Laurel Heights

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Zabel Chochian conduct a required annual visit. Upon arrival LPA met with staff and Executive Director (ED) Joey Alvarado. Reason for visit was explained. The following documents/records was requested and reviewed: Resident and Staff roster; Emergency Disaster Plan, Infection control plans, fire alarm inspection and drills. Emergency Disaster and Infection control plan bot were reviewed this year 3/2026. Fire alarm inspection and drills are conducted by Fire Safety Company once a month and in addition in-service disaster drills are conducted quarterly by the ED. Last fire drill was conducted 7/2/2026. At approximately 12pm-3:15m, LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Fire extinguishers checked throughout the building observed full charged and last serviced on 01/20/2026. All required postings observed posted in the common areas. Facility consists of three floors: the basement has a theater, fitness room and a beauty salon for residents use. The 1st floor has lounge area, library, dining/bar area, kitchen and dining. The second floor has a activity room, therapy room and a poker area for residents use. All floors have 2 common restrooms which were checked and observed with sufficient paper products and soap; hot water measured within required range at 117.3-120 Fahrenheit in each common bathroom. The kitchen/food service and dining area located on the 1st floor was checked. Kitchen appliances were in operable condition; the facility has a sufficient supply of perishable and non-perishable food. (Continue to LIC809c) Refrigerator, freezer and food pantry were checked for proper labels and expiration dates. Adequate supply of emergency food and water observed maintained at facility. Memory Care kitchen/dining activity area was also checked. Everything observed in good repair in the memory care dining activity area. Sufficient snack and water also observed in the memory care dining area. Delayed egress exit doors checked and observed in working order. During the tour the LPA also toured 10 (ten) randomly selected resident bedrooms (6 rooms in the assisted living and 4 rooms in the memory care). LPA met with residents and conducted random interviews during the room tour. Resident bedrooms were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths. The hot water measured within required range 105 – 120 degrees Fahrenheit. Emergency alert alarm system checked from random resident rooms observed functioning properly and staff response time was under 5 minutes at the time of today's visit. Due to time constraints, the annual inspection will be completed on a follow-up visit. No deficiencies cited at this time. Exit interview conducted and a copy of report provided.the state’s words, verbatim · CDSS document, Jul 24, 2026

Allegation investigated: Facility is over charging resident for services not provided Staff do not ensure residents care needs are being met Resident is not accorded adequate nourishment resulting in weight loss Staff did not ensure copies of resident records were provided to residents responsible party Staff did not ensure resident received medical attention in a timely manner Resident sustained an unexplained injury while in care

