Varenita of Westlake

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced Case Management - Incident visit at 11:25 AM. The purpose of this visit is to conduct an investigation for self-reported concerns regarding safeguarding of resident belongings. LPA met with staff, Interim Executive Director (ED) Shawn-Patrick Ross, and Senior General Manager (GM) Edith Kennedy. Reason for the visit was explained. On 08/31/2026, the Department received an incident report stating that on 08/25/2026, Resident #1 (R1) left a Ziploc bag of their jewelry on their walker in their apartment, and when R1 returned back to their apartment, the Ziploc was missing and one earring was found on the floor. R1 reported the incident to staff on 08/26/2026. On 09/10/2026, the Department also received a Resident Theft and Loss Record documenting R1’s missing jewelry, Resident #2 (R2)’s missing gold ring, and Resident #3 (R3)’s missing necklace. The record indicates that the items were identified as missing in Mid-July 2026 for R2 and Mid-August 2026 for R3. ED Ross searched through the residents’ apartments, interviewed staff members, and notified family members. During today’s visit, LPA interviewed five (5) residents, including R1, R2, and R3, and observed their apartments. On 09/08/2026, R1’s missing jewelry was found in their kitchen cabinet; however, one earring was still missing. R2 and R3 have not recovered their jewelry as of today’s visit. Residents and staff stated that the facility staff took their allegations seriously, thoroughly checked their apartments, and offered solutions such as purchasing a locked safe box, installing cameras in resident rooms, or filing a police report. Residents indicated that they did not wish to proceed further with these actions. ED stated that the facility is actively investigating the matter and will continue to update the Department. No deficiencies cited at this time. An additional report may follow if warranted. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Sep 17, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Angela Barutyan at the facility unannounced to conduct a required annual visit at 11:25AM. LPA met with staff, Interim Executive Director (ED) Shawn-Patrick Ross, and Senior General Manager (GM) Edith Kennedy. Entrance interview conducted. Beginning at 12:13PM, the LPA, along with the ED and GM, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: At 12:14PM, LPA toured the main kitchen on the ground level. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food as well as an emergency food and water supply. At 12:40PM, LPA observed the kitchen in the memory care unit which is kept locked and inaccessible and contained snacks and drinks; food is not prepared in the kitchen. BEDROOMS: LPA observed a random selection of ten (10) bedrooms at the facility. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting. Rooms in the memory care unit are single occupancy and have no appliances. The assisted living resident rooms are equipped with a refrigerator, microwave, stove top, sink, and in-unit washer and dryer. RESTROOMS: LPA observed resident restrooms to be clean, sanitary, and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in resident restrooms and were between 105.2-109.8 degrees F, which is within the required range. Report Continued on LIC 809-C. COMMON SPACES/AMENITIES: Common areas include the dining area, theater, gym, salon, physical therapy room, the Bistro, game room, arts and crafts room, a small outdoor courtyard, and a Wellness Center. Several common living spaces were observed throughout the facility. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the hallways. The emergency telephone numbers are posted in the entryway. Other required postings are posted on the first floor near the elevator. LPA observed the Ombudsman Poster and DSS Complaint Poster throughout the community. LPA observed pull cords available in the residents’ rooms and observed residents to be wearing signal pendants. LPA observed fire extinguishers on every floor which were fully charged and last serviced on 08/25/2026. Fire alarm devices are tested annually by Academy Fire Life Safety and were last tested on 08/29/2026 with a scheduled repair visit on 09/22/2026 to replace the fire pull station that malfunctioned during the initial testing. Memory Care unit contains two (2) delayed egress doors; one (1) was tested at 12:37PM and was functional at the time of the visit. MEDICATION REVIEW: At 01:36PM, LPA reviewed medications for three (3) residents. All medications reviewed were stored and documented per regulation. No errors observed. RECORD REVIEW: Beginning at 02:57PM, LPA reviewed five (5) resident and five (5) staff files for documents including but not limited to: Admission Agreement, TB test, health screening, fingerprint clearance, and staff training. All resident and staff files reviewed were complete. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed 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. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 09/09/2026. No deficiencies cited. Exit interview conducted and report was provided.the state’s words, verbatim · CDSS document, Sep 17, 2026

