Varenita of Simi Valley

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. Upon arrival, the LPA met with the Resident Care Director (RCD), Cassandra Sadowsky, and the reason for the visit was explained. The LPA conducted a plant tour with the RCD and focused today’s visit on ensuring there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Starting at 02:25 p.m., ten (10) randomly selected resident bedrooms were observed. The LPA inspected eight (8) bedrooms in Assisted Living and two (2) bedrooms in Memory Care. All bedrooms were observed to be properly furnished and had sufficient lighting. Hot water temperatures in Assisted Living bathrooms measured between 113.9 and 118.2 degrees Fahrenheit. In Memory Care bathrooms, hot water temperatures measured between 115.3 and 117.0 degrees Fahrenheit at the time of the visit. At the time of the visit, common area furniture was observed to be in good condition. The facility maintained a comfortable temperature. Several fire extinguishers were observed throughout the facility, all fully charged and with a service date of 12/05/2025. The facility’s Annual Fire Alarm Inspection was conducted on 12/11/2025 with no discrepancies noted. Required postings were observed throughout the common areas. The facility includes a courtyard which was observed to have adequate patio furniture for resident use. All interior and exterior passageways were observed to be free of obstructions. The kitchen and food service area were inspected during today’s visit. The LPA observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. An adequate amount of emergency food and water was observed during today’s visit. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, May 11, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Incident visit to follow up on a self-reported incident which took place on 02/25/2026. Upon arrival the LPA met with Executive Director (ED), Helen Lee and explained the reason for the visit. Entrance interview conducted. On 02/26/2026, the Department received an incident report (LIC 624) and SOC 341 regarding Resident #1 (R1) reporting to concierge at approximately 12:00 p.m., that Resident #2 (R2) had hit them in the face yesterday (02/25/2026) at lunch time in the dining room. Report states that incident was reported by R1 and was unwitnessed by any staff member. During today’s visit, between approximately 9:20 a.m. and 11:30 a.m., the LPA conducted interviews with the ED and three residents and reviewed and obtained copies of pertinent documents. No immediate health and safety concerns were observed during today’s visit. Interviews revealed that R1 reported the incident to the concierge the day after the alleged incident. R1 stated that R2 had been calling them names for several weeks. R1 reported feeling tired of hearing R2 call them names and stated that they stood up and placed both hands in front of R2. According to R1, R2 then slapped them in the face with an open palm. Report Continued on LIC 809C... Report Continued from LIC 809... An interview with R2 revealed that they only referred to R1 as the name of the city they were from. R2 stated that when R1 raised their hands in front of their face, their reaction was to push R1 away. R2 denied calling R1 any other names. R2 also denied hitting R1 in the face and expressed regret for anything that may have occurred that day. An interview with another resident, who is a mutual friend of both R1 and R2, revealed that although R2 may occasionally make rude comments to others, they have never witnessed R2 behave aggressively toward anyone while residing at the facility. The ED stated that they checked R1 for any visible marks or redness; however, no signs of injury or redness were observed on R1’s face the following day. Additionally, the police report indicated that R1 had no visible injuries and that their dentures were not damaged. Furthermore, record review and interviews revealed that there were no witnesses to the alleged incident. The ED reported conducting an internal investigation, following proper reporting protocols, and taking steps to ensure that R1 continues to feel safe within the facility. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur. No citations issued at this time. Exit interview conducted. Report was reviewed and a copy provided.the state’s words, verbatim · CDSS document, Mar 3, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Martha Arroyo and Brian Balisi conducted an unannounced annual inspection today. Upon arrival, the LPAs met with Executive Director (ED) Helen Lee and the reason for the visit was explained. Entrance interview. Starting at 10:30am, the LPAs along with the ED, 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: Kitchen: 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. An adequate amount of emergency food and water was observed; properly stored. Resident Rooms / Restrooms: The LPAs observed six (6) resident rooms in the assisted living side and two (2) resident rooms in memory care. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:39am, the hot water temperature was measured in eight (8) resident bathrooms, and the temperature measured between 112.9 – 118.8 degrees Fahrenheit. Report Continued on LIC 809C... Report Continued from LIC 809... Common Areas: The LPAs observed common areas to be clean and in good condition. There are games and/or activity supplies in the activity rooms as well as throughout the facility. There was sufficient space to accommodate both indoor and outdoor activities. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 12/06/2025. Outdoor Space: The LPAs observed the outdoor garden in Assisted Living and Memory Care which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. Record Review: The LPAs reviewed seven (7) resident records and seven (7) staff records starting at 11:31am. 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. All records were in order. 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 were in order. During today’s visit, the LPAs conducted interviews with five (5) staff and two (2) residents. No concerns were noted. Report Continued on LIC 809C... Report Continued from LIC 809C... Medication Review: The LPAs reviewed medications at approximately 12:10pm. Medications are centrally stored in the medication room on the 2nd floor. The LPAs reviews six (6) randomly selected resident’s centrally stored medications. Medications were properly documented on the centrally stored medication & destruction record and appear to be given as prescribed at the time of the inspection. 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 they pertain to infection control are adequate. Daily vehicle inspection list were reviewed for facility vehicles. The last fire safety inspection was completed on 12/02/2025 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 12/10/2025. No citations issued. Exit interview conducted. Report was reviewed and copy provided.the state’s words, verbatim · CDSS document, Jan 15, 2026

Allegation investigated: Residents are not being given 90 days written notice for an increase in rates.