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit regarding above allegations. Upon arrival LPA met with staff and later with Executive Director (ED) Joey Alvarado. The reason for the visit was explained. On 11/12/2025, Community Care Licensing Division received the above allegations. On 11/20/2025, LPA conducted the initial complaint visit. During the complaint visit copies of records relevant to the case was requested. LPA met with and interviewed two (2) staff at approximately 3:50 p.m. LPA also toured the memory care unit with staff. Staff were observed assisting residents in the dining and activity area. Attempt was made to speak with Resident #1 (R1) however R1 was agitated and showed signs of aggression. During a cite visit on 2/20/2026, additional staff and random residents were interviewed. LPA reviewed R1’s records including but not limited to care assessments, progress notes, internal incident reports, notification letters to family and admission agreement. (Continue to LIC9099c) Unsubstantiated Following is a summary of the allegations and investigation finding: Regarding allegation “Facility is over charging resident for services not provided” – Information was received that the facility overcharged R1 for services not provided for R1 being a level 4 in the memory care unit. It was reported that the facility hired a third party care giver for one-on-one care in addition to the care services facility staff were to provide. According to the reporting party R1 was charged for services facility staff did not provide. Facility staff interviewed and records reviewed revealed that initially R1 was assessed to be a level 1 care and within 2-3 weeks R1’s level of care change to level 3 and soon after requiring level 4 assistance due to requiring one-on-one care. Staff interviews and records reviewed revealed that facility hired staff from third-party agency to provide additional supervision. ED reported that the facility paid for the third party staff for additional supervision for R1. Records reviewed and interviews conducted with staff revealed that the charges for the third party staff were showing on the statements, however reflect paid/credited back by the facility. The credit was confirmed by staff and R1’s responsible person. 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 allegation “Facility is over charging resident for services not provide” is deemed unsubstantiated at this time. Regarding allegations “Staff do not ensure resident’s care needs are being met and Resident is not accorded adequate nourishment resulting in weight loss” – Information was received that the facility staff did not provide care services to R1, such as showers, transferring assistance to the bathroom, eating assistance, or medication assistance. Staff interviewed denied the allegation. Staff reported that they provided all ADLs for R1; additional help was hired for supervision since R1 was showing rapid change in level of care; requiring additional one-on-one care due to mental status, fall risk and aggressive behavior. According to staff, despite staff trying to attend to R1’s needs and care R1 was very combative and would decline assistance from staff in dressing, showers and routine hygiene care. During the initial visit LPA observed R1 and other residents dressed appropriately, clean and dry. Staff interviews and records review revealed that R1’s family and physician was kept informed regularly on R1’s condition. Regarding allegation “Resident is not accorded adequate nourishment resulting in weight loss” – Interview with staff and records reviewed revealed that R1 would not sit down for meals and constantly move around; family and physician was aware. Order for ensure was received from the physician; medications were also adjusted. Staff reported that R1’s responsible person would control R1’s medication and choose which to fill and bring to the facility. There was no record of R1’s weight at the time of admission in 3/2025; R1’s weight was documented in 4/2025 (116lb) 10/2025 (104lb) and in 11/2025 (102lb). (Continue to LIC9099c) According to staff and ED R1 was very combative and aggressive, which made it difficult to assist R1 with ADLs. Records reviewed showed that the family and physician were informed of incidents and provided updated care plans. Staff reported that R1’s responsible person was contacted frequently and informed of every detail to R1’s needs and care. Timeline of events and care plans documented by facility was reviewed. R1 required hire level of care then what facility could provide and R1's responsible person was made aware of the issues following each level of care change assessments. 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 allegation “Staff do not ensure residents care needs are being met and Resident is not accorded adequate nourishment resulting in weight loss” is deemed unsubstantiated at this time. Regarding allegation “Staff did not ensure copies of resident records were provided to residents responsible party” - Information was received that each time R1's level of care would go up, the facility staff never provided in writing, a copy of what those services were. Interview with staff and facility records reviewed revealed that R1 was admitted to the facility on 3/21/2025; resident’s appraisal completed and signed by facility representative and R1’s responsible person; 30 day assessment completed and signed by facility only. According to staff the assessment was discussed with R1’s responsible person and they refused to sign. Staff reported that they made several attempts to coordinate a meeting with the responsible person and failed. Record of R1’s needs and services plan dated 10/7/2025 and 11/27/2025 observed on file with only facility representative signature. According to staff the service plans were discussed with the responsible person and provided to them for signature however never received. Staff interviews and records reviewed revealed that R1’s level of care change and service needs was discussed with R1’s responsible person. Also progress notes kept by the facility documented communication about R1’s care needs and service plan update with R1’s physician and responsible person from the 30day assessment in 4/2024 to 11/27/2025. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not ensure copies of resident records were provided to residents responsible party” is deemed unsubstantiated at this time. Regarding allegations “Staff did not ensure resident received medical attention in a timely manner and Resident sustained an unexplained injury while in care” – (Continue to Lic9099c) Information was received that R1 sustained an injury to foot and a wound on the toe and facility staff ignored it and did not seek medical attention. Interview with staff and records reviewed revealed that on 10/18/25, R1 was observed with a minor injury to right toe and left leg; it was unknown to facility staff how the injury occurred. According to staff the injury to R1’s toe did not require higher medical attention and it was not ignored. Staff reported that R1’s responsible person and physician was notified; first aid was provided to R1’s toe. Staff denied the allegation and reported that R1 was continuously monitored by facility staff and a third party caregiver. Staff reported that R1 had other incidents/injury which required medical attention and was sent to the hospital for evaluation. 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 allegation “Staff did not ensure resident received medical attention in a timely manner and Resident sustained an unexplained injury while in care” is deemed unsubstantiated at this time. Exit interview conducted an copy of report issued.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 29-AS-20251112083024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)4 · Plan of correction due date: Apr 30, 2026

Incidental Medical and 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 was not met as evidenced by: Based on records review, the facility failed to assist resident #1 with medication prescribed and instead, gave resident #1 another resident’s medication which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Executive Director stated that since the incident staff was pulled from med-tech duties provided in-service and retrained on medication management and prior to resuming medtech duties staff was supervised by Health and Wellness Director on 3 medication passes.

