Regency Palms Oxnard

Allegation investigated: Facility staff did not properly maintain resident’s records/logs. Facility staff did not ensure to provide adequate food service, resulting in resident weight loss.

At 2:00pm, on 8/17/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to deliver final findings to the allegations above. LPA met with Sales Director Ty Hanson, announced who he was and the reason for the visit. During visits conducted on 3/4/2026, 3/11/2026, and 3/18/2026 LPAs Peraldi, Dulek, Huynh, and Barutyan conducted interviews, collected relevant documentation and toured the facility. During today's visit LPA toured the facility, checked the wellbeing of select residents and conducted interviews. On the allegation, facility staff did not properly maintain resident’s records/logs; it was alleged that the facility does not keep records of daily care provided to the residents, including Resident #1 (R1). It was also alleged that the facility does not keep records of when residents are sick or when staff provide them assistance with adult brief changes/incontinence care. (Continued on LIC9099-C) Substantiated Review of R1’s preadmission assessment, medical assessment, and service plan reveal R1 is independent regarding their toileting, but does require stand-by assistance from staff with bathing and dressing. The facilities Standard Operating Procedures states, “Staff are required to document all assistance provided with Activities of Daily Living (ADLs) using either the paper or electronic system, depending on the Community’s current documentation method.” Staff interviews revealed that just recently within the last couple of months they are required to document resident bowel movements, but they do not document when assistance is provided with all ADL’s. Additionally, during this investigation record review revealed that on 2/5/2026 R1 fell and cut one of their hands on a broken dish they dropped and first aid was applied. The facility’s Standard Operating Procedures states, “All falls and near-falls shall be documented in the Community’s eHR and Incident Report. The resident’s care plan shall be reviewed and updated following a fall.” It also states that after a fall a review will be conducted to identify contributing factors, evaluate effectiveness of current interventions, and implement additional preventative measures. Additionally, staff will receive training on fall risk identification, safe transfer and mobility assistance, and fall response procedures; this training will be documented in employee training records.” Review of R1’s records indicate R1’s care plan was not updated following the fall on 2/5/2026, and staff stated that they do receive fall prevention training but do not recall receiving any additional training after resident falls, including R1’s fall on 2/5/2026. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be substantiated, the facility is not operating in accordance with the plan of operation. On the allegation, facility staff did not ensure to provide adequate food service, resulting in resident weight loss; it was alleged that R1 lost approximately ten (10) pounds in about twenty-two days and was not eating, staff did provide R1 full plates of food but they went untouched and staff made no note of this. Additionally, it was alleged that staff were not recording, monitoring or addressing the weight loss. According to allegations the Administrator at the time, Kenneth Mahler, stated to R1’s responsible party that they should look at the menu to identify foods R1 would like and that the facility does not document if residents eat their meals. (Continued on LIC9099-C) Review of R1’s medical assessment dated 1/21/2026 states R1 is not on a special diet and can feed themself. The preplacement assessment dated 1/30/2026 states R1 is able to independently eat but needs to be offered specific items to choose from and the food must be placed in front of them. It also notes R1 is on a regular diet and does not have any food allergies. R1’s Service Plan dated 2/3/2026 states regarding meals and nutrition that R1 is independent, requires no assistance with meal reminders or feeding support; the care team will monitor for changes in condition and conduct a reappraisal as appropriate. The facilities Standard Operating Procedures dated states, “the Wellness Director (or designee) is responsible for ensuring resident’s weight and vital signs are taken monthly, recorded, tracked and reported to the Medical Provider if abnormal. The Executive Director will ensure the Weights & Vital Signs Monitoring policy is in effect and consistently followed.” It also states, “Upon admission, the Wellness Director or designated staff will obtain resident’s baseline weight and baseline vital signs. Baseline data will be recorded in the resident’s chart and used for comparison in ongoing monitoring.” According to the procedures, a significant change in weight is defined as weight loss or gain of 5% or more within a month or 10% within six months. Interviews and record review reveal the facility did not take R1’s weight upon admission. Staff also stated that resident weights are not obtained upon admission and are not taken monthly. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be substantiated, since the facility did not follow their plan of operation by obtaining R1’s weight and is unable to monitor R1’s weight each month. Exit interview conducted, deficiency cited on LIC809-D page, report signed, appeal rights and report provided to the Sales Director. LPA review of R1’s records reveal a medical assessment conducted on 1/21/2026 states R1 does not have motor impairment/paralysis; does not require assistance with repositioning and transferring; and R1 is not able to leave the facility unsupervised due to being a high fall risk and having cognitive difficulties. A preplacement assessment dated 1/30/2026 states R1 is able to move around a room without help from another person; has mild mobility impairment; is a fall risk due to recently starting to use a walker; they become dizzy when they stand; and they have a diagnosis of multiple systems atrophy. R1’s Service Plan conducted on 3/3/2026 states regarding R1’s mobility that they require verbal reminders and queuing from staff and staff are to support R1 with safe ambulation, mobility, and repositioning. It also states R1 requires assistance with observation, fall management, and uses a cane, walker, or wheelchair. Review of incident reports submitted by the facility to Community Care Licensing (CCL) revealed no incident reports were submitted for R1 during February 2026. Internal facility accident/injury reports noted; on 2/3/2026 R1 had a change in condition, 911 was called, R1’s responsible person spoke with emergency responders and the decision was made to not transport R1 to the local ER, no indication that R1 sustained a fall during this incident; and on 2/5/2026 R1 fell and cut their hand on a broken dish they dropped and first aid was applied. Records maintained by the facility for R1 document the fall occurring on 2/5/2026, as noted above, but no additional falls are noted. LPA attempted to interview the staff scheduled to provide care for R1 on 2/3/2026, 2/4/2026, 2/5/2026, and 2/11/2026; however, some of those staff are no longer employed at the facility. Staff who were interviewed stated that they do not recall R1 falling since they arrived at the facility. They stated that they do receive fall prevention training but do not recall receiving any additional training after residents fall. The facilities Standard Operating Procedures states, “All falls and near-falls shall be documented in the Community’s eHR and Incident Report. The resident’s care plan shall be reviewed and updated following a fall.” It also states that after a fall a review will be conducted to identify contributing factors, evaluate effectiveness of current interventions, and implement additional preventative measures. Additionally, staff will receive training on fall risk identification, safe transfer and mobility assistance, and fall response procedures; this training will be documented in employee training records. (Continued on LIC9099-C) Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. During this same visit, LPA addressed the facility’s failure to follow its Plan of Operation, specifically its lack of updating R1’s care plan following the fall on 2/5/2026 and its failure to provide additional staff training after the incident, despite this allegation being unsubstantiated. On the allegation, facility staff did not communicate with authorized representative in a timely manner; it was alleged that on 2/24/2026, R1’s responsible party requested documents kept by the facility regarding R1, and the facility provided the documents that day. The responsible party arranged to meet on 2/25/2026 with a medication technician (med-tech) to discuss questions they had regarding the documents. On 2/25/2026 the med-tech canceled the meeting due to an emergency. On 2/26/2026, R1’s responsible party text the med-tech seeking clarification on the documents the facility provided and six hours after initially texting the med-tech, the med-tech replied. Based on the information obtained through interviews and record review, the investigation confirmed that the facility provided requested documents on the same day they were requested, follow-up communication from the med-tech was delayed. Although incidents did cause a delay in communication, the evidence did not establish a pattern of intentional withholding of information or repeated failure to notify. Therefore, the allegation that facility staff did not communicate with R1’s authorized representative in a timely manner is unsubstantiated. On the allegation, facility is not ensuring that the facility is staffed effectively; it was alleged that the facility is dangerously understaffed and that residents are unsupervised. Additionally, it is alleged that mid-February 2026 a med-tech left and there was no Memory Care Director or Wellness Director. LPA reviewed staffing schedules, time sheets, and invoices for agency staff for the month of February 2026. Documents indicated a minimum of three (3) care staff in the Assisted Living unit and three (3) care staff in the Memory Care unit during both the am and pm shift. Additionally, there was one (1) medication technician scheduled in Assisted Living and one (1) scheduled in Memory care on both shifts. The overnight shift consisted of one (1) shared medication technician and between two (2) to three (3) caregivers. (Continued on LIC9099-C) Interviews revealed the Memory Care Director position is now called the Wellness Lead, they are one in the same. Records reveal the facility had a Wellness Lead all of February 2026 who left in March 2026 and in April 2026 a new employee was hired to take the position. The Wellness Director position opened in September 2025, consultants and the corporate nurse were brought in to support the empty position until it was filled in March 2026. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and report provided to Sales Director.the state’s words, verbatim · CDSS document, Aug 17, 2026 · control 29-AS-20260303093047

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Aug 31, 2026

Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49… This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure the facility is operating in accordance with the plan of operation which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 17, 2026

Plan of correction: The Sales Director states the Executive Director and Wellness Director will review the facilities Standard Operating Procedures, create a written plan of implementation including staff training on any new procedures. The plan will be emailed to the LPA on or before 8/31/2026.

Allegation investigated: Licensee allows uncleared staff to provide care to residents

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 10:00 a.m. LPA met with Ty Hanson, Sales Director, and explained the purpose of the visit. Administrator was unavailable during today's visit, however the Sales Director is authorized to sign today's reports. Entrance interview conducted. Throughout the course of the investigation, LPA reviewed all documents obtained and the following was determined: Regarding the allegation of “Licensee allows uncleared staff to provide care to residents” it was the Reporting Party’s (RP’s) concern that corporate staff allowed uncleared individuals to provide care and supervision to resident, adding that Staff #1 (S1) and Staff #2 (S2) did not have the required criminal record clearances. The RP also reported that the licensee rents office space located on the second floor to third-party agencies and individuals, including volunteers, who utilize these areas and they do not have criminal record clearances. Continued on LIC 9099-C Substantiated Continued from LIC 9099 During the initial visit, the LPA conducted a physical plant tour and observed that the second floor was shared by facility residents and individuals not employed by the facility. The second floor contained office rooms and a gym designated for residents’ use. Staff interviews revealed that the Executive Director and General Manager are responsible for ensuring that employees complete the required on-boarding documentation, training, criminal record clearance and association requirements prior to providing care and supervision to residents. A review of the Guardian system check revealed that all volunteers had a fingerprint clearance. The LPA observed Nurse #1 (N1), an individual employed by Unlimited Home Health, utilizing a room on the second floor. LPA requested documentation verifying criminal record clearance and/or association to the facility. General Manager, Nancy Aguirre, was not able to provide these documents and explained that they were not aware that it was required. LPA explained to facility staff explained that all individuals who have access to residents are required to have the appropriate criminal record clearance and association to the facility, regardless of whether the individuals are directly employed by the facility. Regarding S1, records revealed that the individual was eligible to work when hired on 10/2025 but was removed from all duties upon the facility’s receipt of an ineligible notice on 02/2026. Regarding S2, a review of records revealed that S2 was not eligible to work due to a pending exemption process. On-boarding documentation further revealed that S2 was hired in June 2023 and worked as the Dietary Director for approximately eight (8) months. The LPA also identified that Staff #3 (S3) was hired on 04/07/2026 but was not associated to the facility in the Guardian system until after the LPA’s initial visit on 04/30/2026. The RP also presented additional concerns that were not related to applicable Title 22 regulations. The LPA explained that those concerns would not be addressed as part of this complaint investigation. Continued on LIC 9099-C Continued from LIC 9099-C Based on observations, documentation and interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Licensee allows uncleared staff to provide care to residents” is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited at this time (refer to LIC 9099-D) with $1,100 civil penalties. Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report, civil penalties and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 29-AS-20260424153846

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1-4) · Plan of correction due date: Aug 14, 2026

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: 1-4. This requirement is not met as evidenced by: Based on record review, and interviews, licensee did not comply with the above section by not ensuring that all individuals that have direct access/contact to residents had a fingerprint clearance,were associated to the facility and/or had an approved excemption, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: All volunteers were associated to the facility. Staff #2 is not longer an employee at this facility. Staff #3 was recently associated to the facility. The ED agreed to provide a statement of understanding regarding regulation 87255(e)(1-4) and implement a plan to ensure that all... ... individuals renting office space on the second floor, as well as volunteers participating in the Path Point Program, have the required fingerprint clearance and are properly associated to the facility.

Allegation investigated: Staff do not ensure that residents’ colostomy bag care is being properly maintained

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit regarding the above noted allegation. Upon arrival, LPA was greeted by front desk staff. LPA then met with Sales Director Ty Hanson. Entrance interview conducted. During today’s visit, LPA interviewed five (5) staff and one (1) family member from 10:37AM to 11:45AM, and from 12:44PM to 03:54PM. LPA conducted a tour of the facility with Sales Director at 12:16PM. During an initial visit conducted on 05/13/2026, LPA conducted interviews with four (4) staff from 10:44AM to 04:35PM, toured the facility with staff at 04:40PM, and LPA reviewed and obtained copies of documents relevant to the investigation. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted additional interviews with staff and other relevant parties. The following was then determined: Report Continued on LIC 9099-C Substantiated The complaint alleges that Resident #1 (R1)’s colostomy care needs are not being met. Interview with staff revealed that at the time of the complaint, care staff had not been trained on colostomy care. Since the care staff had not been trained on emptying the bag, they were not assisting R1 in emptying their colostomy bag. Staff indicated that R1, who resides in the memory care unit, can at times empty their own colostomy bag, but is not consistently able to do so. When R1’s colostomy bag would get full, staff would inform R1’s home health provider and if the nurse was available, she would come out to change the bag. Previously, there had been a home health nurse visiting daily, however at the time of the complaint, home health was regularly able to visit three (3) times a week. No home health care plan was available to review for R1. Staff also indicated that if needed, R1’s family member can change R1's colostomy bag if the home health provider was not available, but there were times when neither the family member nor home health were available to change the bag and the facility staff had to seek emergency medical treatment for R1. Record review revealed R1 had been seen at the hospital and was discharged on 10/09/2025 with colostomy care instructions. This document states “empty your bag at bedtime…and whenever it is one-third to one-half full. Do not let the bag get more than half-full with stool or gas.” Interview revealed R1’s home health provider is not visiting the facility to empty R1’s colostomy bag before bedtime, as ordered. Instead, home health would come to the facility when requested, as the home health nurse’s availability allowed. Staff interviewed stated the staff did not empty R1’s colostomy bag before bedtime, as they had not been trained. Interview with staff and witness revealed that R1’s colostomy bag was not emptied regularly, but was changed by the home health nurse when it was observed to be well over half-full, when R1 would begin picking at it, or when it had been dislodged from the stoma site. Based on observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation 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 LIC 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 12, 2026 · control 29-AS-20260506152647

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87621(b)(1) · Plan of correction due date: Aug 26, 2026

87621 Colostomy/Ileostomy (b) In addition to Section 87611(b), the licensees shall be responsible for the following: (1) Ensuring that ostomy care is provided by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 was admitted to the facility with a colostomy, no home health care plan addressing colostomy care, nor staff training related to colostomy care, which posed a potential health & personal rights risk to R1.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: Facility conducted a colostomy training with a medical professional on 07/03/2026. Designee will send a statement indicating a tentative schedule for ongoing staff training. Additionally, designee will obtain and send a copy of a complete home health plan for R1 to CCL by POC due date.

