Sage Mountain Senior Living

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent case management visit to deliver findings for an investigation initiated on 01/09/2025. LPA met with Executive Director Christian Castillo and explained the reason for the visit. On 11/05/2024, the Department received a self-reported death report from the facility. The death report stated that on 11/02/2024, Resident #1 (R1) was found unresponsive in the common area of the memory care unit. The caregiver began life-saving efforts and assessed R1 for possible choking. On 01/09/2025, from 10:55pm to 4:30pm, Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. LPA Cortez met with the Executive Director Christian Castillo and explained the reason for the visit was to follow up on the self-reported death report received on 11/05/2024. The report pertained to the 11/02/2024 death of Resident #1 (R1). During the visit, the LPA conducted an interview with the ED, conducted a brief tour of the facility and obtained copies of pertinent documents. Community was experiencing a power outage; any necessary pertinent documents were to be sent to the LPA. The LPA informed the administrator that the incident was referred to the Community Care Licensing (CCL) Investigations Branch (IB) for review and further investigation was required prior to issuing findings. On 01/17/2025, the Department contacted the facility ED, Christian Castillo, via email and requested additional documents regarding R1 pertinent to the investigation and on 01/20/2025, Castillo provided the requested documents. Report will continue on LIC809-C, 2nd page. On 01/24/2025, from approximately 11:00am to 04:00pm, the Investigator conducted interviews with the Executive Director, staff, residents, and one resident’s family member; on 01/28/2025, at approximately 12:30pm with staff. On 04/15/2025 and 04/17/2025, the Investigator conducted telephone interviews with staff. In addition, the Investigator requested and reviewed medical records from Los Robles Medical Center, R1’s facility records, facility Death Report, Ventura County Autopsy Report, and Death Certificate. On 10/27/2025, from 09:45am to 04:15pm Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA interviewed the Executive Director, attempted to interview two (2) residents, conducted a file review and collected pertinent documents relevant to the investigation A review of R1’s facility file documents indicate that R1 was admitted to the facility on 05/18/2021. R1’s Physician Report, dated 05/13/2021, lists diagnosis as CADASIL and Vascular Dementia. The report also lists Mild Cognitive Impairment (MCI), does not need assistance with self-care, is able to feed self, disoriented, confused, and able to follow instructions and able to communicate needs. The investigation revealed that on 11/02/2024, at approximately 08:40am, R1 finished their breakfast and proceeded to the common area. While in the common area, Staff 1 (S1) saw that R1 needed assistance. S1 began life-saving efforts and assessed R1 for possible choking. S1 conducted a finger sweep and found no obstruction. S1 began abdominal thrust. The facility staff’s Memory Care Unit responded to the area and called 911. CPR was initiated and continued until local paramedics arrived and continued life-saving efforts. R1 was pronounced dead at 09:15am. A review of the documents obtained noted that R1 was not identified as having a choking alert diagnosis. R1 was able to self-feed independently. Staff interviews revealed that R1 was a fast eater and staff would direct R1 to slow down. Medical records reviewed by the Investigator noted no history of choking. The autopsy stated that the cause of death is asphyxia due to airway obstruction (choking) and the manner of death was accidental. Vascular dementia and CADASIL was also noted as contributing factor to R1’s death. There were no apparent signs of acute trauma or neglect associated to the death. Report will continue on LIC809-C, 3rd page. On 11/02/2024, staff revealed that R1 was not seen or heard coughing or reaching for their neck and after breakfast, R1 was seen talking to another resident before needing assistance. LPA Cortez attempted to interview other residents present during the incident, however due to their cognitive state was unable to. No deficiencies are being cited at this time pertaining to this self-reported death report. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Jun 15, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management-Incident inspection regarding a self reported Unusual Incident/Injury report. The LPA met with Executive Director Christian Castillo at 09:45 AM and explained the reason for the inspection. The ED had to leave during the visit, however designated Business Office Manager December Zavala to review and sign the report. On 02/02/2025, Community Care Licensing (CCL) received a self reported Unusual Incident/Injury report regarding Resident 1 (R1) and a staff. It was reported that on 01/28/2026, R1 reported at the front desk that a caregiver allegedly hit them. R1 was asked by the Memory Care Manager (MCM) where were they hit? R1 stated, I don't know, thank you. When asked how they were hit, R1 stated with a voucher. It was further reported that a body assessment was done and no marks or discoloration were noted. During today's visit the LPA interviewed the ED, R1, eight (8) additional residents, three staff including the alleged staff (S1), conducted a file review and collected pertinent documents. Interview conducted with R1 reflected that R1 feels safe at the facility, stated that the facility staff is great and R1 was not able to provide clear information regarding the incident. When asked if any staff has ever hit them, R1 stated "she was going to hit me," and when asked who? R1 replied "I don't know". File review revealed that R1 is diagnosed with Dementia. Interviews conducted with the eight additional residents revealed that residents are happy and feel safe in the care of the staff and have never observed staff hit any resident. Interview conducted with S1, revealed that they denied ever hitting or speaking inappropriately to R1. Report will continue on LIC809-C, 2nd page. Furthermore, interviews and file review reveal there were no witnesses to the alleged incident. Interviews with the ED revealed that they conducted an internal investigation, ensured to follow the proper reporting protocols, and is ensuring S1 obtains any necessary training if needed. No immediate health and safety concerns were observed during the visit. . Exit interview conducted and copy of report providedthe state’s words, verbatim · CDSS document, Feb 5, 2026

Allegation investigated: Facility staff did not notify authorized representatives of falls.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegation. Upon arrival, LPA met with the Executive Director (ED), Christian Castillo and explained the reason for the visit. Entrance interview conducted. ED was unavailable during exit enterview and designated Director of Health and Wellness Gina Taylor to review and sign the report. During today's inspection, between 10:00 a.m. and 2:30 p.m., the LPA interviewed the ED, two (2) staff, conducted one (1) phone interview with Individual #1 (I1) and attempted to conduct a phone interview with Individual #2 (I2) and one (1) 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 Regarding the allegation, “Facility staff did not notify authorized representatives of falls”; it is the concern of the Reporting Party (RP) that Resident 1 (R1) has had three falls in the facility with the last one being on November 12, 2025, and staff did not notify R1’s authorized representatives of all three falls. A review of R1’s Identification and Emergency Information (LIC601) signed and dated 09/19/2024 revealed that Individual #1 (I1) is listed as their responsible person and Individual #2 (I2) as their person(s) responsible for financial affairs, payments for care, legal guardian if any. A review of R1’s Family Communication Form also lists I1 as R1’s primary contact/emergency contact #1 and I2 as R1’S primary contact/emergency contact #2. Interview with the Executive Director Christian Castillo revealed that I1 would be the person that needs to be contacted to notify of falls and the MedTech (MT) would usually be the one to notify them. Interview with one randomly selected MT revealed that based on R1’s file on their electronic medical record system I1 would be the person they need to contact to notify if R1 sustained a fall as they are listed as their Power of Attorney (POA). However, Interview conducted with I1 revealed that they were never notified by the facility that R1 had sustained a fall, were notified by R1 after being at the hospital for 8 hours and denied being R1’s POA. They further revealed that I2 is four hours away from R1 compared to them being only an hour away and they had already previously discussed with staff after prior falls that they should be the one to be notified. Furthermore, a review of an Unusual Incident/Injury report (LIC624) submitted to Community Care Licensing (CCL) on 11/18/2025, revealed that on 11/13/2025 staff responded to a pendant call and observed R1 on the floor, R1 was transported to the hospital and I2 was contacted. LIC624 does not indicate if I1 was contacted at all, however I1 denies they were contacted. Record review revealed that the facility does not have any POA records for R1, however has I1 listed as their POA in their electronic medical record system. Interview with Director of Health and Wellness Gina Taylor revealed that R1 was admitted to the facility as independent and their own responsible person, however they did confirm that even in these circumstances residents have emergency contacts listed as to whom staff should be notified of incidents. Based on the information gathered there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 29-AS-20251217153345

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87568.1(a)(8) · Plan of correction due date: Dec 22, 2025

(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. Based interviews and record review, the licensee did not comply with the section cited above when they did not inform R1’s responsible party of a fall with injury, which posed a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Director of Health and Wellness agrees to update their electronic medical record system on who should be contacted first and will submit a plan of action on all of the details and when this will be done to LPA by 12/22/25

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and Executive Director (ED) Christian Castillo they were informed of the reason for the visit. The LPA conducted a tour of the physical plant with the ED 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 four (4) story residence that consists of assisted living units on all floors and a memory care unit on the second floor. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 07/09/2025. Smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed required postings near the mail room hallway. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. KITCHEN: The LPA began the inspection in the kitchen/food service area. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: The LPA toured all four floors and common spaces in both the assisted living and memory care unit. Activity rooms and common spaces were clean and in good repair. The facility maintained a comfortable temperature. The LPA observed the stairwells and they each had an emergency evacuation chair. Report will continue on LIC809-C, 2nd page. BEDROOMS: The LPA observed ten (10) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. RESTROOMS: All resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms .The hot water temperature was measured in 10 resident rooms and ranged between 116.2*F– 123.8*F with five (5) restrooms including restroom in the dementia care unit going over 121*F. Interviews: The LPA interviewed nine (9) residents and one (1) staff. No immediate concerns were voiced. Record Review: A review of facility files was initiated and the LPA reviewed five resident files however due to time constraints, the LPA will return at a later date to complete the inspection. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 20, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent unannounced Case Management – Incident visit to the above facility. The LPA met with Executive Director Christian Castillo and explained the reason for the visit. Entrance interview conducted. The reason for today's inspection is to follow up on a self-reported death report received on 11/05/2024, and The report pertains to the death of Resident #1 (R1). It was reported that on 11/02/2024, R1 was found unresponsive in the common area of the memory care unit. During today's visit, the LPA interviewed the Executive Director, attempted to interview two (2) residents, conducted a file review and collected pertinent documents relevant to the investigation. It has been determined further investigation is required prior to issuing findings. Exit interview conducted. Today's report was reviewed and provided to the Executive Director.the state’s words, verbatim · CDSS document, Oct 27, 2025

Allegation investigated: Staff refused to assist resident to the bathroom

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), Christian Castillo and explained the reason for the visit. Entrance interview conducted. On 12/13/24, between 01:00 p.m. and 4:15 p.m., the LPA interviewed two (2) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 09/25/25, the LPA conducted three (3) staff interviews and a file review. On 10/02/25, the LPA conducted one (1) staff interview with a former staff, and attempted to conduct a second staff interview. During toda's visit the LPA conducted a file review. In addition, interview with Staff 1 (S1) conducted by LPA Cortez on 12/16/2024, as part of a separate compliant investigation (CC# 29-AS-20231030120440) was incorporated and reviewed for the purpose of this investigation; this includes any relevant findings, witness statements, and documented evidence. Report will continue on LIC9099-C, 2nd page. Substantiated On the allegation, “Staff refused to assist resident to the bathroom”; it is the concern of the Reporting Party (RP) that on 06/18/24, Resident #1 (R1) needed assistance to go to the bathroom and staff refused to help R1, so the resident called 911 to assist them. It was further reported that Staff 1 (S1) told staff not to assist with R1 because the residents’ bed was too low. Staff interviews confirmed there was an incident where R1 could not be assisted to the restroom. Interview with S1 confirmed that even though they do not recall the exact date, they do recall the incident with R1 and confirmed that staff could not assist R1 to the restroom due to them having a new bed, the bed being too low to fit a Hoyer lift due to the legs being taken off, and the staff not being able to lift R1. S1 further revealed that R1 wanted to be taken to the restroom and S1 told R1 that “they couldn’t help because the Hoyer lift” and that they were happy to change them in bed. Phone Interview with staff 2 (S2) who was present the night of the incident, revealed that even though they did not refused to assist R1 they could not assist R1 to the restroom, there was no Hoyer lift available, and could also not change R1 in bed due to the bed being too low and their back would hurt. Both S1 and S2 revealed that paramedics were called by either R1 or R1’s family member and the paramedics assisted R1 to the restroom. Additionally, S2 revealed that management staff were notified of the incident and they approved for 911 to be called to assist R1. Based on staff interviews, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. On the allegations, “Staff did not do a proper assessment for a level change and Staff did not do a proper rate change”; it is the concern of the Reporting Party (RP) that Resident 1 (R1) and/or their responsible party received a letter that the facility would be raising the cost of rent due to being bought by a new company. On 09/05/24, the facility informed them the new amount would be $3300.13 then five (5) days later on 09/10/24, staff said it would be $6000.00. It was further reported that the levels of care did not change and staff never did an assessment or added anything to the care plan. File review revealed that R1 and/or their responsible person were sent a letter, dated 02/01/2024, informing them of changes to the community’s level of care system. On that letter it was explained that “All existing residents (anyone who has moved into a community before February 1, 2024) will switch to this new care-level plan on April 1, 2024. The actual change will occur at a resident’s first regularly scheduled assessment or change of health condition assessment after April 1, 2024.” File review also revealed that an additional letter dated 02/06/2024 was sent out with detailed information on the number of points that fit into each care level along with the cost per care level. The community now had four levels of care plans and one custom care plan for residents who received 4201 points or higher. This new custom care level would be capped at $6000.00. Furthermore, file Review revealed that R1 was receiving an allowance care discount of approximately $1200 starting in January of 2024, and on November 12th of 2024 the changes of the new level of care system took into effect for R1 and the allowance care discount was removed. Based on R1’s assessment conducted on 08/01/2024, R1 was assessed at 7,972.08 points. Based on R1’s assessment conducted on 09/10/2024, R1 was assessed at 6,568.50 points and R1’s level of care had decreased. The LPA did not observe anything to suggest the assessment was not done properly. However, per the new care-level plans due to the changes to the community’s level of care system, R1 was now receiving a custom level plan and both assessments were capped at $6000 due to the high amounts of points scored in both assessments regardless of the level of care decreasing from August to September. Based on the information gathered through interviews and file review, the allegations “Staff did not do a proper assessment for a level change and Staff did not do a proper rate change” are deemed Unsubstantiated at this time. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 29-AS-20241212090013