Allegation investigated: Staff left resident on floor for an extended period of time. Resident sustained a pressure injury while in care. Staff leave resident soiled for extended periods of time.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit regarding above allegations. Upon arrival LPA met with receptionist. Executive Director (ED) Joey Alvarado was contacted. LPA spoke with ED and reason for the visit was discussed. ED approved Sarah Crompton-Smith, Program Coordinator to met with LPA and sign today's report. On 05/12/2025, Community Care Licensing Division received the above allegations. On 05/15/2025, LPA Chochian conducted the initial complaint visit and obtained copy of the resident roster, staff roster and staffing schedule. LPA met with and interviewed four (4) staff from approximately 11am-1pm. LPA conducted a physical plant tour with staff beginning in the Memory Care unit at approximately 1:15pm. During the tour from approximately 1:15pm-2:30pm, LPA conducted interview with five (5) random residents residing in the Assisted Living side and interviewed visitors in the Memory Care unit. LPA also attempted to interview residents in the Memory Care unit. On 2/20/2026, LPA reviewed additional records were reviewed and interview was conducted with Infinite Home Health staff. (Continue to 9099c) Unsubstantiated Following is a summary of the allegations and investigation finding: Regarding allegation “Staff left resident on floor for an extended period of time” – Information was received that resident #1 had two fall incidents and was left on the floor for an extended time. Also, additional information received that when resident fell (date unknown) R1 contacted the family member who lives close to the facility for help/assistance back into bed. To investigate this allegation, records reviewed revealed that R1 had two falls one on 2/11/2025 and another on 3/23/2025 since admission to the facility memory care on 2/20/2024. Service care plans dated 10/07/2024; 11/24/2024 and 3/26/2025 documented that R1’s level of assistance in mobility/ambulation was minimal to moderate; just prompting and cueing; not required hands on. Records reviewed indicated R1 requiring escort/redirection in the memory care unit and encourage use of walker. Regarding fall incident on 2/11/2025 it was documented that R1 sustained a fall in resident bathroom; R1 fell in the bathroom; R1 had a cell phone which R1 used to call family. The family contacted the facility at which time staff went to assist R1. R1 was found on the floor in R1’s bathroom (incident time documented 8:30pm). The second fall was on 3/23/2025; R1 was out with family; upon returning to the facility R1 sustained a fall transferring out of the family car. Staff were alerted and attended to R1 accordingly. In both fall incidents 911 was contacted and R1 was transferred to the hospital. Staff reported that all residents in memory care are out during the day in the common areas and constantly monitored by staff. Staff stated that when residents are in their room at night, they are checked on at minimum every 2hrs. 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 allegation “Staff left resident on floor for an extended period of time” is deemed unsubstantiated at this time. Regarding allegation “Resident sustained a pressure injury while in care” – Information was received that R1 had a level 1 pressure sore which was do to leaving R1 unattended for long periods each day. R1’s records reviewed did not indicate/note any pressure injury. Interview was conducted with Infinite home Health registered nurse (RN). RN reviewed R1’s records and confirmed that R1 did not have any pressure injury. RN verified through their records that the family took resident to the doctor on 05/08/2025 at which time the doctor provided R1 a referral for home health service; as precaution due to small (dot size) pink rash to R1’s sacral area. RN verified that an LVN from the home health agency evaluated R1 on 5/9/2025, 5/14/202 and on 5/20/2025 and no wound was observed. RN confirmed that they evaluated R1 on 6/2/2025 and no wound was observed to stage. (Continue to 9099c) 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 allegation “Resident sustained a pressure injury while in care” is deemed unsubstantiated at this time. Regarding allegation “Staff leave resident soiled for extended periods of time” - Information was received that R1 was observed continuously found with a full diaper. Records reviewed and interview conducted with staff revealed that for hygiene and toileting, staff wound provide verbal prompts and cues. Staff reported that despite engorgement from staff R1 continuously demonstrated refusal of assistance with hygiene care and showers. Staff state that the family and doctor were informed. Staff reported that despite R1 refusing hygiene care, R1 was reminded and encouraged good hygiene care; family and doctor were aware of the situation. Staff interviewed reported that residents requiring assistance with toileting and showers are always assisted with hygiene care. Staff reported that residents are not left unclean or unsanitary. LPA attempted to interview residents in the memory care however they were unable to interview due to cognitive difficulties. LPA did not observe residents in the memory care unit soiled or unkempt during the initial visit and subsequent visits thereafter for other reasons. Visitors in the memory care unit interviewed during the initial visit expressed satisfaction with the care team services. Assisted living resident interviews were also conducted and five (5) out of five (5) residents interviewed reported no issues with care service provided by staff. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff leave resident soiled for extended periods of time” is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 14, 2026 · control 29-AS-20250512163131

