The Gables of Ojai

Type of visit: Case Management - Deficiencies

At 09:25 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to deliver an amended deficiency regarding Annual visit conducted on 10/16/2025 . The LPA was greeted by staff and informed them of the reason for the visit. The LPA met with Executive Director Deedee Heninger at 9:57 a.m. and informed them of the reason for the visit. Based upon an appeal that was received for a deficiency regarding Fire Clearance, Title 22, 87202(a) that was cited on 10/16/2025 for two (2) resident apartments and a clubhouse that were observed without smoke detectors. The appeal was granted and the citation along with the related $500 civil penalty was dismissed. However a violation still exists for 22 CCR 87203 Fire Safety and therefore a citation is being issued. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to ED.the state’s words, verbatim · CDSS document, May 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 18, 2026

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above in the clubhouse and two resident apartments that were misisng smoke detectors which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 18, 2026

Plan of correction: POC is cleared, photos were submitted of smoke detectors placed in the appartments and clubhouse.

Type of visit: Required - 1 Year

At 09:45 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. The LPA met with Executive Director Deedee Heninger shortly after and informed them of the reason for the visit. The LPA and Executive Director DeeDee conducted a tour of the physical plant inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility has 14 buildings on the licensed property. The memory care (Gardens) building has 17 apartments with a capacity of up to 19 residents. The assisted living (AL) buildings have 66 apartments with a capacity of up to 99 residents. The LPA observed fire extinguisher throughout the whole facility which were fully charged and last serviced on 07/02/2025. The LPA observed all required postings. Smoke alarms and carbon monoxide detectors were tested and functioned properly, however, the club house did not have a smoke detector, room 7 did not have a smoke detector in the bedroom, and room 24 did not have a smoke detector in the living room. Kitchen: The main building contains the ED's office, kitchen, dinning room, and lounge area. The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Snacks and beverages are always available for the residents. Emergency food and water was observed on the second floor of the main building. Bedrooms/Bathrooms: The LPA observed eleven (11) randomly selected resident bedrooms in both AL and MC, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report will continue on LIC809-C, 2nd page. There are 89 total bedrooms; 76 (seventy-six) are in AL and 13 (thirteen) are in MC. The LPA observed thirteen (13) resident bathrooms which included a communal bathroom in the clubhouse, and a communal shower room in the MC building. All bathrooms were properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Hot water temperature read at 131.7 (RM6), 129.7(clubhouse), 134.4 (rm7), 113.7 (rm19), 122.2 (rm24), 122.4 (rm26), 118.9 (rm36), 125.9 (rm87), 120.7(rm61), 109.2 (MC shower room), 117 (rm306), 121.1(rm314), and 113.9 (rm308) degrees Fahrenheit in resident bathrooms. At 12:20 p.m. the LPA observed Fluticasone Propionate nasal spray in resident bathroom of room 19, per the resident's Physician's report they cannot store own medications. Upon observation, the ED stated that was an error and resident is able to store medications, and will verify with their Primary physician if it was indicated as a mistake. At 1:07 p.m. the LPA observed the bathroom floor tile in disrepair with broken tile in an unlocked shower room in MC. Common Areas/Surrounding Grounds (Outdoors): These included the club house, Wellness area, and lounge areas. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. All fire places observed in the common areas and bedrooms were appropriately screened. The facility has a fenced pool with two locked gates. The clubhouse had a theater room, library and small kitchen. The wellness center had exercise machines. The dining room was clean with sufficient amount of seating and was well lit. The beauty salon was kept locked while not in use. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. At 1:36 p.m. the LPA observed the side gate on the Memory Care Unit locked with a combination lock. Record Review: A a review of facility files was initiated. The LPA received a copy of resident and staff rosters and Insurance Liability. Interviews: The LPA conducted four (4) resident Interviews. No immediate concerns were voiced. Due to time constraints the LPA will return at a later time to complete the annual. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to ED.the state’s words, verbatim · CDSS document, Oct 16, 2025

Allegation investigated: Staff do not have planned activities for the residents Staff interfered with a resident's religious beliefs Staff interfered with the residents visitations

Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit. LPA met with Executive Director (ED) DeeDee Heninger and explained the reason for the visit. LPA interviewed ED starting at 11:30 a.m. LPA reviewed pertinent documents at 1:42 p.m. LPA interviewed staff 1 (S1) at 1:13 p.m. and staff 2 (S2) at 2:19 p.m. LPA interviewed Resident 1 (R1) at 2:02 p.m., attempted to interview Resident 2 (R2) at 1:55 p.m. and interviewed Resident 3 (R3) at 2:25 p.m. Allegation: Staff do not have planned activities for the residents LPA reviewed the activities schedules for the assisted living (AL) and memory care (MC) residents. Some of the entertainment and event activities are held only in AL or sometimes only in MC. During those events, the MC residents are brought over to AL if they want to join in and the same happens with AL residents going to (continued on LIC9099C) Unsubstantiated (continued from LIC9099) MC. Just this week there was a sing along event in MC where AL residents joined as well. LPA confirmed with R1 when they want to go to an event in AL the staff take R1 to the event. LPA confirmed with staff that when MC residents want to go to events in AL they take them over to AL and stay with them. Based on interviews and records review, this allegation is deemed Unsubstantiated at this time. Allegation: Staff interfered with a residents' religious beliefs. R1 had an arrangement with a friend who attended the same church. The friend would pick up R1, take R1 to church, and bring R1 back to the facility after church services. R1's ambulatory condition declined and R1's friend was not comfortable transporting R1. The facility then started taking R1 to church, meeting up with R1's friend and leaving R1 with the friend. After church services the facility staff would pick up R1. However, R1's friend was not meeting up with staff to receive R1. If R1's friend is not available or no-shows, they take R1 back to the facility. They have offered R1 virtual church service but R1 does not enjoy it. The Resident Services Director is currently searching for a priest in the area who would be willing to give R1 communion at the facility. R1 stated, while they would prefer to go to church, they would also enjoy having a priest visit and give communion. R1's needs and services plan indicates church drives are offered when available. They also offer a bible study group and virtual church services. Based on interviews and records reviewed, this allegation is deemed Unsubstantiated at this time. Allegation: Staff interfered with the residents visitations. The facility has an open door policy for family and friends of residents. They ask visitors to be in good health (no viral symptoms) and to sign in and out at the front door. Any volunteers at the facility, such as entertainment or art teachers, must complete a volunteer form in order to be at the facility. The facility recently had an issue with a former uninvited employee coming to the facility, pushing residents around in their wheelchairs and going into residents' apartments. The former employee would visit the facility on Sundays when there are no directors working. In an effort to ensure the safety of residents, the ED has informed the former employee they are not welcome back at the facility and any further visits will be considered trespassing. Based on this information, the allegation is deemed Unsubstantiated at this time. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Feb 7, 2025 · control 29-AS-20250206161442

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara conducted a required annual visit. LPA met with Executive Director (ED) DeeDee Heninger and explained the reason for the visit. The current Administrator is Christine Fenn but she was unavailable to meet with LPA. A tour of the inside and outside of the facility was conducted with ED. The facility has all required postings. Menus and activity calendars are also posted. Infection Control: The facility has submitted a current Infection Control Plan. The facility has a sign in and out area for visitors at entry with hand sanitizer. The facility has EPA approved disinfectant sprays and cleaners. Trash cans have tight fitting lids. The facility has a sufficient supply of PPE and can obtain more if needed. Operational Requirements: The facility has a current plan of operation. The facility is approved for a capacity of 118 residents with 54 Ambulatory, 60 Non-Ambulatory, of which four (4) may be bedridden in the memory care building rooms 302, 306, and 307. Facility has a current Hospice wavier granted for 15. The Facility is operating in compliance with the granted fire clearance. Physical Plant & Environment Safety: The facility has 14 buildings on the licensed property. The memory care (Gardens) building has 17 apartments with a capacity of up to 20 residents. The assisted living buildings have 66 apartments with a capacity of up to 98 residents. Each apartment has at least one bathroom in assisted living apartments and the memory care units have one half bath in each unit and two shower rooms. In addition, there are four public restrooms. All restrooms and shower rooms had grab bars, non-slip surfaces, toilet paper, soap and paper towels. LPA toured ten resident rooms in all buildings. (continued on LIC9099-C) (continued from LIC9099) The facility has a fenced pool with two locked gates. The clubhouse had a theater room, library and small kitchen. The wellness center had a small kitchen area, seating and was well lit. The dining room was clean with sufficient amount of seating and was well lit. The beauty salon was kept locked while not in use. The maintenance building was kept locked. The building which houses the generator is kept locked. Facility grounds were free of hazards. Kitchen: The facilities main kitchen is clean, safe and sanitary. The facility has a sufficient supply of perishable and non-perishable foods. LPA will return at a later date to finish this annual to review records and medications. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Oct 25, 2024

