Ventura Grand Chateau

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian conduct a required annual evaluation visit. Upon arrival LPA was greeted by MedTech staff and Administrator Sean Beharry. Introductions conducted and reason for the visit was explained. The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility compliance with Title 22 Regulations. The facility consists of upstairs staffing area, first floor resident rooms, bathrooms, activity room, common sitting area, dining room, kitchen. All indoor and outdoor passages were free of obstruction. Facility had a comfortable temperature of 70 degrees. Water temperatures were taken in eight randomly selected resident/common bathrooms which ranged from 105.8 degrees F to 124.5 degrees F. Administrator adjusted the water heater temperature during the visit. COMMON AREAS: LPA observed required postings through-out the facility. Common areas observed, including furniture and activity equipment, to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. LPA toured the outside area of the facility. The LPA observed exit gates to be locked, including the front gate, and both side gates around the side of the facility building at the time of the inspection. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water noted. Area is maintained clean; with designated smoking areas. BEDROOMS: Ten resident rooms were toured. Rooms observed furnished and maintained per regulation. LPA tested resident pull cords. Staff responded within a reasonable amount of time. Smoke detectors and carbon monoxide detectors were tested and were operational at the time of the visit. Fire extinguishers observed throughout the facility, which were fully charged and last serviced on 2/18/2025. KITCHEN: Sufficient supply of seven-day nonperishable, two-day perishable and emergency food supply. Due to time constraints, the visit will be continued at a later date. The following deficiency observed and cited from the California Code of Regulations - Title 22 Regulations. Exit interview conducted, copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 23, 2025

Allegation investigated: Facility staff do not allow residents to use the medical provider of their choosing Facility staff do not dispense medications as prescribed

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with Administrator Sean Beharry and explained the reason for the visit. During today's visit, LPA interviewed Administrator at 10:45AM, interviewed staff at 11:17AM, and conducted a medication audit at 11:29AM. LPA also reviewed and obtained copies of relevant documents. During an initial complaint visit conducted on 10/02/2025, LPA met with and interviewed Administrator at 02:22PM, interviewed staff at 2:49PM, toured the facility with Administrator at 03:19PM, and LPA obtained copies of pertinent documents. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Regarding the allegation “staff do not allow residents to use the medical provider of their choosing:” It was alleged that the facility has one preferred hospice provider and residents are not able to choose another provider. LPA reviewed documents for the fifteen (15) residents on hospice. At this time, there are four (4) different hospice care providers contracted to provide hospice care for the residents. Interview revealed that previous residents also used different providers, but at this time there are no residents using these other providers. Additionally, there are two (2) different companies providing home health services to two (2) residents in care. In total, LPA reviewed documentation of six (6) different outside agency providers. Interview with staff revealed that residents and their families choose which agency provides care to the resident. 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 violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “staff do not dispense medications as prescribed:” The complaint alleges that residents requiring a PRN (as needed) medication are required to wait for the medication to be administered until their medical provider is contacted. Interview with staff and management revealed that all residents do have a PRN authorization form on file signed by their individual medical provider. This form allows the medical provider to indicate whether the resident is able to determine their own need for a PRN medication, whether they can clearly communicate signs and symptoms related to the PRN medication, or whether the resident cannot determine their need for a PRN medication or communicate their symptoms. Based on the resident’s determined PRN status, the facility handles PRN medications differently, which is required in Title 22 regulations. Staff interviewed stated there are some residents in the facility who cannot determine their need for a PRN medication. For these residents, the medication technicians do reach out to these residents’ medical providers, whether a primary care physician or their hospice medical professionals, to allow the medical provider to determine whether PRN medication administration is appropriate at that time. Per Title 22 regulation for Residential Care Facilities for the Elderly, trained medication technicians are only permitted to assist with the self-administration of medications. When the resident cannot determine their own need for PRN medication, nor can they communicate their symptoms, regulation states that the facility staff must Report Continued on LIC 9099-C contact the medical provider for administration instructions. Staff interviewed stated they have personal cell phone numbers of most residents’ medical providers and can easily send a text message for easy response. They also have the option to call the office or send a request in writing. Staff interviewed stated they have never had to wait to administer a PRN medication, as they receive prompt response to their requests to administer PRN medications. 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 violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. No deficiencies observed during today's visit. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Nov 4, 2025 · control 29-AS-20250930162427

