The Varsity Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 01:35PM. LPA initially met with facility staff. Facility Designee was contacted via telephone and arrived at the facility at 02:20PM. Entrance interview conducted. Beginning at 02:23PM, the LPA, along with Facility Designee 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: Hardwired smoke detectors were tested at 02:31PM and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 09/15/2025. BEDROOMS: There are 5 (five) total bedrooms, of which 2 (two) are designated as private resident rooms, 2 (two) for shared resident use, and 1 (one) staff room. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: The LPA observed 2 (two) restrooms in the facility. 1 (one) is for shared use and 1 (one) is designated as a private restroom. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Water temperature measured within the required range. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened. Auditory exit alarms were observed on exit doors. Report Continued on LIC 809-C KITCHEN/GARAGE: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Emergency food and water was observed. Adjacent to the kitchen is a locked garage. Garage was observed and contained the laundry area, extra food, cleaning supplies and storage. There is an additional staff room in the garage area. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be clear of hazards. Gate was observed to be self-closing and latching. RECORD REVIEW: Beginning at 01:43PM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Four (4) staff files and four (4) resident files were reviewed. All staff and resident files reviewed contained all required documents. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 11/01/2025. MEDICATION REVIEW: Beginning at 02:33PM, medications for two (2) residents were observed. Both two (2) of two (2) residents' medications were observed to be maintained and administered in compliance with regulation. INTERVIEWS: Throughout the visit, LPA interviewed staff and residents. No concerns were noted during facility interviews. No deficiencies cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 19, 2025

Allegation investigated: Administrator did not ensure resident’s medications were available Administrator speaks inappropriately in the presence of resident in care Resident was charged for services not agreed upon in the care assessment

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose continuing the investigation related to the above noted allegations. LPA met with Facility Designee John Davis and explained the reason for the visit. During an initial complaint visit conducted on 02/12/2025, LPA interviewed staff at 10:39AM, Facility Designee throughout the visit, and interviewed Administrator Alexander (Alex) Tecson and Facility Designee John Davis via video conference beginning at 11:09AM. LPA toured the facility at 01:04PM and interviewed 2 (two) residents during facility tour. LPA reviewed and obtained copies of documents relevant to the investigation. Throughout the course of the investigation, LPA reviewed all relevant documents and telephonically interviewed additional relevant parties. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation: “Administrator did not ensure resident’s medications were available:” The complaint alleges that on 02/05/2025, medications were delivered for Resident #1 (R1), however medications were not provided to R1 nor their hospice care provider. LPA reviewed hospice plan of care, medications and medication orders for R1, as well as interviewed staff and Administrator related to this allegation. Administrator indicated R1’s outside medical provider did not inform the facility of a change in R1’s care plan. LPA reviewed R1’s hospice plan of care and confirmed these medications were not included in the care plan on file at the facility, which was dated 11/07/2023. However, interview revealed that Administrator called and spoke to R1’s family member who verbally confirmed there had been a change in R1’s plan of care, additional medications were prescribed by R1’s doctor, and the medications were authorized by R1’s family member. Interview revealed that the 2 (two) medications in question were delivered to the facility between 10:40-11:00PM on 02/05/2025. Staff signed for the medications and contacted the Administrator. Administrator instructed staff to place the medications in the refrigerator. Although the medications were not listed on the plan of care on file at the facility, facility staff still signed for the medications and centrally stored these medications per the Administrator’s instructions. Additionally, R1’s hospice nurse was present in R1’s room at the time of delivery, however facility Administrator nor staff informed R1’s hospice nurse that the medications were delivered and available to be administered. Interview revealed that at 10:00AM, a different hospice nurse arrived to take over R1’s care. This nurse requested R1’s medications and facility staff provided the medications to the hospice nurse at 10:16AM, which is almost 12 (twelve) hours after the medications had been delivered. Based on interview and record review, the preponderance of evidence standard has been met, therefore, the allegation “administrator did not ensure resident’s medications were available” is deemed SUBSTANTIATED at this time. Allegation: “Administrator speaks inappropriately in the presence of resident in care:” It was alleged that on 02/05/2025, the Administrator arrived at the facility, entered R1’s room, and was raising their voice at R1’s outside medical provider. Interview revealed that facility staff had noticed a rapid decline in R1’s health condition and facility staff had contacted the facility Administrator to inform them of this observation. Facility staff then contacted R1’s hospice care provider to inform them. Hospice staff arrived at the facility to assess R1’s changing needs and with R1/their family member’s consent, hospice staff remained at the facility to provide additional care to R1. Administrator arrived at the facility that afternoon and entered R1’s room. Interview with Administrator revealed the hospice agency had not communicated the change in Report Continued on LIC 9099-C plan of care to the Administrator and therefore, the nurse should not be present in the facility and further, Administrator needs to know who is coming to the facility and when. However, the facility’s visiting policy in R1’s signed Admission Agreement indicates facility visiting hours are from 09:00AM to 06:00PM daily and resident personal rights indicate residents have a right to visit privately without prior notice. Administrator admitted having the conversation with the hospice nurse while both parties were in R1’s room, with R1 present. Telephonic witnesses confirmed the conversation was “heated” and Administrator stated to LPA that he was upset that hospice had not informed him. Based on interview and record review, the preponderance of evidence standard has been met, therefore, the allegation “Administrator speaks inappropriately in the presence of resident in care” is deemed SUBSTANTIATED at this time. Allegation: “Resident was charged for services not agreed upon in the care assessment:” It was alleged that after R1 had fallen at the facility, the Administrator informed R1’s family that R1 required a 1:1 caregiver at an additional cost, however this was not agreed upon nor indicated in R1’s assessment. LPA reviewed R1’s admission agreement signed on 12/15/2021 when R1 moved into the facility. Admission Agreement states “if the facility rates for basic services change because the resident’s needed/desired services change, a written notice will be provided to the resident and the resident’s representative within two (2) business days of providing service at a new level of care.” However, there was no new care plan completed at that time, indicating the need for increased supervision and a change in level of care. No new Physician’s Report was filled out either, which is also required for a change in condition. Hospice plan of care dated 11/07/2023 states resident is “ambulatory: requires walker. Maximum assist,” however it does not indicate 1:1 supervision is required. Staff interviewed indicated they believe there was a verbal agreement with R1’s representative related to the additional care, as R1 had a diagnosis of dementia, had broken their leg, and needed additional supervision to remind R1 not to get up and re-injure their leg. LPA requested proof of written notice or signed new care plan following R1’s fall, however nothing in writing was provided by the licensee. R1’s representative stated they did not receive such written notice, but was charged in excess of $17,000 for additional care. Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegation above is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. A copy of today’s reports and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 29-AS-20250207094516

