Pacifica Senior Living Oxnard

Allegation investigated: Staff do not ensure that residents are administered their medications as prescribed.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegation. Upon arrival, LPA met with Executive Director Francesca West and explained the reason for the visit. On 05/05/2026, between 03:45 p.m. and 5:00 p.m., the LPA interviewed the Executive Director, the Health and Wellness Director, one (1) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's visit the LPA conducted file review for three (3) residents and interviewed the ED. Report will continue on LIC9099-C, 2nd page. Substantiated Regarding the allegation, “Staff do not ensure that residents are administered their medications as prescribed,” it is the concern of the Reporting Party (RP) that Resident 1 (R1) did not receive their medication from 04/01/2026 – 04/09/2026, or on 1/8, 1/10, 1/13, 1/17, and 1/21/2026. If R1 does not receive their medication, it causes them to decompensate quickly and suffer side effects. It was further reported that Resident 2 (R2) continued to receive medication from September 18, 2025, through March 25, 2026, despite the prescription being discontinued. Lastly, Resident 3 (R3) did not receive their medication sometime in April 2026. To investigate, the LPA conducted interviews and a file review. During an interview, Executive Director (ED) Francesca West confirmed the allegation. The ED stated that there had been issues obtaining medications for R1 from the pharmacy in April. This was due to the pharmacy rejecting a medication order because it was signed by a nurse practitioner at R1’s primary care provider’s office rather than their psychiatrist’s office. Regarding the missed doses in January, the ED stated that the refill order was pending; however, the medication was documented as administered on the days in between. The ED was unsure why the medication was given on some days and not others, noting that "pending refill" was written on the Medication Administration Record (MAR). The ED also stated that R3 did not receive medication in April due to a pending refill. Furthermore, the ED confirmed that R2 was receiving medication that had been discontinued in September 2025 until mid-March 2026. The ED stated this was an oversight by the previous Wellness Director, Giovanni Guirra. The ED revealed that facility staff did not bring any of these issues to her attention; instead, she was made aware by the residents’ case manager and states they should of never happened. Once notified of the discrepancies, the ED implemented the following corrective actions: Conducted a Medication Technician in-service training, initiated a new training platform on Relias, met with the pharmacy to troubleshoot the issues and subsequently switched pharmacies for the three residents, implemented a new policy requiring two staff members to review discharge notes and verify that the pharmacy has received all medication orders. Report will continue on LIC9099-C, 3rd page. A review of the MARs for all three residents confirmed that R1 did not receive Clozapine 100 mg on 1/8/26, 1/10/26, 1/13/26, 1/17/26, 1/21/26, and from 4/1/26 to 4/09/26. The MAR review also confirmed that R3 did not receive Clozapine 100 mg on 04/01/26. The LPA observed R2’s After Visit Summary from Community Memorial Brent Neurology on file, dated 9/18/25, which instructed to stop Carbidopa-Levodopa due to drug induced Parkinsonism. The LPA was unable to review R2’s MARs for September and October due to resident was admitted to the facility on 10/08/2025; however, the LPA observed that the MARs from November 2025 to March 2026 reflected that R2 was administered Carbidopa-Levodopa from January 24, 2026 until March 24, 2026. According to the ED, the medication was finally stopped in March when the resident’s case manager informed them it had been discontinued in September 2025. Based on the interviews and record reviews, the statements from the ED and the residents' MARs confirmed the allegation. Therefore, the allegation, “Staff do not ensure that residents are administered their medications as prescribed,” is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was cited during the visit (See 9099-D). Civil Penalty issued for the amount of $250. The ED was informed that failure to correct deficiency may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 18, 2026 · control 29-AS-20260427145037

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 19, 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 record review, the licensee did not comply with the section cited above, by allowing R1 and R3 missed one or multiple prescribed medications and continuing to administer a discontinued medication to R2 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 18, 2026

Plan of correction: The ED stated that all MT's have received corrective action plans, conducted a in service training, switched all three resident pharmacies, and will submit proof of all this to LPA by 05/19/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melisa Rankin arrived unannounced to conduct a required annual visit. LPA met with Executive Director Francesca West and explained the reason for the visit. LPA started the physical plant tour. The facility's fire suppression system was last inspected by the Premier Fire Protection on 2/3/2026 and the inspection was satisfactory. The facility's smoke detectors were last inspected by Boyd & Associates in December 2025. Fire extinguishers were last serviced in 7/2025 and those viewed appeared registered as charged. Kitchen: At the time of the visit, the kitchen was clean and appliances appeared operable. There was a sufficient supply of perishable and nonperishable food, properly stored. The menu was posted and copies are available for residents. The kitchen staff have residents with special dietary needs posted in the kitchen identifying each resident’s needs, there is a picture of the resident next to the dietary requirements. Dining area was spacious and can accommodate a capacity of 44 individuals if needed the activity room located nearby can accommodate more for dining. Mealtimes are posted for breakfast, lunch and dinner, but the kitchen is open all day. Snacks and drinks were noted in the dining room as well. Common Areas: The facility is a three-story building. There are resident rooms designated for assisted living residents on all three floors and a separate unit on the first floor is designated for memory care residents. There were no obstructions or tripping hazards observed. The facility maintains a comfortable temperature. There are three stairwells; all are equipped with emergency evacuation chairs. (continued on LIC9099-C) Outside areas: LPA observed appropriate outdoor furniture for residents on both the memory care and assisted living patio areas. There was plenty of space outdoors for visitors, including areas that are shaded. Resident Rooms: LPA toured sample rooms but will review individual resident rooms during return visit. Medications: LPA reviewed a sampling of medications for randomly chosen residents in the memory care unit. Review of records, discussion of processes including PRN Authorization, resident medication cycle refills, and hospice refills. Medications reviewed were not expired, did not have any writing on the labels, and were recorded on the Centrally Stored Medication and Destruction Record (CSMDR). Facility uses an electronic Medication Administration System for record keeping of doses given. LPA will return to complete the final elements of the annual at another time. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, Apr 8, 2026

Allegation investigated: Staff are mismanaging residents medication.

Licensing Program Analysts (LPAs), Emily Peraldi and Quoc Huynh conducted an unannounced subsequent complaint visit to this facility to deliver findings at 9:57 a.m. The LPAs met with Executive Director (ED) Francesca West and explained the reason for the visit. Entrance interview conducted. During the initial visit conducted on 12/29/2025 between 10:28 a.m. and 2:15 p.m., LPA Peraldi conducted a brief physical plant tour and interviewed the ED and two (2) staff. During today’s visit between 10:30 a.m. and 3:08 p.m., LPAs reviewed and obtained pertinent documents, interviewed the ED, and conducted a physical plant tour. Between 1:44 p.m. and 3:05 p.m., the LPAs conducted a review of medication and medication documentation with the ED for three (3) residents. Continued on LIC 9099-C. Substantiated Regarding the allegation: 1.) Staff are mismanaging residents’ medication. It was alleged that medication technician (med tech) staff did not assist residents with their medication on time and missed medications. During today’s visit, the LPAs conducted a review of resident medication and documentation with staff for three (3) residents. Resident #1 (R1’s) Noon Acetaminophen Extra 600MG tablet instructed for 1 tablet for every 6 hours had 20 tablets remaining. The medication started on 02/07/2026 with 30 tablets for the month and 17 tablets should have remained. R1’s Bedtime Acetaminophen Extra 600MG tablet also instructed for 1 tablet for every 6 hours had 17 tablets remaining. The medication started on 02/05/2026 with 30 tablets for the month and 16 tablets should have remained. The ED stated that she will review the facilities medication procedures and audit all resident medications. Based on observation and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff did not assist resident with self-administration of medications as prescribed” is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). Civil Penalty issued for the amount of $250. The ED was informed that failure to correct deficiency may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 29-AS-20251219143302

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 20, 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 record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R1’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Within 24 hours, the ED will notify the LPA when medication training will be completed. Civil Penalty issued for the amount of $250 for repeat violation.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Emily Peraldi and Quoc Huynh conducted an unannounced Case Management visit in conjunction with Complaint #29-AS-20251219143302. At 9:57 a.m. The LPAs met with Executive Director (ED) Francesca West and explained the reason for the visit. Entrance interview conducted. During today’s visit between 10:30 a.m. and 3:08 p.m., LPAs reviewed and obtained pertinent documents, interviewed the ED, and conducted a physical plant tour. Between 1:44 p.m. and 3:05 p.m., the LPAs conducted a review of medication and medication documentation with the ED for three (3) residents. During the review of resident medication and documentation, it was observed that two (2) out of three (3) residents’ centrally stored medication and destruction record (CSMDR) were not updated and documented correctly. The ED stated that she will review the facilities medication procedures and ensure that all CSMDR are current and accurate. The LPAs also followed up on a self-reported incident report dated 01/21/2026. The report indicated that on 01/20/2026 a medication error occurred, as Staff #1 (S1) gave Resident #1 (R1) the incorrect medication. The error was identified and staff monitored R1 for any symptoms. It was also noted that R1’s responsible party and physician were notified of the medication error. During today’s visit, LPA Peraldi cited for medication errors on the above mentioned Complaint. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 19, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Feb 27, 2026

87465Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications...This requirement is not met as evidenced by: Based on medication review and interview, the licensee did not comply with the section cited above as two (2) out of three (3) residents’ CSMDR which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: The ED stated that she will review the facilities medication procedures and ensure that all CSMDR are current and accurate.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 10:30 a.m., the LPA met with Executive Director (ED) Francesca West and Wellness Director (WD) Jovany Guerra and explained the reason for the visit. The reason for today's inspection is to follow up on a self-reported incident report and Report of Suspected Dependent Adult/ Elder Abuse (SOC 341) received on 12/19/2025, regarding three (3) staff members consuming alcohol and sleeping while working at the facility. On 12/17/2025, LPAs Peraldi and Huynh conducted a subsequent complaint visit for Complaint 29-AS-20251119143627 and LPA Peraldi Substantiated the allegation, “Staff sleep at the facility while on shift.” During the visit, LPA Peraldi Unsubstantiated the allegation “Staff members consumed alcohol during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care”, due to inconsistent statements provided by staff interviewed and insufficient evidence to corroborate the allegation. Per incident report and SOC 341, on 12/18/2025, the ED received pictures of three (3) staff members consuming alcohol and sleeping while working at the facility. On 12/19/2025, the ED began an internal investigation and contacted the Department regarding the pictures and information obtained from the day prior. On 12/19/2025, the three (3) staff members were terminated. The ED also provided copies of staff schedules and explained that residents’ care would not be interrupted by the terminations, as the ED and WD are providing assistance with residents’ care and supervision as needed. The ED explained that they are also in the process of hiring additional care staff. No immediate health and safety concerns were observed during today's inspection. Continued on LIC 809-C. Due to new information and evidence being presented, LPA Peraldi conducted today’s visit and cited the following: Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.58(a)(2) · Plan of correction due date: Dec 30, 2025

§1569.58(a) (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as facility staff consumed alcohol while working, which posed an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 29, 2025

Plan of correction: ED took immediate disciplinary action and terminated the three (3) staff.