Allegation investigated: Licensee/Administrator does not ensure there is sufficient staff to meet the needs of residents

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit regarding the above noted allegation. Upon arrival, LPA was greeted by front desk staff. LPA then met with Executive Director (ED) Stephani Smith at 10:23AM. Entrance interview conducted. During today’s visit, LPA conducted interviews with four (4) staff and ED from 10:23AM to 01:20PM and LPA reviewed and obtained copies of pertinent documents. During an initial complaint visit conducted on 05/13/2026, LPA conducted interviews with five (5) staff from 02:12PM to 04:35PM, toured the facility with staff at 04:40PM, and LPA reviewed and obtained copies of documents relevant to the investigation. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated It was alleged that management does not schedule a sufficient number of staff to meet the resident needs in an attempt to save money. LPA reviewed staffing schedules and the personnel report for the facility. Both documents indicated a minimum of three (3) care staff in the Assisted Living unit and three (3) care staff in the Memory Care unit during both the am and pm shift. Additionally, there is a medication technician scheduled in Assisted Living and one (1) scheduled in Memory care on both shifts. The overnight shift consists of one (1) shared medication technician and between three (3) to four (4) caregivers. Interviews revealed the schedule does show sufficient coverage, but there are staff who regularly call out. All staff and management interviewed indicated the schedule recently changed to better meet the resident needs, which includes staff shifting their weekday schedules to ensure weekend coverage. Additionally, management has been working on hiring and training additional staff. During today’s visit, there were four (4) caregivers working on each side of the building and an additional staff was being trained. Staff interviewed stated that three (3) or four (4) caregivers during the am shift and pm shift is sufficient to meet the needs of residents in care. Currently management is scheduling four (4) caregivers to ensure adequate coverage even in the event staff call out. 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. No citations issued. Exit interview was conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 28, 2026 · control 29-AS-20260511145227

Allegation investigated: Staff handle resident roughly causing injury. Staff do not treat resident with dignity or respect.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility. At 10:24 a.m., the LPA met with Interim Executive Director (ED) Stephani Smith and explained the reason for the visit. During the initial visit on 01/21/2026 between 9:30 a.m. and 12:16 p.m., LPA Peraldi conducted a brief physical plant tour and interviews with the Executive Director (ED) at the time, Kenneth "Ken" Mahler and one (1) staff. During a subsequent visit on 01/29/2026, LPA Peraldi conducted interviews with five (5) staff. During a second subsequent visit on 02/12/2026, between 9:52 a.m. and 11:56 a.m., the LPA conducted interviews with the ED, six (6) staff and two (2) residents. In addition, during another visit conducted on 03/18/2026, between 10:00 a.m. and 3:10 p.m., LPAs Peraldi and Barutyan conducted a brief physical plant tour and interviews with the Interim ED and two (2) residents. During all visits, the LPA reviewed and obtained copies of pertinent documents. Continued on LIC 9099-C. Substantiated Regarding the allegation: Staff handle resident roughly causing injury. On 01/20/2026, it was alleged that Individual #1 (I1) handled Resident #1 (R1) in a rough manner causing bruising on R1’s arm. Record review revealed that R1 requires full assistance for bathing, dressing, transferring and toileting. Interviews with R1 revealed that Individual #1 handled R1 in a rough manner when assisting R1 with getting out of bed. R1 described how I1 handled R1’s arm in an aggressive manner and squeezed R1’s arm causing R1’s arm to bruise. During the course of the investigation, the LPA was provided with pictures of R1’s bruised arm. Interviews with the ED at the time, revealed that I1 was not staff and instead was a staffing agency staff that only worked for a few days, no exact dates were provided. Interviews with staff revealed no witnesses to the incident involving I1 handling R1 in a rough manner, however staff stated that R1 is alert and can verbalize when issues arise. Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Staff handle resident roughly causing injury” is deemed Substantiated at this time. 2.) Staff do not treat resident with dignity or respect. It was alleged that Staff #1 (S1) told R1 that if R1 were to walk away and fall, that S1 will not help R1. When interviewed on two separate dates, R1 revealed consistent statements and descriptions of the interaction between R1 and S1. Interviews with R1 revealed that in January 2026, R1 was trying to get out of bed and S1 told R1 if R1 does not listen to S1 and if R1 walks away and falls that S1 is not going to help R1. R1 did fall on 01/08/2026 and was sent to the hospital, no fractures were noted. However, R1 discharge diagnosis was listed as sacral contusion and left hip pain. Interviews with S1 denied the allegation. Interviews with staff and R1 revealed that S1 is no longer assigned to assist R1. R1 stated that R1 does not want S1 to assist with their care needs. Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Staff do not treat resident with dignity or respect.” 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). Civil Penalties issued for the total amount of $500. The Interim ED was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted with Interim Executive Director (ED) Stephani Smith. A copy of the report and appeal rights were provided. Regarding the allegation: 1.) Staff left resident in soiled clothing/linens for an extended period of time. It was alleged that R1 would be left in soiled clothing. Interviews with R1 did not reveal any concerns regarding being left in soiled clothing for extended periods of time. R1 stated that when R1 calls for assistance staff respond within a few minutes. Interviews with staff did not reveal any concerns regarding R1’s incontinence care. 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, Apr 24, 2026 · control 29-AS-20260120130811

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 27, 2026

Personal Rights of Residents in All Facilities (b) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement is not met as evidenced by: Based on interviews, the Licensee did not comply with the section cited above as, R1 was handled in a rough manner by Individual #1 which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Apr 24, 2026

Plan of correction: Interim ED stated that an inservice will be held regarding the regulation. Civil Penalty issued for the amount of $250 for repeat violation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 27, 2026

87468.1(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...This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as S1 did not treat R1 with dignity and respect which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2026

Plan of correction: Interim ED stated that an inservice will be held regarding the regulation. Civil Penalty issued for the amount of $250 for repeat violation.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management visit in conjunction with Complaint # 29-AS-20260120130811. At 10:24 a.m., the LPA met with Interim Executive Director (ED) Stephani Smith and explained the reason for the visit. Entrance interview conducted. Throughout the complaint investigation, the LPA conducted a record review of Resident #1 (R1’s) documents and noted that R1 had a fall on 01/08/2026. Per discharged paperwork, R1 had a fall on 01/08/2026 and was sent to the Emergency Room (ER). No fractures were noted, however, R1 discharge diagnosis was listed as sacral contusion and left hip pain. The Executive Director (ED) at the time, Ken Mahler did not send an incident report regarding R1’s fall. 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, Apr 24, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 24, 2026

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as the ED at the time, did not report to the Department R1’s fall which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2026

Plan of correction: Interim ED stated that she will submit a statement of understanding regarding the regulation.

Allegation investigated: Staff do not ensure that outside vendors are not video recording/taking pictures of residents in care.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:30 a.m., the LPA met with Sales Director (SD) Ty Hanson and explained the reason for the visit. During today’s visit the LPA conducted a brief physical plant tour, and interviews with the Interim Executive director (ED) Stephani Smith and Activity Director (AD). The LPA also conducted a file review and obtained copies of pertinent documents. Continued on LIC 9099-C. Substantiated Regarding the allegation: 1.) Staff do not ensure that outside vendors are not video recording/taking pictures of residents in care. It was alleged that an outside vendor hired by the facility took videos of residents and posted it on social media without consent from the residents. The complainant is alleging that the videos posted are a privacy violation towards residents. Interview the Activity Director (AD), Sarina Espinosa confirmed that an outside vendor did perform at the facility on February 26th, 2026. Interview with AD revealed that majority of residents have signed consent forms for photographs. The AD explained that the vendor reached out to them to perform, as the vendor had already performed at the facility’s other location. The AD explained that she did not sign the vendor’s disclaimer regarding residents being recorded and the possibility of the videos being uploaded to the vendors social media accounts. The LPA reviewed the vendor’s social media, specifically Instagram and noted that the vendor posted six (6) videos of their performance at the facility since February 27th, 2026. The videos are of the vendor singing and dancing with residents. In the videos, the vendor is singing inappropriate jokes. One video posted on March 4, 2026, the vendor said the following “We moving we grooving falling and bruising” and “Got pain all in ur neck? In ur back? In your crack?” The AD stated that the residents appeared to be enjoying the performance. The AD and Interim ED were not aware that the videos of the performance and residents were posted onto the vendors social media accounts. The LPA had a conversation with the AD regarding personal rights and appropriate entertainment for the residents. The AD stated that going forward she will ensure that all outside vendors are appropriate for the residents. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff do not ensure that outside vendors are not video recording/taking pictures of residents in care” 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). Exit interview conducted with Interim Executive Director (ED) Stephani Smith. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 29-AS-20260403130014

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 10, 2026

87468.1(a) (3)Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities... (3)To be free from punishment, humiliation... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as the facility staff did ensure that residents were free from humiliation as an outside vendor posted videos of the residents online which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: The AD will submit a statement of understanding and ensure that all activities and entertainment are appropriate.

Allegation investigated: Staff do not have proper training.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility. At 9:30 a.m., the LPA met with Sales Director (SD) Ty Hanson and explained the reason for the visit. During the initial visit on 10/28/2025 between 10:30 a.m. and 4:05 p.m., LPAs Peraldi and Barutyan conducted a physical plant tour and interviews with the Executive Director (ED) at the time, Kenneth "Ken" Mahler, eight (8) staff and two (2) residents. During a subsequent visit on 02/12/2026, LPA Peraldi conducted interviews with ED Ken Mahler, six (6) staff and two (2) residents. During both visits, the LPA reviewed and obtained copies of pertinent documents. During today’s visit, the LPA reviewed personnel records. Continued on LIC 9099-C. Substantiated Regarding the allegation: Staff do not have proper training. It was alleged that caregivers are not properly trained on how to use a Hoyer lift. Interviews with staff conducted on 10/28/2025 revealed that four (4) out of eight (8) staff stated that they did not receive formal or proper training on how to use a Hoyer lift. Two (2) out of eight (8) staff interviewed revealed that they did receive proper training from a hospice agency but that it was a long time ago and that newer employees have not received training from an outside vendor on how to properly use a Hoyer lift. The LPA spoke with the Interim ED regarding Hoyer lift training and inquired if there are residents that require the usage of a Hoyer lift. The Interim ED stated that Regency does not accept residents who require a Hoyer lift and currently there are no residents who require the Hoyer lift. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff do not have proper training” 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). Exit interview conducted with Interim Executive Director (ED) Stephani Smith. A copy of the report and appeal rights were provided. Regarding the allegations: 1.) Staff placed resident in the secured memory care unit without proper authorization. It was alleged that a resident was placed in the Memory Care (MC) unit due to the Assisted Living (AL) unit being full. Record review of the resident census and roster did not confirm or match the name given by the complainant. Interview with the ED at the time, Ken Mahler revealed that once a resident is showing signs of dementia or similar behaviors, discussions are held with the residents and responsible party to go over options such as Memory Care (MC). The ED stated that there are a few residents that go to the MC side during the day but return to their rooms in the AL to sleep. Per record reviews and staff interviews, the LPA could not determine which resident is in the MC due to AL being full. Additionally, the complainant did not provide additional information regarding the 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. 2.) Staff pinched resident in care. 3.) Staff covered resident's mouth with a piece of clothing. It was alleged that Staff #1 (S1) pinch residents and cover residents mouths with a piece of clothing. Four (4) out of thirteen (13) staff interviewed stated that they heard about S1 pinching and covering residents’ mouths with clothing but they did not directly witness it. However, staff interviewed revealed that they have witnessed S1 be aggressive and rude towards residents. The LPA cited for S1 not according residents with dignity under a Case Management Deficiencies visit on 04/09/2026. 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 with Interim Executive Director (ED) Stephani Smith. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 29-AS-20251021124839

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87613(a)(2) · Plan of correction due date: Apr 10, 2026

87613(a)(2)General Requirements for Restricted Health Conditions (2)Ensure that facility staff complete training provided by a licensed professional…training shall be completed prior to the staff providing services to the resident. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as staff assist residents with a hoyer lift prior to getting training by a skilled professional, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: The Interim ED stated that the facility is no longer accepting residents who require a hoyer lift. Currently no residents require a hoyer lift.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management visit in conjunction with Complaint # 29-AS-20251021124839. At 9:30 a.m. he LPA met with Sales Director (SD) Ty Hanson and explained the reason for the visit. Entrance interview conducted. During complaint visits conducted on 10/28/2025, 02/12/2026 and 03/11/2026, the LPA conducted interviews with a total of 15 staff. Complaint # 29-AS-20251021124839 had allegations regarding Staff #1 (S1) pinching and covering residents mouths with clothing. Four (4) staff interviewed stated that they heard about S1 pinching and covering residents’ mouths with clothing, but they did not directly witness it. However, staff interviewed revealed that they have witnessed S1 be aggressive and rude towards residents. On 03/16/2026, the facility sent a Report of Suspected Dependent Adult/ Elder Abuse (SOC 341) to the Department regarding S1 being suspended and terminated on 03/16/2026 as it reported that S1 spoke to residents in a disrespectful and unprofessional manner. 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, Apr 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 10, 2026

87468.1(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...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as S1 was observed to be rude or aggressive towards residents which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: The interim ED stated that S1 was terminated on 03/16/2026. Additionally the interim ED conducted an Inservice regarding reporting requirements and personal rights.