Licensing Program Analyst (LPA) Martha Arroyo conducted an initial complaint investigation for the allegation listed above. Upon arrival, the LPA met with met with Executive Director (ED), Helen Lee and explained the reason for the visit. Entrance interview. During today's visit, the LPA conducted interviews with one staff member and five residents 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 residents are not being given 90 days written notice for an increase in rates. It is the complainant’s concern that the letter of increase was received in the first week on November; however, the increased rate is to take in effect on the first of the year. Record review and interviews conducted revealed that the facility issued written notices to all residents whose level of care was affected by the rate increase. The LPA obtained and reviewed a copy of the notice, dated 11/01/2025, which stated that the new service rates would be effective 02/01/2026. Interviews with facility staff revealed that following a change in management, resident care plans were reviewed, and it was determined that several residents were receiving services that were not reflected in their current care plans. As a result, care plans were updated to accurately reflect the appropriate level of care and corresponding fees. Interviews with residents revealed that they received written notice of the rate increase in their mailboxes. Four out of four residents interviewed confirmed receiving the notice in early November. Furthermore, residents interviewed did not express or report any concerns regarding insufficient notice of the rate increase. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “residents are not being given 90 days written notice for an increase in rates”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 29-AS-20251208151834

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced cased management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. Upon arrival, the LPA met with Interim Executive Director (IED), Melon Rivera and the reason for the visit was explained. During today’s visit, the LPA along with the IED 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. Starting at 11:19 a.m., nine (9) randomly selected resident bedrooms were observed. The LPA inspected five (5) bedrooms in Assisted Living and four (4) bedrooms in Memory Care. All bedrooms were observed to be properly furnished and had sufficient lighting. Hot water temperatures in Assisted Living bathrooms measured between 105.2 and 113.1 degrees Fahrenheit. In Memory Care bathrooms, hot water temperatures measured between 107.2 and 109.7 degrees Fahrenheit at the time of the visit. Memory Care bathrooms were also observed to have locked cabinets for residents’ personal hygiene items. Report Continued on LIC 809C... Report Continued from LIC 809... At the time of the visit, common area furniture was observed to be in good condition. The facility maintained a comfortable temperature. Several fire extinguishers were observed throughout the facility, all fully charged and with a service date of 01/07/2025. The facility’s alarm signal system was tested on 01/15/2025 with no discrepancies noted. Required postings were observed throughout the common areas. Residents were observed participating in activities during the visit. The facility includes a courtyard which was observed to have adequate patio furniture for resident use. All interior and exterior passageways were observed to be free of obstructions. The kitchen and food service area were inspected at approximately 12:05 p.m. Emergency food supplies were observed for appropriate labels and expiration dates. Several boxes of cereal were noted to be past their "best before" dates. However, the facility still has a sufficient supply of both perishable and non-perishable foods. Staff reported that an order of non-perishable food items is scheduled for delivery later this week. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance. Upon arrival, the LPA met with Executive Director (ED), Margie Veis and the reason for the visit was explained. The LPA focused today’s visit on ensuring the Medications and Centrally Stored Medications and Destruction Records (CSMDR) are in order and in compliance with Title 22 Regulations. During today’s visit, the LPA conducted a medications review in assisted living starting at 09:50 a.m. and memory care starting at 10:40 a.m. A total of five (5) randomly selected residents’ medications and CSMDR were reviewed, and the following was noted: During the medication review, it was revealed that 3 out of 5 residents have routine medications that were started but are not documented on the CSMDR. Additionally, 2 out of 5 residents have medications missing start dates on both the CSMDR and the corresponding start date sticker on medication, preventing the LPA from verifying whether the medications are being administered as prescribed. The review also revealed that Resident #1 (R1) is prescribed bedtime medications—Melatonin 3 mg tablet, one tablet at bedtime as needed, and Carbamazepine 200 mg, half a tablet twice daily—both with a documented start date of 07/05/2025. However, each medication is missing one dosage, and there are no documented notes indicating that staff have observed the missing doses. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D). Exit interview conducted. A copy of report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 1, 2025