Allegation investigated: Staff sleep at the facility while on shift.

Licensing Program Analysts (LPAs), Emily Peraldi and Quoc Huynh conducted an unannounced subsequent complaint visit to this facility to deliver findings at 9:52 a.m. The LPAs met with Executive Director (ED) Francesca West and Wellness Director (WD) Jovany Guerra and explained the reason for the visit. Entrance interview conducted. During the initial visit conducted on 11/25/2025 between 1:30 p.m. and 3:20 p.m., LPA Peraldi conducted a brief physical plant tour and interviews with the ED and three (3) staff. During today’s visit, the LPAs conducted interviews with five (5) residents and six (6) staff. Starting at 11:06 a.m., LPA Huynh along with the ED and Wellness Director (WD) conducted a physical plant tour. The LPA also obtained copies of pertinent documents during all visits. Continued on LIC 9099-C. Substantiated 1.) Staff sleep at the facility while on shift. It was alleged that staff sleep during their shift and that management has not taken any actions towards the issue. Interviews with residents stated that they have not observed staff sleeping while on duty in addition to interviews with staff members who denied the allegation. Interview with the WD, revealed that two (2) staff members have received disciplinary actions for sleeping while on shift within the last year. Based on the information provided by interviews and record review, the above allegation is deemed Substantiated at this time and is considered a technical violation. No citations are being issued at this time, as the facility took the appropriate measures. Exit interview conducted. A copy of the report and appeal rights were provided. Regarding the allegations: 1.) It was alleged that staff consumed alcohol during their shift at the facility, impairing their ability to provide adequate care and supervision. Interviews conducted with staff revealed inconsistent statements regarding the allegation. Interview with the ED denied the allegations. Interviews with residents did not reveal any concerns regarding the allegation. The LPAs had conversations with the ED regarding the allegation and explained the importance of maintaining appropriate staff conduct to ensure residents health and safety. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. 2.) It was alleged that staff members from the afternoon (PM) shift locked the residents in their rooms. Physical plant tours revealed that Memory Care (MC) rooms cannot be locked without the residents having the ability to unlock the door on their own. The Assisted Living (AL) rooms have individual keys for each resident and can also be unlocked from the inside. Per interview with the ED, the main entrance door locks at night from the outside, however, remains unlocked from the inside. Interviews conducted with staff denied the allegations of staff locking residents inside their rooms. Resident interviews did not reveal any concerns regarding the above allegation. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. 3.) Staff did not meet the residents' diapering care needs in a timely manner. It was alleged that residents in MC were left in soiled diapers as a result of MC staff sleeping during their shift. Interviews with WD revealed that once residents press their pendants for assistance, the wait time is approximately 7-10 minutes. Residents interviewed did not express concerns regarding soiled diapers. Staff interviews revealed that wait times vary depending on current tasks, but that they try to assist residents in a timely manner to ensure residents are not in soiled diapers. Staff interviews reveal that for MC residents, they check on residents every 2 hours. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 29-AS-20251119143627

Allegation investigated: Staff did not prevent a resident in care from developing pressure injuries.

Licensing Program Analysts (LPAs) Quoc Huynh and Emily Peraldi conducted a subsequent complaint visit to deliver findings for the above allegation. LPAs arrived at 09:52AM and met with the Executive Director (ED) Francesca West and Wellness Director (WD) Jovany Guerra. Entrance interview conducted. On 08/07/2025, LPA Huynh conducted an initial complaint visit at 10:14AM. Between 10:36AM and 4:10PM, the LPA conducted a physical plant tour, interviewed five (5) residents and six (6) staff, attempted one (1) resident interview, reviewed and obtained pertinent documents, and conducted a medication review. Report Continued on LIC 9099-C Unsubstantiated During today’s visit, LPA Huynh, ED, and WD conducted a physical plant tour at 11:06AM. No immediate concerns were observed. The following was then determined: Allegation: “Staff did not prevent a resident in care from developing pressure injuries.” It was reported that Resident #1 (R1) sustained two (2) Stage II or Stage III pressure injuries on their buttocks, despite Staff repositioning R1 hourly. Interviews with five (5) staff indicated R1 experienced a rapid decline and was transitioning toward end of life. As a result, R1 was placed on hourly comfort checks. Staff were expected to reposition, provide incontinence care, and administer comfort medication as needed. Staff reported no observable changes in R1’s skin prior to 08/06/2025. Record review revealed R1 admitted to the facility on 01/05/2024 and was placed on Hospice care on 12/20/2024. R1’s hospice care plan reflected diagnoses of Chronic Obstructive Pulmonary Disease, Asthma, Hypertension, Anemia, Protein-Calorie Malnutrition, and was dependent on supplemental oxygen. Physician’s Report dated 10/08/2024 documented R1 as non-ambulatory, requiring full assistance with bathing, dressing, toileting, and transfers. The report also noted a history of skin redness to the buttocks with skin intact. Hospice records revealed that between 06/02/2025 and 06/17/2025, R1 had a Stage II pressure injury on their upper right buttock that required daily wound care which subsequently healed and did not require further care. On 07/22/2025, R1 reportedly had redness on their sacrum that staff treated with Calmoseptine ointment during incontinence care. On 07/30/2025, Hospice visit notes indicated R1 was unable to feed themselves and began to transition and was ordered to receive comfort measures. Between 08/02/2025 to 08/05/2025, R1 received daily visits from Hospice due to their imminent-death status and was reported to be non-responsive to verbal or tactile stimuli. Additionally, visit notes indicated R1 had a severe risk of developing pressure ulcers. Report Continued on LIC 9099-C On 08/06/2025 at approximately 1:30AM, staff reported that R1 had one (1) bleeding, open bed sore on the buttocks and one (1) skin irritation on the right shoulder that was accompanied by redness. The observations were reported to the Wellness Director and R1’s Hospice Agency. Calmoseptine ointment was ordered and applied per Hospice instructions after each incontinence change. Narrative Charting between 08/04/2025 to 08/07/2025, documented facility staff monitoring R1 every thirty (30) minutes to two (2) hours which included repositioning and incontinence care. Additional wound documentation was unavailable due to R1 passing on 08/07/2025. Based on interview and record review, R1 was bedbound, dependent on all activities of daily living, and experiencing rapid decline with multiple comorbidities, incontinence, and a documented history of skin breakdown. These factors placed R1 at high risk for pressure injuries despite preventative measures in place. Although R1 developed a pressure injury, there is not sufficient evidence to prove the alleged violation was a result of staff neglect, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 29-AS-20250806084714

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Quoc Huynh and Emily Peraldi conducted an unannounced Case Management visit in conjunction with Complaint # 29-AS-20250806084714. LPAs arrived at 09:52AM and met with the Executive Director (ED) Francesca West and Wellness Director (WD) Jovany Guerra. Entrance interview conducted. Between 11:06AM and 12:10PM, LPAs conducted a physical plant tour, reviewed and obtained pertinent documents, and interviewed staff. No immediate concerns were observed. Between 06/02/2025 to 06/17/2025, Resident #1 (R1) sustained one (1) Stage II pressure injury to their upper right buttock that required daily wound care and dressing changes. Hospice visit notes on 06/02/2025 indicated wound care would be performed by a SN (skilled nurse) or facility staff. On 06/03/2025 and 06/11/2025, visit notes documented that the Hospice nurse was unable to assess R1’s wound or provide wound care because “caregiver completed care.” While the ED and WD denied staff providing wound care, interviews with staff confirmed that caregivers occasionally provide residents with wound care, without notifying the med-techs. The expectation is for caregivers to notify med-techs, who in turn notify residents’ Home Health or Hospice Agency for wound care services. It was also confirmed that staff are not licensed professionals. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87631(a)(3)(A) · Plan of correction due date: Dec 18, 2025

(a) Except as specified in Section 87611(a)…: (3) Residents with a stage one or two pressure injury... (A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional. 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 that unlicensed staff provided wound care to R1 which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: The Licensee will conduct staff in-service training for each shift on wound care protocols. The Licensee will provide CCLD proof of in-service training by POC due date.

Allegation investigated: Staff did not assist resident with self-administration of medications as prescribed. Staff did not accept resident back from hospital.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:30 a.m., the LPA met with staff and explained the reason for the visit. At 9:34 a.m., the Executive Director (ED), Francesca West met with the LPA. At 9:36 a.m., the LPA conducted interviews with the ED and Wellness Director (WD) Jovany Guerra. At 9:41 a.m., the LPA requested and obtained copies of pertinent documents. At 9:45 a.m., the LPA conducted a file review Resident #1 (R1’s) records. Starting at 10:10 a.m., the LPA conducted interviews with two (2) staff and two (2) residents. Between 10:13 a.m. and 10:55 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents. Continued on LIC 9099-C. Substantiated Regarding the allegation: 1.) Staff did not assist resident with self-administration of medications as prescribed. On 11/14/2025, the Department received a complaint alleging staff did not assist Resident #1 (R1) with R1’s PRN medications as prescribed. Interview with the ED and WD revealed that R1 is no longer residing at the facility. Due to R1 not residing at the facility, the LPA was not able to do a medication audit for R1, however the LPA conducted a random medication audit for four (4) residents. During today’s visit, between 10:13 a.m. and 10:55 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents and observed the following: Resident #2 (R2’s) Bedtime Melatonin 5MG tablet had 9 tablets remaining, however the medication was started on 11/05/2025 and with the quantity listed as 30, meaning there should be a total of 16 tablets remaining instead. R2’s Morning Atorvastatin Calcium 80MG had 15 tablets remaining, however the medication started on 11/04/2025 and with the quantity listed as 30, meaning there should be a total of 14 tablets remaining instead. R2’s Morning Lisinopril 5MG had 15 tablets remaining, however the medication started on 11/04/2025 and with the quantity listed as 30, meaning there should be a total of 14 tablets remaining instead. Resident #3’s (R3’s) Bedtime Senna 8.6MG had 11 tablets remaining, however the medication was started on 10/29/2025 and with the quantity listed as 30, meaning there should be 9 tablets remaining instead. R3’s Bedtime Trazodone HCL 100MG had 14 tablets remaining, however the medication started on 11/01/2025 and with the quantity listed as 30, meaning there should be 12 tablets remaining instead. Resident #4’s (R4’s) AM Aspirin EC 81 MG had 12 tablets remaining, however the medication was started on 11/01/2025 and with the quantity listed as 30, meaning there should be 11 tablets remaining instead. Based on observation and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff did not assist resident with self-administration of medications as prescribed” is deemed Substantiated at this time. Regarding the allegation: 2.) Staff did not accept resident back from hospital. On 11/14/2025, the Department received a complaint alleging facility staff refusing to accept Resident #1 (R1) back to the facility from the hospital. Interview with the ED and WD revealed that R1 was admitted to the facility on 11/13/2025 and on 11/13/2025, R1 was hospitalized due to behaviors. The ED and WD explained that R1 was throwing items at staff in which staff did not feel safe for themselves and other residents. Once R1 was hospitalized, the ED wanted to reevaluate R1 to ensure that R1 was a correct fit for the facility. The ED explained that she assisted the hospital and referred them to a placement agency to assist R1 with placement. The ED said that on 11/18/2025, she followed up with the hospital and confirmed that R1 is going to be placed at a different facility that better fits their needs. Continued on LIC 9099-C. The LPA explained to the ED and WD that if they felt that R1 was endangering the health and safety of residents and staff or if R1 required a higher level of care, that a proper eviction notice and procedure is required. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff did not accept resident back from hospital” is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 29-AS-20251114135432