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 31, 2025

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on staff interviews, the licensee did not comply with the section cited above when staff did not assist R1 to the restroom and paramedics were called to assist R1 which posed an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Licensee will submit a plan how they will ensure residents receive the appropiate care.

Type of visit: Case Management - Other

Licensing Program Analyst, Esther Cortez arrived on October 21, 2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with Executive Director Christian Castillo. On February 1, 2024, the Department concluded a complaint investigation regarding the following allegation: Neglect/Lack of Care and Supervision – Resident (R1) choked to death without any medical intervention while under the care and supervision of the facility. The licensee was cited for California Code of Regulations (CCR) 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. At the time of the complaint visit on February 1, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the licensee and administrator not ensuring that a sufficient number of competent personnel were present and available to meet R1’s needs when R1 was observed choking on food, which resulted in death. Report will continue on LIC809-C, 2nd page. Today, October 21, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on February 1, 2024, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Executive Director Christian Castillo and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Oct 21, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management-Incident inspection regarding a self reported Report of Suspected Elder Abuse SOC341 received. LPA met with Executive Director Christian Castillo at 09:45 AM and explained the reason for the inspection. On 08/21/2025, Community Care Licensing (CCL) received a self reported Report of Suspected Elder Abuse SOC341 regarding Resident 1 (R1) and Staff 1 (S1). It was reported that S1 did not report or advocated for R1 to be seen in a timely manner after observing and noting resident had a wound that was infected on 08/10/2025. On 08/22/2025, LPA Cortez spoke with the ED telephonically. ED stated that R1 had a little abrasion on their leg and it was reported on 8/10 by S1, S1 reported it had a foul smell. S1 is a nurse, and knows that when you have a foul smell it could be an infection or something. S1 called home health to set up someone who could go out and look to determine if it was a wound and was told it would take 14 days to get the process. On 8/20 a MT was frustrated and asked the Director of Nursing (DON) what was going on with R1. The DON saw R1 and said there was a foul smell and sent R1 to urgent care, where they were told they needed to be taken to the hospital. During today's visit the LPA interviewed the ED, briefly spoke to the DON, and conducted a file review. The ED revealed that they were informed by the doctor at the hospital that R1's abrasion was not a pressure injury, however R1 was getting Home Health to treat their abrasion on their leg and O2. File review revealed that R1 was at the hospital from 08/22/25 to 08/26/25, and reason for their visit was listed as cellulitis. Wound infection was also listed as a medical problem. Report will continue on LIC809-C, 2nd page. A review of R1's charting notes revealed that on 08/10/25, a caregiver reported that the resident's wound on their left shin "seemed infected." The resident's skin was examined. The skin was broken about an inch and a half in diameter and foul odor was noted. Even though, staff were treating the wound with normal saline and patted dry, R1 was not seen by a medical provider until 08/22/25, leaving them with an infected wound for over ten (10) days. The following deficiency was cited from the California Code of Regulations, Title 22 and California Health and Safety Code. (See LIC 809-D) Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 28, 2025

87468.2(a)(4)...residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on self reported SOC341, the licensee did not comply with the section cited above, as resident was left with an infected wound for over 10 days before getting medical care which posed an immediate safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: S1 is no longer at the facility. Licensee agreed to submit a self-certification letter of understanding of regulation 87468.2 in its entirety and submit to LPA by 08/29/25.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a Case Management - Annual Continuation visit continuing the inspection that began on 11/18/2024. The LPA met with Executive Director (ED) Christian Castillo. Entrance interview conducted. Medication Audit: At 12:00 p.m. the LPA conducted Medications audit for two (2) residents. The medications are locked in medication carts. Medications are labeled and checked for expiration dates. Medications were observed to not be properly documented on the centrally stored medications and destruction record (CSMDR). During Resident 1's (R1's) audit the LPA observed three medications were not documented on the CSMDR, all medications were missing start dates on the CSMDR, and one medication did not have the date filled on the CSMDR. However, all the information was on their online system. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 28, 2025

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.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management-Incident inspection regarding a self-reported Unusual Incident/Injury Report (UIR) received. LPA met with Executive Director Christian Castillo and explained the reason for the inspection. On 08/13/2025, Community Care Licensing (CCL) received a self-reported Unusual Incident/Injury Report (UIR) pertaining to missed medications that occurred on 08/05/2025, and 08/06/2025 regarding Resident #1 (R1). It was reported that on the morning of 08/05/25 and and 08/06/25 R1 did not received their prescribed dose of Synthroid 50 mcg. R1 has two seperate orders for their medication depending on the day of the week, R1 received a new order changing the days, and when updating the EMAR, Staff 1 (S1) mistakenly discontinued the old order without approving the new one. It was reported, R1's POA and PCP were notified and S1 received medication training on 08/12/25. During today's visit, the LPA interview the Executive Director, who stated R1 is doing fine, and there were no symptoms or reactions to the missed medications. The following deficiency was cited from the California Code of Regulations, Title 22 and California Health and Safety Code. (See LIC 809-D) Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 13, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 14, 2025

A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on Special Incident Report submitted Resident 1(R1) did not received medication ordered by physician on two seperate days which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: S1 received medication training on 08/12/25. Administrator will submit proof of that training and Administrator agrees to submit a written statement of understanding of CCR 87465 in its entirety and plan on how they will ensure this wont happen again and will submit by 08/14/25.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management-Incident inspection regarding two self-reported Unusual Incident/Injury Reports (UIRs) received. LPA met with Executive Director Christian Castillo at 09:30 AM and explained the reason for the inspection. On 07/25/2025, Community Care Licensing (CCL) received two self-reported Unsual Incident/Injury Reports (SIRs) pertaining to two incidents that allegedly occurred on 07/21/2025 and 07/23/2025 regarding Resident #1 (R1). It was reported that on both dates R1 was inebriated, sustained falls, 911 was called and Paramedics transported R1 to Los Robles hospital for further evaluation. On 07/29/2025, Licensing Program Analyst (LPA) Cortez spoke with the Director of Nursing, Gina Taylor, over the phone, and it was reported that R1 sustained a Left Rib fracture on the second fall. It was further reported that on 7/7/25, R1 was placed on hourly safety checks, and on 07/21/25 after their first fall a 1:1 was put in place as a safety precaution. 1:1 was in the room with R1, when R1 sustained the second fall on 07/23/25. During today’s visit, the LPA conducted an interview with Executive Director Christian Castillo, Director of Nursing Gina Taylor, four (4) staff, attempted to contact private 1:1, and obtained copies of pertinent information. No immediate health and safety concerns were observed during the visit. LPA will return at a later date if warranted. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Aug 13, 2025

Allegation investigated: Staff did not prevent resident from harming other residents in care

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegation. Upon arrival, LPA met with the Executive Director (ED), Christian Castillo and explained the reason for the visit. Entrance interview conducted. During today's inspection, between 09:00 a.m. and 1:30 p.m., the LPA interviewed the ED, five (5) staff, two (2) residents, 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. Unsubstantiated On the allegation, "Staff did not prevent resident from harming other residents in care" it was reported that three memory care residents were in a common hallway when Resident 1 (R1) became upset and lunged at Resident 2 (R2) causing them to fall and then R1 punched Resident 3 (R3). On 05/15/25 Administrator Christian Castillo called LPA Cortez to notified them of the incident and left a voicemail. On 05/16/25, LPA Cortez interviewed Administrator Castillo telephonically regarding the incident. Administrator Castillo informed the LPA that R1 had no history of aggression at the facility, there was staff present when the incident occurred, and law enforcement, resident's family member's and other appropriate agencies were notified. The Administrator further stated that they are working with the residents to ensure their safety, and provided R1 a 1:1 for the first 12 hours after the incident as a precaution. Per R1's Physician's Report dated 06/28/24, R1 had listed diagnosis of Mild Cognitive Impairment and Benign Prostatic Hyperplasia. The report indicated R1 did not have any inappropriate or aggressive behaviors, is able to follow instructions as well as communicate needs. Communities internal charting notes revealed that R1 had exhibited aggression towards R3 on one other occasion, however staff was present and intervened. Staff interviews revealed that even though R1 has exhibited agitation and verbal aggressive behavior, they had not observed R1 be physically aggressive towards another resident prior to this incident. When residents are exhibiting aggression staff will re-direct, attempt to see if activities will help the resident, monitor them, report it to their family and physician and suggest a medication evaluation. Staff interviews also revealed that staff was present when the incident occurred, the residents were in the staff's line of sight, staff does not believe anything could have prevented the incident as R1 did not show any alarming behavior prior to the incident, staff intervened as soon as they could and re-directed R1. Furthermore, staff interviews revealed that the community has addressed R1's agitation and aggressive behaviors with family and physician. R1 was interviewed and does not recall pushing or punching anyone. R1 revealed that they do not know who R2 is and that their relationship with R3 is good. R2 declined to be interviewed and R3 was not available for an interview. During today's visit the LPA observed R1 and R2 interacting amicably. Based on the information obtained, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, May 19, 2025 · control 29-AS-20250516122438

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management-Incident inspection regarding two self-reported Unusual Incident/Injury Reports (UIRs) received. LPA met with Executive Director Christian Castillo at 09:00 AM and explained the reason for the inspection. On 04/17/2025, Community Care Licensing (CCL) received a self-reported Unusual Incident/Injury Report (UIR) pertaining to an incident that allegedly occurred on 04/10/2025 regarding Resident #1 (R1). It was reported that on 04/10/25, R1 was noted to be sitting on the floor and R1 complained of hip pain. 911 was called and Paramedics transported R1 to Los Robles hospital for further evaluation. It was further reported that R1 had a fractured pelvis and was receiving treatment at Los Robles as of 04/15/25. On 04/30/25, CCL received a self-reported Unusual Incident/Injury Report (UIR) pertaining to an incident that allegedly occurred on 04/26/2025 regarding Resident #2 (R2). It was reported that on 04/26/25, R2 was noted to be lying on the ground in their bedroom, R2 had bleeding around their left ear. 911 was called ad paramedics transported R2 to Los Robles hospital for further evaluation. It was further reported that R2 was evaluated and admitted to the hospital for sustaining two (2) small subdermal brain bleeds. During today’s visit, the LPA conducted an interview with Executive Director Christian Castillo, four (4) staff, and obtained copies of pertinent information. No immediate health and safety concerns were observed during the visit. LPA will return at a later date if warranted. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, May 19, 2025