Allegation investigated: Staff do not ensure that medication disposal procedures are being followed.

Licensing Program Analysts (LPAs) Teresa Camara and Trevor Byrne conducted a complaint investigation visit regarding the above noted allegation. LPAs met with Assisted Living Director (ALD) DeeDee Heninger as the administrator is on vacation. LPAs explained the reason for the visit. LPAs interviewed staff starting at 10:38 a.m. LPAs reviewed medications to be destroyed starting at 11:10 a.m. LPAs found medications that needed to be destroyed and the Centrally Stored Medication and Destruction Record had been signed by the administrator and ALD that they had already been destroyed when in fact they were still stored in the medication room. Based on the medication review, the allegation Staff do not ensure that medication disposal procedures are being followed is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 9099-D). Exit interview conducted. The report and appeal rights were issued. Substantiatedthe state’s words, verbatim · CDSS document, Aug 7, 2024 · control 29-AS-20240730104218

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Aug 14, 2024

87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services...or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult wo is not a resident. Both shall sign a record, to be retained for at least three years. Based on record review, the licensee did not comply with the section cited above as there were medications signed off as destroyed but still stored in the med room, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2024

Plan of correction: Licensee will submit a statement of understanding that they reviewed the regulation and confirm medications awaiting destruction have been destroyed.

Allegation investigated: Facility staff are retaining a resident requiring a higher level of care.

Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegation. Upon arrival, LPA met with the Executive Director (ED), Matteo DiGrigoli and was explained the reason for the visit. Entrance interview conducted. On 2/08/2024, between 09:45 a.m. and 12:00 p.m., the LPA conducted an initial compalint visit, interviewed the Administrator, Resident #1 (R1), R1's private caregiver, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's visit the LPA conducted one (1) staff interview, and reviewed records collected during the initial complaint visit. Report will continue on LIC9099-C. Unsubstantiated On the allegation that Facility staff are retaining a resident requiring a higher level of care, the reporting parties concern is that Resident#1 (R1), needs a higher level of care due to R1 being aggressive, refusing to take medication, walking off property and nothing is being done. To investigate the allegation, the LPA conducted interviews and conducted a file review. Interviews and documents revealed that R1 has a 24hr private caregiver that is not affiliated with the facility. Administrator Matteo stated that R1 did show signs of needing a higher level of care, however they took the steps necessary to assist R1. Administrator Matteo stated that R1's physician and R1's responsible party were notified of R1's behavior and were working collaboratively to provide the care needed. Documents reviewed revealed that staff was in constant communication with R1's physician, addressing R1's behavior. Based on the information gathered, the above allegation is deemed Unsubstantiated at this time. Exit interview was conducted, and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 3, 2024 · control 29-AS-20240201103428