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Angela Barutyan and Kelly Dulek arrived at the facility unannounced to conduct Case Management - Other visit at 10:15AM. Upon arrival, LPAs met with staff and Memory Care Coordinator Christina Hickman. Entrance interview conducted. During today's visit, LPAs conducted a brief physical plant tour between 10:33AM-12:05PM, conducted interviews with three (3) staff, two (2) residents, and one (1) visitor between 10:23AM-12PM, and reviewed and obtained copies of pertinent documents. On 01/30/2026, the Woodland Hills North Regional Office (WHN RO) received a self-reported notice from Sunrise Senior Living informing that the facility, Varenita of Westlake Village, is filing for Chapter 11 restructuring process on 01/28/2026. The notice states “the building owner...has initiated a voluntary Chapter 11 restructuring process...operations to continue uninterrupted.” The resident notification letter was also attached and states, "the owner of our building...has decided to reorganize their debt by entering into a Chapter 11 restructuring process...this building ownership decision will not affect daily life...” During today’s visit, LPAs observed a sufficient amount of perishable and non-perishable food, staffing, operational amenities, activities, and functional utilities. LPAs interviewed staff, residents, and a visitor who confirmed that they had received notice of the Chapter 11 restructuring by email. Persons interviewed stated that there have been no shortages. LPAs reviewed records and observed proof of emails/letters sent to staff and resident families on 01/30/2026. LPAs also reviewed the staff roster and observed adequate coverage. Staff and residents interviewed stated that there have been no staffing issues. The facility notified the Department, residents/responsible parties, and staff in a timely manner and no significant changes in facility operation due to financial hardship were observed. No concerns noted. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Feb 11, 2026

Allegation investigated: Staff stole resident's personal belongings

**This report has been amended to include additional information regarding facility’s response and prevention measures** Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 12:35PM. Upon arrival, LPA met with staff and Executive Director (ED) Zachary "Zak" Howell. Entrance interview conducted. During today's visit, LPA interviewed two (2) staff and one (1) resident between 12:35PM-02:00PM, reviewed and obtained copies of pertinent documents relevant to the investigation between 01:15PM-01:45PM, conducted a brief physical plant tour between 01:48PM-02:20PM, and discussed allegation with ED at 02:45PM. Report Continued on LIC9099-C. Substantiated It was alleged that an unknown staff member made several unauthorized purchases on Resident #1 (R1)’s personal Amazon account. The purchases consisted of three (3) $200 gift cards, totaling $600, an outfit, a pair of boots which was able to be canceled, and multiple streaming/video subscription charges such as Apple TV and Prime Video. The gift cards were delivered to the facility but were never received by R1. ED Howell was notified by R1’s responsible party on 12/01/2025 who noticed the unauthorized charges and that a gift card was delivered that day but not received by R1. ED conducted an internal investigation and was able to match the address of the outfit delivery to Staff #1 (S1)’s personal address; all other orders were made to the facility’s address. S1 claimed the outfit was a gift and denied the other purchases. S1 was terminated on 12/02/2025. The facility notified the Woodland Hills North Regional Office (WHN RO), Ventura County Sheriff Office (VCSO), and the Long-Term Care Ombudsman (LTCO) on 12/01/2025. VCSO conducted a visit on 12/01/2025. ED stated that the facility will conduct an in-service with all staff to review the theft and loss policy and resident rights. ED also discussed holding a cybersecurity and internet safety activity with residents. LPA reviewed the facility’s theft and loss policy and record which were in compliance. LPA interviewed R1 and R1’s responsible party who had no concerns and stated that the facility followed all proper procedures regarding the incident. The facility took appropriate measures in response to the incident by terminating S1, notifying all agencies within the reporting requirements timeline, conducting an internal investigation, offering reimbursement to R1/R1’s responsible party, and discussing plans to implement proactive measures to prevent such incidents from reoccurring. However, based on interview and record review, the allegation “Staff stole resident's personal belongings” is deemed SUBSTANTIATED at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. Appeal rights and a copy of the report were providedthe state’s words, verbatim · CDSS document, Dec 9, 2025 · control 29-AS-20251203083210

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Dec 10, 2025

Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1...residents...shall have all of the following personal rights: (8) To be free from...financial exploitation... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as S1 financially exploited R1 which posed an immediate health, safety, or personal rights risk to R1.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: S1 was terminated on 12/02/2025. R1's responsible party was offered reimbursement. ED stated that the facility will conduct an in-service with all staff to review the theft and loss policy and resident rights. ED will submit proof to CCLD by the due date.