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, the licensee did not comply with the section cited above as R1's medications Melatonin 3mg and Carbamazepine 200 mg each missing one extra dose, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: The Licensee has agreed to have an in-house training on properly administering medications to residents and submit proof to CCL no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6)(A-F) · Plan of correction due date: Aug 1, 2025

The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: name of resident, physician, drug name, strength, quantity, date filled, prescription number and the name of the issuing pharmacy. This requirement is not met as evidenced by: Based on medication review, the licensee did not comply with the section cited above as meds for 3 out of 5 residents were not documented on the CSMDR and meds for 2 out of 5 residents were missing start dates, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: The Licensee has agreed to have an in-house training on properly documenting medications on the CSMDR and submit proof to CCL no later than POC due date.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance. Upon arrival, the LPA met with Executive Director (ED), Margie Veis and the reason for the visit was explained. The LPA focused today’s visit on ensuring records are in order and in compliance with Title 22 Regulations. During today’s visit, the LPA conducted a records review of ten (10) resident files and ten (10) personnel files. The following was noted: Resident files were reviewed for, but not limited to the following: signed admissions agreement, current medical assessment with TB results, consent for treatment form, and current needs and service plan. All files were complete. Personnel files were reviewed for, but not limited to the following: personnel records, health assessment with TB results, criminal record clearances, first aid / cpr certifications, and the appropriate yearly training. All files were complete. No deficiencies issued. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, Apr 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted an unannounced annual inspection. Upon arrival, the LPAs met with Executive Director (ED), Margie Veis and explained the reason for the visit. Entrance interview conducted. Beginning at 10:10am, the LPAs started reviewing records which included the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The last fire safety inspection was completed on 01/15/2025 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; the last one being a fire drill on 12/31/2024. Beginning at 11:15am, the LPAs along with the Executive 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: RESIDENT ROOMS/RESTROOMS: The LPAs observed five resident rooms and their accompanying restrooms were observed during today's facility tour. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Beginning at 11:30am, the hot water temperature was measured in four assisted living bathrooms and one memory care bathroom, and the temperature measured between 113.4 – 118.4 degrees Fahrenheit. Report Continued on LIC 809C... Report Continued from LIC 809... KITCHEN: 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. COMMON AREAS: The LPAs observed common areas to be clean and in good condition. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 1/07/2025. The LPAs observed hand sanitizer stations throughout the facility. OUTDOOR SPACE: The LPAs observed the outdoor garden in Assisted Living and Memory Care which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. RECORD REVIEW: The LPAs reviewed resident and staff records beginning at 12:35pm. 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. All records were in order. Ten 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. Three out of ten staff files reviewed did not have up to date yearly training and Staff 1 (S1) was fingerprint cleared but not associated to the facility. Report Continued on LIC 809C... Report Continued from LIC 809C... MEDICATION REVIEW: Beginning at 12:00pm, the LPAs reviewed medications for five residents. The medications are centrally stored in the medication room on the second 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 appear to be given as prescribed. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D). Exit interview conducted. A copy of report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 27, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced cased management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with Executive Director (ED), Margie Veis and the reason for the visit was explained. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. During today’s visit, the LPA along with the ED and Maintenance Director conducted a walk through of the facility at 1:35pm. Five (5) randomly selected resident bedrooms were observed. Resident rooms were observed to be furnished appropriately with sufficient lighting. Resident bathrooms were sufficiently stocked with supplies and paper towels. Hot water temperature was measured in three (3) bedrooms in assisted living; and two (2) bedrooms in memory care. Water temperature measured within 105- and 120-degrees Fahrenheit. Fire extinguishers were observed throughout the facility fully charged on 01/16/2024. The facility has a sufficient supply of perishable and non-perishable food. No obstructions or hazards were observed inside or out. Additionally, the LPA and ED discussed the new resident Admissions Agreement and Assessment Tool submitted to CCL as it needs to be updated to meet Title 22 Regulations. No deficiencies issued. Exit interview conducted. Report was reviewed and copy was issued.the state’s words, verbatim · CDSS document, Sep 17, 2024

Allegation investigated: Staff is mishandling the residents incontinence needs while in care Staff are not meeting the residents dental needs Staff are not meeting the residents hygiene needs