Allegation investigated: Facility staff do not respond to residents call buttons in timely manner. Facility staff are not dispensing medication as prescribed. Facility staff did not seek timely medical attention for resident in care. Facility staff do not ensure resident's hygiene needs are met.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility. At 1:20 p.m., the LPA met with the Interim Executive Director (ED) Stephani Smith and explained the reason for the visit. During the initial visit on 03/27/2025 between 12:30 p.m. and 2:35 p.m., LPAs Peraldi and Barutyan conducted a physical plant tour and interviews with the ED, three (3) residents and one (1) staff. During today’s visit starting at 1:36 p.m., the LPA conducted a physical plant tour and interviewed the Interim ED and five (5) staff. During both visits, the LPA reviewed and obtained copies of pertinent documents during the visit. Continued on LIC 9099-C. Substantiated Regarding the allegation:1.) Facility staff do not respond to residents call buttons in timely manner. It was alleged that Resident #1 (R1) had waited for more than 30 minutes to get assistance, leading to R1 being left in soiled clothing. The LPA was provided with pictures dated 12/29/2024, of R1 being left in soiled diaper and clothing. During the time of R1 being left in soiled diapers, it was brought up to the Wellness Director (WD) at the time, Gloria Morales and the ED at the time, Ken Mahler. Interviews conducted with staff revealed that during the time of the complaint, there were staff shortages and response times were longer than 20 minutes. Interviews with staff confirmed that R1 had been left in soiled pull ups on occasions. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff do not respond to residents call buttons in timely manner” is deemed Substantiated at this time. 2.) Facility staff are not dispensing medication as prescribed. It was alleged that facility staff were not properly assisting Resident #1 (R1) with their medication, as R1’s medication was found on the floor multiple times. During the initial visit, the LPA could not conduct a medication audit for R1, as R1 no longer resided at the facility. The LPA requested R1’s medication records. Per record review, on 12/26/2024, R1’s physician ordered R1 to start taking Macrobid 100 mg (twice daily for 7 days) and Phenazopyridine 200 mg (three times daily for 5 days). On 12/27/2024, it was noted on R1’s medication pass history that R1 only took Macrobid 100 mg once and Phenazopyridine 200 mg twice. The medication pass history did not document the reason for the missed medications. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff are not dispensing medication as prescribed” is deemed Substantiated at this time. The same deficiency was cited for another complaint on 03/26/2026 therefore it will not be duplicated on this complaint. 3.) Facility staff did not seek timely medical attention for resident in care. It was alleged that during December 2024, R1 was not receiving timely medical attention which resulted in the hospitalization of R1. Per record review, on 12/27/2024, R1’s physician ordered “Urgent Home Health (HH) order to administer suppository and blood sugar checks” as well as “blood sugar checks once daily in the morning before breakfast.” During the initial visit, LPA Peraldi conducted a file review of R1’s records. There were no HH documents or plan of care for R1. Interviews with the previous ED and WD revealed that they were not aware of R1 needing HH in December 2024. Interview with R1’s family member revealed that they believed R1’s blood sugar was not getting checked. Continued on LIC 9099-C. R1 was sent to the hospital soon after (no specific date or reason was provided) and returned to the facility on 01/22/2025 under hospice. The facility did not produce proof that R1 was getting their blood sugar check per physician order. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff did not seek timely medical attention for resident in care” is deemed Substantiated at this time. 4.) Facility staff do not ensure resident's hygiene needs are met. It was alleged that R1’s hygiene needs were being neglected as R1 did not receive assistance with showers. The LPA was provided with text messages and pictures of R1’s hygiene concerns from 2024. The text messages demonstrate R1’s hygiene concerns being brought to the WD at the time and no direct response was given to R1’s family. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff do not ensure resident's hygiene needs are met” 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). The Interim ED was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. Regarding the allegation: 1.) Facility staff do not keep resident rooms clean and orderly. During physical plant tours, the LPA observed multiple resident rooms and restrooms which appeared clean. Interviews with staff and interim ED explained that there are three (3) housekeepers, one (1) for the Memory Care (MC) side and another for the Assisted Living (AL) side, and another part time housekeeper. Interviews with housekeepers revealed that they have a schedule and are assigned to clean different rooms each day. Housekeeping staff explained that each resident room gets cleaned once a week or as needed. Interviews with residents during the time of the complaint did not reveal any concerns regarding the cleanliness of their rooms and facility. 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, Mar 26, 2026 · control 29-AS-20250325145942

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(2) · Plan of correction due date: Mar 27, 2026

87625(b)(2) Managed Incontinence...the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as they did not ensure R1’s incontinence was properly managed, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: The Interim ED will conduct an in-service training with all staff regarding regulation 87625 Managed Incontinence. Submit proof to the LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 27, 2026

87465 (a)A plan for incidental medical and dental care shall be developed…(1) The licensee shall arrange...medical and dental care appropriate to the conditions&needs of residents.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as the Licensee failed to seek medical attention in a timely manner to R1 which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: The Interim ED will conduct an in-service training with all staff regarding regulation Submit proof to the LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Mar 27, 2026

(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...indicated in the pre-admission appraisal, with those activities of daily living such as dressing,... bathing... This requirement is not met as evidenced by Based on interviews, licensee did not comply with the above section by not providing R1 basic services such as bathing and grooming which poses potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: The Interim ED will conduct an in-service training with all staff regarding regulation. Submit proof to the LPA.

Allegation investigated: Staff did not assist resident(s) with self-administration of medications as prescribed.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 1:00 p.m., the LPA met with the Interim Executive Director (ED) Stephani Smith and explained the reason for the visit. During today’s visit starting at 1:36 p.m., the LPAs conducted a physical plant tour and interviewed the Interim ED, and five (5) staff. At 2:03 p.m., the LPA reviewed and obtained copies of pertinent documents during the visit. Continued on LIC 9099-C. Substantiated Regarding the allegation: Staff did not assist resident(s) with self-administration of medications as prescribed. It was alleged that Resident #1 (R1) was not receiving their medication of Vesicare, 5mg tablet (take 1 tab every day) as prescribed by physician. Per record review, R1’s Vesicare 5mg tablet is not documented on R1’s current centrally stored medication and destruction record (CSMDR). Additionally, on 03/11/2026 LPA Peraldi audited R1’s medications and did not observe Vesicare 5mg tablet in R1’s medication. On 03/11/2026, LPA Peraldi reviewed R1’s CSMDR and Vesicare 5mg tablet was not documented. The LPA was unable to determine when R1 was first prescribed Vesicare 5mg tablet, however R1 was not given Vesicare 5mg tablet until 03/19/2026. Based on observation and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff did not assist resident(s) 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 Interim 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, Mar 26, 2026 · control 29-AS-20260325153239

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 30, 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 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, Mar 26, 2026

Plan of correction: Pharmacy will audit medications, as well at the Interim ED. The Interim ED will send proof of audit. Civil Penalty issued for the amount of $250 for repeat violation.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Emily Peraldi and Angela Barutyan conducted an unannounced Case Management - Other inspection. At 10:15 a.m., the LPAs met with Regional Director of Operations (RDO) Lisa To and Interim Executive Director (ED) Stephani Smith and explained the reason for the visit. The reason for today's inspection is to follow up on the facility’s change of management. The LPAs had conversations with both RDO To and Interim ED Smith regarding the change of management transition, including their plans of managing residents’ care, staffing, and current open complaints. The RDO and Interim ED explained that they are reviewing and auditing resident and staff records and meeting with residents, families, and staff. They are currently working on filling any management vacancies, including the Wellness Director position. No immediate health and safety concerns were observed or noted. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 18, 2026

Allegation investigated: Facility staff did not ensure resident receives prescribed medication.

Licensing Program Analysts (LPA) Emily Peraldi and Quoc Huynh conducted an unannounced subsequent complaint visit to this facility. At 10:15 a.m., the LPAs met with the Executive Director (ED) Ken Mahler and explained the reason for the visit. During today’s visit starting at 10:18 a.m., the LPAs conducted a physical plant tour and interviewed the ED, four (4) residents and three (3) staff. At 11:36 a.m., the LPAs reviewed and obtained copies of pertinent documents. Between 4:43 p.m. and 5:54 p.m., the LPAs conducted a review of medication and medication documentation with staff for six (6) residents. Continued LIC 9099-C. Substantiated Regarding the allegation: Facility staff did not ensure resident receives prescribed medication. It was alleged that staff did not assist residents with their medication on time and multiple missed medications. During today’s visit, the LPAs conducted a review of resident medication and documentation with staff for six (6) residents. Resident #1 (R1’s) Droxidopa 100MG tablet instructed for 1 capsule orally 3 times a day had zero (0) capsules remaining with no refills, meaning R1’s evening medication was missed. Staff stated that medication was ordered today, however they do not have an expected delivery date. Resident #2 (R2’s) Docusate Sodium 100MG instructed for 1 tablet daily with start date of 03/03/2026 and on 03/06/2026 tablet was not administered, no explanation given. The ED stated that he 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, “Facility staff did not ensure resident receives prescribed medication” 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). The ED was informed that failure to correct 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, Mar 11, 2026 · control 29-AS-20260303093047

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 12, 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 & R2'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, Mar 11, 2026

Plan of correction: Within 24 hours, the ED will notify the LPA when medication training will be completed. Training will be conducted by a credited training vendor.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff neglect led to hospitalization of resident. Staff did not seek timely medical care for resident. Staff leaves resident in soiled diapers.

Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit for the purpose of delivering findings. At 9:30 a.m., LPA Peraldi met with staff and explained the reason for the visit. At 11:24 a.m., the LPA spoke with Executive Director (ED) Kenneth "Ken" Mahler via telephone call. The Department received a complaint on 01/28/2025 and a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). During the initial visit conducted on 1/28/2025, between 2:19 p.m. and 4:10 p.m., LPA Peraldi conducted a physical plant tour and interviews with the ED, and one (1) staff. During a subsequent visit conducted on 3/21/2025, between 09:58 a.m. and 2:51 p.m., LPA Peraldi conducted a physical plant tour, reviewed records and conducted interviews with the ED, five (5) residents, and nine (9) staff. During the subsequent visit 01/29/2026, the LPA conducted interviews with five (5) staff. During all visits, the LPA also obtained copies of pertinent documents. Continued on LIC 9099-C. Unsubstantiated Regarding the allegations: 1.) Staff neglect led to hospitalization of resident. 2.) Staff did not seek timely medical care for resident. It was alleged that Resident #1 (R1) was hospitalized for pneumonia, urinary tract infection (UTI) and dehydration due to staff neglect. The complainant also alleged that R1 was constantly dehydrated and that staff would not bring water to R1 unless R1 asked for it. Per record review, R1 was admitted to the facility’s memory care (MC) on 12/22/2021 and resided at the facility until 02/08/2025. Per an Unusual Incident/ Injury Report dated 01/28/2025, R1 was hospitalized on 01/26/2025, due to care staff hearing R1 making gurgling sounds and having a hard time swallowing food. LPA Peraldi subpoenaed R1’s medical records and conducted a file review. Per R1’s medical records, R1 was admitted to the hospital with the diagnosis of acute hypoxic respiratory failure, multifocal pneumonia and severe sepsis. R1 was eventually discharged back to the facility with hospice services on 02/04/2025 with the terminal diagnosis of cerebral atherosclerosis. A review of R1’s medical records and hospital progress notes revealed no indication or evidence of staff neglect or lack of timely medical care that would have led to R1’s medical conditions/ hospitalization. Per R1’s Social Service Documentation from a Medical Social Worker (MSW) dated 01/28/2025, R1’s Power of Attorney (POA) was made aware of the above allegations and R1’s POA did not have any current concerns regarding R1’s safety. Furthermore, the MSW educated R1’s POA on community resources available should there ever be a concern of R1’s safety or care. In addition, an interview conducted with Staff #1 (S1) revealed that care staff are trained to identify if a resident is not at their baseline and needs medical attention, which is why R1 was sent to the hospital. Based on information obtained during the investigation, there is insufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time. 3.) Staff leaves resident in soiled diapers. It was alleged that staff do not change R1’s diapers or clothing. Per staff interviews, incontinence care is done every two (2) hours and before each shift leaves, staff do their last rounds and check on residents. The facility does not document progress notes of residents in their file. Resident interviewed did not reveal concerns regarding the above allegation. The information obtained during the investigation did not include sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time. Exit interview conducted with staff, Lily R. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 28, 2026 · control 29-AS-20250128121119

Allegation investigated: Staff do not ensure that resident hygiene needs are met.

Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit for the purpose of delivering finding. At 9:00 a.m., LPA Peraldi met with Executive Director (ED) Kenneth "Ken" Mahler and explained the reason for the visit. The Department received a complaint on 01/28/2025 and a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). During the initial visit conducted on 1/28/2025 between 2:19 p.m. and 4:10 p.m., LPA Peraldi conducted a physical plant tour and interviews with the ED, and one (1) staff. During a subsequent visit conducted on 3/21/2025 between 09:58 a.m. and 2:51 p.m., LPA Peraldi conducted a physical plant tour, reviewed records and conducted interviews with the ED, five (5) residents, and nine (9) staff. During all visits, the LPA also obtained copies of pertinent documents. During today’s visit the LPA conducted interviews with five (5) staff. Continued on LIC 9099-C. Substantiated 3.) Staff do not ensure that resident hygiene needs are met. It was alleged that R1’s hair would be greasy. Interviews with two (2) staff confirmed that R1 was observed with greasy hair on multiple occasions and staff would bathe and groom R1 even if R1 was not assigned to them. Based on the information provided by interviews, the preponderance of evidence standard has been met, therefore the above allegation 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). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 29-AS-20250128121119

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Feb 6, 2026

(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...indicated in the pre-admission appraisal, with those activities of daily living such as dressing,... bathing... This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the above section by not providing R1 basic services such as bathing and grooming which poses potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: ED stated that he will conduct an in-service training regarding the above regulation.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Emily Peraldi and Anegla Barutyan arrived at the facility unannounced to conduct a required annual visit. At 10:30 a.m., the LPAs met with Executive Director (ED) Ken Mahler and explained the reason for the visit. RECORD REVIEW: Between 11:05 a.m. and 2:00 p.m., the LPAs conducted a file review for ten (10) residents and eight (8) staff. Resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order. Disaster drill was last conducted on 12/29/2025. Administrator certificate is current and valid until 10/18/2027. The LPAs obtained a copy of the liability insurance, resident roster and staff roster. At 1:28 p.m., LPA Barutyan along with the ED conducted a physical plant tour to ensure there are no health and safety hazards. During the physical plant tour, the LPA conducted interviews with five (5) residents and no concerns were noted. The facility consists of one (1) memory care unit (MC), and an assisted living unit (AL). The memory care unit is secured with delayed egress doors which lead to secured outdoor patios. The second floor has no resident apartments but was observed to have a gymnasium for resident use, facility storage, and office space. KITCHEN: At 1:28 p.m., the LPA observed the kitchen and dining area. Knives are stored in the kitchen which remains inaccessible to residents. Kitchen appliances are in operable condition. The facility has a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was posted throughout the dining area. Snacks and beverages are available for residents. Continued on LIC 809-C. BEDROOMS: The LPA observed 10 randomly selected resident rooms throughout facility. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: The LPA observed restrooms in resident units and common area restrooms. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was tested throughout the visit and measured within the required range. COMMON AREAS: The LPA observed common areas to be relatively clean and properly furnished. The LPA observed the fire extinguishers throughout the facility to be fully charged and last serviced on 04/15/2025. The LPA observed required postings on the wall near the entrance and hallways. At 1:34 p.m., the LPA observed residents watching a movie in the theater room. The facility's smoke alarms are hard wired, and the facility is equipped with sprinkler system. During the time of the visit, the LPAs spoke with the ED regarding annual fire inspection, and he scheduled the fire inspection with Oxnard Fire Department for February 2026. OUTDOOR SPACE: The LPA observed the courtyards throughout the facility, which has a covered outdoor area for resident use. There are multiple emergency exits located throughout the facility. Passageways were free and clear from obstruction. There were no bodies of water noted. Due to time constraints the LPA will return to complete the annual at a later date. No deficiencies cited at this time. Exit interview conducted. A copy of the report of provided.the state’s words, verbatim · CDSS document, Jan 14, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff handled resident in a rough manner. Facility staff did not assess resident properly.