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Case Management - Incident visit at the facility today. Upon arrival LPA met with the Business Office Manager, Adriana Castor and reason for the visit was stated. LPA later met with Joey Alvarado, Executive Director (ED). The purpose of today's visit was to conduct interview with staff and resident #1 (R1), review records and obtain pertinent copies of facility records pertaining to a self reported incident involving R1. Facility reported that on 02/16/2026, they were notified by R1's family that a theft incident happened on 2/11/2026. Family stated that they were notified of the incident by R1 on 02/15/2026. R1 did not report the incident to the facility and first contacted law enforcement on 2/13/2026 and later reported to their family on 2/15/2026. ED also contacted law enforcement after being informed of the incident and was told that a case is already open and under investigation with the Ventura County Sheriff's Office. During today's visit LPA reviewed R1's records from approximately 12:30pm-1:15pm; conducted interview with the ED from approximately 1:30pm - 2:15pm, and interviewed R1 along with Sarah Belgard from Adult Protective Services. R1 reported that they were a victim of financial scam. R1 did not report the incident to the facility or their family until after the incident occurred. R1 stated that they filed a police report on 2/13/2026 and later that weekend informed their family. Records reviewed revealed that R1 is responsible for self; able to leave facility unassisted and handles own finances. R1 was a victim of fraud and financial scam. Pending case investigation report from the Ventura County Sheriff's Office, a supplemental report will be issued, if warranted. Exit interview held and copy of report provided.the state’s words, verbatim · CDSS document, Feb 20, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Executive Director Joey Alvarado and explained the reason for the visit. On 02/11/2025, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a report of the death of Resident #1 (R1). The report noted on 02/01/2025, R1 sustained a fall in their room. R1 was transferred to Los Robles Regional Medical Center Emergency Room (ER) and returned to the facility on 02/02/2025. On 02/04/2025, R1 reported not feeling well and was transported to the hospital and re-admitted. On 02/06/2025, it was reported that R1 passed away due to a brain bleed. On 02/11/2025, the RO referred this case to the Community Care Licensing (CCL) Investigations Branch (IB) Investigations Branch to investigate the allegation of Questionable Death. The case was assigned to Investigator Johnny Canto to conduct the investigation. On 02/11/2025, from 10:15am to 12:45pm, Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management – Incident visit. Upon arrival LPA Chochian met with the Administrator/Executive Director Johnny Ortiz and explained the reason for the visit. The reason for the visit was to follow up on a self-reported incident report. The report pertained to an incident involving Resident #1 (R1) who sustained an unwitnessed fall on 02/01/2025 at the facility and subsequently passed away on 02/06/2025 at Los Robles Regional Medical Center. (Continue to LIC809c) Due to the circumstances surrounding the death of R1, the LPA informed the Administrator/Executive Director that the incident was referred to the Community Care Licensing (CCL) Investigations Branch (IB) for further review. On 03/03/2025, from approximately 11:45am to 3:55pm, Investigator Canto conducted interviews with the Administrator/Executive Director, facility staff, and Resident #2 (R2). In addition, Investigator Canto reviewed Los Robles Regional Medical Center records, Ventura County Clerk Records Office Death Certificate, and facility file documents related to the investigation. A review of R1’s Physician Report, dated 09/23/2024, listed R1 as ambulatory; able to leave the facility unassisted; able to independently transfer to and from bed; able to store and administer their own medication; able to administer their own oxygen; able to perform their own glucose testing; and able to care for all of their activities of daily living (ADLs). R1’s Health and Services Evaluation, dated 09/18/2024, indicated R1 was non-ambulatory, listed the mobility/ambulation level of assistance as independent (“resident does not require assistance with mobility/ambulation”); has occasional left knee discomfort when ambulating, relieved by lidocaine patch; does not require supplemental oxygen, has an oxygen concentrator but does not use. The MFS (Morse Fall Scale) evaluation determined R1 was a high fall risk due to a history of falling, uses an ambulatory aid (walker/cane), and has a weak gait. The evaluation indicated to “implement high risk fall risk reduction interventions”. R1 did not require assistance with ADLs, except for help with putting on socks and shoes, and bathing may require reminding or standby assistance. R1’s Service Plan, dated 10/06/2024, lists diagnosis as diabetes, type II; gastroesophageal reflux disease (GERD); heart disease; atrial fibrillation; congestive artery disease (CAD); congestive heart failure (CHF); spinal stenosis; coronary artery disease; and chronic kidney disease stage 3. The Service Plan includes the same information found in the Health and Services Evaluation. (Continue to LIC 809c) Additionally, the plan documents the potential for high fall risk and indicates “R1 is a high fall risk, encourage to always ambulate with cane or walker, keep room free of clutter, encourage to wear proper shoes”. Medical records reviewed document that on 02/04/2024, R1 was admitted to the Los Robles Regional Medical Center with a chief complaint of respiratory failure. On 02/05/2025, R1’s diagnosis included increasing lethargic and shortness of breath. Further tests and x-rays were completed which indicated “the patient most likely has acute respiratory distress ad hypoxia secondary to COPD exacerbation secondary to pneumonia versus CHF exacerbation as well as AKI and hypoglycemia”. In addition, the records indicated a subdural hemorrhage. R1 was placed on comfort care and passed away on 02/06/2025. The Department’s investigation revealed on 10/05/2024, R1 was admitted to the Laurel Heights facility. R1’s physician report noted that R1 was independent and not a fall risk. However, the Facility Health and Services Evaluation and Service Plan both noted R1 was a high fall risk, was non-ambulatory, used a cane and/or walker, and was independent with mobility and ambulation. Staff interviews revealed R1 had no history of falls while residing at the facility, was independent, and only needed standby assistance for showering. On 02/01/2025, R1 sustained an unwitnessed fall in R1’s apartment. R1 was discovered on the floor by facility staff when doing rounds. R1 verbalized that they had fallen in their bedroom. Facility staff noted several lacerations to the back of R1’s head. 911 was called, paramedics arrived, and R1 was transported to the Los Robles Regional Medical Center via ambulance. R1 was medically treated and then discharged back to the facility on 02/03/2025. On 02/04/2025, the facility staff noted that R1 appeared lethargic and unable to answer simple questions. The facility staff called 911 again, paramedics arrived, and transported R1 to the hospital. On 02/06/2025, the facility received notification that R1 expired while at Los Robles Regional Medical Center due to a brain bleed. The cause of death was noted as blunt force head injury with subdural hematoma. The Department’s investigation found insufficient evidence to support the facility neglected the care and or safety of R1. Therefore, no citations are being issued at this time. Exit interview, copy of report given.the state’s words, verbatim · CDSS document, Nov 20, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management – Incident visit in conjunction with the annual continuation inspection today. LPA met with Executive Director (ED) Johnny Ortiz and discussed the reason for the case management visit/report. The purpose of today's visit was to investigate, review records and obtain pertinent copies of facility records pertaining to a self reported incident on 09/15/2025, of alleged resident to resident sexual abuse. During today's visit the LPA conducted interview with the staff and requested copies of pertinent documents. Further investigation is needed regarding the alleged sexual abuse. Exit interview held. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 17, 2025

