Oakview

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Case Management – Incident visit for the purpose of investigating a self reported incident by the facility. Upon arrival LPA met with Executive Director (ED) James MacKay and Assisted Living Director (ALD) Shaulett Dela Cruz. Reason for the visit was discussed. On 05/06/2026 late afternoon, it was discovered of a possible psychological abuse. It was reported that on 05/2/2026, night shift staff (S1) refused to assist R1 stating "you can do it yourself". In addition it was reported that S1 would not assist R1 with care needs and made R1 fearful. ED and ALD cross reported incident to law enforcement and the Long Term Care Ombudsman. Law enforcement arrived to the facility on 05/6/2026 and spoke with R1. ADL and ED also interviewed R1. Initially R1 reported that S1 pushed resident down on the toilet and later recanted and stated that S1 did not touch R1. R1 reported that S1 would not assist R1 with toileting needs and said to R1 "you can do it yourself". S1 is placed on leave pending facility internal investigation. At approximately 1:30pm, LPA interviewed staff, reviewed and obtained copies of pertinent documentation relevant to the incident in question. From approximately 2:00pm-3:30pm, LPA and ALD toured the facility and LPA interviewed a total of nine (9) residents. Based on interviews and records review no immediate or potential health and safety concerns were observed during the visit. ADL reported that they will be conducting an in-service training for all caregivers on better approach technics on encouraging residents independence. No deficiencies cited at this time. LPA has determined should further investigation be warranted, LPA will return at a later date. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Zabel Chochian arrived unannounced to conduct a required annual visit. Upon arrival, LPA met with Executive Director (ED), James Mackay, and Assisted Living Director, Shaulett Dela Cruz. The reason for the visit was stated. Entrance interview conducted. Copy of the residents and staff roster obtained. Current census is 52 of which three (3) residents are receiving hospice services and ten (10) residents are receiving home health services. Facility's approved Infection Control Plan and Emergency Disaster Plan was reviewed with the ED. Both plans have been reviewed with in the year and no changes were made. The facility has a comprehensive disaster plan. Emergency disaster drills are conducted quarterly as per regulation; monthly fire drills conducted the last one being a fire drill and was conducted in 02/2026 and major disaster drills conducted quarterly; last one being an earthquake drill (great shake out) in 10/2025. At approximately 12:30 p.m., LPA, ED, Assistant Director Shaulett Dela Cruz and Safety Director John Miller and his team toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. COMMON AREAS: The facility is a two story building; units are designated for assisted living residents on the first and second floor, and a separate unit on the first floor is designated for dementia care. There were no obstructions and/or tripping hazards observed. The facility maintains a comfortable temperature. The fire extinguishers were charged and last serviced 1/23/2026. Smoke Detectors and Carbon Monoxide detectors were tested by Service Pro-Fire Protection Inc. on 12/8/2025; all were found functioning properly. Individual smoke and carbon monoxide detectors in resident rooms were tested during today's visit by the Safety team. Seven out seven room smoke and carbon monoxide detectors tested were operational.(Continue to Lic809c) There are four (4) stairwells that all have emergency evacuation chairs. ACTIVITIES: Planned activities are offered, and the activity schedule was posted. Activity rooms and common spaces appeared clean and in good repair. KITCHEN: At the time of the visit, there was a sufficient supply of perishable and nonperishable food. Refrigerator, freezer, and pantry/storage area were observed; food labels were observed and checked for expiration dates, and food labels had dates clearly marked. The facility also has an emergency supply of food and water good for current census (residents and staff). The weekly menu was posted by the dining room entrance. Appliances appeared to be clean and in operable condition. Dining room also observed clean and appropriate furnished with tables and chairs. BEDROOMS: LPA toured ten (10) randomly chosen rooms; two (2) in memory care, and eight (8) in assisted living. Rooms appeared clean, well kept, with sufficient lighting and appropriately furnished. Eight (8) out of ten 10) residents were interviewed during the tour. RESTROOMS: Restrooms on all floors were clean and sanitary. Restrooms were fully stocked with supplies. The hot water temperature was tested on all floors and ranged from 107.5- and 118.7-degrees Fahrenheit. OUTSIDE AREAS: LPA observed appropriate outdoor furniture with a covered shaded area for residents. There was an enclosed patio for residents who reside in the memory care unit. MEDICATIONS: Medications are centrally stored in the medication room; there is a medication room on each of the two (2) floors and one (1) in the Memory Care Unit. Random resident medication review conducted on each floor medication room including the memory care unit; PRNs observed with physicians order on file; residents medications observed recorded on the centrally stored log; Medications appeared to be given as prescribed. Some records were missing start dates; staff recorded the start dates from the bubble pack. In-service training provided during today's visit. No citations issued during today's visit. LPA will return to review personnel and resident records on a later date. Exit interview conducted. Copy of report was provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Allegation investigated: Resident sustained unexplained injuries while in Care

Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to initate complaint investigation for the above allegation. Upon arrival LPA met with staff and shortly after with the Executive Director (ED) James Mackay. Reason for the visit was explained. On 10/15/2025 the Department received a complaint regarding the following allegation: Resident sustained unexplained injuries while in care. To investigate this complaint, LPA obtained pertinent documents relevant to the investigation and interviewed the ED at approximately 12:45pm. Interview with the ED and documentation received revealed that the individual identified in the complaint report did not reside at this facility which is licensed by Community Care Licensing Division (CCLD). However, it was confirmed through record review that the individual resides at the Oakview Skilled Nursing Facility which is on the same property and is licensed by a different regulatory agency of which CCLD has no jurisdiction over. The complaint will be appropriately cross-reported. Based on the information obtained, the allegation is deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of the report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Oct 22, 2025 · control 29-AS-20251015162546

Allegation investigated: Facility staff mismanaged residents medication Licensee does not have enough staff to meet the needs of residents in care

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation finding. Upon arrival LPA met with James Mackay and explained the reason for the visit. Entrance interview conducted. On 09/23/2024, Community Care Licensing Division received the above complaint allegations. It was reported that resident #1 (R1) was in sever pain on the weekend of 09/21/2024 and was not administer Morphine. It was also reported that the facility staff admit to missing the medication delivery and noted that they didn't have the staffing. No additional information was provided by the reporting party to support allegations made. Email notification was sent to the reporting party however no return response was received. Following is a summary of the investigation finding: On 10/01/2024, from approximately 3:15pm-4pm, LPA reviewed resident #1’s (R1) records which included R1’s Centrally Stored Medication and Destruction records; MARs, Controlled Drug Record and Controlled Substance Inventory form. (Continue to LIC9099c.) Unsubstantiated LPA also interviewed staff and reviewed staffing schedules. Furthermore, during an annual inspection on 03/26/2025 randomly selected residents were interviewed regarding staffing and medication services. Regarding allegation “Facility staff mismanaged resident’s medication”: Interview with staff and records review revealed that Resident 1 (R1) lived at the facility until they passed away on 09/23/2024; R1 had a prescription for Morphine Sulfate 15mg and 20mg (tablets); records noted last fill date of morphine medication was on 09/21/2024 (20mg-tablets-as needed 3x a day). Medication Administration Records (MAR) indicated that on 09/21/2024, R1 received Morphine, which was prescribed by a physician solely for pain and comfort. Interviews with staff indicated that they did not have a problem filling R1’s medications on time. Staff denied the allegations. Records reviewed indicated morphine medication was provided according to physician and hospice instructions. Further interviews with the medication technicians and facility LVN confirmed that all controlled drugs are stored separately, recorded and inventoried at every shift. According to staff they never ran out of R1’s morphine. Interview with staff and records reviewed indicated that morphine was administered to R1 by a hospice and facility nurse following physician and hospice instructions. Controlled Substance Inventory form indicated facility had a supply of morphine for R1 until they passed on 09/23/2024. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, there is insufficient evidence to support the allegation. Therefore, the allegation “Facility staff mismanaged residents medication” is deemed unsubstantiated at this time. Regarding allegation “Licensee does not have enough staff to meet the needs of residents in care”: Interview with staff and facility records reviewed revealed facility staffing for the Assisted Living (AL) side with census of 35 residents, consist of three (3) caregivers; two (2) medtechs and Wellness nurse for both AM and PM shifts; NOC shift: one (1) caregiver and one (1) medtech; for the Memory Care unit with census of 15. Additionally, Five randomly selected residents of the assisted living side were interviewed and all five expressed no issues or concern with facility managing medications and care service. LPA attempted to interview residents in the memory care unit however residents were unable to comprehend questions asked due to lack of capacity. 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 above allegation “Licensee does not have enough staff to meet the needs of residents in care” is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, Apr 30, 2025 · control 29-AS-20240923155324