Licensing Program Analyst (LPA), Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 9:00 a.m., the LPA met with the Executive Director (ED), Kenneth “Ken” Mahler and explained the reason for the visit. During the initial visit conducted on 10/09/2025 between 10:30 a.m. and 1:00 p.m., LPA Peraldi conducted a physical plant tour and interviews with the ED, five (5) residents, and five (5) staff. During a subsequent visit conducted on 10/28/2025 between 10:30 a.m. and 4:05 p.m., LPA Peraldi and Barutyan conducted a physical plant tour and interviews with the ED, eight (8) staff and two (2) residents. On 10/28/2025, the LPAs conducted record review for Resident #1 (R1). During today’s visit, LPA Peraldi conducted an interview with R1 and one (1) staff. The LPA also obtained copies of pertinent documents during all visits. Continued on LIC 9099-C. Unsubstantiated Regarding the allegations: 1.) Facility staff handled resident in a rough manner. It was alleged that an unnamed resident, possibly, Resident #1 (R1) screams in the middle of the night and refuses to have their diapers changed and fights with the caregivers leading to the caregivers handling R1 in a rough manner. Interview conducted with R1 revealed that there are no concerns regarding staff treatment. Interview conducted with a night shift staff revealed that R1 can be difficult but that caregivers are trained to handle residents with behaviors and that night shift staff care greatly for all residents. Staff interviewed during both visits denied the allegation. Staff interviews revealed that staff are trained on how to assist residents with behaviors. Record review of staff training revealed that staff take online courses on Relias and staff have taken training courses of the following: Person-Centered Care in Assisted Living, Preventing, Recognizing and Reporting Abuse, Dementia Care: Managing Challenging Behaviors, and The Meaning Behind Behaviors. Interview with the ED denied the allegation and stated that his staff are trained properly on how to assist residents with aggressive behaviors. Interviews conducted with five (5) out of five (5) residents revealed that staff are helpful and have not handled them in a rough manner. Furthermore, none of the staff or residents interviewed during all visits corroborated the 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. 2.) Facility staff did not assess resident properly. It was alleged that an unnamed resident, possibly, Resident #1 (R1) requires a higher level of care and is a better fit in the Memory Care (MC) side as R1 screams all night. Record review of R1’s documents reveal that R1 does not have a dementia diagnosis and is responsible for themselves. Per record review, R1 moved into the facility on 05/07/2022 on the Assisted Living (AL) side. Upon admission, per preplacement appraisal R1 did not require assistance with bathing, dressing, grooming and transferring. R1’s service plan was last updated on 5/10/2025; per service plan, R1 needs full assistance with dressing, and grooming. Interview with the ED revealed that once a resident is showing signs of dementia or similar behaviors, discussions are held with the resident and responsible party to go over options such as Memory Care (MC). The ED explained that the decision is made by the residents and their family or the party responsible, not him. The ED explained that R1 is self-responsible and has no desire to move into MC. The ED explained that he cannot forcibly move R1 to MC. 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, Nov 13, 2025 · control 29-AS-20251008095504

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

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:00 a.m., the LPA met with the Executive Director (ED), Kenneth “Ken” Mahler and explained the reason for the visit. At 9:06 a.m., the LPA conducted an interview with the ED. At 9:13 a.m., the LPA requested and obtained copies of pertinent documents. Between 9:18 a.m. and 11:06 a.m., the LPA conducted interviews with five (5) staff and two (2) residents. At 10:10 a.m., the LPA, along with the ED conducted a physical plant tour. Continued on LIC 9099-C. Substantiated Regarding the allegation: Staff did not ensure facility was free from pests. On 11/04/2025, the Department received a complaint alleging that two (2) rooms had bed bugs. Interviews conducted with the ED and staff revealed bedbugs were observed in Rooms #145 and #146. Interviews with the ED and staff reported inconsistent dates of when the bed bugs were first observed. The ED explained that he was made aware of the bed bugs on 11/07/2025 and reached out to a pest control company the same day. Per record review and interviews with staff and the ED, Western Exterminator Company began “Bed Bug Heat Treatment” on 11/10/2025. The ED explained that the residents affected received new mattresses and cleaned bed sheets. The ED explained that the surrounding rooms were also inspected and sprayed to ensure that the bed bugs did not spread any further. Interviews with staff reported that they do regular room checks and if any bed bug activity is noticed they report it to management. The ED provided the LPA a copy of the invoice/ receipt of Western Exterminator Company dated 11/10/2025. Based on the information provided by interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation 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). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 29-AS-20251104153042

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Nov 14, 2025

87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times...safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews and records review, the licensee failed to comply with the section cited above as bed bugs were observed in two (2) resident rooms, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: On 11/10/25, the pest control company treated the rooms. The ED provided the invoice to the LPA. Plan of correction met. The ED stated that he will follow up and ensure that the bed bugs do not spread to other rooms.

Allegation investigated: Staff do not ensure infection control guidelines are being followed. Staff do not ensure care needs of resident are being met.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 10:30 a.m., the LPA met with staff and explained the reason for the visit. At 10:35 a.m., the Executive Director (ED) Kenneth "Ken" Mahler and Wellness Director Gloria Morales met with the LPA. During the initial visit conducted on 08/22/2024 between 9:58 a.m. and 1:30 p.m., the LPA conducted a physical plant tour and interviews with the ED, two (2) staff, and six (6) residents. During today’s visit, the LPA conducted a physical plant tour and interviews with the Wellness Director, two (2) staff and one (1) resident. The LPA also obtained copies of pertinent documents during both visits. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: 1.) Staff do not ensure infection control guidelines are being followed. It was alleged that during a potential Coronavirus disease (COVID-19) outbreak at the facility that the facility did not have any PPE for staff to wear when entering the residents rooms. Interview with the ED revealed that in August 2024, there were two (2) COVID-19 positive cases, one (1) staff and one (1) resident. The ED explained that the facility has sufficient amount of Personal Protection Equipment (PPE) such as gloves, mask and gowns. The ED explained that when a resident test positive for COVID-19, staff place a three (3) tier storage drawer filled with PPE outside the residents room along with a trash can to dispose of the used PPE. During the physical plant tours, the LPA observed sufficient amount of PPE at the facility. The Wellness Director, Gloria Morales explained that supplies, including PPE are ordered on a monthly basis. Additionally, the Wellness Director explained that staff get trained on infection control policies and procedures annually. 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. 2.) Staff do not ensure care needs of resident are being met. It was alleged that Resident #1 (R1’s) needs were not being met as staff would bring R1’s food tray when R1 was isolating and would leave it outside of R1’s door in which R1 was not able to reach down to the floor for the food. It was also alleged that the facility was not restocking adult diapers in a timely manner for R1. Interview conducted with R1 did not reveal any concerns regarding staff and R1’s care. Staff interviewed denied the allegations. Staff interviewed revealed that if residents require food trays to be brought to them, staff bring the food inside the rooms and next to the residents. The Wellness Director explained that R1’s family supplies adult briefs for R1 and that the facility provides extra adult briefs for R1 as needed. The LPA observed the facility to have additional incontinent supplies such as briefs for resident use. 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 with Wellness Director. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 29-AS-20240814093937

Allegation investigated: Staff did not seek timely medical care to resident in care. Staff did not ensure resident's room was kept free of ants. Staff did not ensure sufficient hygiene supplies were available at the facility to meet resident's care needs. Staff did not ensure resident's bedding was kept clean. Staff did not ensure residents were provided with sufficient food.

Licensing Program Analysts (LPAs) Emily Peraldi and Angela Barutyan conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 10:25 a.m., the LPAs met with staff and explained the reason for the visit. At 10:26 a.m., the Executive Director (ED) Kenneth "Ken" Mahler met with the LPAs. During the initial visit conducted on 03/12/2025 between 10:55 a.m. and 4:00 p.m., LPA Peraldi conducted a physical plant tour and interviews with the ED, nine (9) staff, and twelve (12) residents. During the physical plant tour, LPA Peraldi observed and inspected 22 randomly selected resident rooms throughout facility. During a subsequent visit conducted on 03/21/2025 between 9:55 a.m. and 3:35 p.m., LPA Peraldi conducted a physical plant tour and interviews with the ED, five (5) residents, and nine (9) staff. During today’s visit, the LPAs conducted a physical plant tour. The LPAs also obtained copies of pertinent documents during all visits. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: 1.) Staff did not seek timely medical care to resident in care. It was alleged that an unnamed resident had a fever in February 2025 and that staff did not seek medical treatment for the resident as the resident passed away on 02/27/2025 and complainant alleged that delay in medical care could be a factor. Per record review, only one (1) resident passed away on 02/27/2025, Resident #1 (R1). LPA Peraldi reviewed resident records for R1 and it was noted that R1 was admitted to the facility on 07/30/2021, was placed on hospice services on 07/11/2023, and had no record of hospitalizations during the alleged period. Interviews with staff and the ED did not reveal any concerns regarding staff not seeking timely medical care to residents as staff were aware of protocols and procedures and when to call emergency services. Record review revealed that on 02/25/2025, R1 had orders from their hospice agency to have daily nursing visits for five days for symptom management. Interviews with the ED and Wellness Director, Gloria Morales stated that R1 did not get hospitalized in February 2025. Due to lack of information provided by the complainant and lack of records of fevers or hospitalizations during the alleged period, 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. Regarding the allegation: 2.) Staff did not ensure resident's room was kept free of ants. It was alleged that an unnamed resident had ants on their body when staff would change their diaper. All staff interviews revealed that ants had not been observed on residents’ bodies or in residents’ rooms, however three (3) out of eighteen (18) interviews with staff revealed that they had heard of ants on a resident in the past. Specific details or time frames of the incidents could not be provided. During physical plant tours conducted on 03/12/2025, 03/21/2025 and 08/20/2025, the LPAs did not observe ants or insects inside resident rooms. 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. Regarding the allegations: 3.) Staff did not ensure sufficient hygiene supplies were available at the facility to meet resident's care needs. 4.) Staff did not ensure resident's bedding was kept clean. It was alleged that the facility had insufficient amount of basic hygiene supplies which led to residents having urine-soaked bedsheets. Interviews with staff revealed that families provide majority of incontinence and hygiene supplies, however, the facility does have a storage room which holds incontinence and hygiene supplies if needed. Continued on LIC 9099-C. The LPAs observed hygiene products supplied by residents/responsible parties stored in resident rooms. The LPAs also observed the storage room which had sufficient supplies of basic hygiene items such as diapers, bed pads, wipes, PPE, mattress covers, extra bed sheets, and disposable underwear. Interview with the ED revealed that the facility does provide hygiene and incontinence supplies if families do not provide it or if a resident’s supply runs out. During physical plant tours conducted on 03/12/2025, 03/21/2025 and 08/20/2025, the LPAs did not observe soiled bed sheets in resident rooms. All bed sheets and bed pads observed were clean and dry. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or are 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. Regarding the allegation: 5.) Staff did not ensure residents were provided with sufficient food. It was alleged that the facility provided inadequate amounts of food to residents in care. Seventeen (17) out of seventeen (17) residents interviewed did not express any immediate concerns regarding the quantity of the food or the food service. Eighteen (18) out of eighteen (18) staff interviews conducted did not reveal any immediate concerns regarding the quantity of food served. Interview with the Dietary Director revealed that the food delivery company, Sysco, deliveries large quantities of perishable and non-perishable foods once a week on Wednesdays. The Dietary Director explained that if the facility needs more food in between deliveries, the facility staff will call Sysco or go to the grocery store to get more food. During physical plant tours conducted on 03/12/2025, 03/21/2025 and 08/20/2025, the LPAs observed the facility to have sufficient amounts of perishable and non-perishable foods. The LPAs also observed a sufficient amount of snacks available for residents. 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 20, 2025 · control 29-AS-20250306091802

