The Reserve at Thousand Oaks

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian conducted an annual inspection today. At approximately 2:15 p.m. LPA met with staff Nancy Burns and introduced self. Staff contacted Executive Director (ED) Elizabeth Spencer and LPA explained the reason for the visit. At approximately 3:00 p.m., the LPA and Executive Director and Maintenance Director, toured 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. The following was observed: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPA observed sufficient perishable and non-perishable foods to meet the minimum requirement for two day perishable and seven day non-perishable food supply; emergency food and water supply for 72 hours. Refrigerator and food storage areas were checked for proper labels and expiration dates and food labels; opened food items were sealed properly and had expiration date clearly marked. Common spaces on the first floor include the theater, salon, secured pool, and spa. The second floor includes the reception area/lobby, library, activity rooms, fitness room, and physical therapy room. The third floor includes the kitchen/dining services, and activity rooms. Fire extinguishers were checked and observed full charged. The pool was observed to locked and inaccessible to residents in care. There were no obstructions and/or tripping hazards throughout the facility. The main facility structure is a three story building. There are resident rooms on all three floors. In addition, there are additional resident units in six (6) stand-alone buildings. LPA observed six (6) resident rooms randomly chosen in the main building. All resident rooms observed were furnished appropriately, with furnishings and clean linens. The bathrooms were sufficiently stocked with supplies and paper towels. Hot water temperature was measured between 116.2 – 127.8 degrees Fahrenheit. Assistant Maintenance Director adjusted the boiler during the visit. The outer building were not toured during today's visit. Due to time constraints the annual will continue to another date. Exit interview held.Copy of report provided.the state’s words, verbatim · CDSS document, Jul 25, 2026

Allegation investigated: Staff do not ensure that outside vendors maintain resident privacy during the provision of services.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility to deliver investigation report. Upon arrival LPA met with the Executive Director (ED) Elizabeth Spencer. Reason for the visit was explained. On 04/07/2026, Community Care Licensing Division received the above complaint allegations. Information was received that on 03/18/2026 resident #1’s apartment front back door was open with two men standing in the resident’s apartment near the back door. It was reported that the men were painting contractors who had been let in by the maintenance supervisor. In addition, on a previous date an employee of the facility used their key and entered resident #1’s apartment without any notice. The employee had gone in to check on the resident because they had not gone to the monthly wellness clinic. During the initial visit on 04/15/2026, LPA met with the ED and discussed the allegation. (Cont.to LIC9099c) Substantiated Discussion was held about how the facility ensures residents privacy and safety with outside vendor services. ED stated that they provide advance notice to residents of any projects in place that involves resident unit access. ED stated that they send out letters and call residents to provide a date and time frame when any work is scheduled. LPA also toured the outer buildings (B, C, D, E, F, G) and conducted interviews with random residents. Total of fifteen (15) residents were interviewed by LPA from approximately 12pm-3:30pm. Following is a summary of the investigation findings: Regarding allegation “Staff do not ensure that outside vendors maintain resident privacy during the provision of services”. Interviews conducted with staff and resident revealed that the facility had outside vendor painters conduct work on residents apartment unit in the month of 3/2026. It was reported that the non-staff personnel working on resident apartments painting the doors were not accompanied by facility staff and were allowed access to the resident units. On 3/18/2026, non-personnel staff (painters) were given access to resident #1’s unit while resident were in their room sleeping. Interviews conducted revealed that although the facility notified residents of the projected work the facility did not ensure residents safety and left the contractors unsupervised in resident #1’s apartment while residents were sleeping. Based on the above information gathered, allegation “Staff do not ensure that outside vendors maintain resident privacy during the provision of services” is deemed substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted. A copy of the report and appeal rights were reviewed and provided. Staff interviewed reported that they will always knock before entering resident units. Staff stated that they would knock at least three (3) to four (4) times and if the resident does not answer they would use their key to enter residents room for safety check. According to staff there is a three-knock rule that all staff follow. ED reported that if residents don’t respond staff will enter to ensure residents’ safety. Regarding this allegation it was reported that a staff #1 entered resident #1’s unit without permission and did not wait for a response. According to resident they did not hear the staff knocking and staff entered the resident’s unit while resident was in the restroom. Staff recalled the incident and stated that they were checking on the residents since they did not show up for the monthly wellness clinic. According to staff this wellness check is mandatory. Staff stated that they were conducting a wellness check and when resident did not answer they open the door and called out for the resident without entering the unit. Staff reported the resident was just getting out of the restroom, so they waited by the door. Resident #1 confirmed that the facility staff never entered their bedroom. Interview conducted with additional residents shared that the staff always knock and call out to the residents before entering their unit. 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 “Staff do not ensure residents' have privacy in their bedroom” is deemed unsubstantiated at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 18, 2026 · control 29-AS-20260407115058