Type of visit: Case Management - Other

Licensing Program Analyst Kelly Dulek arrived on 03/24/2025 at 03:40PM for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA intially met with front desk staff, then Director of Nursing and explained the reason for today's visit. LPA met with Executive Director Christian Castillo at 05:08PM. On October 26, 2022, the Department concluded a complaint investigation regarding the following allegations: Staff did not report a change in condition to resident's authorized representative; staff did not seek medical attention for resident in a timely manner; staff mismanaged resident's medication; staff did not ensure that resident's needs were met; and resident fell multiple times while in care. The licensee was cited for California Code of Regulations (CCR) 87466 Observation of the Resident, 87463(b) Reappraisals, 87464(f)(1) Basic Services, 87465(a)(4) Incidental Medical and Dental Care, and 87555(b)(5) General Food Service Requirements. At the time of the complaint visit on October 26, 2022, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury Report Continued on LIC 809-C involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility did not seek guidance for the resident’s changes of condition, including weight loss of 36 pounds, multiple hypoglycemic episodes, and fall events, which resulted in dehydration, acute kidney injury and hospitalization. Today, 03/24/2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on October 26, 2022, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Executive Director Christian Castillo’s signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Mar 24, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted a case management visit at the community regarding a self reported incident that occurred on 03/02/2025. The LPA met with Administrator Christian Castillo and explained the reason for the visit. It was reported that on 03/02/2025, Resident 1 (R1) went down to the front desk and asked the Concierge to call the paramedics because they "took a bottle of pills a couple hours ago in their room." Concierge called 911 immediately then radio the Med tech/Wellness Assistant. Resident was observed until paramedics arrived. Paramedics assessed the resident and transported to the hospital for further evaluation. It was further reported that R1 was on med management, left the community on 2/18/25, returned on 02/27/25 and did not disclosed filing a prescription with outside pharmacy on 02/19/25. During today's visit the LPA conducted an interview with the Administrator, one (1) staff, conducted a file review, started a medication audit, and obtained pertinent documents relevant to the investigation. Further investigation will need to be conducted and LPA will return at a later date. No citations issued during today's visit. Exit interview conducted. Report provided.the state’s words, verbatim · CDSS document, Mar 14, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Executive Director Christian Castillo and explained the reason for the visit. Entrance interview conducted. The reason for today's inspection is to follow up on a self-reported death report received on 12/23/2024, and the report pertains to the death of Resident #1 (R1). It was reported R1 was found unresponsive in bed on 12/20/2024. During today's visit, the LPA conducted an interview with the ED, conducted a brief tour of the facility and conducted a file review. Community was experiencing a power outage, any necessary pertinent documents will be sent to the LPA. If warranted, the LPA will return at a later date. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 9, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Executive Director Christian Castillo and explained the reason for the visit. Entrance interview conducted. The reason for today's inspection is to follow up on a self-reported death report received on 11/05/2024, and The report pertains to the death of Resident #1 (R1). It was reported that on 11/02/2024, R1 was found unresponsive in the common area of the memory care unit.. During today's visit, the LPA conducted an interview with the ED, conducted a brief tour of the facility and obtained copies of pertinent documents. Community was experiencing a power outage, any necessary pertinent documents will be sent to the LPA. This incident was referred to Community Care Licensing Investigations Branch (IB) for review. If, further investigation is warranted an investigator or the LPA will return at a later date. Exit interview conducted. A copy of the report was issued to the ED.the state’s words, verbatim · CDSS document, Jan 9, 2025

Allegation investigated: Staff did not ensure residents medication was dispensed in a timely manner Licensee does not ensure facility has sufficient amount of staff to meet the care needs of residents

At 10:30 a.m.. Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit at the facility to deliver findings for the allegation listed above. The LPA met with Executive Director Christian Castillo and explained the reason for the visit. On 11/07/2023, LPA Elsie Campos conducted observations of staff and residents pertaining to the complaint allegations, attempted resident interviews at 1:40 p.m. and 1:50 p.m., conducted interview with Executive Director at 3:10 p.m. and collected and reviewed pertinent records. On 11/25/2024, LPA Esther Cortez starting at 11:00 a.m., conducted a file review and four (4) staff interviews. The LPA has determined further investigation is needed. Report continued on LIC9099-C.... Substantiated Report continued from LIC9099... On 11/26/2024, LPA Cortez starting at 1:00 p.m. conducted four (4) resident and two (2) staff interviews. On 12/02/2024, between 11:40 a.m. and 4:30 p.m. LPA Cortez conducted two (2) staff and five (5) resident interviews. On 12/13/2024, LPA Cortez, between 01:00 p.m. and 4:15 p.m. interviewed two (2) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/16/2024, between 10:30 a.m. and 4:30 p.m., LPA Cortez conducted five (5) staff interviews and obtained copies of pertinent documents relevant to the investigation. On the allegations, “Staff did not ensure residents medication was dispensed in a timely manner, and Licensee does not ensure facility has sufficient amount of staff to meet the care needs of residents”; it is the concern of the reporting party that approximately around or on 10/10/2023, staff took three (3) hours to dispense morning medication to Resident 1 (R1) and Resident 2 (R2) and that the facility does not have enough care staff to provide care for all of the residents needs in a timely manner. To investigate the allegations, the LPA conducted interviews and file review. Staff interviews revealed that MedTechs (MTs) are trained to document the time that a resident’s medicine is prepared and document after the medicine has been administered. The MT will log on to their online system and check what residents they will be assisting with medications. They will select the resident that they will be dispensing medications, after the medication has been prepared and is ready to be given, they will press the “PREP MED” button, and give the medication to the resident. After the medication is given, the MT will go back to their online system and press the “PASS MED” button to chart that the medication has been given. Staff revealed that there is certain times that after a medication has been given a MT may be called or stopped to assist with other things and may not chart right after the medication was passed. A review of R1’s Electronic Medication Administration Record (eMAR) revealed that on 10/12/2023, two of R1’s medications that were scheduled for 7:00 a.m. and one medication that was scheduled for 8:00 a.m. were documented as prepped at 11:27 a.m. and charted at 12:12 p.m. A file review revealed that R2 is no longer at the facility, and the LPA could not view R2’s eMAR. Furthermore, staff revealed that they have heard residents complained that they do not receive their medication on time and have heard other staff over the walkie talkie report that certain resident is still waiting for meds and has been an hour. Report continued on LIC9099-C.... Report continued from LIC9099... Interviews conducted with care staff and MedTechs revealed that a full staffed morning shift is four (4) caregivers and (2) MedTechs (MT) in Assisted Living and three (3) caregivers and one (1) MT in Memory Care. Six (6) out of eight (8) staff that were working at the community during 2023, recall or have knowledge of the community being understaffed, including in October of 2023 during the time the complaint was submitted. A staff revealed that there has been plenty of times that there have only been two (2) staff on the floor, they further revealed that there was one shift where they were the only staff in all four (4) floors in Assisted Living. The staff also revealed that it was noticeable that there were times that R1 had peed on themselves because staff did not get to them on time due to there not being enough staff. Other staff revealed that residents brought up concerns of staff being understaffed in the town hall meetings many times. Many staff revealed that the community is currently doing a lot better this year and believe their workload is manageable, however their workload can become not manageable if staff calls out and management does not have anyone to cover their shift. Additionally, staff revealed that their workload was not manageable in 2023. Staff revealed they often had to take on other’s responsibilities due to lack of staff and felt stressed and rushed. Furthermore, staff revealed that they felt bad for the residents during that time, because they were not getting the good service that they deserve. Two residents revealed that in 2023, the community was understaffed, and it was noticeable as staff would be in a hurry to assist, there were times they had to wait as much as two (2) hours for assistance. Based on the information gathered through interviews and file review, although staff interviews revealed that staffing has improved, at the time the complaint was submitted the community did not have adequate staffing to assist resident with care needs. File review revealed that medications for R1 that were scheduled for 7:00 a.m. and 8:00 a.m. were documented as prepped until 11:27 a.m. and charted until 12:12 p.m. making them over three (3) hours late. Therefore, the allegations, “Staff did not ensure residents medication was dispensed in a timely manner, and Licensee does not ensure facility has sufficient amount of staff to meet the care needs of residents” are deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. Report continued from LIC9099... On 11/26/2024, LPA Cortez starting at 1:00 p.m. conducted four (4) resident and two (2) staff interviews. On 12/02/2024, between 11:40 a.m. and 4:30 p.m. LPA Cortez conducted two (2) staff and five (5) resident interviews. On 12/13/2024, LPA Cortez, between 01:00 p.m. and 4:15 p.m. interviewed two (2) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/16/2024, between 10:30 a.m. and 4:30 p.m., LPA Cortez conducted five (5) staff interviews and obtained copies of pertinent documents relevant to the investigation. On the allegation, “Staff has inappropriate conversations with other facility staff in front of residents,” it is the concern of the reporting party that Staff 1 (S1) yells and uses foul language at the care staff while in presence of the residents and visitors. The RP further revealed that they personally have never witness S1 yell or use foul language in front of the residences. Staff and File review revealed that S1 no longer works at the community. All staff interviewed regarding the allegation revealed that they have never witness or heard any staff speak inappropriately or yell in front of the residents. All residents interviewed revealed that they have not heard staff speak inappropriately in front of them. Based on interviews, there is insufficient evidence to support the above-mentioned allegation. The allegation, “Staff has inappropriate conversations with other facility staff in front of residents,” is unsubstantiated at this time. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Dec 27, 2024 · control 29-AS-20231030120440

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 10, 2025

Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: This requirement was not met by evidence of eMAR indicating medication not provided in a timely manner. Which poses an immediate risk to Residents in care.the state’s words, verbatim · CDSS document, Dec 27, 2024

Plan of correction: POC- Administrator agrees all MTs will receive Medication training that includes documentation, and medication distribution. Submit proof of training to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 31, 2024

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement is not met as evidenced by:Based on file review and interviews, the licensee did not comply with the section cited above as staff revealed that in 2023 the community was understaffed and were rushed to assist residents and residents had to wait long period of times to get assisted. This posed a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Dec 27, 2024

Plan of correction: The ED agrees to submit a written plan that will be implemented when staff call out to ensure that there is always staff coverage at all times by 12/31/2024.

Allegation investigated: Facility does not have adequate staffing to assist resident with care needs.