Allegation investigated: Staff handled resident in a rough manner

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation with the purpose of delivering findings for the allegation listed above at 10:40AM. Upon arrival, LPA met with staff and Executive Director (ED) Zachary "Zak" Howell. Entrance interview conducted. During the initial visit on 10/06/2025, LPA interviewed five (5) staff and one (1) resident, reviewed and obtained copies of pertinent documents relevant to the investigation, conducted a brief physical plant tour, and discussed allegation with ED. After further review, it was determined this complaint was erroneously created and therefore the allegation “staff handled resident in a rough manner” is deemed unfounded at this time. However, the alleged incident will be investigated via a case management visit instead. Nothe state’s words, verbatim · CDSS document, Nov 4, 2025 · control 29-AS-20250930092027

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced Case Management - Incident visit at 10:40AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 08/15/2025. LPA met with Executive Director (ED) Zachary "Zak" Howel and explained the reason for the visit. During today’s visit, LPA conducted a brief physical plant tour to ensure there are no immediate health and safety hazards and conducted interviews with two (2) staff members. During LPA’s initial visit on 10/06/2025 regarding this incident, LPA interviewed five (5) staff and one (1) resident, reviewed and obtained copies of pertinent documents relevant to the investigation, and conducted a brief physical plant tour. On 08/19/2025, the Department received an incident report and SOC341 stating that on 08/15/2025, Staff #1 (S1) was observed telling Resident #1 (R1) to “shut up.” S1 was immediately placed on administrative leave pending the facility’s internal investigation and was subsequently terminated on 08/22/2025. R1 was assessed for injuries immediately after the incident was reported and no injuries or marks were observed on R1. R1’s responsible party, the Department, the Long-Term Care Ombudsman, and local law enforcement were notified. Ventura County Sheriff conducted a visit regarding the incident on 08/19/2025. Elder abuse and reporting standards training was proactively conducted with staff on 08/19/2025. LPA interviewed R1 on 10/06/2025 and no concerns were noted. LPA discussed mandated reporter requirements with staff and reviewed their signed and dated SOC341A acknowledgments. An additional report may follow if warranted. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Angela Barutyan at the facility unannounced to conduct a required annual visit at 11:10AM. LPA met with staff and Executive Director (ED) Zachary “Zak” Howell. Entrance interview conducted. Beginning at 11:27AM, the LPA, along with the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: LPA observed fire extinguishers on every floor which were last serviced on 09/12/2024 and not within the last 12 months. ED scheduled the annual fire extinguisher servicing for the current year during the visit. Fire alarm devices are tested annually by Academy Fire Life Safety and were last tested 08/06/2025. Delayed egress door in the memory care unit was tested at 11:39AM and was functional at the time of the visit. COMMON SPACES/AMENITIES: Common areas include the dining area, theater, gym, salon, physical therapy room, the Bistro, game room, arts and crafts room, a small outdoor courtyard, and a Wellness Center. Several common living spaces were observed throughout the facility. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the hallways. The emergency telephone numbers are posted in the entryway. Other required postings are posted on the first floor near the elevator. LPA observed the Ombudsman Poster and DSS Complaint Poster throughout the community. LPA observed pull cords available in the residents’ rooms and observed residents to be wearing signal pendants. Continued on LIC 809-C. BEDROOMS: LPA observed a random selection of seven (7) bedrooms at the facility of which two (2) were on the first floor, three (3) were on the second floor, and two (2) were in the memory care unit. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting. Rooms in the memory care unit are single occupancy and have no appliances. The assisted living resident rooms are equipped with a refrigerator, microwave, stove top, sink, and in-unit washer and dryer. RESTROOMS: LPA observed resident restrooms to be clean, sanitary, and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in resident restrooms and were between 106.2-112.8 degrees F, which is within the required range. At 11:44AM, LPA pulled the signal cord in resident restroom and staff arrived promptly in response at 11:51AM. KITCHEN: At 11:30AM, LPA toured the main kitchen on the ground level. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food as well as an emergency food and water supply. At 11:41AM, LPA observed the kitchen in the memory care unit which is kept locked and inaccessible and contained snacks and drinks; food is not prepared in the kitchen. MEDICATION REVIEW: At 01:12PM, LPA reviewed medications for two (2) residents in the assisted living unit and at 02:02PM, LPA reviewed medications for one (1) resident in the memory care unit. All medications reviewed were stored and documented per regulation. RECORD REVIEW: Beginning at 02:40PM, LPA reviewed five (5) resident and five (5) staff files for documents including but not limited to: Admission Agreement, TB test, health screening, fingerprint clearance, and staff training. All resident and staff files reviewed were complete. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed 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. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 09/08/2025. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Civil penalties were issued in the amount of $500. Administrator was informed that failure to correct deficiency may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 12:07PM. Upon arrival, LPA met with staff and Executive Director (ED) Zachary “Zak” Howell and reason for the visit was explained. Entrance interview conducted. On 06/26/2025, the Department received an SOC 341 stating that on 06/25/2025, a family member reported to the facility that Staff #1 (S1) verbally abused Resident #1 (R1) and other residents on 06/08/2025 and various unknown days. Another staff member, Staff #2 (S2), supported the allegation. The facility cross-reported to the Ventura County Sheriff and the Long-Term Care Ombudsman. During today’s visit, LPA conducted a brief physical plant tour, interviewed ED, attempted interviews with one (1) resident, one (1) staff, and one (1) family member, and reviewed and obtained copies of pertinent documents relevant to the investigation. Prior to issuing final licensing report, it has been determined that further investigation is needed at this time. Exit interview conducted. Copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 10, 2025