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Zabel Chochian arrived unannounced to conduct a required annual visit. Upon arrival, LPA met with Executive Director, Jeannette Ruggiero, Assistant James Mackay, and Assisted Living Director, Shaulett Dela Cruz. The reason for the visit was stated. Entrance interview conducted and check list provided. At approximately 12 p.m., LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. COMMON AREAS: The facility is a two story building; units are designated for assisted living residents on the first and second floor, and a separate unit on the first floor is designated for dementia care. There were no obstructions and/or tripping hazards observed. The facility maintains a comfortable temperature. The fire extinguishers were charged and last serviced 04/19/2024. Smoke Detectors and Carbon Monoxide detectors were tested by Fire Protection Inc. on 12/20/2024; all were found functioning properly. Facility elevator was operating properly. There are four (4) stairwells that all have emergency evacuation chairs. ACTIVITIES: Planned activities are offered, and the activity schedule was posted. Activity rooms and common spaces appeared clean and in good repair. Currently group activities are on hold due to the outbreak. KITCHEN: At the time of the visit, there was a sufficient supply of perishable and nonperishable food. Refrigerator, freezer, and pantry area were observed; food labels were inspected and checked for dates and expiration dates, and food labels had dates clearly marked. The facility also has an emergency supply of food and water. The weekly menu was posted by the dining room entrance. Appliances appeared to be clean and in operable condition. At this time due to the outbreak dining room is closed and meals are being served to residents in their room. Continued on LIC 809C... BEDROOMS: LPA toured seven randomly chosen rooms; two (2) in memory care, and five (5) in assisted living. Rooms appeared clean, well kept, with sufficient lighting and appropriately furnished. Five (5) out of seven (7) residents were interviewed during the tour. RESTROOMS: Restrooms on all floors were clean and sanitary. Restrooms were fully stocked with supplies. The hot water temperature was tested on all floors and ranged from 107.5- and 120-degrees Fahrenheit. OUTSIDE AREAS: LPA observed appropriate outdoor furniture with a covered shaded area for residents. There was an enclosed patio for residents who reside in the memory care unit. MEDICATIONS: Medications are centrally stored in the medication room; there is a medication room on each of the two (2) floors. Random resident medication review conducted; PRNs observed with physicians order on file; residents medications observed recorded on the centrally stored log; Medications appeared to be given as prescribed. Some records were missing start dates; staff recorded the start dates from the bubble pack. In-service training provided. RECORDS REVIEW: LPA reviewed seven resident records at approximately 3p.m. All seven (7) 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, personal rights form, and current needs and services plan. All records were in order. Five (5) personnel files were reviewed at approximately 4:30 p.m. for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records observed in order. The facility has a comprehensive disaster plan. Emergency disaster drills are conducted quarterly as per regulation; the last one being a fire drill and was conducted in 01/2025 (1st shift); 2/2025 (2nd shift); third shift is scheduled in 3/2025. No citations issued during today's visit. Exit interview conducted. Copy of report was provided.the state’s words, verbatim · CDSS document, Mar 26, 2025