At 10:30 a.m. Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit at the facility to deliver findings for the allegation listed above. The LPA met with Executive Director Christian Castillo and explained the reason for the visit. On 09/18/2023, LPA Elsie Campos conducted interviews with witness at 10:45 a.m., Executive Director at 11:10 a.m. and collected and reviewed pertinent records beginning at 12:20 p.m. On 11/25/2024, LPA Esther Cortez, starting at 11:00 a.m., conducted a file review and conducted four (4) staff and one (1) phone interview with Phillips Lifeline Technical Support. Report continued on LIC9099-C.... Substantiated Report continued from LIC9099... On 11/26/2024, LPA Cortez, starting at 1:00 p.m., conducted four (4) resident and two (2) staff interviews. On 12/02/2024, LPA Cortez, starting between 11:40 a.m. and 4:30 p.m. the LPA conducted two (2) staff and five (5) resident interviews and obtained copies of resident records and other pertinent documents relevant to the investigation. 12/13/2024, LPA Cortez, between 01:00 p.m. and 4:15 p.m., the LPA interviewed two (2) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/16/2024, LPA Cortez, between 10:30 a.m. and 4:30 p.m., conducted five (5) staff interviews and obtained copies of pertinent documents relevant to the investigation. On the allegation "Facility does not have adequate staffing to assist resident with care needs"; it is the concern of the reporting party that there is not enough staff on shifts. It was further reported that on 09/11/2023, Resident 1 (R1) was up at 7:00 a.m., called, and had no one to assist them for one and a half hours to get out of bed and dressed until someone went at 8:30 a.m. To investigate the allegation the LPA conducted a file review and interviews. A report of residents Personal Help Buttons (PHB) calls made between 09/10/2023 starting at 12:59 a.m. and ending on 09/11/2023, 11:18 p.m. revealed that on 09/11/2023, R1 had a registered pendant call at 7:21 a.m. Per the report, it took staff 35 minutes and 54 seconds to reach R1 to assist them with their call. In addition, R1 had to wait for over 15 minutes when pressing their pendant call in eight (8) out of nineteen (19) pendant calls made between 09/10/2023 and 09/11/2023, with the highest wait time being 43 minutes and 34 seconds. Furthermore, the average wait time for the residents to be assisted noted on the report was 38 minutes and 12 seconds. Interviews conducted with staff revealed that a full staffed morning shift is four (4) caregivers and (2) MedTechs (MT) in Assisted Living and three (3) caregivers and one (1) MT in Memory Care. Six (6) out of eight (8) staff that were working at the community during 2023, recall or have knowledge of the community being understaffed, including in September of 2023 during the time the complaint was submitted. A staff revealed that there has been plenty of times that there have only been two (2) staff on the floor, they further revealed that there was one shift where they were the only staff in all four (4) floors in Assisted Living. Report continued on LIC9099-C.... Report continued from LIC9099... The staff also revealed that it was noticeable that there were times that R1 had peed on themselves because staff did not get to them on time due to there not being enough staff. Other staff revealed that residents brought up concerns of staff being understaffed in the town hall meetings many times. Many staff revealed that the community is currently doing a lot better this year and believe their workload is manageable, however their workload can become not manageable if staff calls out and management does not have anyone to cover their shift. Additionally, staff revealed that their workload was not manageable in 2023. Staff revealed they often had to take on other’s responsibilities due to lack of staff and felt stressed and rushed. Furthermore, staff revealed that they felt bad for the residents during that time, because they were not getting the good service that they deserve. Two residents revealed that in 2023, the community was understaffed, and it was noticeable as staff would be in a hurry to assist, there were times they had to wait as much as two (2) hours for assistance and one of the residents stated that there was an incident where they had to wait for their medication over three (3) hours. Based on the information gathered through interviews, although staff interviews revealed that staffing has improved, at the time the complaint was submitted the community did not have adequate staffing to assist resident with care needs, therefore the allegations is deemed Substantiated at this time. Although allegation is Substantiated, a citation will be issued for this deficiency under complaint control #29-AS-20231030120440 for same allegation. Exit interview conducted, appeal rights discussed, and a copy of this report issued. Report continued from LIC9099... On 11/26/2024, LPA Cortez, starting at 1:00 p.m., conducted four (4) resident and two (2) staff interviews. On 12/02/2024, LPA Cortez, starting between 11:40 a.m. and 4:30 p.m. the LPA conducted two (2) staff and five (5) resident interviews and obtained copies of resident records and other pertinent documents relevant to the investigation. 12/13/2024, LPA Cortez, between 01:00 p.m. and 4:15 p.m., the LPA interviewed two (2) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/16/2024, LPA Cortez, between 10:30 a.m. and 4:30 p.m., conducted five (5) staff interviews and obtained copies of pertinent documents relevant to the investigation. On the allegation, “Staff did not assist resident with restroom needs resulting in resident developing multiple UTI's” it is the concern of the reporting party that Resident 1 (R1) had three (3) Urinary Tract Infections and believes that a slow call light response is a contributor. No additional information was provided regarding the resident’s UTI’s. Staff interviews revealed that residents are changed every two (2) hours, however many staff revealed that R1 frequently pressed their pendant and was checked on a lot more often. File review revealed that R1 was able to use the restroom with assistance and wore briefs. No specific dates or timeframes were provided regarding when UTIs were diagnosed. There are no medical records on file to confirm that the resident developed UTIs. Furthermore, there was no evidence indicating the source of R1’s UTIs. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Dec 27, 2024 · control 29-AS-20230912151611

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

At 12:35 p.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent complaint visit at the facility regarding the above allegation. The LPA met with Executive Director Christian Castillo and explained the reason for the visit. On 09/18/2023, LPA Elsie Campos conducted interviews with witness at 10:45 a.m., Executive Director at 11:10 a.m. and collected and reviewed pertinent records begining at 12:20 p.m. On 11/25/2024, starting at 11:00 a.m. LPA Cortez conducted a file review and conducted four (4) staff and one (1) phone interview with Phillips Lifeline Technical Support. During today's visit starting at 1:00 p.m. the LPA conducted three (3) resident and two (2) staff interviews. Report will continue on LIC9099-C, 2nd page. Substantiated On the allegation " Staff does not respond to resident's call button in a timely manner"; it is the concern of the reporting party that residents experienced long wait times and on 09/11/23, Resident #1’s (R1’s) caregiver called out and they had no one to assist them for one and a half hours to get out of bed and dressed. It was further reported that R1 was up at 7:00 a.m. and called and no one came until 8:30 a.m. To investigate the allegation the LPA conducted a file review and interviews. A report of residents Personal Help Buttons (PHB) calls made between 09/10/2023 starting at 12:59:00 a.m. and ending on 09/11/23, 11:18:00 p.m. revealed that on 09/11/2023, R1 had a registered pendant call at 7:21:28 a.m. Per the report, R1 has two (2) different noted times for how long it took for the resident’s call to be answered; one being 29 minutes with 55 seconds and the second being 30 minutes and 9 seconds. The report also noted two reset times: 5 minutes with 45 seconds (which is how long it took the staff to reach the resident after claiming the call) and the second noted time being 35 minutes with 54 seconds (which is the total time from when the resident pressed their pendant to when the staff contacted the resident). Staff revealed that the “answer” times is how long it took the staff to claim the pendant call on their iPad, the reset time is when the resident is reached and the staff can reset the call, and the complete time is when the staff goes back and presses complete button on their iPad and would be the overall time it took the staff to complete the call. LPA Cortez conducted a phone interview with the Technical Support team from Phillips Lifeline, whose pendant system was used in the community in 2023. Tech Support revealed that whenever there is two different times reflecting under the “Answer” time, the bottom time is ultimately the time it took for staff to claim a call. Based on the information gathered, on 9/11/2023, at 7:21:28 a.m. it took staff 35 minutes and 54 seconds to reach R1 to assist them with their call. In addition, R1 had to wait to be assisted for over 15 minutes when pressing their pendant call in eight (8) out of nineteen (19) pendant calls made between 09/10/2023 starting at 12:59:00 a.m. and ending on 09/11/23, 11:18:00 p.m., with the highest wait time being 43 minutes and 34 seconds. Furthermore, the average reset time for residents noted on the report was 38 minutes and 12 seconds. Based on the information gathered through file review, the allegation Staff does not respond to resident's call button in a timely manner is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 29-AS-20230912151611

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 10, 2023

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on records review, the licensee did not comply with the section cited above as Staff did not respond to R1’s call for assistance in a timely manner, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: ED agreed to have an in service with all staff regarding how to respond resident calls in a timely manner. Will submit proof of inservice to CCL by 12/10/23

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 is overcharging resident Resident was not provided an itemization of charges.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival, the LPA met with the Executive Director (ED) Christian Castillo, and was explained the reason for the visit. Entrance interview conducted. On 09/23/2024, between 02:10 p.m. and 5:15 p.m., the LPA interviewed the Executive Director, one (1) staff, five (5) residents, conducted a tour of the kitchen/dinning areas and obtained copies of resident records and other pertinent documents relevant to the investigation. On 10/22/2024, the LPA conducted file review, interviewed one (1) staff, five (5) residents, and obtained pertinent documents relevant to the investigation. During today's visit, the LPA conducted a file review at 11:15 a.m. and two (2) staff interviews. Report will continue on LIC9099-C, 2nd page. Unsubstantiated On the allegations "Facility is overcharging resident and resident was not provided an itemization of charges."; it is the concern of the reporting party that starting 09/12/24 Resident #1’s (R1’s) cost of care would increase to $6,000 from $3,100 and it is unclear how R1’s care plan justifies the $6000 cost. RP further reported that R1 and/or their authorized person had not received any additional information from facility staff or an itemization of the charges. To investigate the allegation the LPA conducted interviews and a file review. Interview conducted with current Executive Director (ED) Christian Castillo revealed that when the new management company, Agemark, took over about a year ago, it was decided that the community would be implementing new prices for the care costs. The community did not want to scare the residents with the new prices, therefore residents were notified of the new care cost and those residents who were receiving care were given the option to either put a freeze on their account or give them a concession and in six (6) months after the concession was given the resident would start paying the new prices. If the resident opted to have their account be placed on a “freeze”, it meant that they would continue to pay their current rate and not be charged the new care rate up until their new re-assessment or a change in condition. If the resident opted to get a concession, it meant that they would get an allowance care discount on their on their bill and the discount would vary from resident to resident. File review revealed that R1 was sent a letter, dated 02/01/2024, informing them of changes to the community’s level of care system. On that letter it was explained that “All existing residents (anyone who has moved into a community before February 1, 2024) will switch to this new care-level plan on April 1, 2024. The actual change will occur at a resident’s first regularly scheduled assessment or change of health condition assessment after April 1, 2024.” File review also revealed that an additional letter dated 02/06/2024 was sent out with detailed information on the number of points that fit into each care level along with the cost per care level. The community now had four level of care plans and one custom care plan for residents who received 4201 points or higher. Furthermore, file Review revealed that R1 was receiving an allowance care discount of approximately $1200 starting in January of 2024, and on November 12th of 2024 the changes of the new level of care system took into effect for R1 and the allowance care discount was removed. Based on R1’s assessment conducted on 09/10/2024, R1 was assessed at 6.568.50 points and per the new care-level plans was now receiving a custom level plan and was capped at $6000. Based on the information gathered through interviews and file review, the allegations Facility is overcharging resident and resident was not provided an itemization of charges." are deemed Unsubstantiated at this time. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 29-AS-20240918103350

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 10:30 a.m. The LPA was greeted by staff and Executive Director (ED) Christian Castillo and informed them of the reason for the visit. At 11:00 a.m. the LPA conducted a tour of the physical plant with the ED 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 four (4) story residence that consists of assisted living units on all floors and a memory care unit on the second floor. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 07/18/2024. Smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed required postings near the mail room hallway. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. KITCHEN: The LPA began the inspection in the kitchen/food service area at 11:00 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: The LPA toured all four floors and common spaces in both the assisted living and memory care unit. Activity rooms and common spaces were clean and in good repair. The facility maintained a comfortable temperature. The LPA observed the stairwells and they each had an emergency evacuation chair. BEDROOMS: The LPA observed ten (10) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. Bedroom #249 was observed with a lot of dirt/crumbs on the carpet. Bedroom #233 was observed with a lot of dirt/crumbs on the carpet. Report will continue on LIC809-C, 2nd page. At 12:06 p.m. the LPA observed two spray bottles of wound cleanser in bedroom #249 in the MC unit. At 12:39 p.m. the LPA observed bedroom #238 had a strong odor, the carpet was stained and had food stuck on the carpet, the wood floor in the entrance had streaks and was sticky. RESTROOMS: Almost all resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. Restroom in bedroom #233 and #238 and had a sticky floor. The hot water temperature was measured in resident rooms (#112, 254, 225, 239, 249, 233, 238, 304, 408) ranged between 105.8– 111.7*F. At 11:28 a.m. the LPA observed prescribed medication in the bathroom of room #112, however resident in the room cannot administered medications per their LIC602. At 12:01 p.m. the LPA observed a bottle of hydrogen peroxide in the bathroom of room #239 in MC. At 12:43 p.m. the LPA observed a bottle of Miralax, a container of Hempvana maximum strength pain relief cream, a prescribed Calmoseptine ointment, and a bottle of toilet bowl with bleach in the the bathroom of room #304. Resident in room 304 cannot administer or store medication per their LIC602. At 12:55 p.m. the LPA observed a container of Comet with Bleach, a bottle of Clorox disinfecting cleaner, and 2 containers of disinfecting wipes in the bathroom of room#408. OUTSIDE GROUNDS: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for resident’s use. No pool on the premises. Parking is available for residents and visitors. At 11:57 a.m. the LPA observed a hose in the memory care court yard. Interviews: The LPA interviewed two (2) residents. No immediate concerns were voiced. Record Review: At 1:45 p.m. a review of facility files was initiated. Facility records are stored in a locked office. The LPA observed documentation of Infection Control, and Disaster prevention. The LPA obtained Client Roster, Staff Roster, and Insurance Liability. The LPA reviewed five (5) of ninety-three (93) resident files. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. Due to time constraints, the LPA will return at a later date to complete the inspection. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 18, 2024