Type of visit: Case Management - Other

Licensing Program Analyst, Kelly Dulek arrived on November 4, 2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with Administrator Sean Beharry. Licensee Michael Dimaguila arrived at 11:40AM. On January 20, 2023, the Department concluded a complaint investigation regarding the following allegation: Resident was physically assaulted by staff, resulting in bruising. The licensee was cited for California Code of Regulations (CCR) 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. At the time of the complaint visit on January 20, 2023, an immediate civil penalty of $500 was issued. However, during a Non-Compliance Conference on May 21, 2025, the licensee was informed that additional civil penalties may apply. The Department has concluded an analysis and has determined that a civil penalty is warranted for physical abuse. The Welfare and Institutions Code Section 15610.63 for physical abuse means any of the following: Assault, as defined in Section 240 of the Penal Code; and Battery, as defined in Section 242 of the Penal Code. This is evidenced by the facility video footage showing the administrator physically abusing the resident by striking the resident and grabbing the resident by the hair, which resulted in the resident sustaining bruises. Today, November 4, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as physical abuse in the amount of Report Continued on LIC 809-C $10,000. However, since an immediate civil penalty of $500 was previously issued on January 20, 2023, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Administrator Sean Beharry and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Nov 4, 2025

Allegation investigated: Illegal Eviction

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct an initial complaint investigation at 11:40 AM. Upon arrival, LPA met with Administrator Sean Beharry and informed them of the reason of the visit. On 09/18/25, LPA Cortez interviewed Licensee representative Michael Dimaguila and Administrator Sean Beharry, conducted a file review, and obtained copies of pertinent documents relevant to the investigation. During today's visit the LPA conducted a file review, interviewed Licensee representative telephonically, conducted interviews with the Admnistrator, one (1) staff, three (3) residents and attemted to interview Resident #1 (R1). Report will continue on LIC9099-C, 2nd page. Substantiated It was alleged that Resident #1 (R1) and/or their POA was issued an unlawful eviction notice on 09/01/2025. LPA reviewed the eviction notice dated 09/01/2025 which indicated the reasons for eviction were that “the resident’s needs have changed, and the facility can longer meet those needs and continued noncompliance with facility policies that results in a danger to the health, safety, or welfare of the residents or others.” LPA’s review of the eviction notice reflected that the eviction notice was not in compliance with Title 22 due to the eviction not containing specific facts to permit determination of the date, place, witnesses, and circumstances concerning the reasons for the eviction. The eviction notice did not contain a statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office. The eviction notice did not have the following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Additionally, the facility did not send a written report to the licensing agency within five (5) days of issuing the eviction notice. Furthermore, the eviction notice did not provide what higher level of care R1 needed that could not be provided by the facility. File review indicated R1’s behaviors have been consistent over their time at the facility. R1’s last assessment on file is dated 11/10/22. Phone interview with Licensee representative during today’s visit revealed that R1’s POA received R1’s charting notes of the incidents reflecting non-compliance of the facilities policies on 09/09/25, after written documentation of the dates and times of any incidents R1 was “being accused of” was requested by the POA and not included in the eviction notice. Based on the information gathered, the above allegation “illegal eviction” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 29-AS-20250916103016

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Sep 26, 0877

Eviction Procedures. (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by: Based on interviews, and record review, licensee did not meet with the section above by not including date, place, witnesses, and circumstances surrounding the concerns of the eviction, which causes a potential personal rights violation to residents in carethe state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: Administrator agreed to do the following: 1.Rescind the eviction notice within the next 24 hours. This must be done in writing. Submit proof to CCL by 09/26/2025. 2.If still proceedign with eviction, create a valid eviction notice for R1 and submit the eviction notice to CCL for prior approval.

Allegation investigated: Residents are being left in soiled depends/clothes for an extended period of time Staff are putting residents to bed at an early time Residents are not being checked on/repositioned every 2 hours Staff are not providing residents nutritious meals