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 Administrator Matteo Digrigoli and Assisted Living Director Dee Dee Heninger explained the reason for the visit. The reason for today's inspection is to follow up on a self reported death report received on 05/01/2024. The report pertains to the death of Resident #1 (R1). Per the report received, R1 was involved in a collision with a vehicle while on their motorized scooter on 04-27-24. Emergency services and law enforcement were called to the location where the collision took place. R1 passed away on 04/28/2024 in the hospital. During today's visit, the LPA conducted interviews with the administrator, two (2) staff, one (1) resident, conducted a file review and obtained copies of pertinent documents. Interviews revealed that R1 was independent and that it was not unusual for R1 to often times leave the facility independently. Additionally, staff interviews revealed that they had not observed any change in condition since R1 was admitted to the facility. File review revealed that according to R1's last LIC 602 Physicians report R1 was independent and could leave the facility unassisted. According to R1's Care Plan, R1 was a assisted living resident admitted on 04/16/2022, R1 did not need assistance with any of their ADL's. Furthermore, R1's last appraisal dated 01/15/24 stated that R1 was active, independent, and did not require any personal help. No Citations were issued during today's visit. Exit interview and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, May 3, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cortez conducted a Case Management-deficiencies visit to address deficiencies noted during Complaint Control #29-AS-20240201103428 investigation visit conducted on 2/08/2024. LPA met with Administrator Matteo Digrigoli and explained the purpose of the visit. During today’s visit, LPA obtained a copy of hospital discharge summary notes for resident #1 who sustained a fracture rib on November 10, 2023. LPA reviewed facility files for notification from the facility of Unusual/Serious Incident Report (SIR) for R1. As of today’s visit, no Unusual/Serious Incident Report (SIR) have been received by CCL for R1's fractured rib. LPA requested an SIR to be submitted for R1's incident. LPA reviewed R1's file and noted several incident reports for R1 have not submitted to CCL. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D). Exit interview conducted, deficiencies cited, and the report and appeal rights issued during today’s visitthe state’s words, verbatim · CDSS document, Feb 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 16, 2024

87211 (a)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to person responsible within seven days of the occurrence of any of the events specified in (A) through (D) below...This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not submit incident reports within 7 days, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Incident report for R1 was submitted during todays visit. Administrator agreed to submit a plan to ensure written reports will be submitted to CCL within 7 days and submit plan to LPA by 2/16/23.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:29 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Matteo Digrigoli and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan. The facility has a sign in and out area for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. Trash can and wastebaskets have tight fitting lids. Infection control and PPE training for staff is completed. Operational Requirements: The facility has a current plan of operation. The facility is approved for a capacity of 118 capacity with 54 Ambulatory, 60 Non-Ambulatory, which 4 may be bedridden in the memory care building rooms 302, 306, and 307. Facility has a current Hospice wavier granted for 15. The Facility is operating in compliance with the granted fire clearance. Physical Plant & Environment Safety: The facility has 14 buildings on the licensed property. The facility has 90 apartments with bathrooms and 7 public restrooms currently occupying 82 residents and employs 41 staff. The facilities common areas were clean, safe and sanitary. Memory Care Building N is located across the street and all exiting doors and gates have alarms. LPA was authorized to enter and inspect facility. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facilities main kitchen is clean, safe and sanitary. Apartment rooms were clean and comfortable for residents use, showers have non-skid textured floors, and grab bars were secured. Toilet, hand washing and bathing facilities were operational. The pathways were clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and kept locked. The facility has sufficient space inside and outside for activities and visiting. The facility is fenced with 3 open areas and 1 gate. The outside courtyard has plenty of shade for resident use. The facility has a pool fully fenced with 2 locked gates for entry. The facility has telephone and internet service for all residents in care. LPA toured 10 resident rooms. Toured rooms 8, 17, 33, 47, 88, 60, 302, 301, 307, and 312, all rooms met regulation requirements. Continued 809-C Staffing: The facility employes 40 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expired 09/2023, Administrator has sent in renewal paperwork and is currently pending with CCL. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and staff met most requirements with some not meeting exact hours and or subjects requirements. Administrator will make sure all staff finish annual training for 2023 with all required subjects and topics covered. Staff handling medications had annual training of 8 hours of medication training. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals were on file. The facility does not handle cash resources for residents in care. Facility does submit incident reports to the department when required. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, and Theft and Loss policy. CCL Complaint poster was 20x26 in size. Administrator agreed to have the Memory Care poster made into a 20x26 size. The LTCO poster was posted in the common area of the facility. The current license was posted in common entryway. Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors as well as an activity room. Continued 809-C Food Service: The facility employs food service staff. The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food was covered, stored and marked appropriately in the main kitchen. A menu is posted for residents in care. Cleaning solutions and equipment were stored separately than food supply. Main Kitchen areas were clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices. Incidental Medical & Dental: The facility has 2 medication rooms both are kept locked. Facility provides or arranges transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication room for prescription and PRN medications, medication were reviewed for expirations dates. No medications labels were altered. The facility has a mini locked refrigerator. The facility has a red sharps container for disposal of syringes. Medication Destruct is done by the facility with Administrator and Medication Supervision. Disaster Preparedness: The current emergency disaster form is posted. The fire extinguishers were charged and last inspected on 06/05/2023. Emergency exits and telephone numbers were posted. Facility is conducting quarterly disaster drills. The facility is currently having the annual fire inspection today and administrator will send certification once completed. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress in the Memory Care Building. The MC building has exiting doors alarms as well as exiting gate alarms on the courtyard gate. The facility does not currently have residents with oxygen. Exit interview completed, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Oct 18, 2023