Allegation investigated: Due to lack of supervision, resident was pushed by another resident causing the resident to fall. Due to staff neglect, resident fell while being changed by staff causing the resident to sustain a bruise.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 11:15 a.m., the LPA met with staff and explained the reason for the visit. At 11:17 a.m., the Executive Director (ED) Kenneth "Ken" Mahler met with the LPA. During the initial visit conducted on 11/20/2024 between 10:00 a.m. and 1:20 p.m., the LPA conducted a physical plant tour and interviews with the ED, nine (9) residents, and five (5) staff. During a subsequent visit conducted on 02/25/2025 between 10:00 a.m. and 2:30 p.m., the LPA conducted a physical plant tour and interviews with the ED, three (3) residents, and eight (8) staff. During today’s visit, the LPA conducted a file review for Resident #1 (R1). The LPA also obtained copies of pertinent documents during all visits. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: 1.) Due to lack of supervision, resident was pushed by another resident causing the resident to fall. It was alleged that Resident #1 (R1) was pushed by another resident (name unknown) causing R1 to fall. Interviews conducted with staff on 11/20/2024 and 02/25/2025 denied witnessing another resident push R1. However, one (1) out of fifteen (15) staff interviewed, Staff #1 (S1) stated that they have witnessed R1 being pushed by Resident #2 (R2) causing R1 to fall. S1 stated that they do not recall when this occurred and that they reported the incident to management. Per record review, there was no documentation of the alleged incident. Interview with the ED denied the allegation and stated that it is rare that residents push each other. The ED explained that care staff are trained to redirect residents when a resident is aggressive. 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. Regarding the allegation: 2.) Due to staff neglect, resident fell while being changed by staff causing the resident to sustain a bruise. It was alleged that Resident #1 (R1) fell while being changed by staff causing a bruise on R1’s face in November 2024. Per Unusual Incident/ Injury Report dated 11/10/2024, on 11/06/2024, R1 fell off R1’s bed as two (2) caregivers were assisting R1 with dressing. Per the report, 911 was called and R1 was transported to the Emergency Room (ER). Per hospital records, R1 was admitted to the hospital from 11/06/2024 with the reason for admission listed as “fall and subdural hematoma” and was discharged on 11/12/2024. Per interviews with staff and record review, R1 was transferred and admitted to a Skilled Nursing Facility (SNF) on 11/12/2024 with the principal diagnosis of “Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter.” Per record review, R1 had a previous fall on 10/15/2024 in which R1 was hospitalized and had computed tomography (CT) scans due to R1 having a facial contusion from the fall. R1’s fall from October 2024 was the source of R1’s facial bruise, not from R1’s fall on November 6, 2024. Interviews with staff revealed that R1 would often make themselves fall or be uncooperative while staff assisted with R1’s Activities of Daily Living (ADL). The interview with the ED revealed that staff have been retrained on ADLs and in overall resident care. Concerns and deficiencies regarding R1’s care are being addressed with a Case Management Deficiencies report. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation as R1 already had a facial bruise from a previous fall. 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 14, 2025 · control 29-AS-20241113085831

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Emily Peraldi conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20241113085831). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation. At 11:15 a.m., the LPA met with staff and explained the reason for the visit. At 11:17 a.m., the Executive Director (ED) Kenneth "Ken" Mahler met with the LPA. During the complaint investigation of complaint # 29-AS-20241113085831, the following deficiencies was observed: Per record review, Resident #1 (R1) had multiple falls and hospitalizations between October 2024 and January 2025. The timeline of R1’s falls and hospitalizations are as follows: 10/15/2024 - R1 had a fall resulting in a left-sided facial contusion; 11/06/2024- R1 had a fall while two (2) caregivers were assisting R1 with dressing resulting in R1 having a subdural hematoma and being sent to a Skilled Nursing Facility (SNF); 12/25/2024- R1 was sent to the hospital due to being lethargic and returned with Home Health orders; 01/01/2025- R1 had a fall and was hospitalized. Per hospital records, R1 was admitted to the hospital on 11/06/2024 with the reason for admission listed as “fall and subdural hematoma” and was discharged on 11/12/2024. Per interviews with staff and record review, R1 was transferred and admitted to a Skilled Nursing Facility (SNF) on 11/12/2024 with the principal diagnosis of “Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter.” During a record review, the LPA did not observe an updated reappraisal for R1 after R1’s fall of 11/06/2024. R1 did have a reassessment/ reappraisal on 10/17/2024 after R1’s 10/15/2024 fall. Per the 10/17/2024 reappraisal/ care plan, R1 required “Complete Assist (x2 per day)” for dressing and “extensive assist” with bathing. Staff neglect led to R1’s basic services not being met and a fall on 11/06/2024 resulted in R1 having a subdural hematoma. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and Health and Safety Code 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, Aug 14, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 15, 2025

87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section as staff did not properly assist R1 while dressing which resulted in R1 falling, and sustaining injury which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: The ED stated that staff will be retrained on ADLs and will send proof. The ED will notify the LPA within 24 hours of when training will be completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Aug 22, 2025

87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary... whichever occurs first...appraisal shall be referred to as the reappraisal.This requirement is not met as evidenced by: Based on record review and observation, the licensee did not comply with the above cited section, as R1’s care plan was not updated as necessary after significant change in condition which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: The ED stated that the Wellness Director and Designee will be trained on reassessments and reappraisals and will send proof to the LPA.

Allegation investigated: Facility did not ensure that staff are trained.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 10:30 a.m., the LPA met with staff and explained the reason for the visit. At 2:00 p.m., the LPA spoke with Executive Director (ED) Kenneth "Ken" Mahler telephonically, as the ED was unavailable to meet the LPA. During the initial visit conducted on 5/15/2025 between 9:49 a.m. and 3:45 p.m., the LPA conducted a physical plant tour and interviews with the ED, two (2) residents, and two (2) staff. The LPA also obtained copies of pertinent documents. During today’s visit, between 11:11 a.m. and 2:20 p.m., the LPA conducted a file review of six (6) personnel files. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Facility did not ensure that staff are trained. It was alleged that medication technician (med techs) are “never trained to administer medications.” Per record review the following was noted: Five (5) out of six (6) med techs do have their annual eight (8) hours of medication related training completed, per Health and Safety Code1569.69(b). One (1) out of six (6) med tech has four (4) hours of medication related training completed and has another four (4) hours scheduled prior to their 12-month period ending. 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. The ED authorized staff, Ty Hanson to sign the report. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 21, 2025 · control 29-AS-20250514081250

Allegation investigated: Staff do not safeguard resident's personal belongings. Staff do not report incidents to appropriate parties.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 10:30 a.m., the LPA met with staff and explained the reason for the visit. At 2:00 p.m., the LPA spoke with Executive Director (ED) Kenneth "Ken" Mahler telephonically, as the ED was unavailable to meet the LPA. During the initial visit conducted on 5/15/2025 between 9:49 a.m. and 3:45 p.m., the LPA conducted a physical plant tour and interviews with the ED, two (2) residents, and two (2) staff. The LPA also obtained copies of pertinent documents. During today’s visit, the LPA conducted a file review for Resident #1 (R1). Continued on LIC 9099-C. Substantiated Regarding the allegations: 1.) Staff do not safeguard resident's personal belongings. 2.) Staff do not report incidents to appropriate parties. It was alleged that in December 2024, the amount of $670.00 dollars was stolen from Resident #1 (R1) and that the ED and Staff #1 (S1) were made aware of it and did not report it to the appropriate parties such as the local police, State Long-Term Care Ombudsman and Licensing. It was alleged that instead of reporting to the police, the ED replaced the $670.00 for R1. The LPA interviewed the ED who stated he does not know if R1’s money was stolen. The ED stated that he is not sure what happened to R1’s money and believes it was misplaced but decided to work with R1 and credited over the amount of $670.00 towards R1’s rent amount. The ED explained that R1 would keep the money in R1’s room but that after the alleged missing money, the ED holds R1’s money in the ED’s locked office. The ED admitted that he did not report R1’s missing money since he discussed and credited the missing money with R1. The LPA explained that the ED should have reported the missing money regardless of crediting R1’s balance towards rent per Health and Safety Code 1569.153. The ED stated that he filed a police report for R1’s money on 05/16/2025. Per record review, in January 2025, R1 was credited $248 and in February 2025, R1 was credited another $452 totaling a credit of $700.00 towards rent. Based on record review and interview, the preponderance of evidence standard has been met, therefore the above allegations, “Staff do not safeguard resident's personal belongings” and “Staff do not report incidents to appropriate parties” are deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and Health and Safety Code the following deficiency was observed and cited during the visit (See 9099-D). Exit interview conducted. The ED authorized staff, Ty Hanson to sign the report. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 21, 2025 · control 29-AS-20250509102647

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.153 · Plan of correction due date: May 30, 2025

1569.153 Theft and loss program; standards, property inventories... A theft and loss program shall be implemented by the residential care facilities for the elderly within 90 days...The program shall include all of the following: This requirement is not met as evidenced by: Based on interview, and file review the licensee failed to make reasonable efforts to safeguard R1’s cash resources and did not follow Theft and Loss Policy, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: The ED stated that he will do the following: 1. Have an in-service training with all staff, including the ED regarding the facility’s theft and loss policy. Submit training documentation to CCL by due date.

Allegation investigated: Facility staff did not shower resident per admission agreement.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent visit to deliver findings for the above allegation. The LPA met with Sales Director Ty Hanson, and and explained the reason for the visit. Administrator Ken Mahler was unable to be present during today's visit. On 04/18/2024, Licensing Program Analyst (LPA) Sandra Urena collected pertinent documents relevant to the investigation. On 03/17/25, LPA Cortez, interviewed seven (7) staff, three (3) residents and observed activities and lunch in Memory Care. On 04/24/25, LPA Cortez interviewed one (1) staff, three (3) residents, three (3) resident's family members and/or their authorized person, observed dinner in Memory Care, conducted a file review and collected pertinent documents relevant to the investigation. On 04/29/25, LPA Cortez conducted two (2) staff, one (1) resident, and two (2) resident family members interviews, observed resident activities, lunch and dinner being served. On 05/12/25, LPA Cortez interviewed six (6) staff, two (2) resident's family members, and observed lunch. On 05/202/25, LPA Cortez interviewed the Administrator telephonically.Report will continue on LIC9099-C-2nd page. Substantiated On the allegations, “Facility staff not meeting resident's incontinence care needs and Facility staff did not clean feces off baseboards in resident's room”; it is the concern of the reporting party that on 06/20/23, Resident #1(R1) had a bowel issue in the morning and that at 1:00 p.m. five hours later R1 was observed to be left with feces on their back, as well as on the base boards. RP further reported that Photos were submitted to the Department. One of the photo’s was a photo of the back of an individual without a shirt with brown streaks and a lump of what appears to be poop. The Photo does not have a date or time stamp. A second photo of what appears to be a yellow wall, and white baseboard with several brown stains was submitted. To investigate the allegation, the LPA conducted interviews with Staff, residents, and resident’s family members/authorized persons; however, the individuals were not present during the incident and therefore, could not offer sufficient information regarding whether it did or did not occur. Interviews with staff revealed that most of the staff that are currently in the Memory Care Unit of the community were employed within the past year, they were not at the facility in 2023, and that they check/change on residents every 2 hours or as needed. If staff notices rooms to be unkept they will clean them. Interview with a care giver in the MC unit that has been at the facility for about three years revealed that they do not have knowledge of any incident involving R1 having feces on them or their baseboards and further revealed that residents are changed right away. Interviews with family members revealed that they have witnessed residents in the common areas that appear to be soiled, they will let the staff know and staff will go change them, and although they can assume how long they have been soiled for based on their appearance they do not know how long residents were soiled for. Interviews with residents revealed that they do not have any concerns about the care being provided, with one resident stating that staff assist residents right away. Based on Interviews there is insufficient evidence to support the above allegations. Therefore, the allegations are being deemed Unsubstantiated at this time. Report will continue on LIC9099-C, 3rd page. On the allegation, “Facility staff not providing quality meals to residents”; it is the concern of the reporting party that the facility does not serve "senior friendly food," the food is always cold, and most residents are unable to hold it, cut it or chew it and that certain items are much too spicy. Residents interviewed revealed that they do not have any concerns regarding the food. On 03/17/25, 04/24/25, 04/29/25, and 05/12/25, the LPA observed lunch, or dinner or both and the LPA found the food items on the menu to be of good quality while served to residents. On those dates, the LPA observed residents eating by themselves and with staff’s assistance. The facility has a main kitchen in Assisted Living of the facility off the main dining room. The resident’s food in the Memory Care unit gets delivered in a food cart, usually about 20 to 30 minutes before it is lunch or dinner time. Then the food gets placed on a food steamer that is turned on to keep the food warm for the residents. There is also a microwave if the food needs to be heated more. Staff interviews revealed that they are aware of what residents can eat and which residents have dietary restrictions. The LPA was provided with pertinent documentation by the facility including a facility menu, meal schedule, and resident documentation relating to any dietary restrictions if applicable. Based on interviews and observations there is insufficient evidence to support the above allegations. Therefore, the allegation is being deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued. On the allegation of, “Facility staff did not shower resident per admission agreement,”; it is the concern of the reporting party that upon admission to the Memory Care Unit in March 2023, facility staff did not shower Resident #1 (R1) for the 1st 10 days R1 was there. RP also reported that “R1 was not on the (shower) schedule". Per R1’s Admission Agreement, signed and dated 3/3/23, pg. 30 Exhibit B under Care Fees “The Community utilizes a resident assessment form to help determine the individual’s functional capabilities, physical status, mental condition, and social factors and the amount of assistance an individual may need with activities of daily living. This tool is divided into categories (for example, bathing, dressing, eating, etc.) and each individual’s needs are evaluated for each category.” Based on R1’s Resident Assessment Form dated 03/09/2023, R1 scored 12 points in the bathing category which indicated that they required stand-by assistance for all showering/bathing needs (2x per week). Additionally, R1 had a score of zero (0) for Hospice and outside providers. Interview conducted with the Wellness Director on 04/24/25, revealed that when R1 was admitted to the facility, they were admitted on Hospice and R1 received showers from Hospice and not the staff and R1 was never on the shower schedule. The community was not able to provide Hospice records for showers provided to R1 for March 2023. On 05/20/2025, Administrator Kenneth Mahler confirmed telephonically to LPA Cortez that when a Hospice Agency provides shower services to the resident, Hospice fully takes over for the showers. Based on Interviews and file review, there is sufficient evidence to prove that the allegation " Facility staff did not shower resident per admission agreement," occurred. Therefore, the allegation is Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See LIC-9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 21, 2025 · control 29-AS-20240417093431

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: May 23, 2025

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interviews, and file review the licensee did not comply with the section cited above when staff did not provide stand by assist showers to R1 as per the admission agreement, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Sales Director agreed they will develop a plan on how they will ensure they comply with all terms of Admission Agreements when residents get placed on Hospice/Home Health. Plan will be submitted by 05/23/25.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Deficiency visit in conjunction with a subsequent complaint visit (CC #29-AS-20240417093431). LPA met with Sales Director Ty Henson and explained the reason of the visit. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint allegations. On 05/12/2025 at approximately 11:30 a.m., the LPA observed a resident in the outside courtyard of the Memory Care Unit that is attached to the dinning area of the residents. The doors to the courtyard were open. As staff and residents were getting ready for lunch, several residents began to complain about being cold and a resident went to close the glass door leading to the court yard. After a few minutes the resident that was outside attempted to open the door, and was not able to as the door was locked. The resident became agitated and started pounding on the door, a guest who was visiting went to open the door for the resident and opened the door with a fob. The resident was noticeably upset and yelling at the guest that they had locked them outside. The guest attempted to calm the resident down. The LPA informed staff the courtyards doors cannot be locked as residents can get locked outside. Staff stated that the doors are usually locked from the outside and can be opened with a fob, however residents do not have a fob. After being notified of the incident the Administrator had maintenance fix the door and unlock it from the outside in. Report will continue on LIC809-C, 2ND PAGE.. On 05/12/25, the LPA observed a bulletin board in the Medication Room with a list of residents who are on either hourly or two hour checks. The bulletin board and staff interviews indicated that R1 needs to be check/changed every two hours. The LPA did not observed any staff checking on R1 to see if they needed to be changed from 2:00 p.m. to 4:40 p.m. At approximately 4:40 p.m. as staff were serving dinner to the residents the LPA asked all four (4) staff working if they had checked on R1 to see if they needed to be changed. All four staff denied checking on R1, with the exception of one staff stating that they just "popped their head in R1's room to say hi and see if they were okay," however they did not check if they needed their diaper to be changed. Staff also revealed that there was confusion on which staff was responsible to care for R1 on that day. MedTech stated that R1 was assigned to staff 1 (S1) and S1 stated R1 was assigned to the MedTech. Citations issued, exit interview, report and appeal rights given.the state’s words, verbatim · CDSS document, May 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: May 23, 2025

87468.1 (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.... This requirement is not met as evidenced by: Based on observations, the Licensee did not comply with the section cited above when a resident was locked out in the memory care courtyard which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Doors were unlucked and fixed on 05/12/24. Sales Director agrees to submit a statement of understanding on regulation 87468.1(a)(6) and ensure doors will remain unlocked. Submit letter by 05/23/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87625(b)(2) · Plan of correction due date: Jun 4, 2025

87625 Managed Incontinence (b) In addition to Section 87611, ... the licensee shall be responsible for ... (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, ...This requirement is not met as evidenced by: Based on observations and staff interviews, the Licensee did not comply with the section cited above when R1 who is an incontince resident was not checked/changed for over two hours.which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: The administrator shall submit a plan on how he will ensure residents are receiving incontinence care in a timely manner and proof staff have received training on this plan to CCLD by 06/04/2025..