Allegation investigated: Staff are mismanaging residents medication

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 1:20 P.M. LPA met with the Executive Director (ED), Johnny Ortiz, and explained the purpose of the visit. On 01/08/2025, LPA Zabel Chochian conducted an initial 10-day complaint visit. During the visit, LPA Chochian completed a physical plant tour, requested and obtained copies of resident roster, staff roster and staffing schedule. LPA also met and interviewed five (5) staff members and eight (8) residents. On 04/03/2025, LPA Conway conducted a subsequent complaint visit. During this visit, a physical plant tour was conducted, along with an audit of resident medications and the centrally stored medication log. LPA Conway interviewed the ED, two (2) Med-Techs, one (1) resident, and reviewed and obtained documents pertinent to the investigation. The Reporting Party (RP) was anonymous therefore, the LPAs were unable to obtain additional information regarding the allegations. Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined: It was reported that “Staff are mismanaging residents’ medications”, as it was reported that the facility does not have sufficient staffing to properly care for residents and that medications were not being administered. Additionally, it was alleged that memory care residents were being left alone in their rooms to manage their own treatments. An interview with the ED confirmed that, during staff shortages, the facility relies on staffing agencies to provide temporary caregivers as needed to fill vacant positions or cover staff call outs. This is being done to ensure that staffing levels remain adequate to meet residents’ needs. Interviews with residents revealed that the facility had been experiencing challenges maintaining consistent staffing levels. Some residents expressed dissatisfaction with the frequent turnover of caregivers; however, they confirmed that their medications were being administered on time and on a daily basis. Staff interviews acknowledged ongoing staffing challenges, with some staff reporting they are occasionally required to take on additional responsibilities or work extended shifts. Despite feeling overwhelmed at times staff emphasized that resident needs are being met and medications are dispensed on time. Staff also denied leaving residents unattended during treatment times. Furthermore, staff reported that they follow physician orders regarding the administration of medications, including when medication must be crushed or dissolved. Interviews with credible witnesses, including family members, indicated that their loved ones are receiving appropriate care, and no concerns regarding medication management were reported. Additionally, LPA selected seven (7) random residents and conducted a comparison of the centrally stored medication log and medication supply in the medication room was conducted. No discrepancies were observed. 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 are mismanaging residents’ medications” is deemed Unsubstantiated at this time. No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was issued. Continued from LIC 9099 LPA Conway interviewed the ED, two (2) Med-Techs, one (1) resident, and reviewed and obtained documents pertinent to the investigation. The Reporting Party (RP) was anonymous therefore, the LPAs were unable to obtain additional information regarding the allegations. Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined: It was reported that “Staff did not ensure facility door was not in disrepair” as it was alleged that the front door of community was not functioning and that no corrective action had been taken to address the issue. During the course of the investigation, interviews revealed that the automatic system for the main entry double doors did not consistently engage when the ADA push plate was activated, preventing the doors from opening automatically. This malfunction was challenging for residents using wheelchairs, walkers or any mobility devices, as well as for staff and visitors to safely enter and exit the facility. An interview with the ED acknowledges that the main double doors had been experiencing issues. However, as soon as the problem was identified, a third-party vendor was contacted to assess and repair the doors. Furthermore, the ED stated that while the doors were not functioning properly, staff and front desk personnel assisted residents who requested and/or required help entering or exiting the facility. On 12/23/24, the diagnosis revealed that the transfer hinge wires were broken, and a new motor drive reaction kit had to be ordered. During this visit, a temporary adjustment was made, and the vendor recommended ordering new parts. On 12/30/24, adjustments were made to the solenoid latch, followed by additional repairs on 1/6/25 and on 1/15/25. On 2/20/2025, the vendor returned and installed a new motor drive retraction kit and replaced broken wires. After the repairs were completed, the main double doors were tested and found to be functioning properly. Continued on LIC 9099-C Continued from LIC 9099-C Documentation gathered during the investigation, including work orders and invoices, supports the information provided by the ED, however, during today’s visit, the LPA observed a sign posted on one of the main double entrance doors that read “Please use other door”, with an arrow pointing to the opposite door. The ED stated that the motor of the ADA push plate device is broken. A replacement part has been ordered, and repairs are scheduled to be completed on 07/17/2025. Between 2:05 P.M. and 3:00 P.M. LPA interviewed staff and residents, who reported that the door has been experiencing intermittent issues for several months and has remained in disrepair for the past two (2) weeks. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that main doors were malfunctioning and the automatic system was not functioning properly. Therefore, the above allegation “Staff did not ensure facility door was not in disrepair” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator 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 and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 16, 2025 · control 29-AS-20241230123842

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 31, 2025

87303(a) Maintenance and Operation.The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by Based on observations the ED did not comply with the section cited above as the main door automatic system was observed to be in disrepair which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 16, 2025

Plan of correction: ED has schedule a company to come an fix the main door. A video showing ADA push plate in operable condition shall be submitted to LPA before POC due

Allegation investigated: Staff financially abused a resident in care.