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Apr 9, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section as R1's medications were delivered to the facility, but were not provided to R1 nor their hospice provider informed of their arrival, which posed an immediate health risk to resident in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Administrator agreed to obtain training for all staff on resident personal rights by an outside vendor. Proof of scheduled training will be submitted to CCL by POC due date. Proof of training including roster, materials, and trainer information will be provided to CCL upon completion.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 22, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the above cited section as Administrator was upset and was having a "heated" conversation with R1's hospice nurse in front of R1, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Facility Designee agreed to ensure Administrator sends a statement of understanding and a plan of communication with outside service providers to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Apr 22, 2025

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1's signed Admission Agreement nor care plan indicated the need for a 1:1 caregiver, and no new care plan was completed and agreed upon, which posed a potential personal rights risk to R1.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Administrator agreed to review the current Admission Agreement for compliance with regulation, will send to LPA for approval by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management - Deficiencies visit to this facility due to deficiencies observed during the investigation of complaint control # 29-AS-20250207094516. LPA met with Facility Designee John Davis and discussed the reason for the visit. Upon entry during today’s visit, LPA observed 2 (two) of the facility’s hardwired smoke detectors had been removed in the facility dining room and the facility’s living room. Facility Designee stated the smoke detectors have been removed a least 2 (two) days ago. Administrator was contacted via telephone and stated they needed new batteries and were taken off site to replace the batteries. During today’s visit, Facility Designee picked up the smoke detectors and returned them to this facility. During the course of the investigation, LPA interviewed Administrator, staff, and reviewed documents. Interview revealed that Resident #1 (R1) had fallen while in care at the facility on 04/28/2023. R1 also passed away under hospice care on 02/07/2025. LPA reviewed the Woodland Hills North Regional Office files for reports related to R1’s fall and subsequent hospitalization as well as R1’s death. LPA found that no reports have been received in the Regional Office via fax or email from this facility since the date the facility opened on 11/03/2022. LPA asked Administrator whether reports were submitted. Administrator stated he was unaware of the requirement to send incident reports to the Regional Office, however, Administrator stated he sent death reports via email. LPA asked for proof of emails sent to the Regional Office, but no such proof was provided during the investigation. Pursuant to Title 22 Division 6 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. A copy of today’s reports were provided.the state’s words, verbatim · CDSS document, Apr 8, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Apr 8, 2025

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 and interview, the licensee did not compy with the above cited section, as 2 (two) smoke detectors were removed from the facility common areas for a minimum of 2 (two) days, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: During today's visit, Facility Designee picked up the missing smoke detectors, ensured the batteries are replaced and reinstalled them in the common areas. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Apr 22, 2025

87211 Reporting Requirements (a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as no incident reports nor death reports have been received at the Regional Office since the facility opened, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: The Administrator agreed to review all emails and see if/when death reports were sent to the Regional Office. If any were sent previously Administrator will provide proof to CCL by POC due date. Administrator will provide a statement of understanding related to reporting requirements, including hospice notifications to CCL by POC due date.