The state marks this report as 9 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff do not keep facility free from vermin Staff do not properly store food

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced initial 10-Day complaint visit to the facility at 09:20 a.m. the LPA was greeted by Marketing Director Christine Fenn and discussed the reason for the visit. Administrator Matteo Digrigoli arrived later during the visit. During today's visit the LPA toured the facility with Marketing Director Christine, obtained copies of pertinent documents, interviewed eight (8) staff, five (5) residents, one (1) residents private caregiver and marketing director between 09:40 a.m. and 02:30 p.m. Report will continue on LIC9099-C. Substantiated On the allegation that Staff do not keep facility free from vermin, it is the reporting party’s concern that there have been rats in the facility for the past month and management has not done anything about it. It was further alleged that the fruit that is being left out for the residents is getting eaten by the rats. To investigate the allegation, the LPA conducted a facility tour, observed the kitchen in the main campus and the dining rooms in memory care (The Gardens) and assisted living (The Cottages). At 10:04 a,m. the LPA observed rodent droppings on the floor of the kitchen in the main campus and at 10:55 a.m. inside a drawer in the dining room of Memory Care. Staff interviews revealed that the facility has had rat sightings for the past two to three weeks and one staff saw one last week. Staff interviews revealed that sticky traps have been placed by maintenance and are periodically checked. Lastly, staff interviews revealed that if the facility cannot control the situation Orkin, a pest control service would be called, however they have not called Orkin to assist with the vermin. Based on observation and interview, the allegations that " Staff do not keep facility free from vermin " is deemed SUBSTANTIATED at this time. On the allegation that Staff do not properly store food, it is the reporting party’s concern that staff do not put start dates on opened food and containers are left open when they are put away. It was further alleged that uncovered frozen meat is left out in the sink overnight to defrost. To investigate the allegation, the LPA conducted a facility tour, observed the kitchen in the main campus and the dining rooms in memory care (The Gardens) and assisted living (The Cottages). At 9:49 a.m. the LPA observed an opened can of whole jalapenos peppers with no start date labeled. At 9:58 a.m. the LPA observed an undated container of sauce, one undated dish of cooked meat, and one undated plate of cooked bacon all inside the fridge. At 10:00 a.m. the LPA observed four (4) uncovered hamburger patties not stored properly with visible freezer burn and a box of hamburger patties left open inside the freezer. At 11:16 a.m. the LPA observed staff grab apple sauce from a closed container inside the fridge in memory care and not properly closing the container. One of the corners of the apple sauce container was left open. Based on observation, the allegation that “Staff do not properly store food” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report and appeal rights were issued to Administrator Matteo Grigoli. On the allegation Staff are not providing adequate food service to residents, it is the reporting party’s concern that the cooks in the kitchen do not take the temperatures of the food and are not properly washing the fruits and vegetables. It was further alleged that the residents were served chicken that was not fully cooked because it had been put in the oven while it was still frozen. To investigate the allegation, the LPA conducted a facility tour, observed the kitchen staff in the main campus while preparing lunch and interviewed staff and residents. At 11:27 a.m. the LPA observed kitchen staff washing lettuce using a colander, properly storing and labeling leftover food and periodically changing their gloves. In addition, the LPA observed kitchen staff checking the temperature of the chicken dish they had just cooked. Resident interviews revealed that the food service at the facility is excellent and that they had no concerns about the food service. Staff interviews revealed that fruits and vegetables are washed thoroughly and that they make sure the meat is fully cooked before serving it to the residents. Based on observations and interviews the allegation “Staff are not providing adequate food service to residents” is deemed UNSUBSTANTIATED at this time. On the allegations Staff do not ensure carpet is kept clean and sanitary and Staff do not ensure that the facility remains free of odors, it is the reporting party’s concern that on 9/28/23 a resident (R1) had a diarrhea accident and the carpet got dirty. It was further alleged that R1’s room smelled due to staff placing a floor mat on top of the feces instead of cleaning it. To investigate the allegation, the LPA visited R1’s room and random resident rooms with carpets, reviewed pertinent documents, and interviewed staff and residents. Record review revealed R1’s private caregiver had washed off what they could from the carpet and that the facility placed a work order on 9/28/23 for the carpet to be cleaned. Administrator Matteo stated R1’s carpet was washed by maintenance staff the same day or the day after. During today’s visit, R1’s room had no odor. In addition, R1’s interview revealed that the accident “got cleaned up nicely” and had no concerns of odors and that it was cleaned in a timely manner. Administrator Matteo stated that depending on the situation, carpets are either washed in house by maintenance staff with an extractor or are professionally cleaned by Regency, a carpet cleaning company. All three residents that were asked if they had any concerns regarding odors or carpet cleaning issues stated that they have no concerns and that they can place work orders if needed. Staff interviews also revealed that they have not smelled any odors coming from resident rooms. Based on the information gathered, although the allegation may have happened or is valid, there was insufficient evidence to confirm "Staff do not ensure carpet is kept clean and sanitary and Staff do not ensure that the facility remains free of odors. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.Exit interview conducted and report issued to Administrator.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 29-AS-20231002090407