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)2 · Plan of correction due date: May 1, 2026

Personal Rights of Residents in All Facilities:(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations... Based on interviews conducted with residents, the licensee did not comply with the section cited above, as outside agency contractors (painters) were allowed access to resident units without supervision and without making sure resident was aware that the contractors will be working in the unit.the state’s words, verbatim · CDSS document, May 18, 2026

Plan of correction: Executive Director (ED)stated that they discussed the issue with the Maintence Director and will be providing in-service to staff by 05/29/2026. Copy inservice will be sent to LPA by

Allegation investigated: Staff are not following safe food service practices.

This is an amended report to include additional supporting information. Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to continue with the complaint investigation. Upon arrival LPA met with the Executive Director (ED) Elizabeth Spencer. Reason for the visit was explained. On 12/30/2025, Community Care Licensing Division received the above complaint allegation. It was alleged that a resident tested positive for Campylobacter. According to the reporting party, the resident’s symptoms started on 11/9/2025. Reporting party also expressed concerns that other residents may be ill. During the initial visit on 01/08/2026, LPA and ED toured the dining and kitchen areas and interviewed staff. In addition, LPA interviewed eight (8) residents including R1. A subsequent visit was made today and additional records were reviewed including but not limited to the facility’s most recent dieticians report. (Continue to LIC 9099c) Unsubstantiated Also during the subsequent visit today, additional eight (8) random residents and other potential witnesses were interviewed at 11:30am and from 12:30pm-2:30pm. Furthermore, LPA and ED toured the facility kitchen and reviewed food service during lunch. Following is a summary of the investigation findings: During the initial complaint visit, LPA observed the kitchen to be clean and without any noticeable issues handling/cooking food items. The LPA noted staff present in the kitchen preparing and cooking meals. During the subsequent complaint visit the kitchen was observed to be clean and hazard free. Facility's January 2026 Dietitian Report did not reveal any food preparation and meal service issues. According to staff interviews, the cooks and staff preparing/handling food items including but not limited to meats wear gloves. Staff in the kitchen observed wearing gloves and hair nets. LPA was informed that the servers that do not handle/prepare meals are not required to wear hair nets or gloves. Staff stated that meats and seafood are put in the refrigerator overnight to thaw for the weeks planned menu. Facility cook stated that all meals are cooked well and nothing is ever under cooked or left out in the kitchen; everything requiring refrigeration is covered and stored appropriately. No complaints received from the residents regarding undercooked meats. According to the ED there have been no known reportable issues with any illness in relation to facility food contamination. Interview conducted with sixteen (16) random residents revealed no issues or concern with the facility, food or food service. Residents interviewed expressed being satisfied with the food service and meals. Sixteen (16) out of sixteen (16) residents interviewed were all satisfied with the culinary team and food quality. Potential witness interview revealed R1 tested positive for “Campylobacter” which is a foodborne illness; cause from cross contamination; consuming undercooked poultry or drinking contaminated water. Interview with R1 and records reviewed revealed that R1 is independent and responsible for self. According to R1 they have no issues or concerns with the meals at the facility. R1 did not recall getting ill from anything that they ate at the facility. R1 shared that they don’t always eat the facility meals. R1 confirmed that they do eat out sometimes. R1 could not recall when they last ate out. R1 did not recall if they ate out in the month of 10/2025 or 11/2026. 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 “Staff do not prepare and serve food in a safe and healthful manner” is deemed unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 29-AS-20251230145835

Allegation investigated: Staff did not ensure that the facility kitchen was kept free of rodents.

Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint investigation visit for the above allegation. Upon arrival, the LPA met with Executive Director (ED), Elizabeth Spencer and explained the reason for the visit. Entrance interview. During today's visit, between 12:45 p.m. and 02:10 p.m., the LPA conducted a plant tour, observed the kitchen / food service area, conducted interviews with five staff, and obtained copies of pertinent documents relevant to the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff did not ensure that the facility kitchen was kept free of rodents. It is the complainant’s concern that rodents have been observed near the kitchen area. During today’s visit, the LPA, along with the ED, toured the kitchen and food service areas. The LPA observed multiple rodent boxes and traps set in place. Record review and interviews conducted revealed that the facility has been receiving monthly pest control services from Pacific Exterminator and that additional rodent control services were initiated as soon as a potential rodent issue was identified. Interviews with kitchen staff indicated that although the pest control company visits several times a week to inspect and replace traps, staff have never personally observed any rodents. Additionally, staff also confirmed that the pest control company consistently inspects and replaces the rodent boxes and traps. Further record review and interviews conducted revealed that the facility has also contracted Ventura Pest Control to provide supplementary services in the meantime. Moreover, staff reported that no residents have expressed any concerns or reported rodent sightings anywhere in the facility. Additionally, the facility has consistently taken measures to ensure that the kitchen remains free of rodents. Based on the information obtained and reviewed, although the allegation may be valid, the Department has insufficient evidence to support allegation "staff did not ensure that the facility kitchen was kept free of rodents". Therefore, this allegation is being deemed Unsubstantiated at this time. Exit interview. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 29-AS-20251030123659

Allegation investigated: Staff did not have proper provisions during a power outage