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: Facility is not providing quality meals

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival, the LPA met with the Executive Director (ED) Christian Castillo, and was explained the reason for the visit. Entrance interview conducted. On 09/23/2024, between 02:10 p.m. and 5:15 p.m., the LPA interviewed the Executive Director, one (1) staff, five (5) residents, conducted a tour of the kitchen/dinning areas and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's visit, the LPA conducted file review, interviewed one (1) staff, five (5) residents, and obtained pertinent documents relevant to the investigation. Report will continue on 9099-C (2ND PAGE). Unsubstantiated On the allegation " Facility is not providing quality meals "; it is the concern of the reporting party that the facility is not providing fresh meals, serves frozen vegetables, do not have a variety of meals, and serve pork two to three times a week. On 09/23/2024, the LPA observed the kitchen around 2:50 p.m. and observed the following vegetables on stock such broccoli, carrots, potatoes, zucchini, tomatoes, squash, bell peppers, and cucumbers. Staff interview with the dining director revealed that food is prepared based on the menu, pork is served once a week, and that the facility has an alternate menu that the residents can order from if they do not like the meals for that day. Residents were interviewed about the food quality on 09/23/24 and during today’s visit. Ten out of Ten residents stated that the food is fresh, there is variety, and they have no concerns regarding the quality of the food, with one resident stating the quality of the food is excellent. On 09/23/24, the LPA observed a resident eating meat loaf with brown gravy, with smashed potatoes and green beans for dinner at approximately 4:06 p.m. During today’s visit, at approximately 1:20 p.m. the LPA observed a Fajita bar served for lunch with chicken, shrimp and beef options and onions and bell peppers. Beginning at 4:45 p.m. the LPA observed residents eating either a soup, sandwich, or seafood newburg over biscuit with mixed vegetables during dinner. Based on the information gathered through interviews and observation, the allegation that the Facility is not providing quality meals is deemed Unsubstantiated at this time. Exit interview conducted. Today's report was reviewed and emailed to the Executive Director.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 29-AS-20240918103350

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 does not provide a clean and safe environment for residents.

Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegation. Upon arrival, the LPA met with the Executive Director (ED) Christian Castillo, and was explained the reason for the visit. Entrance interview conducted. On 10/07/24, between 10:30 a.m. and 2:00 p.m., the LPA toured the facility, interviewed the Executive Director, three (3) staff, six (6) residents, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's inspection, between 1:15 p.m. and 5:00 p.m., the LPA conducted a file review and interviewed five (5) residents, one (1) staff and obtained copies of pertinent documents relevant to the investigation. Report will continue on LIC9099-C (2nd page). Unsubstantiated On the allegation "Facility does not provide a clean and safe environment for residents"; it is the concern of the reporting party that the facility environment is causing Resident #1 (R1) to cough and wheeze. The RP further reported that they believe R1’s room may have mold. To investigate the allegation the LPA conducted observations, file review and interviews. On 10/07/24, the LPA toured the facility and observed R1’s room. The LPA did not observe any evidence of the allegation while at the facility. The LPA did not observe any mold in R1’s room or any other room they visited. The LPA observed the facility clean and sanitary. Interviews with staff, residents and witness revealed that they have not observed mold at the facility and that housekeeping gets done once a week. Six (6) out of seven (7) residents interviewed revealed that they have no issues with coughing or wheezing. Interview with R1 revealed they went to the doctor to get lab testing done for mold exposure. R1’s lab results did not reveal any mold exposure. Staff and file review revealed that a work order had been submitted for mold in R1’s room, and that R1 could not breath. Maintenance staff went to inspect R1’s room and did not find mold in R1’s room. Staff also revealed that they had also previously worked on the air vents in R1’s room after a work order had been submitted regarding dust coming out through the air vent. On the allegation “Facility does not provide a clean and safe environment for residents,” Information obtained from interviews and file review revealed that staff and residents have not seen any mold at the facility, housekeeping gets done once a week, when a resident voices an issue or submits a work order, staff assists the residents and R1’s lab work did not reveal any mold exposure. Although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Today's report was reviewed and emailed to the Executive Director.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 29-AS-20241003142431

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Deficiency visit in conjunction with an initial 10-day complaint visit (CC #29-AS-20241003142431). LPA met with Executive Director Christian Castillo. 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 10/07/2024, during a facility tour, at 11:32 a.m. the LPA observed cleaning supplies left unattended in the hallway accessible to residents in care. The LPA observed a bottle of Lemon-Eze bathroom creme cleaner, a bottle of multi purpose cleaner, and a bottle of floor cleaner. After a few minutes, staff came back and stated they thought they could not leave cleaning supplies out only in memory care. The ED advised staff to lock them away, and that cleaning items could not be left accessible to residents. Citation issued, exit interview, appeal rights given.the state’s words, verbatim · CDSS document, Oct 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 8, 2024

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidence by: Based on observation the licensee did not comply with the section cited above in one carts with cleaning supplies was left unattended which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: Staff secured the cleaning items during the visit. Executive Director agrees to provide training to the staff that left the cart unattended regarding the regulation and submit proof by plan of correction date 10/08/2024.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Executive Director Christian Castillo and explained the reason for the visit. On 07/11/2023, the Department received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) from the facility regarding Resident #1 (R1). The report listed a possible sexual assault of an elderly resident diagnosed with mild cognitive impairment (MCI). The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Juan Lozano. On 07/12/2023, from 1:49pm to 4:10pm, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Incident visit at the facility. LPA Lopez met with interim Administrator Julius Osorio and explained the reason for the visit. On 07/11/2023, the Department received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) completed 07/07/2023 from interim Administrator Julius Osorio. The SOC 341 report pertained to (R1) and Staff #1 (S1) for an alleged incident that occurred on 07/06/2023. On 07/11/2023, the LPA spoke with Mr. Osorio on the telephone regarding the alleged incident and he stated S1 was currently on leave pending an investigation. During the inspection, the LPA reviewed facility records and obtained pertinent copies. When the LPA arrived at the facility, there was a Ventura County Sheriff's vehicle outside the building. The LPA was advised that law enforcement was speaking with R1 at the time. A copy of the report number RB# 23-88897 was obtained. The LPA determined further investigation was needed and informed Mr. Osorio that the Community Care Licensing Division (CCLD) Investigation Branch (IB) Investigator Juan Lozano was assigned to the investigation. REPORT WILL CONTINUE ON LIC809-C. On 07/21/2023, from 11:05am to 11:30am, Investigator Lozano conducted interviews with R1 and R2; and on 07/24/2023, at 3:00pm, with S1. In addition, facility file documents related to R1 were reviewed. Law enforcement interviewed R1 and S1 and did not conduct any further investigation. Information obtained from the investigation revealed that on 07/07/2023, R1 reported that on 07/06/2023 at approximately 1:30pm, when R1 had their meal tray delivered by S1, R1 stated that R1 needed assistance moving up in bed. Per R1, S1 offered to help and placed S1’s arms around R1 to lift R1 and then kissed R1 on the mouth. Per R1, after the incident, R1 asked S1 to leave the room. R1 stated Resident #2 (R2) was also in the room but reportedly did not see anything. R1 and R2 reside in the same room. The facility suspended S1 pending their investigation. The facility took a statement from S1 on 07/08/2023 who denied the allegation. Per S1, the meal tray was delivered to R1 and R2. S1 setup their food on their tables. R1 asked for help sitting up in the bed, and S1 told R1 they were not able to assist but would get someone. S1 then stated that R1 asked if they could help change R1’s shirt to which S1 responded that they could not but would get someone to help with that also. S1 left to go get R1 tea they requested and came back to the room and finished setting up their food as they requested and left the room. S1 stated it was a total of approximately 6 minutes they assisted which included getting tea. S1 confirmed the R2 was present and sitting up. Information obtained from the Department’s interviews with R1, R2, and S1 revealed all parties denied the allegation. Based on the conflicting statements made by R1 and R2, the Department determined it is unlikely that R1 was sexually assaulted at the facility. R1 denied being kissed by S1. R2 stated that R2 lives in the same room with R1 and denied seeing anyone kissing R1. S1 denied the allegation. The Department does not have sufficient evidence to support the above allegation. Therefore, the allegation “Resident was sexually assaulted at the facility” is deemed Unsubstantiated at this time. Exit interview, copy of report given.the state’s words, verbatim · CDSS document, Sep 23, 2024

Allegation investigated: Staff did not ensure that resident's toileting needs were met Staff billed resident for services not received

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Executive Director Betsy Mccoy and explained the reason for the visit. On 06/21/2023, from 10:26 a.m. to 3:30 p.m., LPA KaSandra Lopez conducted an initial complaint inspection at the facility. LPA Lopez met with Business Office Manager Jennifer Miller and informed her of the reason for the visit. Between 10:15 a.m. and 11:16 a.m., the LPA reviewed facility records and requested copies of pertinent records. During the visit, the LPA also conducted an interview with Staff #1 (S1), observed R1’s apartment and the requested records were reviewed. On 07/07/2023, LPA Lopez conducted a subsequent visit and conducted two staff interviews between 11:55 AM and 1:54 PM. On 05/07/2024, LPAs Esther Cortez and Sandra Urena conducted an inspection at the facility and conducted interviews and observed resident rooms between 10:00 AM and 4:30 PM. Report will continue on LIC9099-C (2ND PAGE). Substantiated On 06/17/2024, LPA Cortez conducted a subsequent visit, conducted a record review and staff interview. On 06/18/2024 LPA Cortez conducted staff interviews and obtained pertinent documents. During today’s visit, LPA Cortez delivered findings. Staff did not ensure that resident's toileting needs were met. On the allegation that Staff did not ensure that resident's toileting needs were met, the reporting parties concern is that staff did not respond timely for calls for assistance with toileting, and as a result Resident#1 (R1) would have accidents and wet themselves. To investigate the allegation, file review and interviews were conducted. Staff interviews revealed that when the facility is short staff, residents can go without showers and additionally staff interviews revealed that due to being short-staffed staff would not get to R1 timely and R1 would sometimes be wet when they got to R1. Furthermore, staff interviews revealed that if staff is busy it can take up to forty-five minutes to an hour to assist residents when they pressed their pendant. Record review conducted revealed that on numerous occasions it took longer than 30 minutes for R1’s call button to be answered. During December 2022, R1 had approximately 28 pendant calls that took approximately 30 minutes or longer to be answered, with one pendant call on December 31, 2022 taking approximately one hour and forty-two minutes to answer. Lastly, on 06/18/2024, at approximately 1:50 p.m. LPA Cortez heard staff calling for assistance from other staff to assist with a resident transfer over the radio for over twenty minutes. The staff's call for assistance went without being answered for approximately over twenty (20) minutes. Based on interviews, file review, and observation, the above allegation is deemed Substantiated at this time. Staff billed resident for services not received. On the allegation that Staff billed resident for services not received, the reporting parties concern is that per the admission agreement after a resident is out of the community for fifteen consecutive days a credit/refund for personal care would be issued, and staff charged Resident#1 (R1) for personal care for days R1 was at the hospital, at a skilled nursing and not in the community. It was further reported that R1 was taken to the hospital on January 5, 2023, and did not return to the facility until January 27, 2023. To investigate the allegation, record review and interviews were conducted. The LPA reviewed R1’s admission agreement which states the following: D. Adjustments to Fees or Services. 3. Absences from Sage Mountain Senior Living. If you are absent from _ Sage Mountain Senior Living for a period of fourteen (14) consecutive days or more, you will be entitled to a credit beginning on the fifteenth (15th) day of absence in the amount set forth in Appendix A. Report will continue on LIC9099-C (3RD PAGE). In addition, information obtained during the investigation revealed that R1’s authorized person had inquired with Business Office Manger Jennifer Miller on May 23rd of 2023 via email correspondence about a credit due for the time R1 was absent from the community (1/05/2023-1/27/2023) and Miller stated they would check the dates with staff and verify if a credit was due. On May 31st of 2023, R1’s authorized person requested an update on the credit potentially due, to which Interim Administrator at the time, Julius Osorio was cc’d on and corresponded that they would try to follow up on and provide an update. Staff interviews revealed that yes, depending on the resident’s admission agreement, if a resident would be out for a period of fourteen (14) consecutive days, residents would be entitled to a credit or refund starting on the fifteenth (15th) day of absence. Interview conducted with Julius Osorio, revealed that they never followed up with R1’s authorized person and did not ensure they received their personal care credit they were inquiring about. Staff interviews revealed that Business Office Manager, Jennifer Miller is no longer working at the facility, and it would have been their responsibility to follow up regarding this credit/refund. Staff interviews also revealed that due to the company’s management change that took place in 2023, the new management company, Agemark, does not have access to financial records for January 2023 for residents who are no longer at the community, staff were not aware of any pending refund/credit due to R1 or R1’s authorized person, and staff do not know if R1 and/or R1’s authorized person received a credit/refund for the dates in question. Additionally staff were not able to provide R1's financial records for January 2023. Financial records that were provided for May and June of 2023 revealed that R1’s authorized person received a refund, however the refund was not pertaining to the personal care credit/refund in question. Based on interviews, and file review, the above allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Jun 25, 2024 · control 29-AS-20230619203034