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with medication technician (MT) supervisor Jennifer Diaz and explained the reason for the visit. The MT called the administrator Sean Beharry who was at the hospital and could not return to the facility. The administrator authorized the MT to sign the report. On 5/20/2025, LPA conducted interviews with seven (7) staff and reviewed documents. During today's visit 7/14/2025, LPA met with the MT and interviewed staff and a witness starting at 2:57 p.m. (continued on LIC9099C) Unsubstantiated (continued from LIC9099) Regarding the allegations "Residents are not being checked on/repositioned every 2 hours" and "Residents are being left in soiled depends/clothes for an extended period of time": LPA interviewed staff who stated the residents who require repositioning are checked on and repositioned every two hours. Staff stated all the residents who require incontinence care are checked on and changed every two (2) hours. LPA interviewed a hospice nurse who has patients at the facility and the nurse stated they have not observed any residents at the facility left in soiled briefs and the nurse has not seen any evidence of residents not being repositioned, such as wounds. Based on these interviews these allegations are deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff are putting residents to bed at an early time": LPA interviewed staff who stated they start putting residents to bed around 7:00 p.m. They first put those to bed who seem very tired and might already be dozing off in their chairs. Then they start helping other residents to bed by 8:30 p.m. If a resident resists and wants to stay up they can do so but most residents are ready for bed around 8:30 p.m. Based on interviews this allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff are not providing residents nutritious meals": LPA interviewed staff who stated the residents' heaviest meal is at lunch. Breakfast and dinner are lighter meals but nutritious. For instance, lunch was ham, yams, and mixed vegetables. For dinner tonight they are serving soup, grilled cheese, salad, and watermelon. Residents will be offered snacks during the afternoon and evening which may be peanut butter and jelly, ice cream, milk with cookies, pudding, etc. Staff stated they observe the facility serves vegetables and fruit with lunch and dinner. Residents can have fruit as snacks as well. Based on interviews this allegation is deemed UNSUBSTANTIATED at this time. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 29-AS-20250516101038

Allegation investigated: Staff did not treat residents with dignity and respect Staff did not provide a safe and comfortable environment for residents Staff member handles residents in a rough manner

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial subsequent complaint visit for the above allegations. Upon arrival, LPA met with Administrator Sean Beharry and was explained the reason for the visit. Administrator Sean Beharry left approxiamtely at 4:35 p.m. and authorized Assistant Administrator Jen Diaz to review and sign the report. On 07/01/2024, between 06:10 p.m. and 7:15 p.m., the LPA interviewed two (2) staff, and obtained copies of pertinent documents relevant to the investigation. During today's visit between 11:45 a.m. and 4:30 p.m. the LPA conducted nine (9) staff interviews, sucessfully interviewed three (3) residents, attempted to interviewed three (3) additional residents, toured the facility, conducted a file review of S1's file and collected pertinent documents relevant to the investigation. Report will continue on LIC9099-C, 2ND PAGE. Substantiated Regarding the allegations, “Staff did not treat residents with dignity and respect, Staff did not provide a safe and comfortable environment for residents and Staff member handles residents in a rough manner,” it is the concern of the reporting party that Staff 1 (S1) is not very friendly to the residents, lacks respect in their treatment of them, behaves harshly, shows impatience, handles residents roughly, that certain residents are fearful of S1, and are unhappy when S1 is around. It was further reported that on 06/27/2024, S1 was witnessed roughly grabbing a resident (name unknown, no injuries reported). Interviews conducted with staff revealed that majority of the staff interviewed have witnessed S1, handling the residents in a rough manner by pulling them, yelling at the residents, not allowing residents to wandered around the facility freely and not treating them with respect. Some staff went to say they have witnessed S1 hit some of the residents (No injuries were reported). Interview with Administrator Sean Beharry confirmed that residents, staff and resident’s family members have voiced concerns regarding S1 and how they treat the residents. File review revealed that personal rights have been previously addressed with S1. S1 was interviewed and denied the allegations. However, based on statements from witnesses, the allegations listed above are deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit Interview conducted. A copy of the report and appeal rights were issued. Regarding the allegation, “Staff member did not provide resident with clean linen,” it is the concern of the reporting party that S1 retaliated against a resident by not providing a top sheet for them but providing one for their roommate. Date was not provided. To investigate the allegation, the LPA conducted interviews with Staff, residents, and resident’s; however, the individuals were not present during the incident and therefore, could not offer sufficient information regarding whether it did or did not occur. Staff further revealed that even though S1 is not a good care giver, they are a good housekeeper. S1 was interviewed, denied allegation and further revealed that it is not part of their responsibility to make the resident’s beds, unless they are instructed to and if so they ensure that the resident’s beds are properly made with all the bedsheets. 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 is deemed Unsubstantiated at this time. Exit interview conducted. Report Provided.the state’s words, verbatim · CDSS document, May 13, 2025 · control 29-AS-20240628132104

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 14, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents .. shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff,(... This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as witnesses stated residents are not treated with respect, by S1 which poses an immidiate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: Licensee has agreed to dedvelop a plan how they are going to ensure the health and safety of the residents and provide to the LPA by the end of day on 5/14/2025. Plan shall be detailed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 14, 2025

(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on interviews the Licensee did not comply with the regulation above, as witnesses stated residents are being handled roughly, pulled, and hit by S1 which is an immediate health, saftey and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: Licensee has agreed to dedvelop a plan how they are going to ensure the health and safety of the residents and how they are going to ensure their personal rights are not bing infringed upon and submit to the LPA by the end of day on 5/14/2025. Plan shall be detailed.