Licensing Program Analyst (LPA) Zabel Chochian arrived at this facility today to deliver investigation finding for the above allegation. Upon arrival LPA met with Executive Director (ED) Elizabeth Spencer and explained the reason for the visit. On 03/12/2025, the Department received a complaint regarding the above allegation. Information was received that the facility power was shut off temporarily as a result of high winds in January 2025. It was reported that residents did not have heat and lighting for approximately four days. According to reporting party, residents were terrified of being in complete darkness and freezing cold. The outer buildings had no emergency lighting outside, nor on the walkways or stairs; no lighting in the halls in areas of the main building including areas on the 2nd and first floor. In addition, facility generator failed within the hour, and it was reported that the residents in the outer units did not know about the charging area by the main building or the available blankets and flashlights. (Continue to LIC9099c) Substantiated To investigate the above allegations a complaint visit was conducted on 03/20/2025 and allegation was discussed with the Executive Director (ED) Elizabeth Spencer. Random resident interviews were conducted telephonically on 05/18/2025 from approximately 2pm-4:30 and 5:30pm-7:30pm; on 6/10/2025 from approximately 9am-11am and 2pm-5pm; on 9/24/2025 from approximately 2pm-4:30pm. ED reported that on 01/07/2025, at approximately 4:27pm Community received SCE alert notification that power could be shut off due to expected wind event. Department managers and all residents were alerted, and preparations were made for emergency lighting and power to nurse call system. Community staff were notified; NOC shift staff was prepared with emergency MARs and lighting due to advance communication to be prepared for possible outage. Interview with staff and random residents confirmed that power was shut off on 01/08/2025 at approximately 11:30pm. Power was shut off in Thousand Oaks area due to high winds and power was restored by 11:30pm on 01/09/2025. Residents confirmed that facility staff made rounds throughout emergency to residents’ rooms during the NOC shift staff at least every hour. According to ED, additional staffing was in place throughout the entire emergency, including overnight management in the building. Breakfast and lunch were served in the dining room, and room service was provided for those unable to walk to the dining room. Dinner was served exclusively in apartments to avoid safety issues with limited lighting. Community staff rolled food carts and provided choices of meals to each resident. Staff reported that room checks, fire watch and temperature checks were completed throughout power outage with extra staffing brought in overnight to provide additional support; flashlights were made available to those without working flashlights. Common areas remain lit with ancillary lighting in the main building; space was created for residents to gather, play cards, and visit with others. ED stated that some residents went with family/friends and others stayed and sheltered in place. Staff reported that during room checks, staff also assisted residents with charging their cell phone and hearing aids by creating a charging station, and provided updated communication regarding power outage, meal delivery timelines, and available flashlights and extra blankets for use. ED reported that residents who normally use a powered wheelchair received assistance from staff with ambulation using a manual wheelchair; residents who require oxygen administration were provided with portable tanks for use. Resident interviews confirmed that they had lanterns and flash lights, however it was not sufficient; the outer buildings did not have any emergency lighting outside near walkways, stairs nor by any of the exits. Residents reported that although staff made frequent checks, they were still terrified from being in complete darkness and freezing cold. (Continue to LIC9099c) Residents living in the outer units expressed that better provisions should be in place for future planned power shut off. Residents voiced that additional accommodation should be made to ensure residents aren’t freezing cold and in an unsafe living environment with no emergency lighting for exits, stairs and walkways. ED and residents confirmed facility generator activated lighting of only the main building hallways, nurse call system, and emergency outlets. The generator failed at approximately 12am on 01/09/2025 and two small portable generators were set up to power nurse call system and recharging station. ED confirmed that the outer buildings did not have emergency exit, walkway an stairs lighting. ED reported that following the SCE power shut off incident she contacted the fire department and requested a site visit. ED reported the outcome of the fire inspection was that they were asked to install emergency lighting on the outer building exits. Based on the above information gathered, allegation “Staff did not have proper provisions during a power outage” is deemed substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 29-AS-20250312163313

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 17, 2025

Personal Rights of Residents in All Facilities:(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by: Based on interviews conducted with random residents, the licensee did not comply with the section cited above, as residents living in the outer buildings felt unsafe and uncomfortable room temp. during the SCE power shut off in 1/2025. Room temp. were freezing cold and there was no emergencythe state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Executive Director state thatg since the SCE power outage, emergency lighting is placed on the outer buildings; and they are in the process of updating the facility emergency disaster plan. Submit copy of addendum to the facility Emergency Disaster Plan. lighting the exist, walkways and stairs.

Allegation investigated: Staff did not reappraise residents accurately Staff did not provide residents a comprehensive billing statement