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Emily Peraldi conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20250509102647). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation. At 10:30 a.m., the LPA met with staff and explained the reason for the visit. At 2:00 p.m., the LPA spoke with Executive Director (ED) Kenneth "Ken" Mahler telephonically, as the ED was unavailable to meet the LPA. During the complaint investigation of complaint # 29-AS-20250509102647, the following deficiencies was observed: Per interview with the ED, the facility does not have a surety bond on file in order to safeguard R1’s cash resources. The LPA reviewed the facility’s plan of operation and confirmed that the Licensee does not hold a surety bond. Additionally, the LPA discussed with the ED the following regulation, 87405 Administrator - Qualifications and Duties, as the ED should have known not to safeguard R1’s cash resources without having a proper bond. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and Health and Safety Code the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. The ED authorized staff, Ty Hanson to sign the report. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87216(a)(1) · Plan of correction due date: May 30, 2025

87216 (a)(1) Bonding (a)Each licensee..., who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company... (1) The amount of the bond shall be… This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as the facility did not obtained a surety bond in order to safeguard R1’s cash resources which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: The ED stated that the facility will no longer safeguard R1’s cash resources, as R1 will safeguard their own cash resources. The ED will send proof of the safe containing R1’s cash in R1’s room.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(2) · Plan of correction due date: May 30, 2025

87405 (d)(2) Administrator -Qualifications and Duties (d) The administrator shall have the qualifications specified...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above as the ED/ Administrator did not demonstrate knowledge nor comply with Title 22 Regulations which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: The ED stated that he will submit a Statement of understanding regarding the following regulations: 87216 Bonding and 87405 Administrator - Qualifications and Duties.

Allegation investigated: Staff did not administer medication to a resident in care.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:49 a.m., the LPA met with staff and explained the reason for the visit. At 10:00 a.m., the Executive Director (ED), Kenneth “Ken” Mahler met with the LPA. At 10:00 a.m., the LPA conducted an interview with the ED. At 10:35 a.m., the LPA, along with the ED conducted a physical plant tour. Between 10:40 a.m. and 11:21 a.m., the LPA conducted a review of medication and medication documentation with staff for eight (8) residents. Starting at 10:51 a.m., the LPA conducted interviews with two (2) staff and two (2) residents. At 11:45 a.m., the LPA requested and obtained copies of pertinent documents. At 12:00 p.m., the LPA conducted a file review Resident #1 (R1’s) records. Continued on LIC 9099-C. Substantiated Regarding the allegation: Staff did not administer medication to a resident in care. On 05/14/2025, the Department received a complaint alleging staff not administering Resident #1’s (R1’s) morphine medication as prescribed. During today’s visit, the LPA reviewed R1’s records including but not limited to hospice documents, controlled drug record, and resident appraisal. R1 was admitted to hospice on 04/24/2025 with terminal diagnosis of Alzheimer’s disease. On 04/25/2025, R1 was prescribed through hospice Morphine Sulfate 20 mg/1mL Solution (0.25 ml dosage) for once a day. On 05/07/2025, R1 received a new physician order for Morphine Sulfate 20 mg/1mL Solution (0.25 ml dosage) to be given every six (6) hours. On 05/08/2025, R1 again received a new physician order for Morphine Sulfate 20 mg/1mL Solution (0.25 ml dosage) to be given every two (2) hours. Interview and record review revealed that R1’s Morphine Sulfate 20 mg/1 mL solution was in pre-filled syringes that were centrally stored. On 05/08/2025, per controlled drug record, R1 was last given Morphine Sulfate 20 mg/1mL Solution at 8:30 p.m. and staff did not again offer R1 the medication until the following morning, 05/09/2025 at 6 a.m. R1 was not given four (4) scheduled doses and staff did not properly assist R1 with self-administration of medication as prescribed. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff did not administer medication to a resident in care” 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. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 15, 2025 · control 29-AS-20250514081250

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 16, 2025

87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as the facility staff did not properly assist R1’s medications per physician’s order which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2025

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.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff not providing activities for residents.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent visit to investigate the allegations listed above. The LPA met with Kenneth Mahler, Administrator, and and explained the reason for the visit. On 04/18/2024, Licensing Program Analyst (LPA) Sandra Urena collected pertinent documents relevant to the investigation. On 03/17/25, LPA Cortez, interviewed seven (7) staff, three (3) residents and observed activities and lunch in Memory Care. On 04/24/25, LPA Cortez interviewed one (1) staff, three (3) residents, three (3) resident's family members and/or their authorized person, observed dinner in Memory Care, conducted a file review and collected pertinent documents relevant to the investigation. On 04/29/25, LPA Cortez conducted two (2) staff, one (1) resident, and two (2) resident family members interviews, observed resident activities, lunch and dinner being served. During today's visit the LPA interviwed six (6) staff, two (2) resident's family members, and observed lunch. Report will continue on LIC9099-C, 2ND PAGE. Unsubstantiated On the allegation, “Facility staff not providing activities for residents,” it is the concern of the reporting party that "a select few" (6 out of 35 Memory Care residents) are allowed to engage in planned activities other than watching television. Memory Care Staff interviews revealed that the community provides activities for all the residents, the Activity Director oversees the activities based on the Activity calendar, and staff encouraged all residents to participate. However, due to certain limitations (such as being bedbound or cognitive limitations) some residents are not able to participate, and some choose not to participate, but all are allowed to participate. On 03/17/2025, LPA Cortez observed various residents water painting in the dining room and observed staff asking other residents in the common areas and in their rooms if they wanted to join, some did, and some denied. On 04/29/25, at 10:40 a.m. the LPA observed ten (10) residents exercising in the common area. The LPA observed staff asking other residents if they liked to join the exercise activity and was able to encourage two additional residents to participate. Right after the exercising activity ended, the residents proceeded to do a cognitive activity called “The Chronicles” and residents were observed to be reading “The Daily Chronicle” which is a newspaper style article of random facts and information, trivia and a word scramble. Shortly after, the TV in the common room was turned on, and residents seemed to be enjoying themselves, while other residents were in the patio, or in their rooms. Between 11:00 am and 12:00 pm, the LPA observed staff assisting residents washing their hands and getting ready for lunch. After lunch, the LPA observed 5 residents playing bingo. Around 3:30 pm before dinner, the LPA observed about 12-15 residents out in the courtyard with staff listening to music. The activities the LPA observed matched the planned activity calendar. The LPA took notice of which residents were not present and at 3:50 p.m. the LPA went to a resident’s room of a resident that was not present during activities and asked if they wanted to join. The resident revealed that they were aware of the activities and did not want to participate. Based on interviews and observations, there is insufficient evidence to support the allegation that “Facility staff not providing activities for residents,” Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, May 12, 2025 · control 29-AS-20240417093431

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: Facility staff did not dispense medication to resident resulting in hospitalization. Facility staff did not supervise residents resulting in residents eloping. Facility staff spoke inappropriately to resident.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent visit to investigate the allegations listed above. The LPA met with Kenneth Mahler, Administrator, and and explained the reason for the visit. On 04/17/2024, the Woodland Hills North Adult and Senior Care office received a complaint regarding multiple allegations, one of them being of neglect/lack of supervision. The complaint alleged that the facility staff did not dispense Triamterene medication for Resident #1 (R1) which resulted in hospitalization. This allegation was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Edward Hector. All other allegations were investigated by LPA Cortez. On 04/18/2024, from 11:00am to 1:11pm, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced 10-day visit to investigate the allegations listed above. Report will continue on LIC9099-C, 2nd page. Unsubstantiated LPA Urena met with Kenneth Mahler, Administrator, and Gloria Morales, Associate Administrator and explained the reason for the visit. The LPA advised the Administrator that the case was referred to the Community Care Licensing (CCL) Investigations Branch (IB). At 11:31am, the LPA requested documents pertinent to the investigation. The LPA determined further investigation was needed prior to issuing findings. On 03/17/25, LPA Cortez, interviewed seven (7) staff, three (3) residents and observed activities and lunch in Memory Care. On 04/24/25, LPA Cortez interviewed one (1) staff, three (3) residents, three (3) resident's family members and/or their authorized person, observed dinner in Memory Care, conducted a file review and collected pertinent documents relevant to the investigation. During today's visit, LPA Cortez conducted two (2) staff, one (1) resident, and two (2) resident family members interviews, observed resident activities, lunch and dinner being served. Investigator Hector conducted interviews on 06/05/2024, from 12:50pm to 2:44pm, with Physician’s Preferred Hospice Care nurse, Administrator, and lead med tech; on 06/07/2024, at 3:38pm, with Associate Administrator; on 06/13/2024, at 11:18am, with Ararat Plaza Pharmacy Pharmacist; and on 06/14/2024, at 4:44pm, with Physician’s Preferred Hospice Care Case Manager. In addition, the investigator reviewed Community Memorial Hospital (CMH) medical records, Los Robles Regional Medical Center records, and facility file documents related to R1. A review of R1’s Physician Report, dated 03/24/2023, listed the primary diagnosis as Alzheimer’s Disease with late onset. The report also indicated R1 was on hospice due to the diagnosis. According to the facility timeline report, R1 was given their remaining medication when R1 went out of town with family on 03/29/2024. Since 3/30/2024, and 03/31/2024, was the Easter holiday weekend, the facility gave R1 and R1’s family, the remaining tablets of Triamterene. R1 left the facility to spend time with family during the holiday weekend. The timeline report lists that facility staff attempted to obtain a refill of medication starting on 04/01/2024. The report documents the Med-Tech called the hospice company, unable to reach, then called R1’s resident representative to notify they were unable to reach hospice for the refill. The staff also called and spoke with the hospice nurse on 04/02/2024, and 04/04/2024. On 04/04/2024, R1 was documented as being “out of breath” and was taken to the hospital the following day. Report will continue on LIC9099-C, 3rd page. On 04/05/2024, contacted hospice again regarding the refill. On 04/09/2024, the hospice nurse stated they had already refilled (Triamterene medication) and had placed an order already. On 04/11/2024, the Associate Administrator spoke with the Pharmacist who advised there was an error with how the facility was documented in their records. This error caused a delay in the medication delivery to the facility. A review of the CMH medical records documented R1 was admitted to the hospital on 04/05/2024, with an Admission Diagnosis of Congestive Heart Failure Exacerbation. The history also documented that R1 “presented with shortness of breath”, which was also the Chief Complaint. The patient history listed that R1 had “been having increased shortness of breath as well as leg swelling and heaviness” for the “last 3 days.” Emergency Medical Services (EMS) was contacted two days prior for the same issue. The records state that R1’s “oxygen saturations were low but that they were still functioning well and as such they were not taken to the hospital.” The records confirmed R1 was “positive for extremity swelling” according to the cardiovascular assessment. The Physical Exam noted that R1 had “1+ pitting edema in the bilateral lower extremities.” The medical records noted that R1 developed “delirium and agitation, and R1’s resident representative requested discharge back to the assisted living facility where R1 lives. R1’s agitation was believed to be secondary to change of environment in the setting of dementia.” R1 was discharged back to the facility on 04/07/2024 to resume previous hospice care. During the Department’s investigation, the investigator reviewed records, interviewed facility staff, and interviewed hospice agency staff. The facility staff claimed they made several attempts to contact the hospice agency for the medication refill. The Hospice agency staff denied receiving contact until the medication was refilled 04/11/2024 (the medication ran out at the end of March 2024). However, the hospice agency case manager confirmed receiving contact from R1’s daughter on 04/01/2024, regarding the care of R1. This contact is consistent with the timeline provided by the facility that they asked R1’s resident representative to ask the hospice agency for a medication refill. There is not sufficient evidence to support the allegation of neglect regarding the staff’s efforts to refill R1’s medication. Therefore, the allegation “Neglect/Lack of Supervision: Facility staff did not dispense medication for Resident #1 (R1) which resulted in hospitalization” is deemed Unsubstantiated at this time. Report will continue on LIC9099-C, 4th page. On the allegation, “Facility staff did not supervise residents resulting in residents eloping”; it is the concern of the reporting party that Memory Care residents including Resident #1 (R1) have gotten out of the facility through secure doors to the street or front of the building in 2023 and 2024. Various residents’ names (incomplete) and dates were given of when residents have eloped from the facility. Staff interviews revealed that they have no knowledge of the residents that were named to have eloped from the facility, and that if any resident did elope, they were aware of the protocol to follow. Staff would follow the resident, and re-direct them back to the facility, if the resident eloped and staff was unaware, they would go out searching for the resident, contact 911, and their responsible person, as well as report it to licensing. Three residents’ family members/authorized persons, two of which where the authorized person of two of the residents that were named to have eloped, revealed that they do not have any concerns of the residents eloping, and have not been notified of any elopement incident. File review revealed that in 2023 two residents eloped or attempted to elope from the facility, and the community self-reported one of the incidents to CCL and CCL issued a deficiency for the other incident. During today’s visit the LPA tested the delayed egress in one of the Memory Care’s exits at 1:10 p.m. and the alarm went off, three staff came rushing to the exit door and arrived by 1:12 p.m. Based on the information obtained and reviewed, there is insufficient evidence to support the allegation on “Facility staff did not supervise residents resulting in residents eloping”. Therefore, this allegation is being deemed Unsubstantiated at this time. On the allegation, “Facility staff spoke inappropriately to resident”; it is the concern of the reporting party that staff belittle and taunt a man who had a UTI and was acting erratic. Names of resident and staff was not provided. All staff interviewed denied ever speaking inappropriately to any of the residents and denied witnessing any other staff speaking inappropriately to any of the residents. All residents interviewed denied ever being spoken to inappropriately. Furthermore, interviews with residents’ family members/authorized persons revealed that they have never witnessed residents being spoken to inappropriately. Based on interviews, there is insufficient evidence to support the allegation that “Facility staff spoke inappropriately to resident.” Therefore, the allegation is being deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 29-AS-20240417093431

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not adequately supervise resident while in care.