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

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 record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R2’s, R3’s and R4’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: The ED will schedule a medication audit for all residents and notifity the LPA when the audit is scheduled and completed. Additionally, the ED will follow up with a pharmacy to conduct an audit as well.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Nov 25, 2025

87468.2 (a)(20) Personal Rights of Residents ... residents in privately operated residential care facilities for ... shall have all of the following personal rights:(20) To be protected from involuntary transfers, discharges, and evictions…This requirement was not met as evidenced by: Based on record review and interviews, the Licensee did not accept Resident #1 back to facility from the hospital which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: The WD and ED will conduct an Inservice/ education regarding the above regulation and preplacement appraisals for all staff.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident visit. At 2:30 p.m., the LPA met with staff and explained the reason for the visit. At 2:37 p.m., the Executive Director (ED), Jovany Guerra met with the LPA. The reason for today's visit is to follow up on a self-reported incident report dated 08/08/2025. The report pertains to Resident #1’s (R1’s) missing narcotic medication. The report states that R1’s missing medication was replaced by the pharmacy and that there was no delay in medication administration. The report also noted that disciplinary action was taken against Staff #1 (S1) for the medication error. During today’s visit, at 2:37 p.m., the LPA conducted an interview with the ED. At 2:45 p.m., the LPA requested and obtained copies of pertinent documents. At 3:25 p.m., the LPA, along with the ED conducted a physical plant tour. No immediate health and safety concerns were observed during today's inspection. An additional report may follow if warranted. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Staff do not ensure the facility is kept clean. Staff do not have access to cleaning supplies.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 10:15 a.m., the LPA met with staff and explained the reason for the visit. At 10:17 a.m., the Executive Director (ED), Jovany Guerra met with the LPA. Starting at 10:27 a.m., the LPA, along with the ED conducted a physical plant tour and inspected eleven (11) resident rooms. Between 10:47 a.m. and 3:03 p.m., the LPA conducted interviews with seven (7) residents and five (5) staff. At 12:10 p.m., the LPA conducted an interview with the ED. During the time of the visit, the LPA requested and obtained copies of pertinent documents. Continued on LIC 9099-C. Substantiated Regarding the allegations: 1.) Staff do not ensure the facility is kept clean. 2.) Staff do not have access to cleaning supplies. It was alleged that not all staff members have access to cleaning supplies which has led to the facility not being maintained clean and sanitary and in good repair at all times. Interview with the ED revealed that medication technicians staff (med techs) have keys to the two (2) main cleaning supply rooms. There are a total of three (3) cleaning storage rooms which have chemicals and other cleaning supplies such as cloths, and mops. One (1) out of the three (3) cleaning rooms has a keypad and the ED explained that all care staff know the code. The LPA had a conversation with the ED regarding cleaning supplies and the importance of having sufficient cleaning supplies to all staff. The ED explained that cleaning and housekeeping supplies are ordered semi-monthly. During the physical plant tour the LPA observed the following: At 10:37 a.m., stained/ uncleaned floors in the memory care (MC) dining area. At 10:38 a.m., two (2) open wires were observed on the MC courtyard door. At 10:39 a.m., trash such as empty cups were observed throughout the MC courtyard. Two (2) out of the eleven (11) resident restrooms inspected were observed in an unsanitary condition as there were stains/ discoloration around the toilet bowls waterline. Interviews with staff and the ED revealed that there currently is only one (1) housekeeper, as the other housekeeper is currently not working. The ED explained that there is another staff member who covers housekeeping duties when the full-time housekeeper is off on Fridays and Saturdays. The ED explained that the second housekeeper should be returning to work within the next month. Based on interviews and observations, the preponderance of evidence standard has been met, therefore the above allegations are deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided. Regarding the allegation: 3.) Staff did not ensure the toilets were not in disrepair. It was alleged that when residents have maintenance issues such as “broken toilets”, that it is not fixed in a timely manner. Interviews with residents revealed that if they have any issues, they go to the front desk and ask for help. Seven (7) out of seven (7) residents interviewed did not reveal any concerns regarding staff response time to maintenance request or issues. The interview with the ED revealed that the facility currently does not have a maintenance director or a regular maintenance staff and that the facility is outsourcing their maintenance work and requests with outside vendors. The ED explained that he is in the process of hiring a maintenance director. The ED provided the LPA a copy of completed maintenance work orders. During the time of the visit, the LPA along with the ED followed up on completed maintenance request and ensured items were fixed, including clogged toilets and sinks. Although the facility does not have permanent maintenance staff, the ED ensures that maintenance requests are completed by outsourcing maintenance work. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 29-AS-20250819100046

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 5, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... services and procedures for the safety and well-being of residents... This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above as the LPA observed several areas throughout the facility not maintained clean and sanitary such as residents’ toilets which poses a potential health and safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: The ED state that he will create a checklist to ensure that the resident rooms and common areas are maintained cleaned, safe, sanitary and in good repair at all times.

Allegation investigated: Staff did not safeguard residents medications.

Licensing Program Analyst (LPA) Quoc Huynh conducted an initial complaint visit for the above allegation. LPA arrived at 10:14AM and met with the Executive Director (ED) Jovany Guerra. Entrance interview conducted. Beginning at 10:36AM, the LPA and ED conducted a physical plant tour to ensure there were no health and safety hazards, and the facility was in compliance with Title 22 Regulations. No immediate concerns were observed at this time. Between 10:36AM and 2:00PM, LPA Huynh interviewed five (5) residents and six (6) staff, and attempted one (1) resident interview. At 2:17PM, the LPA reviewed and obtained pertinent documents. At 4:10PM, the LPA conducted a medication review. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation: “Staff did not safeguard residents medications.” It was reported that residents’ medications were missing and were not centrally stored. The LPA conducted a medication review for four (4) residents. Medications were centrally stored in the Medication Room located on the first floor. Medications were checked for labels, expiration dates, and were properly stored on the centrally stored medication and destruction record. No errors were observed during the medication review. During the tour of the physical plant, the LPA observed Resident #1 (R1) had medications stored in their restroom. Medications included Milk of Magnesia, Amlodipine Besylate, Paroxetine HCL, Metroprolol, Ibuprofen, and Meclizine. Interview with staff revealed that R1 was allowed access to their nasal spray and inhalers, and reported that R1 did not have access to other medications. Record review confirmed R1 had physician orders to allow access to nasal sprays and inhalers to have stored at their bedside dated 10/24/2024. R1’s Physician Report dated 10/08/2024 stated R1 cannot manage or store their own medications. During the visit the LPA observed R1’s door remained open and staff stated R1 preferred to always have the door open and did not like being alone, which also allowed other residents to have access to R1's room. Based on observations, interviews, and record review, 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 Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided. Allegations: “Staff did not ensure that resident’s hygiene needs are being met,” “Staff did not ensure that resident is provided clean bedding,” “Facility did not ensure that staff are properly trained,” and “Staff did not ensure that resident’s room is kept cleaned.” It was reported Resident #1 (R1) was left in their soiled clothes and bedding, and R1’s bedroom was not maintained cleaned. Interview with five (5) residents and six (6) staff revealed that housekeeping conducts a comprehensive cleaning of resident rooms once a week. Resident #2 (R2) stated the staff are very attentive and respond right away when they call for assistance. R2 has not had any issues with staff who did not clean their room. If Resident #3 (R3) has a spill, R3 expressed they notify staff who then respond quickly to clean it. Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4) reported caregivers and housekeepers are responsible for the cleanliness of resident rooms. S4 stated caregivers assist with taking out the trash and picking up items off the residents’ floors, while housekeeping sweeps, mops, and vacuums in addition to other cleaning tasks. S1, S2, and S3 reported cleaning resident rooms daily and report to housekeeping if a resident needs a more thorough cleaning to which they respond immediately, sometimes later if they are in the middle of a task. Staff also reported bed sheets get changed every week during the residents’ laundry day, sometimes more often if needed. S1, S2, and S4 reported changing resident beddings when they observe or can smell that it has been soiled. Soiled beddings were addressed right away. S4 stated if they observed food on the bed, they would change the bedding or dust the food off, so the resident was not laying in it. Residents have scheduled showers, and the number of showers are determined based on their care plans. Staff #5 (S5) and the ED stated residents have been scheduled showers at least twice a week and have received more showers if needed. During today’s visit, LPA observed R1 to have clean bedding, clean clothing, and their room was previously cleaned the day prior. Staff stated they received mandated training upon their employment to the facility, with S3 reporting that they received two (2) months of training before directly assisting residents. The facility used Relias, a training platform, to conduct and track staff training. The facility has also conducted monthly self-paced module training through Relias. Report Continued on LIC 9099-C Additionally, the facility provided structured in-service training to all staff. S5 and the ED stated structured in-service training varies but is conducted every other week by the Department Heads or third-party consultants. Record review revealed that Staff received module and in-service training on topics including, but not limited to, medication, documentation and incident reporting, personal rights, skin integrity monitoring, and dementia. At this time, staff training requirements have been met. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency related to the allegations were cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 29-AS-20250806084714

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Aug 7, 2025

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible ... This requirement was not met as evidenced by: Based on observation and record review, the licensee did not comply with the above cited section as a resident had access to medications which posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: The Executive Director secured the medications in the resident's restroom. POC Cleared.