Licensing Program Analyst (LPA) Zabel Chochian arrived to this facility today to deliver investigation finding for above allegations. LPA met with Executive Director (ED) Elizabeth Spencer and explained the reason for the visit. On 03/19/2025, the Department received a complaint regarding allegations “Staff did not reappraise residents accurately” and “Staff did not provide residents a comprehensive billing statement” – Information was provided that residents are charged a $250 fee for base level care (0) zero. Initially residents assessed at a zero (0) level of care upon signing their rental agreements were not charged any additional fees. In addition, information was provided that residents are billed for services and then credited back the amount creating confusion regarding their actual fees. To investigate the above allegations a complaint visit was conducted on 03/20/2025 and allegations was discussed with the Executive Director (ED) Elizabeth Spencer. (continue to LIC9099c) Unsubstantiated ED explained that the rate change was not a result of a reappraisal. ED explained that the company basically made a new structure to the base level of care: Base level care fee of $250 is charged for level 0-10; whereas before the level of care fee started at level 1-10. According to ED the residents were properly informed of the new level of care rate change. LPA requested resident and facility records pertinent to the allegations. Additional records were requested throughout the course of the investigation. Records reviewed included but not limited to letters dated 5/30/24 notifying residents in advance of the care level fee charge of $250 for the base level range 0-10 (points). Prior base level fee started at level 1-10. A memo dated 5/31/24 was issued to the residents with additional explanation of the new Base Level Care rate change; care level fee structure change, including Base level 0-10 fee ($250). In addition, a Town Hall meeting was held on 6/25/24 which included discussion regarding the “Base Level Care” rate change. According to the ED after the town hall meeting, the Company decided to apply the new base level care rate for new admissions and to credit residents who have been with the facility prior to 9/1/2024. A letter dated 8/22/24 was issued to residents noting that the base Level care rate change/increase is being rolled back for all residents residing at the facility prior to 9/1/ 2024. ED provided copy of sample statement invoices showing the proper reversal of the rate increase for $250 credited back for residents admitted prior to 9/1/2024. Random resident interviews were conducted telephonically on 05/18/2025 from approximately 2pm-4:30 and 5:30pm-7:30pm; on 6/10/2025 from approximately 9am-11am and 2pm-5pm; on 9/24/2025 from approximately 2pm-4:30pm. Resident interviews confirmed that the level of care fee was the issue and that has resolved since. Residents confirmed that a credit of $250 was applied for the months charged. Random invoice statements were reviewed and noted the credit of $250 for those residents admitted prior to 9/1/2024. 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 “Staff did not reappraise residents accurately and Staff did not provide residents a comprehensive billing statement” is deemed unsubstantiated at this timethe state’s words, verbatim · CDSS document, Oct 28, 2025 · control 29-AS-20250319131607

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Martha Arroyo and Brian Balisi conducted an unannounced annual inspection today. At approx 10:15 a.m. LPAs met with Executive Director (ED) Elizabeth Spencer and explained the reason for the visit. At approx 11:00am, the LPAs along with the Executive Director and Maintenance Director, toured 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. The following was observed: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two day and seven day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. LPAs observed twelve (12) resident rooms randomly chosen in the main building and the six (6) surrounding buildings. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Hot water temperature was measured between 103 – 117.1 degrees Fahrenheit. The main facility structure is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors. In addition, there are additional resident units in six (6) stand-alone buildings.Common spaces on the first floor include the theater, salon, secured pool, and spa. The second floor includes the reception area/lobby, library, activity rooms, fitness room, and physical therapy room. The third floor includes the kitchen/dining services, and activity rooms. The pool was observed to locked and inaccessible to residents in care. There were no obstructions and/or tripping hazards throughout the facility. The common areas were appropriately furnished, and the lighting was adequate. Smoke alarms, carbon monoxide detectors, sprinklers and fire extinguishers were observed throughout the facility. The emergency exiting plans/sketch are posted throughout the hallways. The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. There is a functioning telephone on the premises. Emergency evacuation chairs were present in all stairways in each building. There is also a large outdoor space with shaded areas and adequate furniture for resident use throughout the facility. All passageways, walkways, driveways, steps and patios are free from obstructions and hazards at this time. Several fire extinguisher were observed throughout the facility to be fully charged and last serviced on 08/02/2024 LPAs reviewed ten (10) resident records and ten (10) personnel records starting at 12:30pm. Ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. (10) personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files appeared to be in order during the visit. LPAs reviewed medications at approximately 1:30pm. The medications are centrally stored in a med rooms on the 3rd floor. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record. Medications appeared to be given as prescribed at the time of the visit. During today’s visit, the LPAs reviewed the facility's infection control policy as well as their emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. The last fire safety inspection was completed on 11/7/2024 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted as per regulation; last disaster drill conducted on 06/25/2025. No citations issued. Exit interview conducted. Report was reviewed and copy provided.the state’s words, verbatim · CDSS document, Jul 15, 2025