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit to continue investigation for the allegations listed above. Upon arrival LPA met with Nancy Nelson and explained the reason for the visit. On 07/26/2024, from 10:00 a.m. – 02:45 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, interviewed staff as well as reviewed and obtained pertinent documents relevant to the investigation. Today LPA conducted physical plant and interviewed staff. It was reported that "Staff is mishandling the residents incontinence needs while in care", as it was alleged that there is insufficient supply of incontinent products. Interviews conducted with eleven (11) staff revealed that all (11) have always seen a sufficient supply of incontinence products available. During a physical plant, the LPA found a proper supply of these products in six randomly selected resident rooms in memory care, as well as in a supply closet next to the medication room, the memory care director's office, and a supply closet on the 2nd floor. Unsubstantiated LPA's interview with five (5) families / responsible parties of residents in care revealed that all (5) did not express any potential or immediate concerns that the facility are not meeting the incontinence needs of residents in care. Based on the information obtained during the investigation, the Department 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 violations did or did not occur, therefore the above allegation, “Staff is mishandling the residents incontinence needs while in care” is deemed Unsubstantiated at this time. It was reported that "staff are not meeting the residents dental needs" as it was alleged that staff are not ensuring residents are brushing their teeth. Interviews conducted with eleven (11) staff revealed that most residents need some type of assistance with brushing their teeth by either reminding them or fully assisting them with brushing. Interviews with staff further revealed that all (11) have not observed a resident who didn't brush their teeth for a prolonged period of time. Each staff interviewed also did not express any potential or immediate concerns for any staff not assisting resident with brushing their teeth. LPA's interview with five (5) families / responsible parties of residents in care revealed that all (5) did not express any potential or immediate concerns that the facility staff are not meeting resident dental needs. Based on the information obtained during the investigation, the Department 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 violations did or did not occur, therefore the above allegation, “Staff are not meeting the residents dental needs” is deemed Unsubstantiated at this time. It was reported that "Staff are not meeting the residents hygiene needs", as it is alleged that residents are not showered in a timely manner. Interviews conducted with eleven (11) staff revealed that most residents usually receive showers 2 to 3 times a week and require some type of assistance according to their care plans. Assistance could involve either reminders or encourage, standby assist, hands on and full assist. All (11) staff also stated they have never seen a resident miss a shower or be delayed in getting one. LPA's interview with five (5) families / responsible parties of residents in care revealed that all (5) did not express any potential or immediate concerns that facility staff are not meeting resident hygiene needs. Based on the information obtained during the investigation, the Department 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 violations did or did not occur, therefore the above allegation, “Staff are not meeting the residents hygiene needs” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 29-AS-20240724111333

Allegation investigated: Facility does not have adequate supplies Staff did not meet residents’ diapering needs

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit to continue investigation for the allegations listed above. Upon arrival LPA met with Nancy Nelson and explained the reason for the visit. On 08/02/2024, from 12:00 p.m. – 02:45 p.m., LPA’s Brian Balisi and Trevor Byrne initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff as well as reviewed and obtained pertinent documents relevant to the investigation. It was reported that "Facility does not have adequate supplies" as it was alleged that they have an insufficient PPE supply. Interviews conducted with eleven (11) staff revealed that all (11) have always observed a sufficient supply of PPE. During physical plant, LPA observed a sufficient supply of PPE located in a supply closet next to the medication room in memory care, in the memory care director's office, in the Executive Director's office, a supply closet on the 2nd floor and at the front desk receptionist area Unsubstantiated Continued from 9099 LPA's interview with five (5) families / responsible parties of residents in care revealed that all (5) did not express any potential or immediate concerns that the facility did not have an adequate supply of PPE. Based on the information obtained during the investigation, the Department 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 violations did or did not occur, therefore the above allegation, “Facility does not have adequate supplies” is deemed Unsubstantiated at this time. It was reported that "Staff did not meet residents' diapering needs", as it was alleged that diapers that were used were too small for most residents and it left marks. Interviews conducted with eleven (11) staff revealed that all (11) have always observed residents using the correct size of diapers and all (11) stated they have never observed any diapers leave marks on any residents. LPA's interview with five (5) families / responsible parties of residents in care revealed that all (5) did not express any potential or immediate concerns of incontinent being too small and leaving marks on the residents. Based on the information obtained during the investigation, the Department 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 violations did or did not occur, therefore the above allegation, “Staff did not meet residents’ diapering needs” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued. Continued from 9099-A LPA's interview with Executive Director Margie Veis revealed that on August 9, before using the test kits they contacted Ventura Public Health to inform them of the expiration dates. Ventura County Public Health advised them to contact the manufacturer of the Flowflex COVID test kit, ACON Labs Inc. Interview with Veis further revealed that they spoke with a representative of ACON Labs Inc and informed them of the expiration date of 02/22/2023 and Veis stated that the representative told them the test kits are still good for two (2) years. Facility staff proceeded to use test kit on one resident, which resulted in a positive test. Upon further research facility staff observed the LOT# (COV2020158) on the Food and Drug Administration (FDA)'s website, which confirmed that the COVID test kits expired in February 2024 based on the Lot # and expiration date. Veis called manufacturer back to gain clarification on the discrepancies and the representative informed them that expiration is 2 years from manufacturing date versus the expiration date. Staff immediately discarded their current supply of COVID test kits and obtained new ones from Ventura County Public Health. LPA's interview with representatives from ACON Labs Inc., the maker of the Flowflex COVID test kit, revealed that the test kits with the specific LOT # should not have been used after February 2024, as their results would be invalid. LPA also reviewed records from the FDA's website, which confirmed that the COVID test kit (LOT#COV2020158) expired in February 2024. Based on information gathered over the course of the investigation, the Department has sufficient evidence to determine the allegation occurred. Therefore, the allegations that “Staff used expired COVID tests to test residents” has been deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 29-AS-20240729092217