Licensing Program Analyst (LPA) Zabel Chochian conducted a complaint visit regarding above allegation. LPA met with Executive Director (ED) Jonny Ortiz. Allegation was discussed with the ED. During today's visit LPA conducted interview with the ED, met with resident #1 (R1) and R1's responsible persons. Interviews revealed that on 06/30/2025, resident #1's respnsible person reached out to the ED and reported fradulant charges on R1's credit card. There were two charges, one on 5/19/2025 for $1675 for StubHub and another for $4717 on 5/20/2025 for Delta Airlines. A police report was filed by the facility. Bank/credit card records confirmed the flight was booked for an individual identified as one of the facility corporate office staff. Facility conducted an internal investigation. Staff was asked about the fradualant transactions on R1's bank/credit card and staff admitted to the fradulent charges. Henceforth, staff was suspended from employment pending termination. The investigation findings revealed that Resident #1, was a victim of financial abuse by facility corporate staff. Staff and other potential witnesses confirmed the validity of the allegation. (contiue to LIC9099c) Substantiated Based on the information gathered, there is sufficient evidence that resident #1 was financial abused by staff. Therefore, allegation “Staff financially abused a resident in care” is Substantiated at this time. Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiency was cited. Exit conducted. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 29-AS-20250703165848

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jul 9, 2025

Safeguards for Resident Cash, Personal Property, and Valuables: Every facility shall take appropriate measures to safeguard residents'... personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met as evidenced by: Based on interviews conducted and records review, licensee did not comply with the section cited above. Staff made fraudulent bank and credit card transactions using resident #1's bank and credit card. This posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2025

Plan of correction: Executive Director (ED) reported/confirmed that the corporate staff was terminated as of 7/2/2025. ED agreed to provide a plan on how they will maintain future compliance with section cited. Submit plan of correction by 7/16/2025.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Zabel Chochian initiated a required annual visit today at approximately 3pm. LPA and Executive Director Johnny Ortiz toured the physical plant areas inside the assisted living and memory care unit to ensure there are no health and safety hazards. LPA observed required postings throughout the common space. The LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguishers are fully charged and were last serviced 01/14/2025. Due to time constraints, the annual inspection will be completed on a follow-up visit. No deficiencies cited at this time. Exit interview conducted and a copy of report provided.the state’s words, verbatim · CDSS document, Jul 9, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to this facility and met with Executive Director, Johnny Ortiz. The case management visit is being conducted due to deficiencies observed during the investigation of complaint control # 29-AS-20241230123842. During the complaint investigation, the following deficiencies were observed: During today’s visit LPA reviewed and compared the Personnel Report (LIC500), LIS system and the Guardian System. During the audit, LPA observed two (2) staff members listed on the Personnel Report (LIC500) that have passed a criminal background clearance, however, they were not properly associated to the facility. LPA was able to look-up employee information in the LIS system and found that Staff #1 has been working at the facility since 06/13/2022 and Staff #2 (S2) has been working since 05/16/2024. Both staff members were separated from facility named above. S1 separation date was 07/01/2023 and S2 was separated on 05/22/2023. ED stated that S1 is not longer an employee for the facility since 03/16/2025 and during today's visit S2 was associated to the facility. Additionally, LPA requested the Personnel Report (LIC 500) for the month of December 2024. However ED was unable to produce this information stating that they were not aware that the facility is required to keep a current roster of all facility personnel. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Citations issued, civil penalty issued, exit interview, appeal rights given.the state’s words, verbatim · CDSS document, Apr 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Apr 4, 2025

87355(e)(1) Criminal Record Clearance (e)...pursuant to Health and Safety Code Section 1569.17(b)...(1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: Based on record review and interview, LPA found 2 staff that were not associated to the facility. The licensee did not comply with the section cited above in 2 counts which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Executive Director will associate staff members to the facility and/or update LIC 500 to remove emloyees that are not longer working in the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87208(a)(5) · Plan of correction due date: Apr 11, 2025