Allegation investigated: Staff are not safeguarding the facility grounds. Staff do not provide a safe environment for residents. Staff are not safeguarding the residents’ personal belongings.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation at 10:05AM. Upon arrival, LPA met with staff and Executive Director (ED) Elizabeth Spencer. Entrance interview conducted. During today’s visit, LPA Barutyan interviewed one (1) staff and the ED, reviewed and obtained copies of pertinent documents, and conducted a brief physical plant tour. During the initial visit on 01/30/2024, LPA Peraldi obtained copies of pertinent documents, conducted a physical plant tour, and interviewed six (6) residents, five (5) staff, and the ED. It was alleged that staff are not safeguarding the facility grounds and providing a safe environment for residents due to unlawful entry to private resident apartments. REPORT CONTINUED ON LIC 9099-C. Unsubstantiated It was further stated that residents feel unsafe in their homes. During the initial visit on 01/30/2024, six (6) residents were interviewed, and all residents stated they felt safe and had no safety or security concerns. Residents were aware and had no concerns of entry to their apartments. ED stated that residents are informed during pre-admission orientation and periodically that although resident apartments are private, the facility has the right to enter when needed. All residents get at least one housekeeping service requiring entry to vacuum, take out trash, and maintenance as needed. LPA reviewed the Admission Agreement which states that “Owner and Manager and our authorized representatives shall have the right to enter the Apartment during reasonable hours and without notice for the purpose of repairs and maintenance, improvements, and routine housekeeping and other services required to be provided by us.” LPA also reviewed the Assisted Living Resident Handbook Exhibit “C” which states that “Housekeeping service is provided once a week…If you have valuable ‘breakables’ you are asked to please take them off of your furniture tops before housekeepers dust…When on a Service Plan, housekeepers and/or caregivers will empty trash from your apartment on a daily basis.” The Resident Handbook also states “Staff regularly monitors the entire grounds to ensure your protection. The Community may be required to authorize admittance to your apartment to outside service personnel. Such cases might include emergency service for a plumbing problem, or to satisfy the requirements of a regulatory agency. We will have an appropriate staff person accompany any non-staff personnel who must enter your apartment while you are away. All such entries are approved by the Executive Director.” ED stated that concerns of apartment entry are periodically mentioned during resident town hall meetings, and when the concerns are voiced, the ED reviews the admission agreement and Resident Handbook with residents and explains why such entries are needed. Furthermore, the facility grounds are kept secure at night through a security agency. The security detail patrols twice per evening, locks the property, secures vacant rooms, and drives around the grounds from 2AM-5AM. From 9:30PM-10PM, security does a walkthrough of the buildings and locks all exterior doors. Past 10PM, entry is from the lobby via a doorbell; residents can gain entrance through the key fob assigned to them. All six (6) residents and six (6) staff interviewed had no concerns of safety or security. Based on record review and interview, the information obtained during the investigation does not have sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegations “Staff are not safeguarding the facility grounds” and “Staff do not provide a safe environment for residents” are deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C. It was further alleged that staff are not safeguarding residents’ personal belongings as residents have reported missing items but have been told that facility is not responsible for lost or stolen items. LPA reviewed the Admission Agreement which states, “We shall not be responsible for the loss of any personal property belonging to you due to theft, fire, or any other cause, unless the loss or damage was caused by our negligence or that of our employees.” LPA also reviewed the Resident Handbook which states “The Community makes every effort to provide a safe environment for the residents and their belongings. Personal effects (including, but not limited to, clothing and jewelry) and furniture are not the responsibility of Management. We recommend that these items be insured by the resident.” The Resident Handbook and Admission Agreements have a theft and loss policy in compliance with California Health & Safety Code sections 1569.152-1569.154. The policy states “Any suspected theft or loss should be immediately reported to the Front Desk. Management should make an immediate search for the item(s), conduct an investigation and present the resident or responsible person with a report. Management will notify law enforcement within 36 hours of regarding a theft of $100 or more. Per applicable law, any lost or stolen item with a value of $25 or more shall be documented within 72 hours of discovery.” The Admission Agreement and Resident Handbook state multiple times that the facility recommends residents to obtain insurance for their personal belongings, keep apartment doors locked when away, and place breakable valuables out of reach. All six (6) residents interviewed had no concerns of safeguarding of their personal belongings. Two (2) out of six (6) residents interviewed stated they felt comfortable enough to leave without locking their apartment door. All six (6) staff interviewed had no concerns of facility failing to safeguard resident belongings. Staff were knowledgeable in theft and loss procedures, which include but are not limited to, reporting thefts and losses to Management when learning of them, logging reports, and investigating. Based on record review and interview, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff are not safeguarding the residents’ personal belongings” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 29-AS-20240123110806