Allegation investigated: Staff handle residents in a rough manner

Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit to the facility regarding the above noted allegation. LPA initially met with a caregiver who called the administrator. Administrator Alex Tecson arrived at 11:57 a.m. and LPA explained the reason for the visit. LPA interviewed three residents starting at 12:25 p.m. LPA interviewed two staff at 11:53 a.m. and 12:22 p.m. LPA reviewed and obtained pertinent records at 12:10 p.m. LPA conducted a brief facility tour at 1:07 p.m. (continued on LIC9099-C, page 2) Unsubstantiated (continued from LIC9099) Staff training records were up to date. Staff received dementia training in June of 2024 and postural support training in July 2024. Based on interviews with staff, they appear to understand how to handle fragile residents. Based on interviews with residents, they have never been handled roughly staff. Residents were happy with how staff treat them at the facility. Residents had nothing negative to say about staff or the administrator. Based on interviews and training records, the allegation staff handle residents in a rough manner is deemed UNSUBSTANTIATED at this time. No deficiencies were observed. Exit interview conducted and report issued to the administrator.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 29-AS-20250218091237

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:25AM. LPA initially met with facility staff. Facility Designee was contacted via telephone and arrived at the facility at 09:37AM. Entrance interview conducted. Beginning at 09:39AM, the LPA, along with Facility Designee and facility staff 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: Hardwired smoke detectors were tested at 11:57AM and carbon monoxide detector was tested at 11:56AM and all were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 09/06/2024. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened. Auditory exit alarms were observed on exit doors. KITCHEN/GARAGE: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Emergency food and water was observed. Adjacent to the kitchen is a locked garage. Garage was observed and contained the laundry area, extra food, cleaning supplies and storage. BEDROOMS: There are 5 (five) total bedrooms, of which 2 (two) are designated as private resident rooms, 2 (two) for shared resident use, and 1 (one) staff room. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report Continued on LIC 809-C RESTROOMS: The LPA observed 2 (two) restrooms in the facility. 1 (one) is for shared use and 1 (one) is designated as a private restroom. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature measured within the required range. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be clear of hazards. Gate was observed to be self-closing and latching. RECORD REVIEW: Beginning at 09:55AM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. LPA observed full bedrails on Resident #1 (R1)'s bed and although R1 does have a physician's order for full bedrails, R1 is not on hospice nor does the facility have an approved exception on file for R1. Bedrails were replaced with half bedrails during the visit. 4 (four) staff files were reviewed. Staff #1 (S1) and Staff #2 (S2) did not have proof of annual medication training, however, both S1 and S2, as well as both Facility Designees stated the training has been completed within the last 12 months. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 09/10/2024. MEDICATION REVIEW: Beginning at 10:49AM, medications for 2 (two) residents were observed. Both 2 (two) of 2 (two) residents' medications were observed to be maintained and administered in compliance with regulation. INTERVIEWS: Throughout the visit, LPA interviewed staff and residents. No concerns were noted during facility interviews. No deficiencies cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 20, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:33PM. LPA initially met with facility staff. Facility Designee was contacted via telephone and arrived at the facility at 12:53PM. Entrance interview conducted. Beginning at 01:08PM, the LPA, along with Facility Designee and facility staff 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: Hardwired combination smoke and carbon monoxide detectors were tested at 02:47PM and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 09/15/2023. BEDROOMS: There are 5 (five) total bedrooms, of which 2 (two) are designated as private resident rooms, 2 (two) for shared resident use, and 1 (one) staff room. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: The LPA observed 2 (two) restrooms in the facility. 1 (one) is for shared use and 1 (one) is designated as a private restroom. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the shared resident restroom and measured within the required range. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of Report Continued on LIC 809-C perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Emergency food and water was observed. Adjacent to the kitchen is a locked garage. Garage was observed and contained the laundry area, extra food, cleaning supplies and storage. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be clear of hazards. RECORD REVIEW: Beginning at 01:25PM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 4 (four) resident records reviewed were complete and contained all required documents. 5 (five) staff files reviewed were complete and contained all required documents. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 09/15/2023. MEDICATION REVIEW: Medications for 2 (two) residents were observed. Both 2 (two) of 2 (two) residents' medications were observed to be maintained and administered in compliance with regulation. INTERVIEWS: Throughout the visit, LPA interviewed 1 (one) staff and 1 (one) resident. During today's visit, LPA gathered the following items: LIC 500 A copy of the facility's liability insurance No deficiencies cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 15, 2023