Allegation investigated: Staff restrains resident by securing resident's shoe laces to the wheelchair foot rest. Resident enters another resident's room and goes through resident's personal items. Staff use furniture to block entrance to resident's room to prevent another resident from entering but it also blocks the resident and visitors from entering their room.

Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegations. LPA met with administrator Sean Beharry and explained the reason for the visit. LPA spoke with administrator regarding this complaint starting at 10:30 a.m. LPA conducted interviews with five staff starting at 10:41 a.m. At noon LPA conducted a brief facility tour. LPA observed Resident 1 (R1) and Resident 2 (R2) eating lunch. LPA attempted to speak with R1 but they were not responsive to questions. R2 nodded and said "hi" but otherwise did not respond to questions. Based on interviews with the administrator and staff, R2 has a tendancy to enter R1's room, as well as other residents' rooms, takes out all of their personal items and places them on the bed to be packed up. R2 tends (continued on LIC9099-C) Substantiated (continued from LIC9099) to focus more on R1's room as R2 used to be R1's roommate. The administrator stated he told staff that once R1 was not in their room they could block the door utilizing the spare bed in the room so R2 could not enter. However, R2 figured out how to get around the blockade by entering the adjacent room and going through the Jack and Jill bathroom. They decided to stop blocking the door and they have not used the bed to block the door since that started happening. Staff stated now they keep a closer eye on R2 and redirect R2 when necessary. R2 also takes their current roommate's property and tries to pack it up. Staff keep most of the property belonging to R2's current roommate stored across the hall in the locked laundry area. Based on interviews with staff, R1's shoe laces were observed to be wrapped around part of the foot rest on R1's wheelchair. R1's visitor had reported to staff they had observed this on more than one occasion. On the day R1's visitor reported this, Staff 2 (S2) took a photo of R1's shoes secured to each foot rest. The staff who were interviewed stated they observed this happened after Staff 1 (S1) had provided R1 with care and before the next shift provided care to R1. S1 stated in the interview that they had not noticed R1's shoe laces around the foot rest and thought it may have happened accidentally. However, the administrator stated he spoke with S1 and S1 initially stated they did not know how it happened but later in a second conversation with administrator admitted to securing R1's laces to the wheelchair foot rests. Based on these interviews, the above noted allegations are deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit Interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, May 2, 2025 · control 29-AS-20250425111303

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5) · Plan of correction due date: May 9, 2025

87608 Postural Supports (a) (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as S1 tied/secured R1's feet to the wheelchair, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Administrator already told staff they cannot tie resident's feet to the wheelchair. Administrator will provide training regarding postural supports to all staff and provide evidence of training by 5/9/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 9, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on interviews, the licensee did not comply with the section cited above as staff did not prevent R2 from entering R1's room and blocked R1's entry to their room, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Administrator has already told staff not to block R1's door with furniture, keep an eye on R2 and redirect R2 when needed. Administrator will conduct personal rights training with staff and provide evidence of training by 5/9/2025.

Allegation investigated: Staff handle resident(s) in a rough manner while in care. Staff do not accord dignity to resident(s) in care.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with administrator Sean Beharry and explained the reason for the visit. LPA spoke with administrator regarding this complaint starting at 10:30 a.m. LPA conducted interviews with five staff starting at 10:41 a.m. At noon LPA conducted a brief facility tour. During a prior visit on 4/10/2025, LPA interviewed staff and attempted to interview Resident 1 (R1). Based on interviews and observations, R1 gets very upset when getting changed. On the date of the incident R1 needed to be changed and was taken to one of the restrooms. R1 tends to yell and curse when being changed which can sound disturbing but it is R1's usual behavior when being changed. Based on these interviews and observations, the above noted allegations are deemed UNSUBSTANTIATED at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 2, 2025 · control 29-AS-20250402093724

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Teresa Camara conducted a continuation of the annual visit to review resident and staff records, emergency disaster plan, and other documentation. LPA met with administrator Sean Beharry and explained the reason for the visit. Resident Records: Resident records were checked for documents including but not limited to emergency identification form, consent forms, medical assessment, appraisal/needs and services plan, admission agreement and TB test results. These records appeared complete. Staff Records: Staff records were reviewed for documents including but not limited to fingerprint/background clearance, health screening, TB test results, and training. These records appeared complete. Medications: LPA reviewed medications for five residents. Medications appear to be given as prescribed based on the review of each centrally stored medication and destruction record and medications. Emergency Disaster Plan: LPA reviewed the facility's emergency disaster plan which appeared sufficient. The facility has an agreement with a facility out of the area to accept residents in the event the facility must be evacuated. Emergency evacuation drills are conducted quarterly with all staff. Infection Control Plan: LPA reviewed the facility's infection control plan which appeared sufficient. No deficiencies were observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Mar 14, 2025