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a required annual visit. The LPA met with Associate Executive Director (AED) Edward (Eddie) Ocegueda and informed them of the reason for the visit. LPA was informed Executive Director is unavailable today. At 10:45AM, the LPA and the Associate Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers throughout the facility buildings were observed to be fully charged and last serviced 08/07/2023. The facility's fire safety system 5-year inspection was conducted on 12/06/2019 by Fraker Fire Protection; all relevant systems passed at that time. The annual inspection was conducted by Fraker Fire Protection on 05/23/2024, noting one area of concern in building G. Proof of repair will be provided to LPA during annual continuation. Common Areas: The main facility structure is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors. In addition, there are additional resident units in six (6) stand-alone buildings. Common spaces on the first floor include the theater, salon, secured pool, and spa. The second floor includes the reception area/lobby, library, activity rooms, fitness room, and physical therapy room. The third floor includes the kitchen/dining services, and activity rooms. There were no obstructions and/or tripping hazards throughout the facility. At 12:22PM, the doors to the fitness room were observed to be propped open with no staff present; 2 pairs of scissors and 2 screwdrivers were observed accessible on top of a desk. At 12:26PM, the ceiling over an open common area in the second floor was observed to be covered in plastic and dripping water. AED indicated there had been a leak in the third floor kitchen and the leak has since Continued on LIC 809-C been resolved, however, repairs on the ceiling have not been completed to date. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. Kitchen: Dining room is located on the third floor and was observed to be clean and sanitary. At 03:45PM, LPA observed a small fruit/drain fly in the kitchen area and immediately outside the kitchen, in the server station near the juice dispenser, LPA observed a large number of small flies, both flying about and on the ceiling. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was posted, and the facility offers daily specials and a standard selection at every meal. Snacks and beverages are available for residents in the Bistro area on the 2nd floor. Resident Units: The LPA and Associate Executive Director toured 14 (fourteen) randomly selected resident units throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Restrooms: The LPA and Associate Executive Director observed restrooms in 14 (fourteen) resident units. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces in the bathing unit. Water temperature was tested throughout the visit and measured at 138.4 degrees F at 11:42AM in room F7 and 133.1 degrees F at 11:49AM in room E1. Outside areas: The LPA and Associate Executive Director toured the outside areas and courtyards. There was appropriate outdoor furniture, with a covered shaded area for residents observed in several facility courtyards. There is a locked pool for resident usage with appropriate fencing and it was locked inaccessible. Parking is available for residents and visitors. Files: Residents records review began at 02:30PM, 10 (ten) records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. Resident records were in order. Personnel records will be reviewed during Annual Continuation Visit. Interviews: LPA interviewed 6 (six) residents during today's visit. LPA will conduct staff interviews during the Annual Continuation visit. Medications: Medications will be reviewed during Annual Continuation Visit Continued on LIC 809-C Infection Control Plan/Emergency Disaster Plan: Infection control plan was not provided today and will be reviewed during Annual Continuation visit. LPA reviewed the facility's Emergency Disaster Plan, which was recently updated, however, the facility is utilizing an outdated form. LPA will email the updated form. Disaster drills are conducted weekly, with the last documented drill conducted on 07/08/2024. Documentation: The LPA obtained a copy of the facility's liability insurance, resident roster, and staff roster. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Jul 16, 2024