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jun 26, 2024

87625(b)(3) Managed Incontinence (b) ...the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.This requirement was 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 respond timely and ensure R1 was kept dry, which posed an immediate health and safety/personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2024

Plan of correction: The ED shall submit a written memo of understanding of 87625 and also a plan indicating how the care staff will ensure that all incontinent residents are receiving proper and timely care in accordance with the regulation. Submit by 06/26/2024. ED will aslo ensure care staff receives training on the plan and submit in-service sign in sheets.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jun 5, 2024

87507(f) Admission Agreements: 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 credit/refund for days R1 was not in the community which posed a potential health, safety, and personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2024

Plan of correction: The ED agreed to write a self-certification letter that they will follow up with coorperate, and Milestone management company in regards to R1's credit/refund, and issue a refund if needed. Will also wite a plan on how they will ensure refunds/credits are handled appropiately. Submit POC by 07/05/2024.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted a Case Management - Incident visit. LPA met with current Executive Director (ED) Betsy Mccoy and explained the reason for the visit. On 06/24/2024, the facility submitted an Unusual Incident/Injury Report (LIC624) pertaining to Resident #1 (R1) and Resident #2 (R2). It was reported that on 06/21/2024, R1 reported to the ED that their credit card was stolen on 06/20/2024 and during the facilities investigation, the ED was informed that R2's credit card was also stolen. During today's inspection, the LPA conducted an interviewed with the ED and obtained pertinent documents. According to the ED, the facility has a theft and loss program in place and are currently conducting an investigation to assist the residents. ED also stated that she was informed police reports were made by the residents or resident's family members. Additionally, the ED revealed that she receive information that R2's credit card information was stolen and not the actual credit card, outside of the facility. If further investigation is required, the LPA will return at a later date. Exit interview conducted and report reviewed. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 25, 2024

Allegation investigated: Staff did not respond to resident’s call for assistance in a timely manner. Staff did not seek medical assistance for resident.

This is an amended report. During today's visit the LPA met with Executive Director Christian Castillo. On 06/18/2024, Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Executive Director Betsy Mccoy and explained the reason for the visit. On 06/19/2023, the Department received a complaint alleging staff did not respond to R1’s call for assistance in a timely manner, and staff did not seek medical assistance for R1. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Olivia Spindola. Report will continue on LIC9099-C. (2nd page.) Substantiated On 05/07/2024, LPAs Esther Cortez and Sandra Urena conducted an inspection at the facility and conducted interviews and observed resident rooms between 10:00 AM and 4:30 PM. On 06/17/2024, LPA Cortez conducted a subsequent visit, conducted a record review and staff interview. During today's visit LPA Cortez conducted staff interviews and obtained pertinent documents. On 06/19/2023, the Department received a complaint alleging Resident #1 (R1) sustained pressure injuries due to staff neglect. The reporting parties concern is that R1 developed a stage III pressure injury at the facility prior to receiving hospice care. According to the facility file documents reviewed, R1 was admitted to the facility on 01/25/2020. Per the facility preplacement appraisal, R1 used a walker/wheelchair and required assistance for transferring, bathing, toileting, and medication management. Per the Physician’s report, dated 01/20/2020, R1 did not have a history of skin condition or breakdown. Per the Physician's report, dated 11/24/2020, R1 had listed diagnoses of congestive heart failure, muscle weakness, hypertension, low back pain and hypothyroidism. R1 was on a low-sodium diet, had bowel and bladder impairment, and required assistance for all activities of daily living, except feeding self and did not have history of skin condition or breakdown. Based on the review of the Milestone semiannual assessment, dated 07/09/2021, R1 required one (1) person or standby assist 8x daily, required staff assistance with showers 2x weekly, required frequent incontinence assist 3x weekly, under medication management required skin treatment 2x daily, and required coordination of care with Home Health 1x weekly. Per the Service Agreement, dated 07/09/2021, effective 01/21/2020 R1 required bathing assist twice a week every Monday and Friday, and assistance with dressing daily; effective 04/21/2020, R1 required LVN to assess skin weekly to monitor skin integrity and progress, Divine Home Health to provide wound care to affected area on Mondays, Wednesdays, and Fridays, LVN/Med Tech to provide skin treatment am and pm as per MD orders, and caregivers were to provide R1 with assistance with transfers through the day; effective 07/09/2021 R1 required staff assist with toileting throughout the NOC hours, staff to check frequently to ensure R1 is clean and dry, and R1 required assistance by staff to toilet throughout the day and overnight hours. Report will continue on LIC9099-C (3RD PAGE). Home health records and hospice care records were subpoenaed and reviewed. The review of home health records revealed R1 was receiving home health services from approximately December 2020 through December 2021, for various health conditions, including stage one and stage two pressure injuries. Records reviewed did not reveal the presence of any stage three pressure injuries during this time. On December 23, 2021, R1 was discharged from home health with no pressure injuries. Record review of the home health records also did not reveal any indication of neglect from facility staff during that time. On January 6, 2022, R1 was seen by their primary care physician who diagnosed R1 with buttocks wound and ordered home health services for treatment. Records did not indicate any staging of the wound. Hospice records reviewed revealed, on January 25, 2022, R1 elected to receive hospice care services. A review of the January 25, 2022, comprehensive nursing assessment indicated revealed R1 had two stage three pressure injuries and one stage two pressure injuries and received treatment. Although the allegation of Resident sustained pressure injuries due to staff neglect including a stage 3 pressure injury prior to the start of hospice services may have occurred. There is insufficient evidence to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time. On the allegations that Staff did not keep the facility free from odor and Staff did not ensure that resident's soiled laundry was cleaned, it is the reporting parties concern that there was a urine smell that was coming from Resident #1’s (R1’s) closet due to soiled laundry left in their hamper in plastic bags. To investigate the allegation, interviews and physical plant tours were conducted. Staff Interviews conducted revealed that R1’s room did have an odor, however R1's room and laundry was constantly clean and laundered. Majority of the resident interviews conducted by LPA Cortez revealed that the facility smells fine and that they have not smelled any odor of urine coming from the rooms. In addition, seven (7) of (seven) 7 residents interviewed on 05/07/2024 revealed that laundry gets done once a week, and soiled laundry has not been left behind. On 06/21/2023 LPA Lopez did not detect any scents or smell of urine in R1's previous apartment. LPA Cortez did not detect any urine odor from any of the rooms or common areas toured during their visits at the facility. Although the allegation may have happened or is valid, based on interviews and observations, the above allegations are deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights were provided. This is an amended report. On 06/21/2023, from 10:26 a.m. to 3:30 p.m., LPA KaSandra Lopez conducted an initial complaint inspection at the facility. LPA Lopez met with Business Office Manager Jennifer Miller and informed her of the reason for the visit. Between 10:15 a.m. and 11:16 a.m., the LPA reviewed facility records and requested copies of pertinent records. During the visit, the LPA also conducted an interview with Staff #1 (S1), observed R1’s apartment and the requested records were reviewed. On 07/07/2023, LPA Lopez conducted a subsequent visit and conducted two staff interviews between 11:55 AM and 1:54 PM. On 07/19/2023, from approximately 12:00 p.m. to 1:45 p.m., Investigator Spindola conducted interviews with facility staff and residents; on 08/18/2023, at approximately 3:00 p.m., with R1’s resident representative; on 09/06/2023, from approximately 12:50 p.m. to 4:45 p.m., with facility staff; and on 09/18/2023, at 10:00 a.m., with R1’s resident representative. In addition, Investigator Spindola reviewed Los Robles Regional Medical Center (LRRMC) medical records, physician reports and records, and other facility file documents related to R1. On 05/07/2024, LPAs Esther Cortez and Sandra Urena conducted an inspection at the facility and conducted interviews and observed resident rooms between 10:00 AM and 4:30 PM. On 06/17/2024, LPA Cortez conducted a subsequent visit, conducted a record review and staff interview. During today's visit LPA Cortez conducted staff interviews and obtained pertinent documents. According to the facility file documents reviewed, R1 was admitted to the facility on 01/25/2020. Per the facility preplacement appraisal, R1 used a walker/wheelchair and required assistance for transferring, bathing, toileting, and medication management. Per the Physician's report, dated 11/24/2020, R1 had listed diagnoses of congestive heart failure, muscle weakness, hypertension, low back pain and hypothyroidism. R1 was on a low-sodium diet, had bowel and bladder impairment, and required assistance for all activities of daily living, except feeding self. Based on the review of the updated facility service plan dated 5/12/2020, caregivers were instructed to monitor R1 for shortness of breath, increased perspiration, radiating pain, and nausea, monitor for signs and symptoms of bleeding, and report to LVN/Med tech on duty. Caregivers were instructed to notify the nurse or med tech for signs and symptoms of low blood sugar. Caregivers to assist with toileting, dressing, bathing, and Neighbor Care Home Health transferring. Report will continue on LIC9099-C. (3rd page.) This is an amended report. The investigation revealed that on or around 12/30/2022, R1 sustained a fall by sliding out of their recliner. The facility staff did not obtain medical care. There was no evidence that the facility monitored the resident closely for signs of pain and injury related to the fall. An unknown staff called R1’s resident representative and informed them of R1’s fall and told them although R1 was in some pain from the fall, R1 was okay. Staff notified the business manager, who described the incident as R1 slipped off R1’s chair. There was no record of an incident report completed. On 01/05/2023, during the early hours of the morning R1 experienced severe vomiting and used their call button to request staff assistance. However, when staff did not come to R1’s room to assist, R1 dialed 911 and was transported to LRRMC where R1 was diagnosed with a Norovirus infection and a displaced left clavicle, a fractured left rib, and left shoulder dislocation with severe bruising to the area. A review of the LRRMC medical records indicated that R1 was admitted on 01/05/2023 with chief complaint of nausea and vomiting since midnight. R1 stated has thrown up 3-4 times… also has left shoulder pain/deformity and had a mechanical fall out of chair 2 days ago in which R1 hit left shoulder. The admitting diagnosis included acute cystitis without hematuria, bilateral leg sores, chronic left shoulder dislocation, acute left clavicle fracture and left first rib fracture secondary to mechanical fall, gastroenteritis, Norovirus. Bruising to the left shoulder was also noted. On 01/10/2023, R1 was discharged with a shoulder sling to Thousand Oaks Post-Acute Care and advised to follow up with a shoulder specialist, pain control with Norco and Morphine. Report will continue on LIC9099-C. (4th page.) This is an amended report. On the allegation “Staff did not respond to resident’s call for assistance in a timely manner” – The investigation revealed that on 01/05/2023, during the early hours of the morning, R1 experienced severe vomiting. R1 requested assistance using their call button. However, when staff did not come to R1’s room to assist, R1 dialed 911 and was transported to LRRMC where R1 was diagnosed with a Norovirus infection and a displaced left clavicle, a fractured left rib, and left shoulder dislocation with severe bruising to the area. Based on witnesses’ statements and medical records, the Department found sufficient evidence to support the allegation of a lack of supervision resulted in staff not responding to R1’s call for assistance in a timely manner. Therefore, the allegation is deemed Substantiated at this time. On the allegation “Staff did not seek medical assistance for resident” - The investigation revealed that on 12/30/2022, R1 sustained a fall for which the facility staff did not obtain medical care, and on 01/05/2023, when R1 called 911 for emergency medical assistance after the facility staff failed to come to R1’s room when R1 called using their call button. LRRMC diagnosed R1 with a Norovirus infection and a displaced left clavicle, a fractured left rib, a left shoulder dislocation with severe bruising to the left shoulder area. Based on witnesses’ statements and medical records, the Department found sufficient evidence to support the allegation of a lack of supervision resulted in staff not seeking medical assistance for R1. Therefore, the allegation is deemed Substantiated at this time. A $250 immediate civil penalty is assessed today due to a repeat violation of 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. The facility was previously cited on 02/01/2024. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Jun 18, 2024 · control 29-AS-20230619203034

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 19, 2024

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when staff did not respond to R1’s call for assistance and did not seek timely medical treatment for R1 on two occasions, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2024

Plan of correction: Licensee will submit a plan how you will ensure residents receive assistance in a timely manner. Submit to CCL by 06/19/2024

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

87465(j) In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services… This requirement is not met as evidenced by: Based on interviews & records review, the licensee did not comply with the section cited above. Facility staff did not seek medical assistance for R1 on 12/30/22 and 01/05/23, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2024

Plan of correction: Licensee will submit a plan how you will ensure residents receive timely medical assistance. Submit to CCL by 06/19/2024.