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 6, 2024

Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by Based on observations and interviews, the Licensee did not comply with the section cited above, as expired COVID test kits were used to test residents, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: POC cleared during visit. Licensee has discarded expired test kits and LPA observed new COVID test kits in storage. No further action required.

Allegation investigated: Staff are not following physician's orders for the resident

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. Upon arrival LPA met with Executive Director Margie Veis and explained the reason for the visit. During the initial visit on 6/11/2024, between 1:50 p.m. and 4:00 p.m. LPA conducted physical plant, interviewed staff, resident and reviewed obtained pertinent documentation relevant to the investigation. Today LPA interviewed staff and reviewed and obtained additional documentation relevant to the investigation. It was reported that "Staff are not following physician's orders for the resident" as it was alleged that staff are not using a waist belt on Resident #1 (R1)'s wheelchair as prescribed. Interviews conducted and records review reflected on 04/13/2024 at approx. 5pm, R1 sustained a fall in their apartment , which resulted in R1 getting admitted into a local hospital. Unsubstantiated Continued from 9099 On 05/02/2024, R1 was discharged from the hospital into a Skilled Nursing Facility. On 05/09/2024, R1 returned to the facility. On 05/21/2024, R1's POA obtained a physician's order to "use a waist belt restraint as needed to prevent falling out of chair" , from a physician at the Skilled Nursing Facility. Facility did not use a waist belt as it was not compliant with Title 22. In addition, R1' s Primary Care Physician did not provide a physician's order to make use of waist belt at this facility. Based on the information obtained during the investigation, the Department 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 violations did or did not occur, therefore the above allegation, “Staff are not following physician's orders for the resident” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Jun 28, 2024 · control 29-AS-20240604133653

Allegation investigated: Staff increased resident fees without providing new additional services.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 03/04/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Margie Veis. Entrance interview. During the initial visit on 03/04/2024, LPA Arroyo conducted an interview with the ED at 1:50 p.m., conducted a file review at 2:30 p.m., and obtained copies of pertinent documents relevant to the investigation. Continued on LiC 9099C... Substantiated Continued from LIC 9099C... It was alleged that staff increased resident fees without providing new additional services. It was reported that no additional services have been added to justify the increase in resident fee. Records review revealed that residents who were assed prior to being admitted to the facility as independent were not charged any additional fees as they required no additional services already being provided in the basic monthly fee. Additionally, residents did not require assistance with any activities of daily living (ADL’s) including medication management. A review of random resident admission agreements revealed that five (5) out of five (5) admission agreements did not have an updated admissions agreement disclosing the rate change. Although the facility submitted a change of Assessment Tool, Structure of Level of Care Levels and Resident Agreements on 03/09/2023, residents who are scheduled to have an increase in resident fees by April 2024 have yet to sign an Addendum to current admissions agreement or an updated admissions agreement that reflects new information pertaining to the Structure of Level of Care Levels. Furthermore, residents received a letter from the facility corroborating the statement that no additional services will be provided to residents following the fee increase in April 2024. Based on the information obtained and reviewed, the allegation of, “staff increased resident fees without providing new additional services” is being deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 22, 2024 · control 29-AS-20240229150859

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655 · Plan of correction due date: Mar 27, 2024

(a)If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount ... of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident.... This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Mar 22, 2024

Plan of correction: The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to Health & Safety Code 1569.655(a); The written letter must be sent to the LPA by the POC due date. Based on record review, the licensee did not comply with the section cited above as the resident’s admissions agreement are not updated or have an addendum on file that reflects residents new structure of level of care levels as stated on plan of operation, which poses a potential personal rights risk to persons in care.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced case management – other visit at 9:00 a.m. The purpose of this visit is to obtain pertinent information regarding an incident that occurred on 01/01/2024. Upon arrival, LPA met with the Marketing Director. The Executive Director (ED), Margie Veis, arrived during the visit. Entrance Interview. During today’s visit, LPA Arroyo met with one staff member at 9:18 a.m., conducted a record review, and obtained copies of pertinent documents. Exit interview conducted. Report was reviewed and a copy was issued.the state’s words, verbatim · CDSS document, Mar 14, 2024

Allegation investigated: Staff speak to residents in an inappropriate manner. Staff does not provide a safe environment for residents. Staff are not properly trained to administer residents’ medications. Staff caused a resident to bleed. Staff eats resident's food. Staff inappropriately cleaned the dining room tables at the facility.