Licensing Program Analysts (LPAs) Emily Peraldi and Angela Barutyan conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 12:30 p.m., the LPAs met with Executive Director (ED) Ken Mahler and explained the reason for the visit. During the initial visit conducted on 3/21/2025 between 9:55 a.m. and 3:35 p.m., LPA Peraldi conducted a physical plant tour and interviews with the ED, five (5) residents, and nine (9) staff. On 03/27/2025, LPA Peraldi conducted a telephonic interview with Resident’s (R1’s) family member. During today’s visit, between 12:40 p.m. and 1:55 p.m., the LPAs conducted a physical plant tour and interviews with the ED, and one (1) staff. During both visits, the LPAs obtained copies of pertinent documents. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Staff did not adequately supervise resident while in care. It was alleged that Resident #1 (R1) was not adequately supervised as R1 was locked out of R1’s room and found on the floor sleeping with a possible fall or head injury. Interviews conducted with the Wellness Director, Gloria Morales revealed that R1 is in the memory care unit, which is a separate and locked unit within the building. Interviews with staff and Gloria revealed that R1 wanders the hallways throughout the memory care unit and occasionally dances. Gloria stated that on 03/12/2025 staff notified Gloria that R1 was verbalizing feeling dizzy. Gloria instructed staff to notify the family of R1 to take R1 to urgent care for examination. R1 was sent to urgent care and the hospital on 03/12/2025 and returned the same day with the diagnosis of a urinary tract infection (UTI) and dehydration. Interviews conducted with nine (9) staff denied R1 of falling. Interview with R1’s family member revealed that they do not believe that R1 had a fall or head injury on 03/12/2025. Additionally, R1’s family member stated that staff are constantly communicating in regard to R1’s condition. 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, Mar 27, 2025 · control 29-AS-20250314160022

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 01/28/2025. At 10:55 a.m., the LPA met with the Executive Director (ED) Ken Mahler and explained the reason for the visit. At 12:07 p.m., the LPA along with the ED conducted a physical plant tour to ensure there are no health and safety hazards. During the physical plant tour, the LPA conducted interviews with twelve (12) residents and no concerns were voiced. The facility consists of one (1) memory care unit (MC), and an assisted living unit (AL). The memory care unit is secured with delayed egress doors which lead to secured outdoor patios. The second floor has no resident apartments but was observed to have a gymnasium for resident use, facility storage, and office space. Starting at 1:15 p.m., the LPA conducted a review of medication and medication documentation with staff for eight (8) residents and observed that medications were properly documented and assisted with as prescribed. BEDROOMS: The LPA observed 22 randomly selected resident rooms throughout facility. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: The LPA observed restrooms in 22 resident units and common area restrooms. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was tested throughout the visit and measured within the required range. Continued on LIC 809-C. COMMON AREAS: The LPA observed common areas to be relatively clean and properly furnished. The LPA observed the fire extinguishers throughout the facility to be fully charged and last serviced on 04/12/2024. The LPA observed required postings on the wall near the entrance and hallways. The facility's smoke alarms are hard wired, and the facility is equipped with sprinkler system. Fire alarm/sprinkler system was last tested on 01/23/2024 with Oxnard Fire Department. At 1:07 p.m., the LPA observed residents watching a movie in the theater room. OUTDOOR SPACE: The LPA observed the courtyards throughout the facility, which has a covered outdoor area for resident use. There are multiple emergency exits located throughout the facility. Passageways were free and clear from obstruction. There were no bodies of water noted. OTHER: Medications and first aid kits are located in locked medication rooms. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the maintenance closet. The laundry units are located inside the locked laundry rooms. The LPA observed sufficient supply of Personal Protection Equipment (PPE). KITCHEN: At 2:45 p.m., the LPA observed the kitchen and dining area. Knives are stored in the kitchen which remains inaccessible to residents. Kitchen appliances are in operable condition. The facility has a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was posted throughout the dining area. Snacks and beverages are available for residents. No deficiencies cited at this time. Exit interview conducted. A copy of the report of provided.the state’s words, verbatim · CDSS document, Mar 12, 2025

Allegation investigated: Facility not providing a refund to authorized representative

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival, LPA met with the Executive Director (ED), Ken Mahler, and was explained the reason for the visit. Entrance interview conducted. On 05/01/2024, between 10:30 a.m. and 12:30 p.m., the LPA interviewed the Administrator, one (1) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's visit the LPA interviewed two (2) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation Report will continue on LIC9099-C, 2nd page. Substantiated On the allegation: Facility not providing a refund to authorized representative. It is alleged that during the time Resident #1 (R1) lived at the facility, an organization that provides services to residents as part of a court ordered conditional release program was paying the charged rent for R1 at the facility. Allegedly the facility overcharged by 3 times the monthly rate for the January 2024 rent for R1, overcharged by 2 times the monthly rate for March 2024 for R1, and charged the full rate for April 2024, even though R1 did not live in the facility in April 2024. The allegation states the facility overcharged by approximately $15,000 and are not providing a refund. According to staff interviewed by LPA, the organization providing rent payment for R1 paid the facility after the scheduled due dates and provided the facility random payments not coinciding with fully charged rent amounts for R1 or scheduled due dates. According to facility staff, the effective end date for financial responsibility of R1 ended on 03/20/2024. Staff indicated to LPA that the organization responsible for R1’s rent payments was reached out to by the facility to schedule a meeting to discuss rent billing for R1, but the organization did not agree to a meeting. Staff interviews also revealed that when the facility gets a request for refunds, an email is sent to the facility accountant who processes and issues the refunds. Staff interviewed by LPA on 05/01/2024 indicated that they were unaware if R1 or their representative requested a refund. The LPA reviewed records obtained from both the facility and RP. The facility resident lease agreement for R1 states that R1 is charged a monthly fee of $4,845 beginning on 11/30/2023. This fee consists of an apartment fee of $2,995 and care fee of $1,850 per month for R1. The billing reconciliation document received by the LPA from the facility and staff interview revealed that R1 had $1,000 of community fees upon admission and a pro-rated rent of $161.50 for November 2023. The facility began to charge the full monthly fee to R1 for December 2023. R1 had unpaid rent for November 2023 and December 2023, with late fees of $250 per month added. The document indicates that the facility received payments for R1’s fees in January 2024 totaling an amount of $13,440. R1 was charged late fees of $250 each for January 2024 and February 2024. As R1 was financially discharged from the facility on 03/20/2024, the facility charged R1 a pro-rated monthly rent of $3,230 for March 2024. The reconciliation shows that the facility received payment for R1 from the organization totaling $13,440 in January 2024, $3,500 in February 2024, $3,230 in March 2024, and $3,500 in April 2024. Report will continue on LIC9099-C, 3rd page. According to the facility billing reconciliation document, the monthly fees charged to R1 from admission to discharge totaled $19,926.50 while the payments received for R1 from admission to discharge totaled $23,670. The billing reconciliation document for R1 indicates that there is an excess of $3,743.50. The organization that submitted payment for R1 is entitled to reimbursement for an excess amount of payment to the facility. A review of emails between R1’s authorized person and facility staff revealed that staff acknowledged that a 30-day notice was given and 2/20/24 would serve as Day 1 of that 30-day notice. Therefore, the organization is responsible for 30 days of rent fees from the date of discharge by R1 on 02/20/2024. This means the facility can charge R1 fees until 03/20/2024. LPA received information from the facility that a refund check had been provided to the authorized representative of R1. A check for the full excess amount documented in the billing reconciliation form for $3743.50 was issued in R1’s name on 05/07/2024. The facility was then contacted by the organization paying R1’s facility fees asking for the refund check to be made out directly to the organization, which was done by the facility. Even though a refund had been provided, per the admission agreement; In the event that Resident is absent from his/her apartment for medical care for a period of more than 10 days, $5.00 per day will be credited to the Resident for meals and Care Fees will be prorated and credited to the account commencing on the 11th day until the Resident returns to the Community. Since R1 never returned to the facility after 01/29/2024, R1 and/or their authorized person are still owed meal and care fees for February to April. Based on the information gathered, there is sufficient evidence to prove that the allegation "Facility not providing a refund to authorized representative" occurred. Therefore, the allegation is Substantiated. 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. On the allegation, “Facility not releasing records to authorized representative” It is alleged that even though resident’s #1 (R1’s) authorized person signed “release of information” for R1, the facility is refusing to provide payment records or medical assessment records as requested. LPA requested and received from the facility the Release of Client/Resident Medical Information form that was signed by the authorized representative of R1 on 11/30/2023. The authorized representative of R1 is an employee of the organization paying R1’s facility fees as part of a court ordered conditional release program. The release of client/resident medical information form is a Community Care Licensing Division (CCLD) form typically required when the resident wishes to authorize the release of their medical information to facility staff. This form ensures that only authorized individuals have access to the client's medical information. R1’s representative who authorized the release is entitled to a copy of the release form itself, and residents have the personal right to request documentation from their facility file. Facility staff interviewed by the LPA stated that they have not had a request for copies of R1’s facility file. All staff interviewed by LPA stated they have no knowledge if R1 or their representative have requested any documents. The administrator of the facility stated to LPA that the facility has not received any request for any documentation, the authorized representative for R1 has not requested any billing/payment documents from the facility nor any medical documentation from the facility records/file on R1. There is no evidence through record review of facility documentation or LPA interviews that the facility withheld any of R1’s records from their authorized representative. LPA received email correspondence between the responsible party of R1 and the facility regarding the need for a 30-day eviction notice. On 02/20/2024, the responsible party for R1 emailed the facility and inquired about whether they can terminate the admission agreement for R1 immediately without requiring a 30-day notice so that they would not have to pay the February 2024 facility fees for R1. The responsible party for R1 indicated that they were informed that the facility needed to complete an “evaluation” of R1 to determine whether they would have to pay for February 2024 or they can terminate the lease immediately without 30-day notice. The assessment mentioned in the email correspondence is in relation for the need to have a 30-day notice of eviction. Furthermore, emails revealed that R1’s authorized person later went on to state they have not received the assessment, however, the LPA did not find any request for the assessment. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Exit interview conducted by LPA. Copy of this report provided to the facilitythe state’s words, verbatim · CDSS document, Feb 24, 2025 · control 29-AS-20240425084305

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Feb 28, 2025

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section by not ensuring R1 and/or R1's authorized person recieved refund which posed a potential health, safety, and personal rights risk for residents in carethe state’s words, verbatim · CDSS document, Feb 24, 2025

Plan of correction: The ED agreed to write a self-certification letter that they will follow up with coorperate/management company in regards to R1's refund, and issue refund to R1 and/or their authorized person. Submit proof by 02/28/2025.

Allegation investigated: Unqualified facility staff are providing wound care to residents. Facility staff are falsifying resident records.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 09:30 a.m., the LPA met with Executive Director (ED) Ken Mahler and explained the reason for the visit. During the initial visit conducted on 12/18/2024 between 10:00 a.m. and 3:15 p.m., LPA Peraldi conducted a physical plant tour and interviews with the ED, ten (10) residents, and three (3) staff. During the initial visit, the LPA also obtained copies of pertinent documents. During today’s visit, between 09:30 a.m. and 3:30 p.m., LPA Peraldi conducted a physical plant tour, reviewed records and conducted interviews with three (3) staff. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Unqualified facility staff are providing wound care to residents. On 12/11/2024, the Department received a complaint alleging Staff #1 (S1) of providing wound care to residents instead of calling hospice or home health agencies. Interviews conducted with the ED and S1 denied the allegation and stated that S1 does not provide wound care to residents. S1 stated that S1 provides first aid if needed, but that wound care is provided by outside agencies such as hospice or home health. Staff interviews conducted on 12/18/2024 and 01/28/2025 revealed that they do not do any wound care, only basic first aid. Staff interviews revealed that staff have not witnessed unqualified staff provide wound care to residents. 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. Regarding the allegation: Facility staff are falsifying resident records. Interview conducted with ED revealed that the ED has not witnessed staff falsify resident records. Staff interviews conducted on 12/18/2024 and 01/28/2025 revealed that staff have not been pressured to falsify resident records. Staff interviewed stated they have not witnessed staff falsify resident records. 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, Jan 28, 2025 · control 29-AS-20241211134457

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:30 a.m., the LPA met with Executive Director (ED) Ken Mahler and explained the reason for the visit. RECORD REVIEW: Between 9:50 a.m. and 2:00 p.m., the LPA conducted a file review for nine (9) residents and eight (8) staff. Resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order. Disaster drill was last conducted on 01/18/2025. Administrator certificate is current and valid until 10/18/2025. Documentation: During the time of the visit, the LPA obtained a copy of the liability insurance, resident roster, staff roster, Infection Control Plan and Emergency and Disaster Plan. Starting at 2:15 p.m., the LPA conducted interviews with three (3) staff and the ED. At 3:20 p.m., the LPA along with the ED conducted a brief physical plant tour to ensure there are no health and safety hazards. Due to time constraints the LPA will return to complete the annual at a later date. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 28, 2025