Type of visit: Case Management - Deficiencies

This is an amended report. This page intentionally left blank, after a citation was removed following an appeal.the state’s words, verbatim · CDSS document, Jun 18, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 00000 · Plan of correction due date: Jun 21, 2024

This is an amended report. This page intentionally left blankthe state’s words, verbatim · CDSS document, Jun 18, 2024

Allegation investigated: Staff did not safeguard resident's personal supplies Staff did not provide resident / resident's authorized person copies of requested records

At 9:50 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent complaint investigation visit regarding the above allegations. The LPA met with Director of Nursing Eugenia Taylor and explained the reason for the inspection. On 06/21/2023, from 10:26 a.m. to 3:30 p.m., LPA KaSandra Lopez conducted an initial complaint inspection at the facility. LPA Lopez met with Business Office Manager Jennifer Miller and informed her of the reason for the visit. Between 10:15 a.m. and 11:16 a.m., the LPA reviewed facility records and requested copies of pertinent records. During the visit, the LPA also conducted an interview with Staff #1 (S1), observed R1’s apartment and the requested records were reviewed. LPA Lopez determined further investigation was needed and notified the facility that Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Olivia Spindola will be investigating the Personal Rights allegations. Report will continue on LIC9099-C (2ND PAGE). Substantiated On 07/07/2023 LPA Lopez conducted interviews with two staff members between 11:55 AM and 1:54 PM. On 05/07/2024 LPAs Esther Cortez and Sandra Urena conducted interviews and observed resident rooms. During today's visit LPA Cortez conducted a record review and staff interview. Staff did not safeguard resident's personal supplies. On the allegation that Staff did not safeguard resident's personal supplies, the reporting parties concern is that a family member and the hospice nurse witnessed staff #2 (S2) come into Resident’s #1 (R1’s) room, take incontinence supplies and leave. To investigate the allegation, interviews were conducted. Interviews with S2, conducted on 07/07/23, revealed that S2 admitted to taking some of R1’s incontinent supplies and stated they knew it was wrong, and that they were in a hurry to assist other residents who needed to be changed. The staff stated a home health nurse observed them take the supplies and said they returned them when confronted. The staff stated this happened only one time. There is sufficient evidence to support the allegation of Staff did not safeguard resident's personal supplies. Therefore, the above allegation is deemed Substantiated at this time. Staff did not provide resident / resident's authorized person copies of requested records. On the allegation that Staff did not provide resident / resident's authorized person copies of requested records, the reporting parties concern is that on numerous occasions R1’s records were requested by the resident and or resident’s authorized person and not provided. It was further reported that when the records were provided, they were not complete, specifically documentation of R1’s fall on 12/30/22 was not provided along with other documents. To investigate the allegation, record review and interviews were conducted. Information obtained revealed that on 02/01/2023 (previous) Administrator Jill Ford received and signed a request for R1’s records, including but not limited to personal and clinical records to be release to R1’s authorized person. On 02/27/2023, the facility received a second medical record request from R1’s authorized person. In addition, information obtained revealed that R1’s authorized person made contact with Administrator Jill Ford via email regarding R1’s records request on 03/26/23, 04/02/23, 04/21/23, 05/06/23, 05/07/23, 05/14/23 and on 05/15/23. On or about 05/15/23, R1’s records were issued to R1’s authorized person, however it was reported to the interim Administrator Julius Osorio on 05/31/23 that the records were incomplete, particularly regarding a fall R1 sustained on 12/30/22. Report will continue on LIC9099-C (3RD PAGE). In 2023 Sage Mountain Senior living transitioned from Milestone management company to Agemark management company. Interview with Julius Osorio, who was the interim Administrator during June of 2023, revealed that they received notification from R1’s authorized person on 05/31/23 via email that R1’s records were incomplete, however all the records that were provided were the same records Agemark had on file. Osorio revealed that R1’s authorized person had been informed Agemark would not have access to digital records once they took over and records would need to be requested through Milestone. It was further revealed that Osario did not verify if R1’s authorized person had received the requested missing documentation as they assumed Milestone would be handling it through their team. Record review revealed that there was no record of an incident report completed for R1’s fall on 12/30/22. Based on the information obtained, the Department found sufficient evidence to support the allegation, Staff did not provide resident / resident's authorized person copies of requested records. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Jun 17, 2024 · control 29-AS-20230619203034

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jun 28, 2024

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. Based on interviews S2 admiited to taking R1's incontinence supplies which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Administrator will submit a plan to properly safeguard residents' property as well as provide staff training regarding safeguarding residents' personal property. Submit to CCL by 06/28/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Jun 28, 2024

87506(c)(1) The licensee shall be responsible for storing active and inactive records...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the facility did not make complete records available to the resident or representative, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Administrator agreed to submit a statement of understanding of regulation 87506 and will make a plan on how to follow up on record requests in a timely manner and notify resident or resident's authorized person if they do not have the records, will submit to CCL by 6/28/24. Administrator will also follow up on the record request for R1.

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.

Allegation investigated: Facility has inadequate food service. Facility staff are not meeting resident's needs. Facility does not provide adequate transportation services.

Licensing Program Analysts (LPA) Sandra Urena and Esther Cortez conducted an unannounced subsequent complaint investigation regarding the allegations listed above. The LPAs arrived at the facility at 10:10 a.m., met with Betsy McCoy, Executive Director, and explained the reason for the visit. On 07/25/2023, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced complaint inspection at the facility regarding the above allegation. The LPA met with Business Office Manager Jennifer Miller and explained the reason for the inspection. During today's inspection between 12:46 PM and 3:15 PM, the LPA conducted interviews with the, Ms. Miler, Ian Gadea Nursing Director, three residents, and three staff members. The LPA also conducted record review at 2:36 p.m. Continues on LIC 9099C... Unsubstantiated Facility has inadequate food service. On the allegation that the facility has inadequate food service; it is the concern of the reporting party that the servers don't wait on residents and when they do, they bring the wrong food. On 05/07/2024, LPA Urena observed lunch in the dining room at approximately 12:15 p.m. Residents were interviewed about the food service and food quality. Ten out of ten residents stated that the food is always good, large portions are served, and when they order room service, the service is on time, and order is correct. Food servers try to serve the meals promptly and are always courteous. Residents stated that food selection has improved because the facility hired recently a new chef. Based on the information gathered through interviews and observation, the allegation that the facility has inadequate food service, is deemed Unsubstantiated at this time. Facility staff are not meeting resident's needs. On the allegation that staff are not meeting the resident’s needs; it is the concern of the resident that the facility has only one caregiver a day to give showers to residents, and a different caregiver every day. LPA Urena interviewed residents about their needs being met, and most of the residents stated that staff are helpful, they assist with showers/baths twice a week. The staff clean their rooms once a week and do their laundry once a week. Based on the information gathered through interviews, the allegation that facility staff are not meeting residents’ needs, is deemed Unsubstantiated at this time. Facility does not provide adequate transportation services: The reporting party’s concern is that the facility does not provide transportation. LPA Urena interviewed residents. Ten out of ten residents stated that the facility does provide transportation services. Residents notify the facility staff about an upcoming appointment, and the residents are dropped off at the appointment place, and if needed the resident may request a companion to go with them to the appointments. At this time the facility has a bus and a company car for the transportation services at this time. Based on the information gathered through interviews, the allegation of inadequate transportation, is deemed Unsubstantiated at this time. No citations were issued. Exit interview was conducted and a copy of the report was issued. Staff do not respond to call pendant in a timely manner. On the allegation that staff do not respond in a timely manner; it is the concern of the reporting party that staff have been taking up to three hours to respond to a pendant call, and the usual wait time is an hour. On 07/25/2023, LPA Lopez interviewed residents and the interviews revealed that staff may respond right away and other times it could take up to 45 minutes to an hour to respond to a pendent call request, but sometimes it may take 2-3 hours to respond, and wait times are longer on the weekend, response times in the mornings are bad and sometimes at night, too. On 05/07/2024, LPA Cortez observed a resident at the front desk requesting assistance with a device, then heard a staff say, “if they call a caregiver, it will take about an hour for the caregiver to respond’, consequently another staff present, helped the resident at the time of the request. On 05/07/2024, LPA Urena interviewed a staff member in regards to the response time for the calls. The staff stated that the goal response time is between 10 to 15 minutes, however if they are busy with another resident, other staff members may assist. When the LPA asked about longer wait times, the staff stated that sometimes the push button may not be fully operating and consequently the staff are not aware of the call button being pushed. Based on the information gathered through interviews, and observation, the allegation that staff do not respond in a timely manner, is deemed Substantiated at this time. Staff does not safeguard resident's personal belongings. On the allegation that staff do not safeguard the resident’s belongings; it is the concern of the reporting party that the staff loses clothes or throws them out without informing the resident. On 05/07/2024, LPA Urena interviewed residents. Five (5) out of 10 residents stated that they don’t have an issue with their laundry or any issues with missing items; five (5) residents stated that clothing items have been lost when staff have washed their clothing. On 07/25/2023, LPA Lopez interviewed staff who stated that some residents have complained about missing laundry and one staff stated that they threw away a piece of clothing that became too soiled to be washed, they attempted to replace the item but was not the right size, consequently had to return the item and get another item. Based on the information received through interviews, the allegation that staff do not safeguard residents’ belongings, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, May 7, 2024 · control 29-AS-20230721163427

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.153(c)(d) · Plan of correction due date: May 31, 2024

Theft and loss. (c) Documentation of lost property with a value of twenty-five dollars or more within 72 hours of the discovery of the loss or theft, (d) A written inventory is established … items brought into or removed shall be added to or deleted from the inventory. This requirement is not met as evidenced by: Based on interview, the licensee failed to make reasonable efforts to safeguard a resident’s property, as the facility lost clothing items, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2024

Plan of correction: POC: The Executive Director has agreed to the following: The ED has agreed to the following: 1. Have an in-service training with staff regarding the facility’s theft and loss policy. Submit training documentation to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 31, 2024

Residents…have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews conducted, the licensee did not comply with the above cited section, as the licensee did not ensure resident’s call buttons were responded to timely which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2024

Plan of correction: POC: Executive Director agrees to re-evaluate care response system that is conducive to residents’ needs.