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff are not providing activities for residents in care. Staff did not prevent a resident from eloping from the facility. Staff are not maintaining a comfortable temperature for residents in care.

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation visit regarding the above noted allegations. LPA met with Executive Director (ED) Jovany Guerra and explained the reason for the visit. At 12:38PM, LPA interviewed ED. Beginning at 01:13PM, LPA and ED toured the facility and observed temperatures in all common areas in the facility, LPA conducted 4 (four) staff and 4 (four) resident interviews from 02:21PM to 03:40PM, and LPA obtained copies of pertient documents. The following was then determined: The complaint alleges that the facility does not offer sufficient activities for the residents in care. LPA observed the activity calendar posted throughout the facility, with various activities offered throughout the day. LPA observed 4 (four) residents engaging with volunteer activity staff, in actitivies per the posted Report Continued on LIC 9099-C Unsubstantiated schedule. Residents interviewed stated there are activities offered and some residents choose to participate in the activities. Staff interviewed stated that activities are offered daily, including outings, games and various clubs such as book club and crochet club. Activity ideas do come from the residents and the staff plan activities according to the residents' suggestions. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. The complaint also alleges that a resident (Resident #1 - R1) eloped from the facility about a month ago due to lack of supervision. LPA reviewed an incident report dated 05/24/2025, which was sent to Community Care Licensing on 05/27/2025. The report does indicate that R1 was found outside of the facility. Interview revealed that R1 was last seen on the patio of the memory care unit during a staffing change. The staff heard an auditory alarm, then oncoming staff discovered R1 was no longer on the patio. Staff found R1 outside the secure memory care unit shortly after. Review of R1's documents indicates that R1 is ambulatory and while staff interviewed did state R1 tends to wander within the secure memory care unit, this was the first time R1 had attempted to exit. Following the incident, management added additional alarms on the memory care exit gates that alert in the medication room, as well as on the staff phones. During today's visit, all delayed egress and auditory alarms were tested and were functional. Staff stated that R1 is now taken on walks to help engage in more suitable activities and since then, R1 has not again attempted to leave the secure memory care unit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. The complaint alleges that the facility does not maintain a comfortable temperature for residents in care. LPA observed individual resident rooms have their own temperature controls. In the common areas, there are thermostats, which both management and medication technicians have keys to access. Interviews revealed that residents can request for the staff to adjust the temperature at any time. Residents interviewed had no complaints related to the temperature of the facility. LPA observed moderate temperature readings throughout the facility during today's visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of today's report was provided via email.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 29-AS-20250708165142

Type of visit: Office

On this day at 11 am, a meeting was conducted by Assistant Program Administrator (APA) Stacy Barlow to verify Chapter 7 Bankruptcy Report filed by the Pacifica Senior Living as reported by the media. Present during the meeting are: Shelley Grace - Assistant Branch Chief, CCLD Craig Lundgren - Legal Counsel, CCLD Carl Knepler - Chief Executive Officer, Marlene Nelson - Director, Quality Assurance and Risk Management APA Barlow verified with Knepler information received by CCL from the media as follows: • $25M lawsuit against the community located in Bakersfield • Photography lawsuit against one of the properties • lawsuit against a Skilled Nursing Facility (SNF) in the Healdsburg location Knepler states that despite the lawsuits, there is no financial impact to any of the properties, residents or staff of the company. Knepler added there are no vendor issues as well. (Continuation on Lic 809C...) Knepler also states that management communicates with the staff and residents to make them aware of the changes. Signages have been changed. Knepler added that the bankruptcy did not affect any of the communities because Pacifica Senior Living Management was no longer the management company for any of the Pacifica Communities, that the communities had given notice to the department and residents back in October or November of last year of the changes in management companies. He said that the judgment in Bakersfield did not involve the operating entity, only the management company. He said there were no other suits pending against any of the Pacifica entities. APA requested the following documents be provided to CCL by today: • Spread sheet of all facilities whose management company was/is Pacifica Senior Living Management Company • management companies for each location • letter provided to the residents notifying them of the changes At the conclusion of the meeting, APA emphasized to Knepler the importance of communicating with CCL any lawsuits that the company may have in the future. Knepler agreed with APA. A copy of this report was provided to Knepler.the state’s words, verbatim · CDSS document, Apr 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek arrived unannounced to conduct a required annual visit. LPAs met with Executive Director Jovany Guerra and explained the reason for the visit. LPA Camara conducted the physical plant tour, medication review and interviews. LPA Dulek conducted the document review. LPAs ensured there were no health and safety hazards and community is in compliance with Title 22 Regulations. At 9:28 a.m. LPA started the physical plant tour. The facility's fire suppression system was last inspected by the Oxnard Fire Department on 3/11/2024 and the inspection was satisfactory. The facility's smoke detectors and carbon monoxide detectors were last inspected by Boyd & Associates in December 2024. Fire extinguishers were last serviced on 7/9/2024 and appeared fully charged. Kitchen: At the time of the visit, the kitchen was clean and appliances appeared operable. There was a sufficient supply of perishable and nonperishable food, properly stored. The menu was posted and copies are available for residents. The facility offers daily specials and a standard selection of alternatives at every meal. The kitchen staff have a binder with the special dietary needs of residents. Common Areas: The facility is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors and a separate unit on the first floor is designated for memory care residents. There were no obstructions or tripping hazards observed in the assisted living areas but there was a trip hazard observed in memory care outside of room 1204 where there was a hole in the floor poorly covered. The facility maintains a comfortable temperature. Both facility elevators were operating properly. There are four stairwells; all are equipped with emergency evacuation chairs. There is one delayed egress door on the west side of the memory care patio which was not functioning but the other delayed egress doors were operating properly. (continued on LIC9099-C) (continued from LIC9099) Activities: Planned activities are offered and the activity schedule was posted. Activity room and common spaces appeared clean and in good repair. Rooms: LPA toured ten randomly chosen resident rooms; two in memory care, three on the first floor in assisted living, three on the third floor and two on the second floor. Rooms appeared clean with sufficient lighting and appropriate furnishings. 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 117.1 - 118.2 degrees Fahrenheit. Outside areas: LPA observed appropriate outdoor furniture for residents on both the memory care and assisted living patio areas. . Records: LPA reviewed five resident files; all records found complete. LPA reviewed five staff files which appeared complete, including training records and CPR certifications. Medications: LPA reviewed medications for randomly chosen residents; medications appeared to be given as prescribed. Interviews: LPA interviewed six residents and three staff; there were no concerns noted. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 21, 2025

Allegation investigated: Staff does not treat residents with dignity Residents missed medications Medications were accessible to residents in care

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with Executive Director (ED) Jovany Guerra and explained the reason for the vsit. At 11:45 a.m. LPA interviewed ED. At 12:40 p.m. LPA obtained pertient documents. LPA interviewed three other staff at 1:12 p.m., 1:56 p.m. and 3:00 p.m. LPA interviewed a resident at 2:25 p.m. Regarding the allegation staff does not treat residents with dignity: It was reported Staff 1 (S1) was speaking to residents in a disrespectful manner. S1 received a disciplinary action write up dated 10/19/2024 in which it (continued on LIC9099C) Substantiated (continued from LIC9099) it indicated S1 needed to "maintain a professional demeanor with residents and refrain from discussing unrelated care matters with them." Staff 2 (S2) and Staff 3 (S3) had witnessed S1 speak to residents in a rude manner, however S1 has improved in how they interact with residents. Resident 1 (R1) stated S1 had spoke to them rudely in the past, however S1 is very nice to them now. While S1's demeanor with residents has improved, based on interviews and record review, the allegation S1 does not treat residents with dignity is Substantiated for the time frame this complaint was reported. Regarding the allegation residents missed medications: It was reported S1 was noting on the medication administration record (MAR) the bedtime medications for memory care residents had been given, however a NOC shift medication technician witnessed the medications remained in the top drawer and were not given. Later, the medications were gone. Bedtime medications are usually given at approximately 8:00 p.m. Staff assumed the medications were destroyed since it was too late to administer the medications but there was nothing noted on the MAR about residents missing their medications. Staff stated this happened on more than one occasion and it was reported to the previous ED. Staff was not sure if anything was addressed with S1 by the prior ED. In addition, a resident complained about being given their medications late by S1 and S1 received a disciplinary write-up with that noted. While S1's performance with medications has reportedly improved, based on interviews and record review, the allegation residents missed medications is Substantiated for the time frame this complaint was reported. Regarding the allegation medications were accessible to residents in care: It was reported while S1 passed out medications cups to the assisted living residents seated in the dining room for dinner, S1 would leave the medications cups on the table rather than wait for residents to take their medications. This was confirmed during interviews with other staff. In addition, this led to one resident taking another resident's medications. Staff stated they informed the previous ED of this medication error. While S1's performance with medications has reportedly improved, based on interviews, the allegation medications were accessible to residents in care is Substantiated for the time frame this complaint was reported. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 29-AS-20241105145942

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 29, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the above cited section, as witnesses stated S1 left medication on dining room tables unattended by staff and left meds in a drawer, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: S1 already received disciplinary action, counseling and training. In addition, licensee has scheduled medication training with all medications technicians again on 1/30/2025. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 29, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the above cited section, as witnesses stated S1 spoke in a rude manner to residents, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: S1 already received disciplinary action, counseling and training. In addition, it has been witnessed S1's demeanor with residents has greatly improved. POC cleared.