Allegation investigated: Facility staff do not dispense medications as prescribed.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 10:00 a.m., the LPA met with Executive Director (ED), Ken Mahler, and explained the reason for the visit. At 10:05 a.m., the LPA conducted an interview with the ED. Between 10:36 a.m. and 1:30 p.m., the LPA conducted a review of medication and medication documentation with staff for ten (10) residents. Starting at 10:22 a.m., the LPA conducted interviews with three (3) staff. At 1:44 p.m., the LPA requested and obtained copies of pertinent documents. At 2:45 p.m., the LPA, along with the ED conducted a physical plant tour. Continued on LIC 9099-C. Substantiated Regarding the allegation: Facility staff do not dispense medications as prescribed. On 12/11/2024, the Department received a complaint alleging staff not dispensing medications as prescribed. During today’s visit, between 10:36 a.m. and 1:30 p.m., the LPA conducted a review of medication and medication documentation with staff for ten (10) residents and observed the following: Resident #1 (R1’s) Bedtime Senna 8.6 MG tablet had 22 tablets remaining, however the medication was started on 11/28/2024 and with the quantity listed as 60, meaning there should be a total of 20 tablets remaining instead. R1’s Noon Carbidopa-Levodopa 25-100 Tab had 16.5 tablets remaining, however the medication started on 11/28/2024 and with the quantity listed as 45, meaning there should be a total of 15 tablets remaining. Resident #2’s (R2’s) Bedtime Eliquis 2.5 MG tablet had 11 tablets remaining, however the medication was started on 11/28/2024 and with the quantity listed as 30, meaning there should be 10 tablets remaining. R2’s Bedtime Atorvastatin 20 MG Tablet had 9 tablets remaining, however the medication was started on 11/26/2024 and with the quantity listed as 30, meaning there should be 8 tablets remaining. Resident #3’s (R3’s) AM Levothyroxine 50 MCG tablet had 13 tablets remaining, however the medication was started on 12/01/2024 and with the quantity listed as 30, meaning there should be 12 tablets remaining. Resident #4’s (R4’s) Bedtime Donepezil HCL 5 MG tablet had 14 tablets remaining, however the medication was started on 11/30/2024 and with the quantity listed as 30, meaning there should be 12 tablets remaining. Based on observation and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff do not dispense 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). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 18, 2024 · control 29-AS-20241211134457

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 19, 2024

87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement 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, 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, Dec 18, 2024

Plan of correction: Within 24 hours, the Administrator will notify the LPA when medication training will be completed. Administrator stated a medication audit for the facility and training for all medication staff and submit documentation to CCL by 12/31/2024.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Lack of care and supervision resulted in resident falling. Resident’s personal rights are being violated.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the facility for the above allegations. Upon arrival, LPA met with Executive Director (ED), Kenneth Mahler, and explained the reason for the visit. Entrance interview. This complaint was initiated on 09/14/2023. During the visit of 09/14/2023, LPA Camara conducted a joint interview with the ED and one staff at 9:10 a.m. and obtained copies of pertinent documents. During today’s visit, LPA Arroyo conducted interviews with the ED, six staff members, and seven residents between 10:12 a.m. and 2:28 p.m. and obtained a copy of the resident roster and staff schedule. Continued on LIC 9099C... Unsubstantiated Continued from LIC 9099... It was alleged that lack of care and supervision resulted in resident falling. It was reported that Resident #1 (R1) fell two (2) times while residing at the facility. Records reviewed and interviews conducted revealed that R1 was admitted to the facility on 08/29/2023 and was only a respite resident for about three (3) days. Incident Reports were reviewed for R1. Per incident reports submitted for dates, 08/29/2023 and 08/30/2023, it states R1 had two (2) separate unwitnessed falls at the facility. However, staff responded as soon as they observed R1 was on the floor and contacted 911 to have R1 evaluated and taken to the hospital to ensure R1 had no injuries caused by the falls. Interviews conducted with staff revealed that residents are typically checked on at least once every two (2) hours unless their care plan indicates differently, depending on the resident’s needs. Additionally, all residents in assisted living have a pendant which they carry at all times in case of an emergency. Staff stated the goal for response time after a pendant has been activated is between 3 to 5 minutes. Staff stated that sometimes it might take a bit longer due to them assisting other residents. However, staff stated they try and take care of the residents needs as best as they can. Interviews conducted with residents revealed that they have no concerns with the response time from the staff as they respond in a timely manner after they have pressed their pendant and added that they have not waited for long periods of time. Furthermore, during the resident interviews, residents denied having any concerns with the care provided by facility staff and added that staff are easily accessible whenever they require assistance. Based on the information obtained and reviewed, there is insufficient evidence to support the allegation on “ack of care and supervision resulted in resident falling”. Therefore, this allegation is being deemed Unsubstantiated at this time. It was further alleged that resident’s personal rights are being violated. To investigate this allegation, interviews were conducted with current staff members and random residents. Interviews with staff revealed that residents have not reported having their personal rights violated. Additionally, staff denied any claims of violating resident’s personal rights. Interviews conducted with residents revealed that staff assist them, and while doing so, staff has not forced them to do anything that they did not want at any time while living at the facility. Furthermore, during the resident interviews, seven (7) out of seven (7) residents denied having their personal rights violated and did not report having any concerns while living at the facility. Based on interviews conducted with facility staff and residents, there is insufficient evidence to support the allegation of “resident’s personal rights are being violated”. Therefore, this allegation is being deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, Apr 5, 2024 · control 29-AS-20230908093134

Allegation investigated: Staff are not acting appropriately while at work

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced subsequent visit to this facility. Upon arrival LPA met with Kenneth Mahler, Executive Director (ED) and the purpose of the visit was explained. On 07/14/2023, information was received that "staff are smoking marijuana while on duty in the facility common restroom". On 07/21/2023, during the initial visit, LPA met with former Wellness Director Meshyll Filipinas, and conducted a physical plant tour at 10:45AM; common areas of the facility, resident rooms and common restrooms were observed through-out the building. Also, eight (8) staff were interviewed from approximately 12PM-3:15pm. During todays visit, LPA toured the facility at approximately 3pm and interviewed six (6) random residents who reported that they have not seen any staff member smoking (marijuana or cigarettes) at the facility or acting inappropriately. Staff interviewed denied the allegation. Staff did confirm that they have observed staff smoke cigarettes outside but never inside the facility. Staff denied ever smoking marijuana while on duty at the facility. Based on the information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore,the above allegation is deemed unsubstantiated at this time. Exit interview held, report copy issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 22, 2024 · control 29-AS-20230714174612

Type of visit: Case Management - Annual Continuation

At 11:00 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 01/04/2024. The LPA was greeted by Administrator Ken Mahler and informed them of the reason for the visit. Today the LPA conducted a medication audit and finished the record review initiated on 1/04/2024. Record Review: At 11:15 a.m. the LPA observed documentation of Infection Control Plan, Disaster prevention and last fire drill (conducted on 12/19/2023). The LPA obtained Resident and Staff Rosters. The LPA reviewed one (1) out of seventy-nine (79) resident files, the file appeared complete and current. The LPA observed five (5) out of fifty-six (56) staff files which included but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid certification. Out of the five files reviewed, three out of five staff (S1, S3, S4) require first aid certification, In addition, the LPA was unable to identify the completed eight (8) hours of annual medication training nor could the LPA identify annual training for restricted health conditions for two out of the five staff (S1,S2). Medications: At 3:00 p.m. a medication review was initiated for two out of five residents and the following was observed. The medications were stored in medication rooms, which are locked and inaccessible to the residents. During Resident #1 (R#1's) audit, the LPA observed Telmisartan 40MG and Memantine HCL 10MG documented on the Medication Administration Record (MAR) as given on 1/7/24, however the medications were still in the bubble packs. During R#2’s audit, the LPA observed four (4) medications not documented on the Centrally Stored Medication and Destruction Record (CSMDR). Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Ken Mahler.the state’s words, verbatim · CDSS document, Jan 22, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At 09:15 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Ken Mahler and informed them of the reason for the visit. At 09:36 a.m. the LPA conducted a tour of the physical plant with Administrator Ken Mahler and Associate Administrator Gloria Morales to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of one (1) memory care unit (MC), and an assisted living unit (AL). The memory care unit is secured with delayed egress doors which lead to secured outdoor patios. The LPA observed one of the delayed egress doors to be functional. The second floor has no resident apartments but was observed to have a gymnasium for resident use, facility storage, and office space. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 03/27/2023. Smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings outside the Administrators office. Kitchen: During the facility tour at 9:38 a.m., the kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents. Bedrooms: During today’s visit, the LPA observed ten (10) randomly selected resident units, of which four (4) were in memory care and six (6) in assisted living. Nine out of the ten resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Report will continue on LIC809-C. Bedrooms continued: At 10:09 a.m. the LPA observed a bottle of over-the-counter 8HR Arthritis Pain Relief acetaminophen pills, a box of prescribed Aspercreme Lidocaine pain relief patches, a small tube of over the counter Maximum Strength Antibiotic Cream + pain relief, a tube of Biofreeze pain relieving gel, inside room# 195 in memory care. At 10:46 a.m. the LPA observed room 192 in memory care without a chair, and without a chest of drawers. Upon observation, the Associate Administrator stated rooms are furnished by the resident and/or their responsible party agreed on their admissions agreement. At 11:28 a.m. the LPA observed room 106 in AL to have a door that was not able to fully close, furthermore room #106 was observed to have prescribed and over the counter medication. Bathrooms: The LPA observed all ten bathrooms in the randomly selected rooms clean and sanitary with grab bars and non-skid mats. Water temperature measured in the restrooms ranged between 113.0 degrees Fahrenheit and 118.0 degrees Fahrenheit. Common Areas: These included the beauty salon, common areas and dining areas in assisted living and memory care. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. At 10:22 a.m. the LPA observed the laundry room in memory care unlocked with chemicals and cleaning supplies accessible to the residents. At 11:03 a.m. the LPA observed a laundry room in assisted living unlocked with chemicals and cleaning supplies accessible to the residents in care. The Administrator locked both laundry rooms upon observation. The facility maintained a comfortable temperature of 69 degrees. There were no obstructions and/or tripping hazards throughout the facility. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with umbrellas available for shade in all of memory care & assisted living courtyards. There were no bodies of water on the premises. Interviews: During today’s visit, the LPA conducted five (5) resident and five (5) staff interviews. No concerns voiced during the interviews. Record Review: At 02:25 p.m. a review of facility files was initiated. The LPA reviewed four (4) of seventy-nine (79) resident files. Out of the four files reviewed, LPA Cortez identified that one out of four residents (R1) require an updated appraisal needs and service plan, due to the diagnosis of dementia. The LPA identified that one out of four residents (R2) did not have a personal rights form LIC 613 or medical consent forms on file. Administrator stated files are online and will sent to the LPA. Due to time constraints the LPA will return to complete the annual at a later date. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 4, 2024

Allegation investigated: Staff did not ensure that a facility door was locked, resulting in resident leaving the facility unsupervised.

Licensing Program Analyst (LPA) Esther Cortez arrived announced to conduct a 10-day Complaint visit to the facility above. The LPA met with Administrator Kenneth Mahler and explained the purpose of the visit. The LPA requested Resident 1 (R1's) preplacement Appraisal, LIC.602A Physicians report, Appraisal Needs and Services Plan, staff roster, residents’ roster, and incident report. The LPA conducted interviews with the Administrator, two (2) Staff and R1, and toured the memory care unit with staff between 9:30 a.m. – 11:30 a.m. On the allegation Staff did not ensure that a facility door was locked, resulting in resident leaving the facility unsupervised, it is the reporting party’s concern that a resident with dementia had run away from the facility and did not want to return. To investigate the allegation, the LPA conducted interviews, and a file review. File review revealed that R1 has a diagnosis of Dementia and cannot leave the facility unassisted. Report will continue on LIC9099-C. Substantiated All staff interviews revealed that on 11/26/2023 the facility experienced an unexpected power outage that triggered all of the exit doors. Staff immediately went to check the exit doors, conducted a headcount, and realized R1 was missing, and began to look for them. R1’s interview revealed that R1’s bedroom is near an exit door at the end of the hallway, they noticed the lights blinking and went out the exit door as they were trying to go to the bank and their house. Neighbors noticed R1 and called the police and R1 was taken to the hospital as they did not want to return to the facility. The facility failed to submit an unusual incident report (LIC624) to CCL and provided a copy of the incident report to the LPA during today’s visit. LIC 624 confirmed that R1 had walked out of the building and taken to the hospital for testing/evaluation after 911 was called by a neighbor. Based on the evidence this allegation is Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator Ken. On the allegation Staff locks resident in their room, it is the reporting party’s concern that the facility mistreats R1 and locks them in their room. To investigate the allegation, the LPA conducted interviews and toured the memory care unit. R1’s interview revealed that even though they would rather be somewhere else with their family, staff treats them “pretty darn good,” and they would select the facility to be in if it was necessary. At 11:26 a.m. the LPA observed R1’s bedroom to only have a lock from the inside of the bedroom. Staff interviews revealed that all bedrooms in memory care have keylocks and bedrooms generally stay unlocked unless requested to be locked by family members. If the doors are to remain locked, the resident must be able to walk and be able to unlock the door and a note on the door would be placed. Bedrooms are to be locked from the outside to prevent people from coming in. The LPA did not observe a note on R1’s door with the indication the door to be locked. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Staff locks resident in their room”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. On the allegation Staff does not ensure that resident is adequately fed, it is the reporting party’s concern that the facility does not feed resident appropriately. To investigate the allegation, the LPA conducted interviews and toured the memory care unit. R1’s interview revealed that even though they do not like the food being served at the facility, they are provided three (3) meals a day and they are not left hungry. At 11:09 a.m. the LPA observed enchiladas, rice, vegetables, smashed potatoes, and a dessert being served for lunch to the residents in care in the memory care unit. At 11:25 a.m. the LPA observed R1 eating their lunch. Staff interview revealed that the facility provides breakfast at 8:00 a.m., lunch at 11:00 a.m., dinner at 4:00 p.m. and snacks in between. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Staff does not ensure that resident is adequately fed”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview and report reviewed with Administrator Ken. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 29-AS-20231127163113

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 13, 2023

87464(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews the licensee did not comply with the regulation above, R1 who is diagnose with dementia was able to leave through the unlocked exit door and walk across the street off the property which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: The administrator agreed to hold an all memory care staff training for supervision of residents, duties, responsibilities, elopement procedures, and on audible alarm sounds and responses. Provide proof of training with all staff signatures to CCL by 12/13/2023.