their normal monthly visits. Unsubstantiated Continued from 9099 Since then, interviews conducted and records review revealed Ecolab has conducted additional visits for preventative measures on 05/09/2025, 05/30/2025 where no new bed bug activity was found. On 06/09/2025 during an Ecolab service call, one (1) bed bug was found in room 227. The room was treated on 06/13/2025. Since 06/09/2025, no additional bed bug activity has been reported by staff. During the LPA's physical inspection of rooms, 226, 225, 227, 223, 217, 231, surrounding rooms, and adjacent areas, no evidence of bed bugs was observed. 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 did not keep the facility free of bedbugs” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Jun 27, 2025 · control 29-AS-20250618085349

Allegation investigated: Staff does not keep resident’s room free from bed bugs.

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA met with Executive Director Lilit E Mnatsakanyan and explained the reason for the visit. At approx 10:50 a.m. LPA conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investgiation. It was reported "Staff does not keep resident’s room free from bed bugs." as it was alleged that the facility has a recurring bed bug problem in multiple rooms, which may be due to staff failing to take appropriate preventative measures. Interviews conducted and a review of facility records, revealed, bed bugs were first identified in Resident #1's (R1) room on 04/09/2025. On 04/11/2025, the pest control company, Ecolab, inspected, treated, and serviced R1’s bedroom. Unsubstantiated According to the Executive Director, all disposable furniture and affected items were replaced, and R1’s clothing and personal belongings were cleaned and sanitized. Ecolab returned on 04/14/2025, to continue treatment in R1’s room and to inspect the adjacent common areas. No new signs of bed bug activity were observed at that time. On 04/21/2025, Resident #2 (R2), who resides in the room next to R1, was admitted to the hospital due to concerns related to possible bed bug bites. Hospital discharge documentation indicates that R2 was diagnosed with cellulitis. On 04/22/2025, Ecolab conducted an inspection and provided pest control services in R2’s room, the room across the hallway, and the nearby common areas. The couches in the memory care common space were also inspected. No new bed bug activity was identified during this inspection. Interviews with facility staff revealed that, since the initial bed bug report, all resident rooms have been inspected each morning for signs of infestation, with no additional activity reported. During the LPA's physical inspection of R1’s room, surrounding rooms, and adjacent areas, no evidence of bed bugs was observed. The facility has demonstrated a proactive approach to pest management and is under a standing contract with Ecolab to conduct monthly inspections and services to help ensure the facility remains free of infestations. 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 keep resident’s room free from bed bugs” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, May 12, 2025 · control 29-AS-20250509152429

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent unannounced Case Management - Incident visit at approx 11:00 a.m. to continue the investigation of a self-reported incident that was initially conducted on 09/05/2024 between 12:30 p.m. - 02:30 p.m. Upon arrival LPA met with Executive Director Lilit Mnatsakanyan and explained the reason for the visit. At approx 11:15 a.m. LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of additional pertinent documentation relevant to the investigation. On 08/23/2024, the Department received an incident reports stating on 08/15/2024 at approx 8am, Staff #1 (S1) was observed to be handling Resident #1(R1) in a firm manner while R1 attempted to swing their arms in an agitated manner, resulting in discoloration / bruising on R1's forearms. R1 did not indicate any discomfort or additional injuries. Interviews conducted with staff and Executive Director revealed on 08/15/2024 at approx 8:00 a.m. Staff #2 (S2) attempted to change R1's clothes for breakfast. R1 reacted with increased agitation and became combative towards S2. S1 entered the room to provide assistance to S2. R1's agitation and combative behavior escalated towards both staff members. S1 then restrained R1 by grasping both wrists, which led to bruising on R1's forearms. LPA's records review indicated S1 was suspended pending an investigation, both law enforcement and R1's family were notified of the incident on the same day it occurred. Additionally, S1 voluntarily resigned from their position following the incident. Based on the investigation's findings, there is sufficient evidence to conclude that S1 handled R1 in a rough manner , resulting in bruising on R1's forearms. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D). Exit interview conducted. Copy of report and appeal rights were reviewed and issued during today's visit.the state’s words, verbatim · CDSS document, Oct 28, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Oct 29, 2024