Allegation investigated: Licensee does not have sufficient staff to meet the care needs of residents Facility staff do not ensure residents toileting needs are met in a timely manner Facility staff do not ensure adequate supervision is provided to residents in care Licensee does not ensure staff are properly trained to care for residents Facility staff was asleep while at work. Facility staff do not ensure reporting requirements are followed Staff allowed resident to leave the facility unattended

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to issue findings on the above noted allegations. LPA met with the Business Office Manager Emely Salinas and explained the reason for the visit. LPA previously visited the facility regarding this complaint on 9/18/2024 and 10/19/2023. During those visits LPA reviewed documents, observed resident 1 (R1), interviewed staff and residents. (continued on LIC9099C, page 2) Substantiated (continued from LIC9099, page 1) Regarding the allegation: “Licensee does not have sufficient staff to meet the care needs of residents” LPA had investigated this same allegation under complaint control number 29-AS-20230918110909. On 3/8/2024, LPA had reviewed the staff schedule for caregivers and medication technicians. LPA went over concerns with the administrator Rick Olds, including no medication technicians on the schedule for Sundays and Thursdays during the NOC shift (10:00 p.m. - 6:15 a.m.). The administrator confirmed they have had some issues finding qualified staff to fill these time slots and on 3/7/2024, they did not have a medication technician during the NOC shift. Based on this information, this allegation is deemed Substantiated. Note: The same allegation was addressed and substantiated under complaint control number 29-AS-20230918110909 which covers the same time frame of this complaint. Regarding the allegations: “Facility staff do not ensure residents toileting needs are met in a timely manner” and “Facility staff do not ensure adequate supervision is provided to residents in care” LPAs had conducted prior investigation visits to the facility on 9/18/2023, 9/25/2023, 12/12/2023, and 3/8/2024 for complaint control number 29-AS-20230918110909. Based on interviews with staff, residents were complaining to them about long wait times to receive assistance, including toileting assistance, from staff. Staff stated due to lack of staffing, residents were not being assisted in a timely manner. Interviews with residents indicated the same issue. Based on interviews, these allegations are deemed Substantiated. Note: These allegations were encompassed under complaint control number 29-AS-20230918110909 which were addressed and substantiated; this complaint covers the same time frame. Regarding the allegation: “Staff allowed resident to leave the facility unattended”. LPA conducted interviews with staff who confirmed that resident 1 (R1) would usually wait outside in the front of the building or inside the lobby for their daughter to pick them up. On 08/21/2023, R1 was waiting in front for their daughter to take them to a dentist appointment scheduled for 3:00 p.m. The dentist is across the parking lot from the facility. Apparently, R1 decided to meet their daughter at the dentist and left the facility in their wheelchair to the dentist. R1’s daughter discovered R1 had left the facility unattended when they arrived at the facility. Although R1 had no cognitive dysfunction, R1’s physician’s report indicated R1 required assistance when leaving the facility. The facility did report this incident to CCL. Based on this information, the allegation is deemed Substantiated at this time. (continued on LIC9099C, page 3) (continued from LIC9099C, page 2) Regarding the allegation: “Facility staff do not ensure reporting requirements are followed” LPA reviewed documentation regarding reported incidents involving R1. The complaint alleged R1’s incidents were not being reported to R1’s responsible party. LPA found a facility internal incident report dated 8/3/2022 involving R1 which had no indication on the report it was reported to R1’s responsible party. Based on this information, the allegation is deemed Substantiated at this time. Regarding the allegation: “Facility staff was asleep while at work.” LPA conducted interviews with staff. It was confirmed that at least one staff (S1) was found asleep during the NOC shift in the common area of the memory care unit. S1 was counseled and written up. Based on this information, this allegation is deemed Substantiated at this time. Regarding the allegation: “Licensee does not ensure staff are properly trained to care for residents” LPA had investigated a similar allegation under complaint control number 29-AS-20230918110909. On 3/8/2024, LPA had reviewed the staff schedule for caregivers and medication technicians. LPA went over concerns with the administrator, including no medication technicians on the schedule for Sundays and Thursdays during the NOC shift (10:00 p.m. - 6:15 a.m.). This complaint was regarding caregivers not receiving proper training for oxygen administration. The administrator Rick Olds stated all medication technicians and some caregivers receive that training. During the time of this complaint, medication technicians were not always at the facility and it was possible some caregivers may not have had training for oxygen administration. Based on this information, this allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 5, 2024 · control 29-AS-20231012084108

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 15, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidenced by: Based on interviews, the licensee did not comply with the above cited section, as R1 was allowed to leave unnoticed by staff, staff was sleeping in a common area and staff require training on oxygen, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: LIcensee will conduct training with staff regarding the importance of maintaining a comfortable and safe environment, including knowing which residents require assistance when leaving the facility, oxygen training and not sleeping in common areas. Evidence of training to CCL by 11/15/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 15, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...: (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... This requirement was not met as evidenced by: Based on record review, R1's responsible party was not notified of at least one incident, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: Licensee will provide a written statement of understanding regarding reporting requirements to CCL by 11/15/2024.

Allegation investigated: Facility staff are not providing resident a copy of signed contract Facility staff are not properly addressing insects in the facility Facility staff are not providing privacy to resident

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. The acting Executive Director Denise Downey was not at the facility. LPA met with Health and Wellness Director Jovany Guerra and explained the reason for the visit. On 8/2/2024 and 9/18/2024, LPA interviewed staff and residents and reviewed documents. Today, 10/24/2024, LPA interviewed staff starting at 1:37 p.m. Regarding the allegation: Facility staff are not providing resident a copy of signed contract. LPA interviewed residents who stated they received their signed admission agreement. LPA interviewed staff who witnessed Resident 1 (R1) receive a paper copy of their admission agreement on the date it was signed. In addition, (continued on LIC9099C) Unsubstantiated (continued from LIC9099) the facility provided an electronic copy of the admission agreement. Later when R1 claimed they had not received a paper copy of the admission agreement, staff printed out another copy and provided it to R1. Recently, R1 claimed again they did not receive a copy of the agreement. Staff printed another copy, however R1 refused to accept it. Based on the information obtained in interviews, this allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility staff are not properly addressing insects in the facility. LPA interviewed residents who stated they had issues in the past with ants in their apartments. These residents stated they told staff who immediately wiped up the ants and then later sent an exterminator to address it further. The facility maintenance director stated they have an exterminator come to the facility twice a month to address any issues with insects. If they need the exterminator to come to the facility between that time, the exterminator will come out right away as part of their contract. R1 stated they were experiencing issues with spiders. LPA interviewed residents near R1's room but they had not experienced any issues with spiders. LPA observed R1 had a lot of boxes in their room. The exterminator informed R1 the boxes may be the issue as spiders tend to be attracted to them. The maintenance director had called the exterminator out to address the spiders. Based on this information, this allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility staff are not providing privacy to resident. LPA interviewed residents regarding privacy at the facility, including residents who consider themselves "independent" in that they do not require hands on care. These residents stated they usually eat meals in the dining room or participate in activities. If staff see them during the day then staff do not go into their rooms to check on them. However, if they stay in their room, for instance due to illness, then staff will knock on their door and enter their room to make sure they are ok. The administrator Rick Olds and the Health and Wellness Director both confirmed if residents who do not require care are seen in the dining room for meals and/or in activities then staff do not need to check on them. However, R1 was not going to the dining room for meals and not checking in with the receptionist so they must have staff check on R1 to make sure R1 is not in need of assistance. This has been explained to R1 by the Administrator and the Health and Wellness Director. Based on this information, this allegation is deemed Unsubstantiated at this time. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 29-AS-20240723093337

Allegation investigated: Staff do not communicate effectively with a resident's licensed physician Staff do not seek timely medical appointments for the resident

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to address the allegations listed above. LPA met with Executive Director (ED) Rick Olds and explained the reason for the visit. During today's visit LPA interviewed staff starting at 12:28 p.m. and residents starting at 1:44 p.m. LPA reviewed and obtained pertinent documents at 1:27 p.m. Based on records reviewed, when resident 1 (R1) moved into the community R1 did not require assistance with status checks or psychosocial cueing. R1's responsible party (family) was responsible for R1's medical appointments but there were issues with (continued on LIC9099C) Unsubstantiated (continued from LIC9099) communicating with R1's family as they do not live in the United States. The Health and Wellness Director (HWD) observed R1's care needs had increased and when R1's family was in town they had a care plan conference in which R1's care plan was revised. The family still controls R1's medical appointments and medical needs but communicates with the HWD by email when R1 has appointments or other medical needs. The HWD arranges for transportation to appointments and a chaperone to the appointments. Based on the information gathered, R1's family was responsible for R1's medical appointments and communicating with R1's physician, therefore these allegations are deemed Unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 29-AS-20240209113957

Allegation investigated: Staff did not administer medication as prescribed.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with Executive Director (ED) Rick Olds and explained the reason for the visit. During today's visit, LPA conducted interviews with staff starting at 11:38 a.m. The allegation above specifically was regarding residents not receiving their medications on time and there were no medication technicians available during the NOC shift to give PRN medications to residents. LPA confirmed with staff that there was a severe staffing shortage during the time of this complaint in March of 2024. Since then the facility has hired and trained new employees in medication management. Staff confirmed there were days at the facility when medications were given late and there were no medication technicians available a couple days a week during the NOC shift. Based on this information, the above noted allegation is deemed Substantiated at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Sep 18, 2024 · control 29-AS-20240325143935

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 18, 2024

87411 Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Ths requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section, as there were no med techs scheduled for Sundays and Thursdays NOC shift, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 18, 2024

Plan of correction: Administrator provided LPA with a current schedule reflecting med techs on each shift. The facility has conducted hiring and medication training for new employees.

Allegation investigated: Facility staff are not responding to residents' calls for assistance promptly

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to deliver findings regarding the above noted allegation. LPA met with Executive Director (ED) Rick Olds and explained the reason for the visit. On 9/27/2023, LPA Camara had conducted an initial complaint investigation visit. During that visit LPA interviewed the interim administrator and obtained pertinent documents. (continued on LIC9099C) Substantiated (continued from LIC9099) Regarding the allegation: Facility staff are not responding to residents’ calls for assistance promptly. LPA reviewed the documents with the pendant call response times for 9/23/2023 (7:50 a.m. – 9:28 p.m.): Calls that took over 15 minutes to respond: seven (7) Calls that were announced nine times and never responded to: seven (7) The administrator stated call response times are expected to be less than 15 minutes. Staff are trained to at least pop in to see what the resident needs and make sure it is not an emergency. At that time, if they are busy with someone else, they should let the resident know they will be back and turn off the call notification. Sometimes staff may forget to turn off the notification. Based on the review of the pendant call response times, the allegation “Facility staff are not responding to residents’ calls for assistance promptly” is deemed Substantiated at this time. A citation was issued on complaint 29-AS-20230807101835 for the same deficiency during the same time period at the facility. Exit interview conducted. Report issued. (continued from LIC9099A) Regarding the allegation: Due to lack of supervision, resident left the facility unassisted. LPA reviewed the documents obtained during the visit. Resident 1 (R1) is able to leave the facility unassisted according to R1’s physician’s report dated 1/18/2022. R1’s diagnosis did not require annual physician’s reports. R1’s assessment dated 1/18/2022 showed they could mentally and physically follow instructions in an emergency. R1 was capable of all self-care, including administering their own medication. The only assistance R1 requested was with laundry services. A re-assessment was completed on 9/27/2023 with the same level of assistance needed. The administrator stated R1 was able to leave unassisted but R1 forgot to sign out. Facility staff were concerned because they could not find R1 and R1 did not sign out. Out of concern for R1’s wellbeing they called the police who located R1 within approximately 30 minutes and brought R1 back to the facility. Based on documentation for R1 being able to leave without assistance, the allegation “Due to lack of supervision, resident left the facility unassisted” is deemed Unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 29-AS-20230926092742