Licensing Program Analysts (LPA’s), Martha Arroyo and Brian conducted a subsequent visit to the facility to issue findings for the above allegations. The initial visit was conducted on 05/30/2023 and a subsequent visit was conducted on 06/08/2023 by LPA M. Arroyo. During today's visit, LPAs met with Executive Director, Margie Veis, and the reason for the visit was explained. Entrance interview. During the initial visit on 05/30/2023, at 1:45 p.m., LPA Arroyo conducted a tour of the facility to ensure there are no health and safety hazards, conducted interviews with seven staff, four residents, and one family member between 2:07 p.m. and 4:45 p.m., and conducted a file review at 3:50 p.m. and obtained copies of pertinent documents. On 06/08/2023, LPA Arroyo conducted interviews with the Executive Director and three staff between 9:32 a.m. and 10:00 a.m. and conducted a file review at 10:30 a.m. and obtained copies of pertinent documents. On 10/03/2023, LPA Arroyo conducted telephonic interviews with three family members at 10:25 a.m., 10:40 a.m., and 11:20 a.m. (Report Continued on LIC 9099C...) Unsubstantiated (Report Continued from LIC 9099...) It was alleged that staff speak to residents in an inappropriate manner and staff does not provide a safe environment for residents. It was reported that Staff #1 (S1) commands and disrespects the residents when talking and interacting and has at times used profanity words causing the resident to be in an unsafe environment. Interviews conducted with staff revealed that facility staff have not observed S1 speak inappropriately to residents in care. Additionally, staff denied observing or hearing any other facility staff mistreating residents. Interviews conducted with family members revealed that they have observed facility staff interact with residents while visiting, and all interactions have been of staff being gentle and respectful when assisting the residents. Also, family members stated they have seen how the staff interact with the residents and the staff were professional and caring. Furthermore, family members stated having no concerns and feel the residents are safe while living at the facility. Based on interviews conducted with staff and family members, the Department does not have sufficient evidence to support the allegations of “staff speak to residents in an inappropriate manner” and “staff does not provide a safe environment for residents”. Therefore, these allegations are deemed Unsubstantiated at this time. It was also alleged that staff are not properly trained to administer residents’ medications. It was reported that S1 has not completed the necessary training to be a medication technician and administer medication to residents. Interviews conducted with staff revealed that training is given to all staff upon hiring. Additionally, staff stated they are required to complete the online training assigned as well as the week of shadowing different staff members prior to being able to start providing care to residents. Records review revealed that facility now utilizes Care Academy as it transitioned to the new management; however, the facility was using the services provided from Relias. Nevertheless, the facility maintains copies of all completed training from their staff. Additionally, review of S1’s training folder revealed that S1 has completed sixty-five out of the sixty-seven training's listed under S1’s Care Staff Initial Training Curriculum. Furthermore, the training that has been completed include all the necessary training on assisting with the administration of medication and the hours from shadowing another care staff. Based on records review and interviews conducted, the Department does not have sufficient evidence to support the allegation of “staff are not properly trained to administer residents’ medications”. Therefore, this allegation is deemed Unsubstantiated at this time. (Report Continued on LIC 9099C...) (Report Continued from LIC 9099...) It was also alleged that staff caused a resident to bleed. It was reported that Staff #2 (S2) had popped a pimple on a resident while they slept. Interviews conducted with staff revealed that they strive to meet the residents’ basic needs. Additionally, staff stated they had no knowledge of the incident mentioned and denied seeing or hearing of other staff mistreating the residents. Interviews conducted with family members revealed that while visiting the facility, they have observed the staff be gentle and respectful when assisting the residents. Furthermore, family members reported having no concerns with the facility or the staff. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff caused a resident to bleed”. Therefore, this allegation is deemed Unsubstantiated at this time. It was further alleged that staff eats resident’s food and staff inappropriately cleaned the dining room tables at the facility. It was reported that S2 has eaten the resident’s food and has been seen cleaning the dining room tables with the floor broom. Interviews with staff revealed that the maintenance director trains all staff in housekeeping at least once a month. The training is conducted with all staff on properly cleaning and maintaining the work area, which includes handling and storing chemicals as they are providing care inside the memory care unit. Additionally, staff stated that residents’ food does not get touched by the staff unless they are assisting the residents during their mealtimes. In addition, staff denied seeing S2 eating the resident’s food and cleaning the dining room tables inappropriately. Furthermore, interviews conducted with family members revealed they had no concerns about the facility staff. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff eats residents’ food” and “staff inappropriately cleaned the dining room tables at the facility”. Therefore, these allegations are deemed Unsubstantiated at this time. Exit interview conducted. No citations issued at this time. A copy of the report was provided. (Report Continued from LIC 9099...) It was alleged that staff is under the influence at work. It was reported that several staff had observed Staff #2 (S2) display questionable actions and behavior while working at the facility and assisting residents. During the course of the investigation, it was revealed that S2 had admitted to being under the influence of marijuana while working as a care provider on 05/22/2023. Additionally, S2 provided photographs of the marijuana S2 was using while working. Furthermore, S2 was terminated August 2023 due to poor performance and not completing their job duties. Based on all information gathered during the course of the investigation in conjunction with CC# 29-AS-20230530092434 from 05/30/2023, the above allegation, “staff is under the influence at work” is deemed Substantiated at this time. Although the allegation was Substantiated. The department may prohibit any person from continuing employment if they have engaged in conduct that is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility… has already been cited on a previous visit from 12/04/2023. Exit interview conducted. Appeal rights and report were reviewed, and a copy was issued.the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 29-AS-20230522161041