The state marks this report as 4 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff yell at residents

On 11/22/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint investigation visit to deliver final findings for the above allegations. During this visit, LPA met with Administrator Sean Beharry and explained the reason for the visit. On the allegation: Staff yell at residents. It is alleged that staff #1 (S1) has been observed yelling at residents like they were being scolded. Allegedly S1 has been previously told to stop but continues to yell at the residents. On 6/13/2023, the Licensing Agency received complaint # 29-AS-20230613124133 with allegations against the same staff member stating that they handle residents in care in a rough manner and they are unable to meet the needs of residents in care due to a language barrier. Interviews with residents and staff confirmed that S1 has been observed handling residents roughly and inappropriately. Continued on 9099-C Substantiated S1 has been observed including but not limited to twisting resident's wrists while changing/cleaning resident to force resident to comply with prompts, pulling a resident's hair and stepping on that resident's foot, forcing residents to sit down at a chair and shoving the table so close to them they cannot get up, leaving residents in postural support chairs to restrict their movement, yelling at residents who do not understand S1 due to a language barrier, and changing a resident's briefs while standing in the hallway not affording the resident privacy or dignity. On 07/11/2024, the allegations in complaint # 29-AS-20230613124133 against S1 were deemed Substantiated, and deficiencies were cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Licensee agreed to a conducted training by an outside vendor with S1 regarding personal rights of clients as well as communication training and submit evidence to the Licensing Agency by 7/19/2024. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is substantiated. Exit interview conducted. Copy of this report provided to the facility. Previously, complaint ## 29-AS-20230613124133 received by the Licensing Agency on 6/13/2023 had the allegation "Facility does not have enough staff to meet the needs of residents in care" deemed unsubstantiated on 7/11/2024. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Exit Interview Conducted. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 29-AS-20240112112248

Allegation investigated: Staff did not address a resident's scabies infection while in care Staff did not meet the resident's dietary needs Illegal eviction