87208(a)(5) Plan of Operation. (a)The licensee shall have and maintain a current, written definitive plan of operation for the facility... The plan and related materials shall contain the following: (5) Staffing plan, qualifications and duties.This requirement is not met as evidenced by: Based on observation and interviews ED did not comply with the above section by not ensuring plan of operation documentation is being kept readily available to licensing departments which poses a potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: ED shall write a statement of understanding and complete/update a LIC 500 form when necessary and have it readily available for when licensing department request it. LPA expects administrator to have updated LIC 500 before POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management – Incident visit. Upn arrival LPA met with Executive Director (ED) Johnny Ortiz. Reason for visit was explained. The reason for today's inspection is to follow up on a self reported incident report received on 02/10/2025. The report pertains to an incident involving Resident #1 (R1) . It was reported that on 2/01/25, R1 sustained an unwitnessed fall at the facility. R1 sustained a bump on the back of the head therefore 911 was called and resident was transferred to Los Roblas Hospital ER; 02/02/2025, R1 was discharged from ER at approximately 3am. R1 was put on a 72 hour monitoring upon return from the hospital. On 02/04/2025, R1 was observed not feeling well therefore 911 was contacted and resident was transferred to ER again. On 02/06/2025, facility was notified by R1's responsible person that R1 had passed way. Per the information received, the circumstances surrounding the death of R1 on 02/06/2025 may be questionable. During today's visit, the LPA conducted interview with the ED and facility's Health Service Director-Pricila Bosdoganian; copies of pertinent documents requested including but not limited to a copy of the death certificate/report. LPA informed ED that this incident was referred to Community Care Licensing Investigations Branch (IB) for review and that further review is required. An LPA will return at a later date to issue findings. Exit interview conducted. A copy of the report wasthe state’s words, verbatim · CDSS document, Feb 11, 2025

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 9:15 a.m. Upon arrival LPAs met with staff and explained the reason for the visit. Operations Specialist Sahar Mosalla arrived shortly after. 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. The following was noted: At approx 10:30am, the LPA's began the physical plant, the furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 01/09/2024. The LPAs observed required postings throughout the common space. The LPAs observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA’s observed an adequate supply of emergency food and water. The LPAs observed seven (7) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPAs observed a sufficient supply of towels and linens. The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water measured between 107.9 – 117 degrees Fahrenheit. At approx 10:48 a.m.-, the LPA’s observed several items accessible in Resident #1’s (R1’s) bathroom in Memory Care. Items observed unlocked and accessible to resident included: Mouthwash, shampoo and various lotions. Upon review of R1’s most recent Physician’s Report (LIC 602A) assessed within the year, R1 is at risk if allowed direct access to personal grooming and hygiene items. These items were stored away inaccessible to resident at the time of visit. The LPAs inspected the kitchen/food service area at 10:56 a.m. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. LPA’s reviewed Resident Records at 11:45 a.m. Six (6) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Personnel files were printed at the time of visit. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. All records were in order. Medications review began at 01:30pm, The medications are centrally stored in the medication room. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Infection Control - Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. Continued from 809 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 an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. LPAs conducted interviews during the visit. LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance. 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 issued.the state’s words, verbatim · CDSS document, Jul 12, 2024

Allegation investigated: Administrator is not on the premises for a sufficient number of hours. A qualified staff is not designated to operate the facility during administrator's absence.

Licensing Program Analyst (LPA), Martha Arroyo conducted an initial 10-day complaint visit for the above allegations. Upon arrival, the LPA was greeted by the front desk receptionist. The LPA met with Executive Director (ED), Johnny Ortiz shortly after and the reason for the visit was explained. Entrance interview conducted. During today's visit, at 10:55 a.m., the LPA along with the ED conducted a plant tour to ensure there were no immediate health and safety concerns, conducted interviews with the ED, four staff, and six residents between 10:05 a.m. and 12:10 p.m., 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 the Administrator is not on the premises for a sufficient number of hours. It was reported that the Administrator is always away from the facility. Interviews conducted with staff revealed that the Administrator is seen coming into the facility everyday Monday through Friday. Staff stated that the Administrator typically comes in the morning and added that the Administrator leaves the facility after they have left for the day themselves. Additionally, during resident interviews it was revealed that six out of six residents often see the Administrator walking through the hallways talking with both residents and staff. Furthermore, interviews with residents and staff corroborated that the Administrator is regularly seen at the facility during normal business hours. Based on the interviews conducted with staff and residents, the Department does not have sufficient evidence to support the allegation of “administrator is not on the premises for a sufficient number of hours”. Therefore, this allegation is deemed Unsubstantiated at this time. It was further alleged that a qualified staff is not designated to operate the facility during the administrator’s absence. It was reported that the facility has designated a receptionist to cover the facility in the Administrator’s absence and they are not qualified. Interviews conducted with staff revealed that the Administrator is regularly at the facility Monday through Friday. However, on weekends when the Administrator is not scheduled, there is management available at the facility. At any time, if the Administrator is unavailable, the facility has a Business Director, Health Services Director, and Marketing Director that are able to assist when needed. Furthermore, interviews conducted with staff revealed that management is available and willing to help whenever the Administrator is not present. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “a qualified staff is not designated to operate the facility during the administrator’s absence”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued at this time. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2024 · control 29-AS-20240108164943