Allegation investigated: Staff does not ensure facility is free of odor

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation with the purpose of delivering findings for the allegation listed above at 02:25PM. LPA met with Wellness Manager (WM) Mehrnoush "Mimi" Ghorbankhani. Reason for the visit was explained. During the initial visit on 01/13/2025, LPA conducted a brief physical plant tour, interviewed two (2) staff members and three (3) residents, reviewed and obtained copies of pertinent documents relevant to the investigation, and discussed allegation with WM Ghorbankhani and Executive Director (ED) Brad Stewart. It was alleged that a sewer gas odor has been emanating from resident bathroom sinks since mid-October 2024. LPA interviewed three (3) residents who stated that an odor has been observed from their bathroom sinks, but the odor is intermittent and can vary in intensity. Report Continued on LIC 9099-C. Unsubstantiated Residents, complainant, ED, and WM confirmed that the facility scheduled maintenance services after the odor was first reported on 10/23/2024. The facility’s maintenance director cleaned out bathroom drains and the facility contracted a licensed plumber on 11/01/2024 who removed seven (7) pop-up drains, cleaned and flushed out drains, scrubbed the drains with brushes and bleach, ran hot water to flush out buildup, and reassembled the pop-up drains. The licensed plumber did not observe issues with the drains or pipes. ED stated that no complaints of odor were made to management after the plumbing service. LPA interviewed residents who confirmed that the issue had not been brought up to management after it was first addressed in early November 2024. Residents interviewed do not receive care-services as they are independent, and therefore, caregivers do not enter the private apartments often and cannot detect or report the odor to management if residents do not notify them. On 01/03/2025, it was reported that the Ombudsman conducted a visit, and the odor was observed in a resident’s bathroom. During the initial visit on 01/13/2025, LPA checked for odor in three (3) resident rooms and no odors were noted. While the odor was confirmed by three (3) residents and an outside agency representative, the allegation that the staff is not ensuring the facility is free of odor is not supported, as staff acted to address the issue when it was first reported, and staff were not notified and did not have another way of knowing that the odor was persisting afterwards. Per interview with ED, drain cleanings are conducted monthly but will now be conducted weekly and staff will be monitoring resident rooms for an odor. Staff will also encourage residents to notify them if an odor is observed from their bathrooms so that facility maintenance can act quickly to address the root cause of the odor. Information obtained through interview, record review, and observation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation “Staff does not ensure facility is free of odor” 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, Jan 24, 2025 · control 29-AS-20250108161737