On 11/22/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint investigation visit to deliver final findings for the above allegations. During this visit, LPA met with Administrator Sean Beharry and explained the reason for the visit. On the allegation: Staff did not address a resident's scabies infection while in care. It is alleged that Resident #1 (R1) suffered a severe scabies infection while in care at the facility above that was not appropriately addressed by staff. On 02/05/2024, Community Care Licensing Division (CCLD) received a complaint alleging that the facility above did not appropriately address a scabies outbreak. According to complaint #29-AS-20240205083319, two (2) residents had been taken to urgent care and diagnosed with suspected Scabies. However, Incident reports regarding the Infectious disease for both residents were not submitted to CCLD and Ventura County Public Health (VCPH) was not notified. Continued on 9099-C Unsubstantiated Review of documents revealed that Resident #2 (R2) had been diagnosed with presumed scabies and prescribed Permethrin on 02/07/2024. Furthermore, Resident #3 (R3) had been prescribed Permethrin on 1/31/2024. Administrator stated they had not notified CCLD or Public Health due to other residents who were presenting with rashes and itchiness being diagnosed with contact Dermatitis and were waiting for a Dermatologist who was scheduled to visit the facility and test the residents and staff for scabies and confirm if they had scabies. Complaint #29-AS-20240205083319 was substantiated by the Licensing Agency, and on 02/12/2024, the Administrator notified VCPH of the two residents with presumed scabies and possible scabies outbreak and obtained guidance from VCPH to address the outbreak. On 11/09/2023, Resident #1 (R1) had a medical examination by the California Dermatology Institute regarding moderate chronic atopic dermatitis and asteatosis eczema. R1 was prescribed fluocinonide and calcipotriene and was informed of a plan to use moisturizers, hypoallergenic soaps/detergents, and anti-inflammatory topical treatments. R1 was not diagnosed with scabies and was not prescribed Permethrin. On 01/02/2024 and 01/30/2024, Hospice Agency documented reports noted that R1 had severe psoriasis and severe skin dryness which were being treated with prescribed medications and moisturizers daily. On 03/14/2024, LPA received documentation that while hospitalized beginning 02/13/2024, R1 had been tested for skin issues such as scabies. All skin tests of R1 were negative, but the hospital did express that R1 had general skin psoriasis. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. On the allegation: Staff did not meet the resident’s dietary needs. It is alleged that R1 has lost a significant amount of weight while in care at the facility above due to R1 not being fed by facility staff. R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) documents that R1 has no special diet and can feed themselves. The facility Preplacement Appraisal Information for R1 documents that R1 does not need help with eating and has no need for adaptive devices or assistance from another person. The Preplacement Appraisal also documents that R1 strongly dislikes fruits and vegetables while enjoying primarily meat and potatoes. Facility Narrative charting for R1 stated that R1 would refuse to eat dinner or eat very little in the evening on sporadic occasions during their time in care at the facility beginning in 2020. Narrative charting also indicated that R1 would frequently ask for cigarettes, candy, and popcorn rather than eat dinner provided by the facility. Staff interviewed by LPA stated that R1 would sometimes refuse dinner or eat very little dinner while being extremely verbally and physically aggressive to staff. LPA interviewed staff and residents regarding staff handling/delivering food to R1. Continued on 9099-C None of those interviewed had ever observed staff mishandling food or beverages for R1. Staff stated they would pass by R1’s room at least every half hour since R1’s bedroom was up front of the facility near the staff office. On 6/4/2024, R1’s conservator/public guardian stated in an interview with the Licensing Agency Investigations Branch that prior to leaving the facility, R1 appeared healthy and strong, unlike after discharge, where R1 is frail and weak. R1’s conservator/public guardian stated they are aware of the allegation and does not believe there was any neglect from the facility. On 11/15/2024 and 11/22/2024, LPA observed the food service area in the facility and found the food items to be of good quality while served to residents according to the facility meal schedule. LPA observed the food preparation and food supply in the facility as well as delivery of food to residents. Residents interviewed by LPA indicated the food was of good quality, and they had no complaints about the food. All residents interviewed stated to LPA that they are always fed by the facility staff every day. All Staff members interviewed by the LPA stated that residents in the facility are fed appropriate amounts of food on a consistent daily schedule. LPA was provided with pertinent documentation by the facility including a facility menu, meal schedule, and resident documentation relating to any dietary restrictions if applicable. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. On the allegation: Illegal eviction. It is alleged that R1 is not being allowed to return to the facility above. On 02/16/2024, an incident report received by the Licensing agency from the facility above showed R1 was sent to the hospital on 02/13/2024 due to weakness and unresponsiveness. The following day, R1’s resident representative contacted the facility informing them R1 was diagnosed with a fractured femur. Hospital medical records from the visit by R1 on 02/13/2024 state R1 was admitted due to weakness. During the visit, R1 was also found to have a hip/femur fracture. However, the cause was unknown. All Records reviewed by the Licensing agency indicated no reported fall or witness to a fall. R1 is non-verbal, so R1 did not report abuse or neglect, and other residents, including R1’s roommate, would not respond to questions due to their cognitive skill level. There was no police investigation for this case and there were no concerns noted on the medical records or expressed by R1’s conservator. According to facility documentation and interviews by LPA, R1 is under Public Guardianship and was removed from the facility by their Public Guardian while hospitalized beginning 02/13/2024. LPA requested and received both the Notice of Hearing for Conservatorship of R1 and the Capacity Declaration for Conservatorship of R1 documentation from the Superior Court of California. Continued on 9099-C All licensing agency interviews with facility staff and the conservator of R1 indicated that the resident would not be returning to the facility after R1 underwent surgery in the hospital for a broken femur. Although the complaint report allegation indicated it was the facility that did not allow the resident to return, both the Administrator and R1’s conservator/public guardian provided documentation indicating R1’s conservator/public guardian suggested discharging R1 to a Skilled Nursing Facility (SNF) for further rehabilitation and medication adjustments with a doctor onsite. R1’s conservator/public guardian stated that they would not allow R1 to return to the facility after the hospitalization on 02/13/2024, and it was not the facility preventing R1 from returning. R1’s family member and public guardian then began removing R1’s personal belongings from the facility on 03/18/2024. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. Exit interview conducted. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 29-AS-20240313113518