Allegation investigated: Facility staff handled resident in a rough manner

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegation. Upon arrival, LPA was greeted by front desk staff. LPA met with Administrator Jeannette Ruggiero at 02:52PM and explained the reason for today’s visit. Entrance interview conducted. During an initial visit conducted on 06/04/2024, LPA interviewed Administrator at 04:10PM, toured the facility at 04:38PM, interviewed Resident #1 (R1) at 04:43PM, conducted interviews with additional management members at 04:59PM, and obtained relevant documents and staff contact information. Throughout the course of the investigation, LPA reviewed documents, additional information provided and conducted interviews. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated The complaint alleges that facility staff handled resident #1 (R1) in a rough manner based on a statement R1 made indicating Staff #1 (S1) “threw [R1] like a sack of potatoes.” Record review revealed that R1 has a diagnosis of dementia and resides in the facility’s memory care unit. Interview with R1 revealed that S1 is their favorite staff, S1 is very strong and has no trouble lifting R1 by themselves without additional staff assistance. R1 indicated they enjoy S1’s company, as S1 understands R1’s sense of humor and R1 stated that S1 is nice to them. When LPA asked R1 if S1 had ever been rough with them, R1 denied this ever occurring and reiterated that S1 is strong. LPA reviewed the police report taken on the night of the alleged incident. In their interview with police, R1 denied that anyone was rough with them. Additionally, S1 denied the allegation and other staff interviewed indicated they have never witnessed S1, nor any other staff handle any residents in a rough manner. Staff that regularly work with R1 stated that R1 does have a sense of humor and they could see R1 saying that as a joke. No bruising was noted on R1’s body on the night of the alleged incident nor in the days following the alleged incident. Communication with R1’s family revealed that R1 had used this same phrase to describe how a family member had pulled R1 to a seated position. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “facility staff handled resident in a rough manner” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 15, 2024 · control 29-AS-20240531145527

Allegation investigated: Staff hit resident

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint inspection at the facility today. LPA arrived at 09:55AM and met with Administrator Jeanette Ruggiero and Assisted Living Director Shaulett Dela Cruz. Entrance interview conducted. During today's visit, LPA interviewed both facility managers at 10:00AM, toured the facility at 10:30AM, and conducted interviews with residents, staff and other relevant parties from 10:40AM to 02:21PM. Additionally, LPA reviewed the facility's incident report that was submitted to the Regional Office related to the complaint allegation as well as a police report filed. The following was then determined: It was alleged that Staff #1 (S1) was providing care to Resident #1 (R1) when S1 hit R1 in the back. Incident report reviewed indicated that a witness was entering the room while S1 was providing care and the witness overheard a sound that appeared to be a slap. R1 was then heard saying "please don't hit me." Report Continued on LIC 9099-C Substantiated While S1 initially stated that R1's care that day was typical and without incident, S1 then stated that R1 grabbed S1's hand and squeezed it, causing pain to S1's fingers and that S1 then in turn grabbed R1's hand. Interviews revealed that other staff characterized S1 as "very stubborn" and wants to do things their own way, rather than how the residents prefer their care. Staff indicated there are residents who have reported to them they do not want S1 working with them due to S1 being rough. Staff interviewed indicated R1 is very respectful, gentle and has never shown aggressive behavior. All persons interviewed agreed that the allegation S1 made about R1 grabbing their hand and causing pain to S1's fingers is very uncharacteristic of R1's behavior. Interview with R1 revealed their story aligned with that of the witness, including S1 appearing agitated, the sound of a slap on exposed skin and R1 stating "please don't hit me" following the sound heard. R1 indicated S1 told them they needed to hurry and to stop asking questions. Then S1 hit R1 on the back with an open hand, but stated that it wasn't too hard. Nurse observed R1 and did not note any marks on their back or any part of their body following the incident. Police report reviewed also indicated the same timeline of events, including a hit or slap with an open hand to R1's back. Other residents management interviewed indicated S1 tends to get frustrated, is in a hurry often, and does things their own way. No other residents the LPA interviewed indicated they have witnessed or been subjected to any physical aggression from S1 or any other staff. Management indicated that S1 had previously been counseled regarding their approach with the residents, but that there had been no previous reports of any physical abuse or altercations. S1 was placed on leave as soon as management was made aware of this incident involving R1 and has not returned to the facility since the date of the incident. Management indicated that due to this incident and the previous counseling that S1 had received, S1 will not be returning to employment at the facility. Based on information gathered in interviews and record review, the allegation that "staff hit resident" is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. Appeal rights were reviewed. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 17, 2024 · control 29-AS-20240515160652