Allegation investigated: Staff did not provide a call assistance button or pendant to resident

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegations listed above at 10:38AM. LPA met with staff and Wellness Manager (WM) Mehrnoush “Mimi” Ghorbankhani and explained the reason for the visit. During today's visit, LPA Barutyan conducted a brief physical plant tour, interviewed three (3) staff and one (1) resident, and reviewed and obtained copies of pertinent documents. During the initial complaint visit which took place on 11/21/2023, LPA C. Yee reviewed and obtained copies of facility records and conducted interviews with Executive Director (ED) Bradley Stewart, Wellness Director (WD) Mark Brassfield, Staff #1, and Resident #1. Continued on LIC 9099-C. Substantiated It was alleged that staff did not provide a call assistance button or pendant to Resident #1 (R1). LPA C. Yee conducted interviews on 11/21/2023 and four (4) out of four (4) parties interviewed stated that R1 did not have a pendant for a time ranging between one (1) to two (2) days to three (3) weeks. On 10/26/2023, R1 was transferred from assisted living where majority of residents are provided call pendants, to memory care where majority of residents are not provided call pendants. R1 does not have dementia but was transferred to memory care with family’s consent because R1 had increased care needs. The memory care unit consists of twenty-eight (28) rooms, which allows memory care staff to check the residents in the memory care unit more frequently and provide higher levels of care. Per interviews conducted on 12/26/2024, residents in memory care are provided with pendants if their assessment determines that they are able to properly use one. R1’s mental capability of using the pendant did not change when moved to memory care as R1 did not have a change of mental condition. R1 was provided with a pendant after request. R1 was moved back to assisted living on 04/14/2024 after R1’s condition improved. LPA Barutyan observed a pendant with R1 on 12/26/2024. Based on interviews and record review, the allegation “staff did not provide a call assistance button or pendant to resident” is deemed SUBSTANTIATED at this time. R1 and responsible parties of R1 did not have current concerns about pendant usage or call assistance buttons as R1 is now provided with a pendant. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. Appeal rights and a copy of the report was provided. It was alleged that staff isolated resident in their room as Resident #1’s (R1) door is kept closed and locked, and R1 is unable to go outside. Interviews conducted on 11/21/2023 explained that R1 does not like to partake in activities and prefers to be in their room. LPA Barutyan interviewed R1 and responsible party of R1 who shared that R1 likes to stay in their room but has been outside a few times when offered by R1’s visitors. It was further shared that staff do not directly offer to take R1 outside, but R1 and responsible party of R1 stated that if R1 requested, staff would take R1 outside. During today’s visit on 12/26/2024, LPA observed R1’s room door open and not locked. R1 stated they did not have concerns about their ability to leave their room, they just prefer to stay in their room. Based on interviews and observation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff isolated resident in their room” is deemed UNSUBSTANTIATED at this time. It was further alleged that staff did not assist resident in receiving physical therapy as needed. Interviews conducted expressed that R1 was not receiving physical therapy as they did not have an order for it. Record review on 11/21/2023 documented that R1 was on hospice and was receiving assistance/education on performing own activities of daily living (ADLs) and receiving assistance/education on mobility and proper passive range of motion exercises from R1’s hospice agency. No order for physical therapy for R1 was prescribed. LPA Barutyan interviewed R1’s responsible party on 12/20/2024 who did not express concerns of R1’s physical therapy needs and stated they were unaware if R1 requires need for it. Based on interviews and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff did not assist resident in receiving physical therapy as needed” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C. Lastly, it was alleged that staff did not assist resident with hygiene needs and staff left resident in wet briefs for extended period. Interviews conducted by LPA Yee on 11/21/2023 with R1 and three (3) facility staff explained that R1 is checked at least every two (2) hours for incontinence and is showered five (5) to seven (7) days a week. R1 did not express immediate concerns about hygiene assistance when interviewed on 11/21/2023 and 12/26/2024. Responsible party of R1 stated that R1 is changed often and is provided showers any time R1 requests. Responsible party further stated that R1 is not left in soiled briefs for extended periods and that the longest period was around one (1) hour. Review of records from 11/21/2023, documents that R1’s laundry is cleaned twice a week on Mondays and Fridays, and showers are provided seven (7) days a week; four (4) days from facility staff and three (3) days from hospice staff. R1’s care plan from 11/21/2023 also documents incontinence assistance twelve (12) times daily and bathing assistance one (1) time daily. R1’s updated care plan from 12/26/2024, documents incontinence assistance three (3) times daily and bathing assistance four (4) times a week. Interviews with facility staff on 12/26/2024 elaborated that the incontinence and bathing assistance frequencies in the updated plan are the minimum provided and that additional assistance is performed as needed. Staff stated that R1 is able to use their pendant to notify when R1 needs assistance and that R1 typically gets changed four (4) to five (5) times per shift. Based on interviews and record review, the Department does not have sufficient evidence to corroborate the allegations. Although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred, therefore, the allegations “Staff did not assist resident with hygiene needs” and “Staff left resident in wet briefs for extended period” are 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, Dec 26, 2024 · control 29-AS-20231114124155