Type of visit: Required - 1 Year

On 11/22/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct an unannounced evaluation visit. When the LPA arrived, they were greeted by Administrator Sean Beharry. LPA informed facility representatives of the reason for the visit upon entry. The LPA 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. This is a Residential Care Facility for the Elderly (RCFE). This facility is approved for a maximum capacity of forty-nine (49) non-ambulatory residents, of which forty-eight (48) may be bedridden. The facility has an approved hospice care waiver with the licensing agency for fifteen (15) residents. The LPA inspected the food service area in the facility and observed that items which could constitute a danger to residents are kept inaccessible to residents. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. LPA observed an appropriate/adequate amount of perishable and non-perishable food items maintained in the facility. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, common areas, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always ensure clean linens for residents. Equipment and supplies for resident personal hygiene is available and on site. Activity supplies are available for residents. As the facility has an approved fire clearance for a maximum forty-nine (49) residents, a signal system was observed by LPA and required by the Licensing Agency. Continued on 809-C Refrigerators and freezers are maintained at an appropriate temperature Fahrenheit as per CCL regulations. Food storage and preparation areas are clean and appropriate for food preparation. The food service areas are clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. Cleaning supplies are kept in areas separate from where food supplies are stored. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. There are locked storage area(s) for poisons, toxic, cleaning solutions, disinfectants, etc. Fire extinguishers and smoke detectors operate properly. Doors and passageways are unobstructed. There are no pools/bodies of water on the physical plant of the facility as observed by LPA. During the inspection, LPA did not observe any firearms that would require trigger locks, locked and inaccessible, or firing pins removed. The facility is enclosed by a metal fence and a locking gate. The physical plant of the facility consists of two (2) stories, however residents cannot access the 2nd story of the building and there is a locked gate in place on the bottom of the interior staircase. At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. The facility common areas include communal restrooms in the hallways, resident bedrooms, a resident activity room, locked laundry room, locked/staff only kitchen area, dining room, locked food storage/pantry, locked closet areas in the hallways containing the storage of clean linens, PPE materials, resident hygiene products, and activity materials. The facility also contains multiple staff offices and staff storage/break room. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the residents. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use. Carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were fully charged and serviced annually. The facility maintained a comfortable temperature in all areas inspected. LPA did not observe any noticeable outdoor hazards. Outdoor activity spaces in the facility are shaded and equipped with furniture for resident use. The facility has adequate storage of additional supplies/emergency supplies. The designated laundry area in the facility has appropriate storage of cleaning products, which are kept locked and inaccessible to residents. Emergency food and water in storage were observed to be in good condition by the LPA. Cleaning supplies, disinfectants, and other items that could pose a danger are kept in areas inaccessible to residents. Continued on 809-C The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms in the facility were sufficiently stocked with soap, paper towels, required postings, and clean trashcans with closed lids. Towels and washcloths are not shared by residents in the facility. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per Title 22 regulations between 105-120 degrees Fahrenheit. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Each resident bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms can store or has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. The facility has provisioned to each resident of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. A continuation is needed for the annual required facility site inspection/evaluation as LPA did not have time to conduct record review of documentation maintained by the facility including personnel records and resident records. LPA was not able to conduct an audit of the centrally stored medications at the facility and during the continuation, a change of administrator process needs to be conducted as the listed administrator for this facility is not the current administrator in the facility. Exit interview conducted by LPA. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Nov 22, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Due to staff, resident sustained multiple fractures and cuts while in care