87468.2(a)(8) To be free from neglect, financial, exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the regulation cited above as S1 handled resident in a rough manner and caused bruising, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2024

Plan of correction: Licensee agreed to hold a training on all Personal Rights, Mandated Reporting and Abuse for all staff, provide proof of training with staff signatures to CCL via email by COB 10/29/2024.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management – Incident visit at 12:30 p.m. for the purpose of investigating self reported incident reports. Upon arrival, LPA met Interim Executive Director Kathleen Olson and explained the reason for the visit. On 08/23/2024, the Department received an incident reports stating on 08/15/2024 at approx 8am, Staff #1 (S1) was observed to be handling Resident #1(R1) in a firm manner while R1 attempted to swing their arms in an agitated manner, resulting in discoloration / bruising on R1's forearms. R1 did not indicate any discomfort or additional injuries. At approx 12:30pm, LPA conducted physical plant interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. LPA has determine further investigation is needed and will return at a later date to complete the investigation if warranted. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 5, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Martha Arroyo conducted a pre-licensing visit to the above noted facility. Upon arrival, LPA was greeted by applicant representative/ Executive Director Jeanne Skondin. This is a change of ownership application, but the facility name will remain the same. Entrance interview conducted. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The facility is two-story. At 9:45am, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for ninety-two (92) non-ambulatory residents; and eight (8) bedridden residents. The facility has a capacity total of one hundred (100) residents. The facility has an approved fire clearance for bedridden in any bedroom on both the first and second floors, front desk will maintain current roster of bedridden residents’ room location. There is one central kitchen that distributes food to the 3 dining rooms. The kitchen contained a walk-in pantry with a sufficient supply of canned foods, and emergency food and water. The walk-in refrigerator and freezer were observed to have an ample supply of perishable and nonperishable food supplies. The freezer was maintained at zero degrees Fahrenheit, and the refrigerator was maintained at 40 degrees Fahrenheit. Stove burners are rendered inaccessible to the residents. The supply of dishes, utensils, pots, pans, and drink ware is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Cleaning supplies are stored separately from food preparation areas in locked storage closets throughout the facility. There are three (3) laundry rooms throughout the facility for resident use. No flies or other vermin were observed. Report Continued on LIC 809C... Report Continued from LIC 809... The common areas were appropriately furnished, and the lighting was adequate. The common areas on the first floor consists of the bistro, 2 separate dining areas, a living room, movie room, and multiple activity rooms. Also, on the first floor were observed several offices, staff lounge, a copy room, and a supply room. The second-floor common areas consists of the beauty salon, dining room, leisure/lounge room, offices, and multiple other activity rooms. Smoke alarms, carbon monoxide detectors, sprinklers and fire extinguishers were observed throughout the facility. LPA obtained a copy of the most recent Sprinkler and smoke detector inspection conducted. The fire extinguishers were observed and are fully charged. The emergency exiting plans/sketch are posted throughout the hallways. The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. There is a functioning telephone on the premises. Emergency evacuation chairs were present in all stairways. The facility has approved delayed egress systems in the Memory Care unit. There is a secured patio area with tables and chairs for residents within the Memory Care unit. There is also a large outdoor space with shaded areas and adequate furniture for resident use throughout the facility. All passageways, walkways, driveways, steps and patios are free from obstructions and hazards at this time. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space. The beds are furnished with box springs, comfortable mattress, and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket, and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath, or toilet. There are no staff rooms – awake night staff only on premises. All rooms were free of odors. All window screens were clean and maintained in good repair. Report Continued on LIC 809C... Report Continued from LIC 809C... The resident bathrooms have a shower with non-skid surfaces. The toilet and shower have grab bars. The hot water temperature was tested in random resident rooms in the Assisted Living area and was found to be within the range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. The hot water temperature was also tested in random resident rooms in the Memory Care area and was found to be within the range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. At 11:00am, the LPA conducted a file review or resident and staff records. Resident and staff records are stored in the Business Director’s office. Medications are centrally stored in the Medications Room / Nurses Station which is located on the second floor. In addition, there are total of four (4) medication carts located throughout the facility. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in the medication room. The physical plant of this facility location is in compliance with Title 22 regulations at this time. No corrections required at this time Comp III conducted with Applicant Representative/Executive Director. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 11, 2024