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 17, 2024

87468.1 Personal Rights of Residents in All Facilities (a) (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 indicated S1 hit them and S1 admitted to grabbing R1's hand, which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Administrator indicated that as of a 03:00PM meeting today, S1 is no longer employed with the facility. As interviews revealed this incident appeared to be isolated to S1 only, no additional staff training is required. POC cleared.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Teresa Camara and Martha Arroyo arrived unannounced to conduct a required annual visit. The last annual conducted at this facility was on 01/13/2023. Upon arrival, LPAs met with Executive Director, Jeannette Ruggiero, and explained the reason for the visit. Entrance interview. LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. KITCHEN: At the time of the visit, there was a sufficient supply of perishable and nonperishable food. Refrigerator, freezer, and pantry area were observed; food labels were inspected and checked for dates and expiration dates, and food labels had dates clearly marked. The facility also has an emergency supply of food and water. The weekly menu was posted by the dining room entrance. Appliances appeared to be in operable condition. COMMON AREAS: The facility is a two story building; units are designated for assisted living residents on the first and second floor, and a separate unit on the first floor is designated for dementia residents. There were no obstructions and/or tripping hazards observed. The facility maintains a comfortable temperature. The fire extinguishers were charged and last serviced 01/13/2024. Smoke Detectors and Carbon Monoxide detectors were tested within the past 12 months and were operable. Facility elevator was operating properly. There are four (4) stairwells that all have emergency evacuation chairs. ACTIVITIES: Planned activities are offered, and the activity schedule was posted. Activity rooms and common spaces appeared clean and in good repair. Continued on LIC 809C... Continued from LIC 809... BEDROOMS: LPAs toured ten randomly chosen rooms; three (3) in memory care, and seven (7) in assisted living. Rooms appeared clean, well kept, with sufficient lighting and appropriately furnished. RESTROOMS: Restrooms on all floors were clean and sanitary. Restrooms were fully stocked with supplies. The hot water temperature was tested on all floors and ranged from 109.2- and 120-degrees Fahrenheit. OUTSIDE AREAS: LPAs observed appropriate outdoor furniture with a covered shaded area for residents. There was an enclosed patio for residents who reside in the memory care unit. There was a water waterfall; however, water level was compliant at the time of the visit. RECORDS: LPA’s reviewed Resident Records at 12:27 p.m. and Personnel Records at 11:40 a.m. Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Five (5) personnel files and the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. The facility has a comprehensive disaster plan. The last fire inspection was completed on 12/27/2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Emergency disaster drills are conducted quarterly as per regulation; the last one being a fire drill and was conducted on 01/26/2024. Continued on LIC 809C... Continued from LIC 809C... MEDICATIONS: Medications review began at approximately 2:17 p.m.; medications are centrally stored in the medication room; there is a medication room on each of the two (2) floors. PRNs have physicians order on file. Medications appeared to be given as prescribed. INTERVIEWS: LPAs interviewed three (3) residents and three (3) staff members during the inspection; no concerns were noted. Exit interview conducted. No deficiencies cited. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Mar 25, 2024