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA’s) Martha Arroyo and Brian Balisi conducted an unannounced case management visit to the above facility. The purpose of this visit is to conclude an investigation regarding an incident that occurred on 01/01/2024. Upon arrival, the LPAs met with Executive Director (ED), Margie Veis, and explained the reason for the visit. Entrance interview. On 01/02/2024, the Department received an incident report stating that on the morning of 01/01/2024, Staff #1 (S1) was assisting Resident #1 (R1) with dressing. R1 was resistant to care and became agitated. R1 slapped S1 across the face, causing S1’s glasses to fall off their face and in response, S1 slapped R1 across the face. Staff #2 (S2) witnessed the incident as they were inside the room assisting S1. During the initial visit on 01/05/2024, LPA Arroyo conducted a tour of the Memory Care Unit at 12:20 p.m., conducted interviews with the ED and two staff between 12:13 p.m. and 12:45 p.m., conducted a file review at 1:05 p.m., and obtained copies of pertinent documents relevant to the investigation. Information obtained during the course of the investigation revealed that R1 was agitated while being provided care by both S1 and S2. This resulted in R1 slapping S1 causing their glasses to fall from S1’s face. In response, S1 slapped R1 across the face. Interviews conducted revealed that S2 had seemed short tempered with the residents lately and S2 had reported to other staff that it was only a reaction that happened without thinking due to being slapped. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) However, staff stated observing S2 being slapped by other residents in the past but denied seeing any reaction from S2. In addition, both law enforcement and R1’s family were contacted and notified of the incident on the same day it occurred. Hospice was also notified shortly after the incident to come to the facility and educate the staff on how to deal with residents’ behaviors. Furthermore, S1 resigned from their position on their own following the incident. Based on the information obtained and reviewed, the Department has enough evidence to say that S1 slapped R1 while providing care. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit. Exit Interview conducted. Copy of report, and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 18, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1)(3) · Plan of correction due date: Jan 18, 2024

87468.1(a)(1)(3) 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: (1) To be accorded dignity in their personal relationships with staff… and to be free from... punishment, humiliation, intimidation, abuse, or other actions of a punitive nature… This requirement was not met as evidenced by:the state’s words, verbatim · CDSS document, Jan 18, 2024