Allegation investigated: Staff did not respond to resident's call button in a timely manner.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with executive director/administrator (ED) Rick Olds and explained the reason for the visit. On 8/10/2023, LPA conducted an initial complaint investigation visit. LPA interviewed the ED at that time, Elizabeth Whittington, and obtained pertinent documents. Regarding the allegation: Staff did not respond to resident's call button in a timely manner. LPA had obtained copies of the call button response times for 7/25/2023, which was the date in question. The following was noted: -calls which took 16 – 30 minutes for response: seven -calls which took over 30 minutes for response: three -calls to resident rooms which went unanswered: two (continued on LIC9099-C) Substantiated (continued from LIC9099) According to the ED at the time, staff are trained to respond immediately or no longer than fifteen (15) minutes. Based on the call response printout for 7/25/2023, the allegation staff did not respond to the resident’s call button in a timely manner is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. (continued from LIC9099) could not return to the facility unless R1 was able to demonstrate the ability to give themselves injections. The ED stated they did not evict R1, they just informed R1’s responsible party that R1 would need to be trained on how to do the injections prior to returning to the facility. The facility is not a medical facility, they do not have a nurse on staff 24/7 to give injections, and the caregivers are not skilled medical professionals. The ED explained to R1’s responsible party that R1 must be able to give themselves the injections in order to remain a resident of the facility. During today's visit, the current ED indicated R1 is still living at the facility and receives the injections from a home health agency nurse on a daily basis. Based on this information, this allegation is deemed Unsubstantiated at this time. No deficiency cited. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 29-AS-20230807101835

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 30, 2024

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and record review of alert response times, some responses were not completed in a timely manner and other calls went unanswered, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: Licensee will submit a plan to conduct testing on the call buttons to ensure they are functioning properly and conduct audits on response times.

Allegation investigated: Administrator is not at the facility a sufficient number of hours to adequately manage facility operations. Staff not assisting resident in a timely manner.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with executive director/administrator (ED) Rick Olds and explained the reason for the visit. Regarding the allegation: Administrator is not at the facility a sufficient number of hours to adequately manage facility operations. LPAs had conducted prior investigation visits to the facility on 9/18/2023, 9/25/2023, 12/12/2023, and 3/8/2024. On 9/18/2023, LPA Kelly Dulek found the facility was being run by the Maintenance Director who had not been fingerprint cleared to work at the facility. The Maintenance Director stated he was the only manager left at the facility. The Executive Director Elizabeth Whittington no longer worked there and (continued on LIC9099-C) Substantiated (continued from LIC9099) corporate representatives who were supposed to be in charge of running the facility until a new executive director was hired had not shown up in several days. The Maintenance Director was struggling to keep all of the shifts fully staffed as staff were calling in sick or just not showing up. The Maintenance Director was even providing care to residents himself even though he had not been trained in caregiving. Based on interviews with staff this allegation is deemed Substantiated at this time. Regarding the allegation: Staff not assisting resident in a timely manner. LPAs had conducted prior investigation visits to the facility on 9/18/2023, 9/25/2023, 12/12/2023, and 3/8/2024. Based on interviews with staff, residents were complaining to them about long wait times to receive assistance from staff. They asked to speak with management regarding the wait times but nobody was available. Staff stated due to lack of staffing, residents were not being assisted in a timely manner. Interviews with residents indicated the same issue. Based on interviews, this allegation is deemed Substantiated at this time. The facility was already cited on this complaint for lack of staffing on 3/08/2024. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 29-AS-20230918110909

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 21, 2024

87405 Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. Based on interviews with staff, the licensee did not comply with the above cited section, as there was no qualified administrator running the facility for several days during a time of severe staffing shortage, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: The current administrator is scheduled at the facility Monday through Friday from 9:00 a.m. to 6:00 p.m. and on-call for emergencies which appears to be a sufficient number of hours to operate the facility.

Allegation investigated: Staff are not properly trained for disaster plans.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with administrator/executive director Rick Olds and explained the reason for the visit. On 5/31/2024, LPA had conducted an initial visit and interviewed the administrator and wellness director. During that visit the management team was not able to locate any evidence of past emergency/evacuation drills conducted with the staff. At that time, the administrator had stated the Oxnard Fire Department was going to come to the facility to conduct fire safety training with staff in mid-June 2024. During today's visit, the administrator stated the Oxnard Fire Department told the facility they would not be able to conduct the training. The facility's life enrichment director reached out to the Ventura Fire Substantiated (continued from LIC9099) Department and they have agreed to conduct training on the use of the evacuation stair chairs with facility staff in August 2024 but they have not set a date yet. In addition, staff recently received fire safety training on 7/31/2024 and a disaster preparedness meeting on 5/30/2024. Based on interviews and lack of records for past disaster evacuation training, the allegation staff are not properly trained for disaster plans is Substantiated at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 2, 2024 · control 29-AS-20240529122225

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Aug 9, 2024

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section, as there were no records showing drills had been conducted, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 2, 2024

Plan of correction: Administrator will provide LPA with a written statement stating he has reviewed and understand the requirements of HSC 1569.695. This will be sent to CCL on or before 8/9/2024.

Allegation investigated: Facility food is of poor quality. Facility food service is not adequate. Facility is not following safe food handling practices. Facility is out of stock of basic food items. Facility staff are not wearing masks. Facility does not have sufficient staff to meet residents' needs. Facility staff does not respond to residents' call buttons.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to issue findings regarding the above noted allegations. LPA met with the current Executive Director (ED) Rick Olds and explained the reason for the visit. Over the course of the investigation, LPA Emily Peraldi visited the facility on 7/22/2022 and 8/11/2022. During those visits, LPA Peraldi conducted interviews with staff and residents. In addition, LPA Camara investigated similar allegations on another complaint from the same time period. LPA Camara visited the facility on 7/22/2022, 3/3/2023, 9/14/2023, and 9/27/2023. LPA Camara also conducted interviews with staff and residents. During these visits, the LPAs met with the former Executive Director (ED) Kortnie Spitznogle who is the ED referred to in the remainder of this report. (continued on LIC9099-C) Substantiated (continued from LIC9099) Regarding the allegation “Facility staff are not wearing masks”: On 7/22/2022 between 10:13 a.m. and 1:20 p.m., LPAs Camara and Peraldi visited the facility together for two separate complaints with similar allegations. During the visit LPAs observed some staff wearing their masks pulled down below their noses. This timeframe was during a COVID-19 outbreak at the facility. In addition, facilities were still mandated to have staff wear masks at that time. Based on this information, the above noted allegation is deemed Substantiated at this time. Regarding the allegations “Facility staff does not respond to residents' call buttons” and "Facility does not have sufficient staff to meet residents' needs": On 7/22/2022, LPA Camara reviewed call button history for 6/17/2022 – 7/16/2022 provided by the Business Office Manager. The call button data showed there were 42 calls that went without a response. The ED stated it could have been that the staff did not clear the call after responding. The ED did not have evidence of this, nor did she have a reason for the long response times (20 – 40+ minutes) on over 100 calls. During interviews with residents, there were concerns voiced about the call button response. One resident stated they heard one of their neighbors call out for help but nobody responded to the resident. Based on this information, the allegation is deemed Substantiated at this time. Regarding the allegations "Facility food service is not adequate" and "Facility is not following safe food handling practices": LPAs Camara and Peraldi conducted interviews with staff and residents during their previously noted visits. LPA Camara also conducted telephone interviews with staff on 9/18/2023. Staff voiced concerns about lack of servers, especially during times when the dining room was closed during COVID outbreaks. Staff stated they had to take food to each room but there was frequently only one server. The food would get to many of the rooms cold. Some residents stated their food arrived at a good temperature while others stated they received cold food. Staff stated the temperature of the food would depend on where the residents lived in the facility because some residents received their food right away while others had to wait longer. One resident recalled receiving a plate of cold fish and chips with warm coleslaw. They also recalled not receiving lunch twice during the holidays, breakfast was frequently served late, eggs had gray streaks, and on the day the resident was interviewed, 1/4/2023, the resident did not receive breakfast at all. Staff stated some residents would ask them to heat up the food in their microwave because it arrived cold. Based on this information, these allegations are deemed Substantiated at this time. (continued on LIC9099-C page 3) (continued from LIC9099-A) Regarding the allegation “Facility is limiting residents’ visitations from family and friends”: LPAs Camara and Peraldi conducted interviews with residents on the dates noted previously. None of the residents interviewed indicated staff limited their visitation with family and friends. The former Executive Director (ED) Kortnie Spitznogle stated whenever the facility had COVID positive residents she sent an email out to families informing them. She requested visitors only meet with their loved ones in their rooms and to avoid exposure to other residents. Based on interviews with residents and the ED, this allegation is deemed Unsubstantiated at this time. Regarding the allegation “Facility does not provide communal activities (including dining room)” ED Spitznogle stated she closed the dining room and communal activities when the facility had a spike in COVID positive residents and staff. The facility provided in-room activities like crossword puzzles and other types of games. Staff took food trays to each room. She made the decision to do this before receiving instruction to do so from Ventura County Public Health (VCPH). The facility had several rounds of COVID spikes since 2020 so the ED was familiar with VCPH guidelines for closing communal activities. Based on interviews and review of COVID positive records, this allegation is deemed Unsubstantiated at this time. Regarding the allegation "Facility staff are not adequately supervising residents": This allegation was regarding an allegation there were a couple residents who were being aggressive and urinating in the halls. During interviews conducted by LPA Peraldi with residents, none had recalled any issues with other residents acting aggressive or causing issues. One resident recalled hearing another resident in the hallway making noise one day but facility staff took care of them. Based on these interviews, this allegation is deemed Unsubstantiated at this time. Regarding the allegation "Facility does not provide a safe environment for residents": LPA Peraldi conducted interviews with multiple residents and asked them if they felt safe at the facility. All of the residents LPA Peraldi interviewed stated they felt safe at the facility and they had no concerns regarding that issue. Based on these interviews, this allegation is deemed Unsubstantiated at this time. No deficiencies observed regarding these allegations. Exit interview conducted and report issued. (continued from LIC9099-C, page 2) Regarding the allegations "Facility food is of poor quality" and "Facility is out of stock of basic food items": LPAs Camara and Peraldi conducted interviews with staff and residents during their previously noted visits. LPA Camara also conducted telephone interviews with staff on 9/18/2023. Staff voiced concerns about the quality of food being served. They had concerns that the type of food being served was inappropriate for the population. The Food Services Director at the time prepared menus with a lot of starchy foods, burgers, spicy foods, etc. Staff stated they did not serve enough fresh fruits and vegetables. Residents had similar concerns and many stated there were far too many starchy items and not enough fresh fruits and vegetables. Staff also had concerns about running out of basic food items such as oil, fruits, vegetables, items to make things that were on the menu like soup. Staff stated they had to pay out of their own pocket for food staples to get them by until the next food order arrived. Staff stated they ran out of these items due to poor ordering by the former Food Services Director. Residents recalled being told the facility was out of things like coffee and juices. One resident stated they should be on a special diet but they were not offered choices for a diabetic diet and was served a lot of starchy food. Based on these interviews, these allegations are deemed Substantiated at this time. Regarding the allegation "Facility does not have sufficient staff to meet residents' needs": LPAs Camara and Peraldi conducted interviews with staff and residents during their previously noted visits. LPA Camara also conducted telephone interviews with staff on 9/18/2023. Staff voiced concerns about being understaffed. They stated the medication technicians frequently had to act as caregivers which led to some residents receiving their medications late. Another staff stated that during periods of COVID outbreaks they would frequently only have one server to deliver trays of food to all residents. Staff recalled when delivering food to the rooms of residents who had COVID, they were told to just leave the trays outside the room but that staff did not believe the residents were aware the food was there and would see the food just sit there uneaten. One resident recalled when they had COVID their food tray was left on the COVID "box" outside their room but they did not know the food was there. Based on these interviews, the allegation is deemed Substantiated at this time. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited: (Refer to LIC 9099-D). Exit interview conducted. Report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jun 27, 2024 · control 29-AS-20220718091342