Allegation investigated: Neglect/Lack of Care and Supervision – Resident #1 (R1) choked to death without any medical intervention while under the care and supervision of the facility.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to the facility. The purpose of today’s visit is to conclude an investigation initiated by LPA KaSandra Lopez on 01/26/2023. LPA met with Nursing Director Betsy Mccoy and explained the reason for the visit. Administrator was unable to be present during todays visit, and authorized Betsy Mccoy to review and sign reports. On 01/25/2023, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that due to neglect/lack of supervision resident #1 (R1) choked to death without any medical intervention while under the care and supervision of the facility. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Philippe Ryan Miles. Report will continue on LIC9099-C (2nd page). Substantiated During the initial visit, LPA Lopez met with Administrator Jill Ford and explained the reason for the inspection. Beginning at 10:40 a.m., the LPA conducted an interview with the Administrator, reviewed facility records, and obtained copies of pertinent records. The LPA also observed the dining room area at 1:50 p.m. and conducted additional interviews with the Administrator at 2:45 p.m. On 02/21/2023, at approximately 9:30 a.m., Investigator Miles conducted interviews with R1’s resident representatives; on 03/09/2023, from approximately 10:36 a.m. to 1:02 p.m., with residents, Executive Director/Administrator, Director of Health and Wellness/LVN, and staff; on 03/17/2023, at approximately 4:18 p.m., with a Nursing Education Consultant from the California Board of Vocational Nursing and Psychiatric Technicians; and on 03/22/2023, at approximately 12:45 p.m., with staff. Additionally, Investigator Miles reviewed facility file documents related to R1 including incident and death reports, Ventura County (VC) Sheriff’s Office Report #23-10188, Ventura County Emergency Medical Services (EMS) and Fire Report #23-0007876, and Ventura County Medical Examiner’s Office Report #150-23. Information gathered during the course of the investigation reflected that R1 required assistance with all Activities of Daily Living (ADLs) but was able to independently feed self during meals. R1 was not on a special diet but requested that all proteins ordered for dinner were always cut up. On 01/24/2023, during dinnertime, R1 began to choke in the facility dinning room. Resident #2 (R2) and Resident #3 (R3) were seated at the same table and witnessed R1’s head slouch downward, and it appeared R1s mouth was slightly moving but no words were verbalized. Per interviews, no staff were present in the dining area at the time. R2 and R3 then started yelling for assistance and were able to get the attention of Dining Server, Staff #1 (S1). S1 witnessed R1 “grasping” their throat and S1 immediately ran out of the dining room for help. The front desk concierge radioed the facility medical staff. Staff # 2 (S2), Director of Health and Wellness/LVN, responded to R1 and observed R1 on a wheelchair slumped over, motionless and R1’s lips appeared to be blue. Per S2, R1 was checked for level of consciousness but R1 was unresponsive and S2 was unable to find a pulse; therefore, S2 requested staff to call 911. Moreover, S2 claimed they provided two Heimlich thrusts and wheeled R1 out of the dinning room. Report will continue on LIC9099-C (3rd page). Interviews with witnesses reflected that it took approximately seven (7) to eight (8) minutes for S2 to respond. Interviews conducted with witnesses also reflected that S2 did not perform the Heimlich maneuver or provide any type of life-saving procedures/medical interventions on R1 in the dining room. S2 later admitted they did not provide any type of medical or life-saving intervention(s) as they assumed R1’s Do Not Resuscitate (DNR) order applied to them. Ventura County Emergency Medical Services (EMS) and Fire Records reviewed reflected that, upon arrival of emergency personnel, R1 was “found sitting in a wheelchair with nurse…behind not performing any life-saving procedures.” Paramedics suctioned airway and performed CPR until directed by the paramedic to cease. S2 provided a copy of R1’s DNR order to the VC Sheriff on scene and informed fire personnel, as well. They confirmed the DNR and discontinued life-saving efforts shortly thereafter. At approximately 5:28 p.m., R1 was pronounced deceased by the paramedic. Per the Ventura County Medical Examiner, the official cause of death on the death certificate is listed as asphyxia due to choking with other significant conditions as acute subdural hematoma and Parkinson’s disease. Based on the interviews conducted and supporting documentation gathered during the course of the investigation, the Department determined that there is sufficient evidence to support the allegation of “Neglect/Lack of Care and Supervision - Resident #1 (R1) choked to death without any medical intervention while under the care and supervision of the facility”. Therefore, the allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Nursing Director Betsy Mccoy was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, civil penalties issued, appeal rights discussed, and a copy of this report issued. During the investigation, Community Care Licensing Investigations Branch Investigator Phillippe Ryan Miles investigated the allegation of “Resident #1 (R1) choked to death without any medical intervention while under the care and supervision of the facility’, on 02/21/2023, at approximately 9:30 a.m., Investigator Miles conducted interviews with R1’s resident representatives; on 03/09/2023, from approximately 10:36 a.m. to 1:02 p.m., with residents, Executive Director/Administrator, Director of Health and Wellness/LVN, and staff; on 03/17/2023, at approximately 4:18 p.m., with a Nursing Education Consultant from the California Board of Vocational Nursing and Psychiatric Technicians; and on 03/22/2023, at approximately 12:45 p.m., with staff. Additionally, Investigator Miles reviewed facility file documents related to R1 including incident and death reports, Ventura County (VC) Sheriff’s Office Report #23-10188, Ventura County Emergency Medical Services (EMS) and Fire Report #23-0007876, and Ventura County Medical Examiner’s Office Report #150-23. Interviews revealed dinner begins at 4:30 p.m. and the residents arrived at approximately 4:45 p.m. for dinner. Interviews revealed while at dinner, Resident #2 (R2) and Resident #3 (R3) were seated with R1 when R1 began to choke on their meal. R2 and R3 then started yelling for assistance and were able to get the attention of Dining Server, Staff #1 (S1). Per interviews, no staff were present in the dining area at the time. Interviews also revealed the residents could not recall if R1’s pendent was pushed for assistance but stated it was better to yell to get staffs attention versus using the pendent as response times varies. When S1 arrived, S1 witnessed R1 “grasping” their throat and S1 immediately ran out of the dining room for help. S1 ran to the front desk but no one was there. S1 ran to another area where the med-techs are located dispensing medications and the breakroom, and no one was there as well. When S1 returned to the front desk they observed another server alerting concierge of the choking of which concierge used their walkie-talkie to alert the facility medical staff. S1 utilized the stairs when trying to locate staff with the knowledge that the elevators can take five minutes or more to arrive at the lobby floor. Interviews revealed servers do not have walkie-talkies to communicate and only care staff, concierge, med-techs, and house keeping have walkie-talkies. Report will continue on LIC9099-C (3rd page). Interviews with Staff #2 (S2) revealed while they were on the third floor of the facility at approximately 5:15 p.m., they received call on the walkie talkie requesting the need for a med-tech or nurse to the dining room stat and they used the elevator to the first floor versus using the stairs. When asked why they did not use the stairs, S2 stated they usually take the stairs, but the elevator was already on the third floor. S2 stated when they arrived, they requested staff to call 911. Interviews with witnesses reflected that it took approximately seven (7) to eight (8) minutes for the S2 to respond to the stat request for assistance. Interviews conducted with witnesses also reflected that S2 did not perform the Heimlich maneuver or provide any type of life-saving procedures/medical interventions on R1 in the dining room. Record review of the pendent call records for R1 revealed R1’s last pendent call for service on 01/24/2023 was at 4:39 p.m. and staff responded within a minute. Pendent call records for R2 and R3 reviewed no calls for service on 01/24/2023. The Ventura County Emergency Medical Services (EMS) and Fire Report #23-0007876 revealed at approximately 5:16 p.m. a 911 call was received regarding a person who was choking and not breathing. Based on interviews conducted and supporting documentation obtained during the course of the investigation, there is insufficient evidence to support that staff did not respond to a pendent call for assistance timely. Although, there is sufficient evidence to support staff did not respond timely to an emergent situation. Therefore, a citation will be issued for this deficiency under separate cover. During the investigation it was also revealed that S2 did not have a valid first aid certificate. Record review revealed S2’s first aid certificate expired in February 2022. A deficiency related to this will also be addressed under separate cover. Exit interview conducted, and a copy of this report issued.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 29-AS-20230125125751

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 2, 2024

87468.2(a)In addition to the rights listed in Section 87468.1 (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by: Based on interviews & records review, the licensee did not comply with the section cited when there was not sufficient, competent staff to provide timely first aid assistance to R1, resulting in death by choking, which posed an immediate health and safety risks tothe state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: Licensee will submit a plan how you will ensure appropriate resident care and supervision, including medical intervention during an emergency. Submit to CCL by due date of 2/02/2024. residents in care.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Deficiencies inspection at the facility regarding deficiencies observed during the investigation of complaint control # 29-AS-20230125125751. The LPA met with Nursing Director Betsy Mccoy and explained the reason for the inspection. During the investigation of complaint control # 29-AS-20230125125751, it was alleged that staff did not respond to a pendent call for assistance timely pertaining to a choking incident regarding Resident #1 (R1). During the course of the investigation, although there was insufficient evidence to support staff did not respond to a pendent call timely, there was sufficient evidence to support staff did not respond to a stat assistance for help with a choking incident timely as interviews revealed it took approximately seven (7) to eight (8) minutes for the S2 to respond and S2 utilized the elevator from the third floor to the first floor instead of using the stairs which is typically faster. Interviews conducted with witnesses also reflected that S2 did not perform the Heimlich maneuver or provide any type of life-saving procedures/medical interventions on R1 in the dining room. More information pertaining to this investigation is under the LIC 9099 dated 02/01/2024 under complaint control # 29-AS-20230125125751. During the course of the investigation, it also revealed S2’s first aid certification expired in February 2022, and S2 did not have a current certificate during the incident on 01/24/2023. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, civil penalties issued, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Feb 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Feb 2, 2024

87468.2 (a) In addition to the rights listed in Section 87468.1,....(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as staff failed to respond timely to an emergent situation pertaining to R1 which posed an immediate health and safety concern to R1 in care.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: Licensee will submit a plan how you will ensure appropriate resident care and supervision, including medical intervention during an emergency. Submit to CCL by 2/2/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Feb 9, 2024

87411 Personnel Requirements (c)All RCFE staff who assist residents... (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by Based on record review, the licensee failed to comply with the section cited above as S2’s first aid certification expired in February 2022, and S2 did not have a current certificate during the incident on 01/24/2023 which posed a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: Licensee will submit a plan how you will ensure all staff have current first aid training. Submit to CCL by 1/09.2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA’s) Elsie Campos, and Zabel Chochian arrived at the facility unannounced to conduct a required annual visit at 9:20 a.m. The LPA's were greeted by staff and Administrator Sherry Nazari and informed them of the reason for the visit. The LPA’s and the Maintenance Director began the tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPAs began the inspection in the kitchen/food service area at 10:55 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. LPA's did not observe a supply of emergency food and water supply. COMMON AREAS: At the time of the visit, units designated for assisted living residents are on all four floors and there is a separate unit on the second floor designated for memory care residents. The LPA’s toured all four floors and common spaces in both the assisted living and memory care unit. Activity rooms and common spaces were clean and in good repair. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were last inspected on 7/11/23 by COBOS Fire & Safety. The fire extinguishers were fully charged and were last serviced 07/11/2023 by COBOS Fire & Safety. The LPA's observed required postings near the mail room hallway. The LPA's observed the stairwells and they each had an emergency evacuation chair. At approx. 11:40 a.m. – LPA’s observed multiple residents doing an activity with the activity’s director in the 1st floor common area. BEDROOMS: At approx. 11:45 a.m. the LPA's observed twelve (12) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. Bedroom #319 was observed to have temperature at 83 degrees F. Interview with resident and staff revealed that this room has had consistent issues with temperature adjustment and room was too hot for resident. ** Continued on LIC 809-C** Bedroom #241 had a strong odor omitting from the carpet near the closet, Bedroom #410 at approximately 2:00 p.m. still did not have lunch tray picked up. LPA’s conducted interviews while touring bedrooms with twelve (12) residents between 11:45 a.m. to 3:00 p.m The LPA's observed a sufficient supply of towels and linens. Resident pendants were tested in multiple rooms, LPA's observed staff arrive in a timely manner to assist residents. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. Restroom in bedroom #237 had a sticky floor and bedroom #241 restroom had a strong odor and sink was not draining the water. The hot water temperature was measured in resident rooms (#101, 111, 110, 228, 237, 241, 254, 257, 319, 343, 410, 407) ranged between 113.0– 117.5*f. (Continue to LIC809c) OUTSIDE GROUNDS: LPA's toured the outside area of the facility. LPA's observed appropriate outdoor furniture, with a covered shaded area for resident’s use. No pool on the premises. Parking is available for residents and visitors. Due to time constraints, the LPA’s will return at a later date to complete the inspection. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 15, 2023