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 04/08/2024. Upon arrival, LPA was greeted by front desk staff, Lyn. LPA met with Business Office Manager Miguel Lino and explained the reason for today's visit. Executive Director (ED) Elizabeth Spencer arrived shortly after the visit began. On 04/18/2024, LPA Dulek received a voicemail from ED Spencer asking for a call back related to an incident that had occurred at the facility. LPA and ED spoke over the phone on 04/19/2024. During the telephone conversation, ED explained that there had been an incident on 04/08/2024 involving Resident #1 (R1). Another resident had backed up their scooter while R1 was ambulating using their walker, causing R1 to fall and hit their head. R1 was hospitalized following the incident and ED was made aware by R1's family that R1 had passed away at the hospital. Written incident report and death report were faxed to the Regional Office on 04/19/2024. During today's visit, LPA interviewed ED related to the incident and LPA, along with ED, toured the pertinent areas of the facility at 10:40AM. No immediate health and safety hazards were identified during today’s visit. LPA also reviewed R1's file and obtained copies of pertinent documents, and interviewed staff from 11:34AM to 12:00PM. LPA may return at a later date if further investigation is needed. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2024

Allegation investigated: Facility staff are not communicating with residents or their representatives regarding outbreak updates.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation finding. Upon arrival LPA met with Executive Director Elizabeth Spencer and explained the reason for the visit. Entrance interview conducted. On 11/30/2023, Community Care Licensing Division received the above complaint allegation. It was alleged that the facility had an "intestinal virus" outbreak on or about 11/17/2023. All activities and the dining room were shut down since that date. It was reported that since 11/24/2023 there have been no residents with the illness however the activities and dining room were still closed. It is unknown why. No one at the facility is communicating with the residents or families. Investigation into the allegation consist of interview with staff on 12/07/202 between 3:15pm-4pm and review of facility records pertaining to the facility “norovirus outbreak” on 12/07/2023 and 12/09/2023. Unsubstantiated In addition, telephonic interview was conducted with twelve (12) randomly selected residents and other potential witnesses through-out the course of investigation and on 04/17/2024 from approximately 9:30am-11:30am. Executive Director Elizabeth Spencer stated that the residents and families were update as she would receive information/updates from Ventura County Public Health (VCPH). According to Ms. Spencer the Community dining and group activities were stopped and resumed per order from VCPH. Ms. Spencer provided records confirming communication with residents and families. Records provided included but not limited to viral outbreak memo letter dated 11/16/2023 and 11/24/2023 providing notification to residents and families of the outbreak and updates; log of the facility “viral outbreak messaging” alert updates sent via phone messaging and live contact; and communication record from 11/16/2023 – 12/07/2023 between the facility and the VCPH from the onset of the outbreak to the VCPH clearance. Staff also confirmed that Executive Director and staff kept residents and families update with the progress and status of the outbreak as they were informed by VCPH. Twelve out of twelve residents and other potential witnesses interviewed confirmed that facility Executive Director and staff kept residents and families up to date with the outbreak back in 11/2023 - 12/7/2023. Resident and families reported no concern with the way the outbreak was handled. Residents confirmed receiving continuous updates by Executive director via letter, phone and in person (live) by staff. Based off the information obtained during the investigation, the Department does not have sufficient evidence to support the allegation of “Facility staff are not communicating with residents or their representatives regarding outbreak updates.” Therefore, this allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Apr 17, 2024 · control 29-AS-20231130132649