Plan of correction: The Licensee has agreed to conduct an in-house training on residents’ personal rights and submit proof to CCL no later than 01/19/2024. Based on the information obtained and reviewed, the Licensee did not comply with the section cited above as S1 slapped R1 while providing care, which posed an immediate safety risk to residents in care.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. Upon arrival, the LPAs were greeted by the front desk receptionist. The Executive Director (ED), Margie Veis met with LPAs shortly after and the reason for the visit was explained. Entrance interview conducted. The LPAs 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 noted: KITCHEN: The LPAs inspected the kitchen/food service area at 10:08 a.m. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 01/16/2024. The LPAs observed required postings throughout the common space. The LPAs observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. The last fire inspection was completed on 12/27/2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Fire and earthquake drills conducted within the last 6 months as per regulation; the last one conducted 12/28/2023. (Report Continued on LIC 809C...) (Report Continued from LIC 809...) BEDROOMS: The LPAs observed three (3) random resident bedrooms in memory care and seven (7) random resident bedrooms in assisted living. All resident bedrooms were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPAs observed a sufficient supply of towels and linens. RESTROOMS: The LPAs observed ten (10) random resident restrooms during the inspection. All resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in seven (7) random assisted living bathrooms between 10:20 a.m. and 10:55 a.m., the temperature measured between 112.5 – 115 degrees Fahrenheit. Between 10:00 a.m. and 10:13 a.m., the hot water temperature was measured in three (3) random memory care bathrooms and the temperature measured between 112.7 – 115.3 degrees Fahrenheit. At approximately 10:50 a.m., the LPAs observed the emergency food supply, and a substantial amount of non-perishable items were in poor condition as they were observed past their expiration date. Staff discarded all expired items and ordered new items during the inspection. RECORDS: LPA’s reviewed Resident Records at 11:05 a.m. and Personnel Records at 12:02 p.m. Nine (9) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Nine (9) personnel files and the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. LPAs conducted interviews with six (6) staff and six (6) residents during the inspection. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) MEDICATIONS: Medications review began at approximately 12:15 p.m. The medications are centrally stored in the medication room on the second floor. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during medications review. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jan 18, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Incident visit for the purpose of investigating a self-reported incident report and SOC 341. Upon arrival, the LPA met with Executive Director (ED), Margie Veis, and explained the reason for the visit. Entrance interview. On 01/02/2024, the Department received an incident report stating that on the morning of 01/01/2024, Staff #1 (S1) was assisting Resident #1 (R1) with dressing. R1 was resistant to care and became agitated. R1 slapped S1 across the face, causing S1’s glasses to fall off their face and in response, S1 slapped R1 across the face. Staff #2 (S2) witnessed the incident as they were inside the room assisting S1. During today’s visit, the LPA conducted a tour of the Memory Care Unit to ensure there are no health and safety concerns at 12:20 p.m., conducted interviews with the ED and two staff between 12:13 p.m. and 12:45 p.m., conducted a file review at 1:05 p.m., and obtained copies of pertinent documents relevant to the investigation. LPA has determined further investigation is needed and will return at a later date to continue. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 5, 2024

Allegation investigated: Staff is using illegal drugs at the facility.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Arroyo met with Executive Director, Margie Veis and explained the reason for the visit. On 05/30/2023, the Department received a complaint alleging Staff #1 (S1) was using illegal drugs (suspected to be crystal methamphetamine or cocaine) while on the premises. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Dennis Seng. (Report Continued on LIC 9099C...) Substantiated (Report Continued from LIC 9099...) On 05/30/2023, from 1:30 p.m. to 5:15 p.m., Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint visit. During the visit, LPA met with Health Services Director Vivian Reyes. At 1:45 p.m., the LPA conducted a tour of the facility to ensure there were no health and safety hazards. At 3:50 p.m., the LPA conducted a facility file review and obtained copies of pertinent documents relevant to the investigation. Investigator Seng conducted interviews on 06/01/2023, at approximately 12:02 p.m., with the reporting party; on 06/05/2023, from approximately 1:07 p.m. to 4:54 p.m., with various facility staff, residents and S1. In addition, the investigator reviewed staff schedules, personnel files, and photos. The investigation revealed on 05/22/2023, at approximately 1:30 a.m., staff reported to the overnight supervisor that S1 had passed out in the bathroom inside a resident's room. S1 needed help with pulling their pants up, S1 was on the bathroom floor. S1 stated they needed help getting up, because S1 had no feelings in their legs or feet. The supervisor went to the resident’s room and found S1 on their knees, "pretending," to clean. S1 appeared to be groggy and under the influence of a drug. The supervisor went to the staff room to check in S1’s purse and found a black container with a white powder inside. The supervisor confiscated the container and turned it in to management for testing. The supervisor was then terminated for an unauthorized search of S1’s purse. S1 admitted that they were under the influence of marijuana (THC crystals) while providing care for the residents on 05/22/2023 and while on duty. S1 provided photographs of the marijuana they used while working. Per S1’s co-workers, they suspected S1 of being under the influence of an unknown drug due to S1’s behavior, S1 would act jittery, and appear to be incoherent while working. S1 was terminated August 2023 due to poor performance and not completing their job duties. Based on the information gathered during the course of the investigation, the Department has sufficient evidence to determine that S1 was under the influence of drugs while working. Therefore, the allegation “Staff is using illegal drugs at the facility” is deemed substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Dec 4, 2023 · control 29-AS-20230530092434

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1558 · Plan of correction due date: Dec 4, 2023

(a) The department may prohibit any person from... continuing the employment of, or allowing in a licensed facility or certified family home, or allowing contact with clients of a licensed facility or certified family home by, any employee, prospective employee, or person who is not a client who has: (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home. This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Dec 4, 2023

Plan of correction: The Licensee has agreed to the following: 1.) The Licensee terminated S1. 2.) The Licensee will submit a plan on how the facility will ensure this situation does not occur again and submit to CCL by 12/15/2023. Civil Penalty issued. Based on S1’s admission and photos of the crystal marijuana submitted by S1, S1 was under the influence of drugs while working at the facility, which posed an immediate health and safety risk to residents in care.