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Jan 2, 2025

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more...shall have a signal system which shall: This requirement is not met as evidenced by: Based on interviews, the licensee did not comply as R1 was without a pendant for a period of time which posed a potential health, safety, and personal rights risk to person(s) in care.the state’s words, verbatim · CDSS document, Dec 26, 2024

Plan of correction: During the time of the visit, R1 was observed with a pendant. POC is cleared.

Allegation investigated: Staff handled resident in a rough manner. Staff hit resident with unknown object.

Licensing Program Analysts (LPAs) Kelly Dulek and Angela Barutyan conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPAs arrived at the facility at 09:57AM and met with Wellness Manager Mehrnosh (Mimi) Ghorbankhani. LPAs were informed that Executive Director and Administrator are both unavailable for today’s visit. Entrance interview conducted. During an initial visit conducted on 06/13/2024, LPA Dulek interviewed ED at 09:55AM, toured the facility's memory care unit at 10:20AM, interviewed staff from 10:34AM to 01:30PM and again at 02:31PM and 03:09PM, interviewed Resident #1 (R1) at 02:55PM and LPA obtained copies of pertinent documents. Throughout the course of the investigation, LPA reviewed all documents and conducted additional interviews. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated The complaint alleges that Staff #1 (S1) was rough with Resident #1 (R1) and that S1 hit R1 with an unknown object while putting R1 to bed. LPA interviewed staff and R1, as well as R1’s family member related to the allegation and reviewed facility documents. Staff interview revealed that on the date of the alleged incident, R1 was having a rough night. R1 was agitated and was hitting the facility staff, including S1. R1 also reported to the police on the night of the incident that R1 had hit S1 in the stomach. R1 showed the police an injury which was reportedly caused by S1 that night, however police noted the injury “appeared to be a scab that was scraped off from a pre-existing injury.” Resident observations indicate that R1 had a fall on 04/16/2024, which resulted in a skin tear to R1’s left leg and small scrape to R1's right leg. Staff notes continue to mention the skin tear somewhat regularly and on 05/24/2024, the skin tear is referred to as “old skin tear” on R1’s right leg. The alleged incident occurred on 06/02/2024 and police noted the injury appeared to be an old picked off scab. LPA observed R1’s left leg during the initial visit and took photographs of the injury, which was scabbed over at that time. Physician’s report reviewed indicates R1 has a diagnosis of Mild Cognitive Impairment. LPA interviewed R1, who initially told LPA that an injury to their leg was caused while R1 was on a boat when the mast hit them in the leg. Later in the interview, R1 indicated the injury was caused by S1 hitting them with a stick, resulting in a cracked kneecap. The injury was noted to be on R1’s left lower leg, not R1’s kneecap. LPA interviewed R1’s family member related to the incident, who stated they were unsure if “it’s happened, imagined, or if [R1] dreamed it.” Staff and R1’s family member stated that R1 has been experiencing confusion and sundowning recently. LPA requested a copy of a police report from the night of the incident, however, the police did not make a written report. Based on interview and record review, although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred, therefore, the allegations “Staff handled resident in a rough manner” and “Staff hit resident with unknown object” are deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2024 · control 29-AS-20240604121259