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jul 11, 2024

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidence by: Based on resident and staff interviews, the licensee did not comply with the section cited above, too many starches and not enough fresh produce, running out of food items, hot food served cold, which poses a potential health, safety, and personal risk to persons in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Licensee will provide a written plan on how they will ensure residents are served food at proper temperatures, offering fresh produce, and ensuring they do not run out of staple foods. Submit to CCL on or before 7/11/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(18) · Plan of correction due date: Jul 11, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply:(18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement is not met as evidence by: Based on resident and staff interviews, the licensee did not comply with the section cited above, due to late or no meal service while meals were served in residents' rooms due to COVID outbreaks, which poses a potential health, safety, and personal risk to persons in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Licensee will submit a written plan on how they will handle meal service in the future in the event all residents must be served meals in their rooms. Submit to CCL on or before 7/11/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 11, 2024

87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on LPAs' observations, the licensee did not comply with the section cited above, as staff were not properly wearing face masks in the facility, which poses a potential health, safety, and personal risk to persons in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Licensee will submit a writtne plan on how they will ensure staff compliance with wearing facemasks during outbreaks at the facility. Submit to CCL on or before 7/11/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 11, 2024

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities... To care, individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on resident and staff interviews and record review of alert response times, some responses were not completed in a timely manner and other calls went unanswered, which poses a potential health, safety, and personal risk to persons in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Licensee will submit a written plan on the expected response time and how they will ensure staff respond to call buttons within the expected response time. Submit to CCL by 7/11/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 11, 2024

87411 Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on resident and staff interviews, the licensee did not comply with the section cited above, late/no meal service when served in room, late/no response to call buttons due to lack of staff, which poses a potential health, safety, and personal risk to persons in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Licensee will submit a written plan on how they will ensure staffing in all aspects of the facility is at sufficient levels to meet the needs of residents. Submit to CCL by 7/11/2024.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Other visit due to receiving notification from an outside party stating the facility is representing themselves as another name: "The Vistas at Oxnard Senior Living". LPA was notified the signage at the facility had already changed. Upon LPA's arrival at 9:10 a.m. LPA observed the signs in the front of the building remain the same: Pacifica Senior Living Oxnard. Signs and calendars inside the facility have not changed either. LPA spoke with the Executive Director (ED) Rick Olds, who stated their management company is in the process of changing the facility's name but it has not been completed yet. LPA explained to ED that any name change must go through a process with Community Care Licensing (CCL). LPA will provide the licensee with the documents that will be needed in order to change the facility's name at a later date. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jun 27, 2024

Allegation investigated: Licensee failed to safeguard resident's perosnal property

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to deliver findings on the above noted allegation. LPA met with Executive Director (ED) Rick Olds and explained the reason for the visit. On 4/18/2023, the Department received a complaint alleging at least one credit card and some cash was taken from the room of resident 1 (R1) and used without R1’s permission. On 4/19/2023, LPA contacted the Oxnard Police Department to see if they conducted an investigation regarding the theft allegation. LPA was informed that due to the amount of money taken, it was not considered a felony and the case was therefore given a lower priority. Once the detective was able to review (continued on page 2; 9099-C) Unsubstantiated (continued from page 1; 9099) the case it was too late to secure video surveillance at the retail establishments where R1’s credit card was used. On 4/21/2023, LPA conducted an initial complaint investigation visit and interviewed R1, three staff members, and reviewed relevant records. On 4/28/2023, LPA conducted a subsequent complaint visit and interviewed one staff member. LPA discussed with the ED the need to safeguard resident’s belongings at the facility. There is insufficient evidence to confirm the credit card and cash were stolen from R1’s room at the facility. Therefore, the allegation the facility failed to safeguard R1’s personal property is deemed Unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, May 3, 2024 · control 29-AS-20230418134450

Allegation investigated: Resident became severely dehydrated while in care due staff not providing adequate hydration. Staff did not provide adequate supervision resulting in resident falling.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to issue findings regarding the above noted allegations. LPA met with facility Executive Director (ED) Rick Olds and explained the reason for the visit. On 5/2/2023, LPA Angel Ascencio conducted the initial complaint investigation visit. LPA Ascencio met with the ED at that time, Elizabeth Whittington. LPA Ascencio toured the facility at 12:05 p.m. and reviewed and obtained pertinent documents at 12:40 p.m. LPA Ascencio informed ED Whittington further investigation was needed, and the case may be assigned to an investigator with the Community Care Licensing (CCL) Investigations Branch (IB). (continued on page 2; 9099-C) Unsubstantiated (continued from page 1; 9099) On 5/2/2023, IB Special Investigator Assistant Eleza Jackson was assigned to the case to obtain medical records regarding Resident 1 (R1). These records were received on 7/6/2023, 7/12/2023, and 8/22/2023. On 5/19/2023, LPA Ascencio conducted a subsequent complaint investigation visit with LPA Ashley Smith and LPA Elsie Campos. LPAs met with ED Whittington. Staff interviews were conducted between 10:00 a.m. and 1:00 p.m. LPAs informed ED Whittington further investigation was needed. On 5/31/2023, LPA Smith and LPA Campos conducted another subsequent complaint investigation visit. LPAs met with ED Whittington and conducted a facility tour. LPAs reviewed pertinent records, interviewed staff between 10:00 a.m. and 11:15 a.m., interviewed residents between 12:00 p.m. and 1:15 p.m., and interviewed two residents’ responsible parties at 10:40 a.m. and 11:16 a.m. LPAs informed ED Whittington further investigation was needed. On 7/13/2023, the case was assigned to IB Investigator Douglas Real for a full investigation. Investigator Real reviewed the records obtained by LPA Ascencio which showed R1 had three falls that resulted in R1 being transported to the hospital. On 2/26/2023, R1 had an unwitnessed fall in their bedroom near the bathroom. Staff found a small cut on R1’s elbow. R1 asked to go to the hospital; 9-1-1 was called and R1 was transported to the hospital. On 4/25/2023, R1 had an unwitnessed fall in their bedroom. R1 reported hitting the back of their head. Staff called 9-1-1 and R1 was transported to the hospital. R1 was released the same day with no new orders. On 4/26/2023, R1 fell from their wheelchair. R1 suffered a skin tear but was also not very responsive so 9-1-1 was called and R1 was transported to the hospital. Investigator Real also reviewed the medical records from three separate hospitals. R1 was seen on 4/25/2023 at a local hospital after an unwitnessed fall. Diagnostic testing was performed. No obvious signs of trauma were found and R1 was discharged back to the facility that day. (continued on page 3; 9099-C) (continued from page 2; 9099-C) R1 was admitted to a different hospital on 4/26/2023 after an unwitnessed fall. Diagnostic testing was performed, and no signs of injuries were observed. R1 was discharged from this hospital on 4/28/2023. R1 was transferred to another hospital on 4/28/2023 for further evaluation and treatment. It was found R1 was not at their baseline in terms of physical abilities so R1 was transferred to a skilled nursing rehabilitation facility on 5/1/2023. None of the medical records identified any signs of abuse, neglect, malnourishment nor dehydration. On 7/17/2023, Investigator Real conducted interviews with a family member and R1. On 8/17/2023, Investigator Real conducted interviews with ED Whittington at the facility. Investigator Real also conducted a telephonic interview with staff on 8/18/2023. On 9/6/2023, Investigator Real conducted interviews while at the facility with staff and other residents as well. None of the residents nor staff had ever witnessed any abuse or neglect. Residents are provided breakfast, lunch, dinner, and snacks with which beverages are provided. Additionally, there is water available throughout the day. Residents who were interviewed felt safe at the facility. The information obtained during the Department’s investigation does not support the allegations, therefore, the allegations “Neglect/Lack of Supervision – Facility employees failed to provide an appropriate level of supervision which resulted in Resident 1 (R1) becoming dehydrated and having multiple falls in the facility” is deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report issued.the state’s words, verbatim · CDSS document, May 3, 2024 · control 29-AS-20230501145259