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(27) · Plan of correction due date: Oct 10, 2023

87555(b)(27) General Food Service Requirements. All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by Based on interviews and observations, the licensee did not comply with the section cited above, as there were rodent droppings observed in the kitchen and staff admitted that the facility has an issue with rodents in the kitchen, which poses and immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: The Administrator agreed to do the following: 1. Submit a written plan of action, detailing how the facility will maintain compliance with the regulation. Indicate the steps the facility is taking to manage the pest concern on a daily basis and submit to CCL by 10/10/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Oct 16, 2023

87555 General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality...Food in damaged containers shall not be accepted, used or retained. Based on observation, numerous food items were observed in the kitchen refrigerator and freezer to be stored with no start label, meats were observed exposed to freezer burn and food not stored properly which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: During today's visit, items identified were disposed of. Administrator agreed to a full audit of all food items, including dry storage, refrigeration and freezer units to ensure all items are properly labeled, stored and within appropriate expiration date range and will provide proof to CCLD by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit in conjunction with an initial complaint visit (Complaint Control#29-AS-20231002090407). The purpose of the visit is to issue citations for deficiency observed during the complaint investigation which is not related to the complaint. The LPA arrived at the facility at 09:20AM and was greeted by Marketing Director Christine Fenn and discussed the reason for the visit. Administrator Matteo Digrigoli arrived later during the visit. At 9:40 a.m. during today's visit the LPA toured the facility with Marketing Director Christine. At 10:58 a.m the LPA observed one (1) full bottle of Dona Sol Merlot, and one (1) full bottle of Barefoot Merlot in an unlocked cabinet inside the dining room of the memory care unit accessible to the residents in care. At 11:01 a.m. the LPA observed a tool box with the following variety of tools: hammer, pliers, screw drivers and other tools inside an unlocked cabinet in the dining room of the memory care unit. At 11:58 a.m. the LPA observed a Clorox spray bottle, a pet stain and odor eliminator spray and disinfectant wipes in the living kitchenette area of room #34 accessible to residents in care. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 9, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Oct 16, 2023

87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by Based on LPA's observations, the licensee did not comply with the section cited above as cleaning supplies, bottles of merlot,hammer and other tools were observed accessible to residents which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: Staff locked all items during todays visit Administrator stated that they will provide documentation staff training regarding regulation 87705(f)(1) to CCL by 1/6/22.