Allegation investigated: Facility has mold. Facility is in disrepair. Staff do not ensure kitchen is clean. Staff are feeding residents food that is not of good quality. Staff dispensed incorrect medication to resident.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver final findings for the above allegations. The initial visit was conducted on 08/31/2023 and a subsequent visit was conducted on 12/05/2023 by LPA M. Arroyo. On today’s visit, LPA Arroyo met with Executive Director, Johnny Ortiz and the reason for the visit was explained. Entrance Interview. During the initial visit on 08/31/2023, LPA Arroyo conducted a plant tour to ensure there are no health and safety concerns at 1:23 p.m., observed resident bedrooms at 1:28p.m., toured the kitchen and food area at 1:35 p.m., conducted a medication audit at 1:58 p.m., conducted interviews with five staff and five residents between 1:15 p.m. and 3:18 p.m., and obtained copies of pertinent documents. On 12/05/2023, LPA Arroyo conducted a plant tour at 1:10 p.m., toured and inspected the kitchen/food area at 1:15 p.m., and interviewed the Executive Director beginning at 1:12 p.m. and throughout the plant tour. (Report Continued on LIC 9099C...) Unsubstantiated (Report Continued from LIC 9099...) It was alleged that facility has mold. It was reported that there is an issue with mold in the basement as well as certain resident bedrooms. During the plant tour on 08/31/2023, LPA observed the basement and specific bedrooms throughout the facility. Upon observation, the LPA did not see any signs of mold on the bedroom walls, behind, or around the bathroom doors. Additionally, there was no smell that indicated there is a mold problem in the facility. Information obtained and reviewed revealed the facility had a leak due to heavy storms; however, the facility had Nu-Cal Pipeline Corp. come out to the facility and do water intrusion repairs where needed. Interviews conducted with staff also indicated the facility had water damage due to water from the rain getting through the walls. Additionally, certain services are provided and offered to residents in the basement which include the salon, movie theater, and fitness center. Interviews conducted with random residents revealed they often visit the basement to take advantage of the services offered downstairs and they did not report smelling mold while being in the basement. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility has mold”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that facility is in disrepair. It was reported that the stairwell leading to the basement is detaching from the foundation and the stairs shift when in use. Document review revealed the facility had contracting company Nu-Cal Pipeline Corp. do water intrusion repairs due to heavy rains that had caused water damage at the facility. The facility had the pipes sealed, walls, and baseboards replaced. Additionally, during the plant tour on 08/31/2023 and 12/05/2023, the stairwell leading to the basement did not move or shift while the LPA and staff went downstairs. Interviews conducted with staff revealed that neither residents nor family members have reported the facility being in disrepair. Based on LPA observations and record review, the Department does not have sufficient evidence to support the allegation of “facility is in disrepair”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff do not ensure kitchen is clean. It was reported that the kitchen staff leave the kitchen unkempt, dirty dishes piled up, food that needs to be refrigerated is being left out, and counters are left dirty. During the plant tour on 08/31/2023 and 12/05/2023, the LPA toured both the kitchen and food service area. (Report Continued on LIC 9099C...) (Report Continued from LIC 9099C...) The LPA observed clean and newly washed dishes on a cart. The sink was empty as all dishes had been recently washed. Kitchen counters appeared clean at the time of the visit. Additionally, all food was observed inside both the refrigerator and freezer and not laying on any counter. Furthermore, interviews conducted with staff revealed that the kitchen is cleaned immediately after all meal services and maintained clean throughout the day. Based on LPA observations, the Department does not have sufficient evidence to support the allegation of “staff do not ensure kitchen is clean”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff are feeding residents food that is not of good quality. It was reported that chunky milk that has been expired is left in the refrigerator and expired food is being served to the residents. During the facility walkthrough on 08/31/2023, the LPA observed the facility’s food supply in the kitchen, pantry, and refrigerator. The LPA observed food from all groups such as meats, dairy, eggs, breads, fresh fruit, and vegetables. Additionally, the LPA inspected the food labels and checked for expiration dates. All food labels had dates clearly marked and no expired food was observed. Interviews conducted with staff revealed the facility’s food is usually ordered to be delivered twice a week and perishables are ordered as needed. Interviews conducted with random residents revealed the food prepared at the facility is better than other places they have been to. Furthermore, residents reported to LPA during interviews that the facility offers a variety of different foods, they had no concerns about the food being served at the facility. Based on LPA observation and interviews conducted, the Department does not have sufficient evidence to support the allegation of “staff are feeding residents food that is not of good quality”. Therefore, this allegation is deemed Unsubstantiated at this time. It was further alleged that staff dispensed incorrect medication to resident. It was reported that one resident’s half pill was found in another resident’s bedroom. During the visit on 08/31/2023, LPA conducted a medication audit for four (4) random residents and no discrepancies were observed. Review of centrally stored medication and destruction records indicate medications are being administered as prescribed. Interviews conducted with staff revealed medication audits are performed to maintain accuracy and make sure medication is being administered correctly to residents. (Report Continued on LIC 9099C...) (Report Continued from LIC 9099C...) Additionally, staff stated medication technicians are trained before they are able to assist residents with medications. Interviews conducted with random residents revealed that their medication is administered by staff around the same time every day and reported having no issue with their medications while living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff dispensed incorrect medication to resident”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued. Report was reviewed and a copy was issued.the state’s words, verbatim · CDSS document, Dec 15, 2023 · control 29-AS-20230823120427