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Teresa Camara arrived unannounced to conduct a continuation of the required annual visit. LPA met with Executive Director (ED) Rick Olds and explained the reason for the visit. LPA reviewed the plan for repairing the delayed egress doors with the ED and maintenance director. The facility had two companies come out to inspect the doors and provide bids. They are awaiting the final bid from one of the companies and will get time frames from that company on ordering parts necessary for repairing the doors and completing the actual repairs. In the meantime, the facility has increased staffing in the memory care unit. The facility provided documentation showing the fire alarm system, including smoke detectors and carbon monoxide detectors, were last inspected by Boyd & Associates on 1/12/2024. The administrator is updating the Emergency Disaster Plan and will have it complete by 4/30/2024. In addition, the administrator will conduct quarterly evacuation drills on all shifts starting on or before 5/10/2024. LPA reviewed medications for five residents. One resident's centrally stored medication and destruction record (CSMDR) was incomplete. However, based on the facility's medication administrator record it appears the medications are given as prescribed. The administrator will ensure all CSMDRs are up to date. LPA reviewed five staff files which were complete. One staff is updating their first aid/CPR but is not on the schedule at this time. There were four residents' files needing updated and/or signed needs and services plans which the administrator is currently working on. One of the residents will need an updated medical assessment to address a possible increase in care needs. LPA interviewed three staff who gave appropriate responses to the questions. Exit interview conducted. A copy of the report issued.the state’s words, verbatim · CDSS document, Apr 18, 2024

The state marks this report as 8 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek arrived unannounced to conduct a required annual visit. LPAs met with Executive Director Rick Olds and explained the reason for the visit. 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. At 8:43 a.m. LPA Camara observed a medication cart in the facility lounge area that was unattended by staff. LPA checked the cart to see if it was locked, however it was not locked and there were medications stored inside the cart. The facility's fire suppression system was last inspected by the Oxnard Fire Department on 3/11/2024. The facility's smoke detectors and carbon monoxide detectors were last inspected by Boyd & Associates on 1/12/2024, however the facility does not have documentation of this inspection. They have requested the documentation and should have it by 4/16/2024. Fire extinguishers were last serviced on 7/21/2023 and appeared fully charged. Kitchen: At the time of the visit, the kitchen was clean and appliances appeared operable. There was a sufficient supply of perishable and nonperishable food, properly stored. The menu was posted and copies are available for residents. The facility offers daily specials and a standard selection of alternatives at every meal. Common Areas: The facility is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors and a separate unit on the first floor is designated for memory care residents. (continued on 809-C) (continued from LIC809) There were no obstructions or tripping hazards observed. The facility maintains a comfortable temperature. Both facility elevators were operating properly. There are four stairwells; all are equipped with emergency evacuation chairs. There were two delayed egress doors in the memory care unit that were not functioning properly (the main memory care entry door and one in a hallway which leads to the outdoor area accessible in assisted living). The delayed egress for these doors were tested and the doors did not open. The doors could only be opened by inputting a security code. Activities: Planned activities are offered and the activity schedule was posted. Activity room and common spaces appeared clean and in good repair. Rooms: LPAs toured ten randomly chosen rooms; three in memory care, one in assisted living on the first floor, three on the second floor and three on the third floor. Rooms appeared clean with sufficient lighting and appropriate furnishings. 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 107.0 -119.1 degrees Fahrenheit. Outside areas: LPAs observed appropriate outdoor furniture for residents. There was an enclosed patio for residents whom reside in the memory care unit. The delayed egress doors in the memory care patio area were not operating properly and one of the doors was wired shut. Records: LPAs reviewed five resident files and five staff files. An annual continuation visit is necessary and records will be reviewed again during that visit. Interviews: LPAs interviewed three residents; no concerns noted. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 15, 2024

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility is understaffed.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with administrator Rick Olds and explained the reason for the visit. At 3:18 p.m. LPA reviewed the staff schedule for caregivers and medication technicians. LPA went over concerns with the administrator, including no medication technicians on the schedule for Sundays and Thursdays during the NOC shift (10:00 p.m. - 6:15 a.m.). The administrator confirmed they have had some issues finding qualified staff to fill these time slots and yesterday, 3/7/2024, they did not have a medication technician during the NOC shift. Based on this information, the allegation the facility is understaffed is deemed Substantiated at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Mar 8, 2024 · control 29-AS-20230918110909

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 12, 2024

87411 Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on interview and record review, the licensee did not comply with the above cited section, as there were no med techs scheduled for Sundays and Thursdays NOC shift, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: Administrator provided LPA with an update on the schedule for this weekend and will update the staff schedule to ensure all shifts have a medication technician. Administrator will provide CCL with the updated schedule on or before 3/12/2024.

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff not providing adequate food service. Resident left in soiled diapers for extended amount of time. Resident needs not being met.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegations. The initial visit was conducted on 04/28/2023 by LPA’s T. Camara and K. Lopez a subsequent visit was conducted on 08/01/2023 by LPA M. Arroyo. During today's visit, LPA met with Interim Executive Director, Karen Enciso, and the reason for the visit was explained. Entrance interview. During the initial visit on 04/28/2023, LPA’s Camara and Lopez toured the kitchen at 10:21 a.m., toured memory care at 10:44 a.m., and reviewed and obtained copies of pertinent documents at 11:05 a.m. On 08/01/2023, LPA Arroyo conducted a plant tour at 12:56 p.m., toured memory care at 1:00 p.m., toured the kitchen/food area and dining room at 1:15 p.m., conducted interviews with the ED, two staff members, and four residents between 1:02 p.m. and 2:46 p.m., and conducted a resident file review at 3:40 p.m. and obtained copies of pertinent documents relevant to the investigation. Additionally, the LPA conducted telephonic interviews with family members on 09/29/2023 at 11:20 a.m., and 11:55 a.m., and 12:20 p.m. (Report Continued on LIC 9099C...) Unsubstantiated (Report Continued from LIC 9099...) It was alleged that staff are not providing adequate food service. It was reported that Resident #1 (R1) and others have been under fed resulting in weight loss. During the visit on 08/01/2023, the LPA observed the kitchen, food supply, monthly menu posted by the kitchen, copies of daily menu by the front desk, and random residents having lunch. The facility had a variety and adequate supply of perishable and non-perishable foods including eggs, meats, breads, canned goods, fresh fruit, fresh vegetables, and milk. Interviews conducted with residents revealed the food is good and stated snacks are passed every day around the same time. The snacks vary by days as sometimes they will get crackers, cheese, or ice cream. Interviews conducted with family members revealed that they get copies of the monthly menus from the front desk when they visit to know what the resident will be having throughout the month. Additionally, family members stated observing residents asking and receiving snacks in between meals while visiting. Furthermore, residents and family members reported having no concerns with the facility. Based on LPA observation and interviews conducted with the staff, residents, and family members, there is insufficient evidence to support the allegation of “staff are not providing adequate food service”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that residents are left in soiled diapers for extended amount of time. It was reported that residents are being left in soiled diapers and residents’ beds have soiled linens. Additionally, urine stains were seen in R1’s bedsheets and R1 had to be changed several times due to R1 being wet. Information obtained and reviewed revealed that about 80% of residents in memory care are incontinent and wear diapers. Interviews conducted with residents revealed that staff are often checking on the residents throughout the day. Staff reported checking on the residents at least every two (2) hours and changing them when needed. Additionally, staff stated they have not had any family members report the residents being dirty or wet while visiting. Interviews conducted with family members revealed they often visit the residents and have not observed them being in soiled diapers. Family members stated the staff is good at changing the residents and keeping them clean. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “residents are left in soiled diapers for extended amount of time”. Therefore, this allegation is being deemed Unsubstantiated at this time. (Report Continued on LIC 9099C...) (Report Continued from LIC 9099C...) It was further alleged that residents’ needs are not being met. It was reported that R1 has not been shaved and bathed for days at a time including brushing their teeth and laundry has not been completed for weeks. Additionally, the facility was to have a podiatrist and hairdresser come to the facility to service residents. Information obtained and reviewed revealed that residents have scheduled showers; however, residents also have the right to refuse any type of service. The end of shift report indicates how the residents interact each day. Additionally, on the narrative charting staff reported when R1 was refusing any service such as bathing and/or shaving and staff reported R1 had refused showers several times while living at the facility. Additional interviews revealed that residents will at times refuse their showers and staff will attempt to try again later the same day if not the following day. Additionally, housekeeping is done once a week for all residents in both assisted living and memory care. Per R1’s Admissions Agreement dated 01/26/2023 it states on page 7 section B that ‘personal laundry is available for an additional charge’ and on page 24 under Appendix A R1’s Power of Attorney (POA) did not indicate that they wanted additional personal laundry services added to their basic services. In addition, record review revealed that the facility places a sign-in sheet for both assisted living and memory care residents to sign up to see the Podiatrist which is scheduled to come to the facility every six (6) weeks. These sign-in sheets are available by the front desk for family members to sign up the residents from both assisted living and memory care. Furthermore, interviews conducted with residents and family members revealed they feel the facility is meeting their needs and had no concerns. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “residents needs are not being met”. Therefore, this allegation is being 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, Oct 30, 2023 · control 29-AS-20230427152417

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Teresa Camara conducted a case management - deficiencies visit due to a deficiency observed during the course of a complaint investigation (complaint control number 29-AS-20231012084108). LPA met with acting Executive Director (ED) Karen Enciso, LVN, and explained the reason for the visit. At 10:53 a.m. LPA reviewed and obtained pertinent records and while meeting with the ED. At 12:00 p.m. LPA observed Resident 1 (R1) in the dining room. Starting at 12:10 p.m. LPA conducted interviews with staff 1 (S1), staff 2 (S2), staff 3 (S3), and staff 4 (S4). Resident 1 (R1) was admitted to this facility in May of 2022. R1's physician report dated 5/10/2022 indicates R1 needs full assistance from facility staff for all activities of daily living: bathing, dressing, toileting, feeding and managing cash resources. R1's family manages the cash resources. During interviews with the ED and staff, they confirmed R1 needs full assistance with all R1's care needs. LPA observed R1 in the dining room during lunchtime. R1 was fully assisted with eating and drinking. LPA observed S4 cutting food, feeding R1 with a fork and picking up R1's glass which had a straw so R1 could take a drink. R1 did not handle any food, utensils, cups or glasses. During interviews with staff it was revealed R1 is unable to take their own medications. Medication Technicians must either put the medications on a spoon into R1's mouth or use a medication cup to pour the medications (pills/capsules) into R1's mouth, followed by holding a glass with a straw so R1 can take a drink. Based on the records reviewed and interviews, R1 depends on others to perform all activities of daily living and appears to need a higher level of care. The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615 · Plan of correction due date: Oct 24, 2023

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5)Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement is not met as evidenced by: The facility did not comply with the section cited above as staff must perform all activities of daily living for R1, which poses an immediate health and safety risk to person in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: The ED will notify R1 and R1's representatives by 10/24/2023 of R1's need for a higher level of care and provide a copy of the notification to CCL by that date.