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angela Barutyan and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:57AM. LPAs met with staff and Wellness Manager (WM) Mehrnoush “Mimi” Ghorbankhani. Entrance interview conducted. Beginning at 10:20AM, the LPAs, along with the WM toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: LPAs observed fire extinguishers on every floor which were fully charged and last serviced 09/12/2024. Fire alarm devices are tested annually and were last tested 07/08/2024. Delayed egress door in the memory care unit was tested at 11:28AM and was functional at the time of the visit. COMMON SPACES/AMENITIES: Common areas include the dining area, theater, gym, salon, physical therapy room, the Bistro, game room, arts and crafts room, a small outdoor courtyard, and a Wellness Center. Several common living spaces were observed throughout the facility. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the hallways. The emergency telephone numbers are posted in the entryway. Other required postings are posted on the first floor near the elevator. LPAs observed the Ombudsman Poster and DSS Complaint Poster throughout the community. LPAs observed pull cords readily available in the resident's restrooms and observed residents to be wearing signal pendants. BEDROOMS: LPAs observed a random selection of nine (9) bedrooms at the facility of which two (2) were on the first floor, three (3) were on the second floor, and three (3) were in the memory care unit. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting. Continued on LIC 809-C RESTROOMS: LPAs observed resident restrooms to be equipped with grab bars near the toilet and shower/tub, non-skid surfaces in the shower/tub, and pull cords. LPAs tested water temperatures in resident bathrooms and were measured to be between 105.4 and 110.7 degrees Fahrenheit, which is within the required range. KITCHEN: At 11:30AM, LPAs toured the kitchen in the memory care unit. At 11:32AM, LPAs observed the cabinet under the sink to be unlocked and containing cleaning chemicals and solutions as well as the drawer next to the sink to be unlocked and containing a pair of scissors. WM Ghorbankhani and Maintenance Director Michael Cornejo locked the kitchen area during the time of the visit. LPAs toured the main kitchen at 12:30PM. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food as well as an emergency food and water supply. MEDICATION REVIEW: At 10:53AM, LPAs reviewed medications for two (2) residents in the memory care unit and at 11:42AM, LPAs reviewed medications for two (2) residents in the assisted living unit. All medications reviewed were stored and documented per regulation. RECORD REVIEW: Beginning at 01:09PM, LPAs reviewed six (6) staff and five (5) residents files for documents including but not limited to: resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. Six (6) out of 6 (six) staff files observed were missing 40 hours initial and 20 hours annual training and three (3) out of six (6) staff files were missing First Aid training. All five (5) resident files reviewed were in compliance with regulation at the time of the visit. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPAs reviewed 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. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 09/12/2024. INTERVIEWS: During today’s visit, LPAs interviewed five (5) residents and four (4) staff. During today's visit, LPAs obtained a copy of the facility's liability insurance. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalties were issued in the amount of $1000. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 16, 2024

Allegation investigated: Staff did not treat resident with dignity and respect

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct an initial complaint visit for the above allegation. LPA arrived at 09:10AM and was initially greeted by front desk staff. LPA was informed that Executive Director (ED) Brad Stewart was unavailable, so LPA met with Wellness Director Mark Brassfield. LPA informed Wellness Director of the purpose of today's visit. Entrance interview conducted. During today's visit, LPA conducted interviews with staff at 09:25AM, 09:38AM, 09:58AM, and 02:29PM. LPA, along with Wellness Director toured the facility at 10:24AM. LPA also interviewed residents between 10:57AM and 02:03PM and ED at 12:55PM. The following was then determined: It was alleged that Staff #1 (S1) spoke to Resident #1 (R1) in an inappropriate manner during a conversation. Interview revealed that R1 had purchased over the counter medication for another resident and Report Continued on LIC 9099-C Unsubstantiated had given the medication to that other resident. When S1 was made aware of R1 having given the medication to Resident #2 (R2), who is on medication management, S1 spoke to R1 related to the facility's policies regarding medications. Other staff present when the conversation occurred indicated that S1 approached R1 while in the facility's salon, but had brought the conversation outside the room for privacy. Staff who witnessed the interaction indicated S1 remained professional when communicating with R1, that S1 was clear in their communication and reiteration of policies. Staff interviewed also indicated R1 was interrupting and speaking to S1 in a rude tone, but that at no time did S1 react negatively. S1 did recall the interaction with R1, but denied the allegation. Interviews with residents throughout the facility revealed that facility staff are kind, courteous and helpful. Neither staff nor residents interviewed had heard of or were aware of any incidents where staff were disrespectful or did not treat residents with dignity. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation, therefore the allegation "Staff did not treat resident with dignity and respect" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, May 2, 2024 · control 29-AS-20240426130757

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a Case Management visit with the purpose of verifying a pending increase in capacity for the facility. LPA arrived at 09:10AM and was greeted by front desk staff. LPA then met with Wellness Director Mark Brassfield, as Executive Director was not available upon arrival. Wellness Director is authorized to sign all reports. A capacity change was requested for the facility to increase capacity from 90 residents to 115. Fire clearance was granted on 04/24/2024 for 8 bedridden residents and 107 non-ambulatory, with 115 total capacity. During today's visit, LPA, along with Wellness Director, toured the facility beginning at 10:24AM. No physical plant or health and safety concerns were noted during today's visit. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, May 2, 2024

Allegation investigated: Facility staff prevented a resident from having visitors.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegation listed above. The LPA arrived at the facility at 11:15 a.m. and met with the Wellness Director (WD) Mark Brassfield and explained the reason for the visit. On 01/02/2024, at 11:24 a.m., LPA Urena interviewed the Wellness Director, at 11:52 a.m. the LPA interviewed the resident (R1). At 11:50 a.m. the LPA requested records pertinent to the investigation. The LPA interviewed the Reporting Party (RP) at 10:15 a.m. Continues on LIC 9099C... Substantiated On the allegation that the facility staff prevented a resident from having visitors, it is the concern of the reporting party (RP) that on two separate occasions two of the resident’s visitors (V1) and V2) were not allowed to visit due to a restraining order being in place preventing them from visiting R1. The first visit was approximately on 12/11/2023, and the second visit was on 12/18/2023. Per the RP, the facility staff stated that they could not visit R1 due to a restraining order (RO) preventing V1 from visiting R1. The facility staff were unable to present proof of the RO to the visitors and were told that if they refused to leave, the facility staff would call law enforcement. The interview with the facility's Wellness Director revealed that on 12/12/2023, a person related to R1 left message at the front desk stating that there was a restraining order for V1 and not to allow them to visit R1. However, the WD added that the facility staff did not confirm the validity or existence of the RO, before preventing the visitors to visit R1. Therefore, on 12/18/2023, when V1 and V2 arrived at the facility they were informed that they could not visit R1. R1’s visitors were asked to leave, and per the WD, the V1 and V2 refused to leave, and V1 and V2 became belligerent in the facility’s lobby, consequently law enforcement was called. Law enforcement from the Ventura County Sheriff’s office was called to the facility. Detective Juarez arrived at the facility and verified that there was not a restraining order in place for any visitors for R1. According to the WD, due to the V1’s belligerent behavior, Detective Juarez asked V1 and V2 to leave the premises on 12/18/2023. The LPA interviewed R1 about their desire to receive visitors, specifically V1 and V2. The R1 stated that at this time, they do not wish to be visited by V1, and that they do want to see and be visited by V2. On 01/02/2024, at approximately 12:30 p.m. R1 informed facility staff that they wish to receive visits from V2. Based on the information received through interviews, the information revealed that the facility did not do their due diligence in confirming that a restraining order was in place, before preventing the visitors from visiting R1. Therefore, the allegation that the facility staff prevented a resident from having visitors, is deemed Substantiated at this time. Per the California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. Citations were issued. Exit interview was conducted, signatures obtained. A copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Jan 2, 2024 · control 29-AS-20231227112658

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Jan 5, 2024

87468.1 Personal Rights of Residents in All Facilities.(a) Residents in all RCFE..shall have all of the following personal rights (11)To have their visitors, including ombudspersons and... permitted to visit privately during reasonable hours and without prior notice...This requirement is not met as evidenced by: Based on interviews review, the licensee did not comply with the section cited above, as one visitors were prevented from visiting R1, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 2, 2024

Plan of correction: POC: Facility Administration staff will review regulation pertaining to visitors, and email the LPA Self-Ceritification by 01/05/2024.