On 11/13/2024, Licensing Program Analyst (LPA) Phillips conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Administrator Sean Beharry and explained the reason for the visit. On 03/13/2024, the Woodland Hills North Adult and Senior Care office received a complaint that due to staff, resident sustained multiple fractures and cuts while in care. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Peter Zertuche. On 03/14/2024, from 11:19am to 3:30pm, Licensing Program Analyst (LPA) Christine Yee conducted the initial complaint visit. LPA Yee met with Sean Beharry, administrator, and explained the reason for the visit. During the visit, the LPA conducted interviews from 12:01pm to 2:42pm with the administrator and staff #1 (S1); and telephone interviews with a family member and R1’s conservator. Facility documents, including R1’s file, were collected during the visit. The LPA determined further investigation was needed prior to issuing findings. Continued on 9099-C Unsubstantiated Investigator Zertuche conducted interviews on 04/02/2024, from approximately 3:00pm to 4:00pm, with R1’s resident representatives; on 05/23/2024, from approximately 9:30am to 11:00am, with administrator and staff; on 06/04/2024, at approximately 3:30pm, with R1’s conservator; on 06/07/2024, at approximately 11:00am, with Community Memorial Hospital (CMH) nursing case manager; and on 06/10/2024, at approximately 8:30am, with the home health nurse. In addition, the investigator reviewed CMH medical records, A Plus Home Health Services records, and facility file documents related to R1. A review of the facility documents for R1 revealed their physician’s report dated 03/07/2020 showed R1 was ambulatory with a diagnosis of memory loss, but able to perform most activities of daily living on their own. An incident report showed R1 was sent to the hospital on 02/13/2024 due to weakness and unresponsiveness. The following day, R1’s resident representative contacted the facility informing them R1 was diagnosed with a fractured femur. The facility conducted an internal investigation which revealed no reported incidents at the facility. There were several visits conducted by the home health agency prior to the incident but nothing of concern was noted. The facility notes and records indicated R1 sustained a previous injury in March 2023 where an unwitnessed fall was documented sustaining a broken arm. There were also notes of follow up visits to the doctor showing the injury had healed. Information reported by the administrator revealed that on 02/13/2024, R1 was not looking well, and the administrator decided to send R1 to the hospital and contacted R1’s resident representative. The following day, R1’s resident representative contacted the facility stating R1 had a fractured femur. The administrator questioned the staff and reviewed video, but there was no reported fall. The administrator denied hitting or pushing R1 and has not witnessed or heard of any of the staff members or residents hit or push R1. The administrator was surprised to hear of the fracture since R1 was able to walk without pain. Staff confirmed R1 did not walk well, as R1 shuffled their feet, but was able to get around on their own. R1 also used a wheelchair for safety. In addition, R1 was constantly supervised by staff members as R1 required assistance for most activities of daily living. R1’s room was placed near the entrance by the front office where there is lots of traffic. However, R1 was always in the activity room with the other residents and staff members. Staff denied witnessing R1 fall or be mistreated. There are cameras in the facility, but they do not record beyond 30 days, so there was no footage available for the Department to review. Continued on 9099-C According to the CMH medical records, the records documented two visits to the hospital, the first one being 03/12/2023 due to an unwitnessed fall where R1 sustained a mild humeral shaft fracture (upper arm area), right lip laceration and shoulder pain. Also found were several fractured ribs but date of injury was unknown. There were no notes of R1’s statement regarding the injury or concerns regarding the facility. The second visit to the hospital occurred on 02/13/2024 where R1 was admitted due to weakness. During the visit, R1 was also found to have a hip/femur fracture. However, the cause was unknown. Records indicated no reported fall or witness to a fall and R1 had minimal response, mostly non-verbal, with one-word responses. According to the A Plus Home Health Services records, R1 was admitted to home health services on 12/14/2022 with a diagnosis of dementia, depression, language disorder, weakness, difficulty in walking and a history of urinary tract infections. R1 was listed as a fall risk and required assistance with most activities of daily living. Notes indicated the facility was proactive in modifying the environment to enhance safety and expressed concern about R1’s balance and fall risk. Visit nursing notes indicated R1 did not verbalize any complaints about the facility but complained of persistent shoulder pain. However, R1 was able to engage in activities (hospital medical records listed no concerns regarding the shoulder). The Department’s investigation revealed there were no witnesses to the incident and facility staff members denied abuse or anything unusual. There was no history of falls except one occurring a year prior. In the recent incident, on 02/13/2024, R1 sustained a fractured hip, which was not witnessed, and was taken to the hospital for an unrelated concern when the fracture was found. R1 is non-verbal, so R1 did not report abuse or neglect, and other residents, including R1’s roommate, would not respond to questions due to their cognitive skill level. There was no police investigation for this case and there were no concerns noted on the medical records or expressed by R1’s conservator. Based on the information obtained, there is insufficient evidence to support the allegation, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 29-AS-20240313113518

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff member physically abuses residents in care. Staff member handles residents in care in a rough manner. Staff member is not according resident(s) dignity while in care. Staff member is unable to meet the needs of residents in care due to a language barrier.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with administrator Sean Beharry and explained the reason for the visit. During the investigation, LPA conducted interviews with the administrator starting at 11:52 a.m., Resident 1 (R1) at 11:34 a.m., and multiple staff starting at 11:57 a.m. LPA also reviewed and obtained pertinent records at 12:03 p.m. LPA previously interviewed residents on 6/20/2023. Interviews with residents and staff confirmed that Staff 1 (S1) has been observed handling residents roughly and inappropriately. S1 has been observed including but not limited to twisting resident's wrists while changing/cleaning resident to force resident to comply with prompts, pulling a resident's hair and (continued on LIC9099-C) Substantiated (continued from LIC9099) stepping on that resident's foot, forcing residents to sit down at a chair and shoving the table so close to them they cannot get up, leaving residents in geri-chairs to restrict their movement, yelling at residents who do not understand S1 due to a language barrier, and changing a resident's briefs while standing in the hallway not affording the resident privacy or dignity. Based on the observations by those interviewed, the following allegations are deemed Substantiated: Staff member physically abuses residents in care. Staff member handles residents in care in a rough manner. Staff member is not according resident(s) dignity while in care. Staff member is unable to meet the needs of residents in care due to a language barrier. 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. (continued from LIC9099) LPA interviewed staff and residents regarding S1 handling food. None of those interviewed had ever observed S1 mishandling food or beverages. Therefore, the allegation "Staff member does not follow proper food sanitation practices" is deemed Unsubstantiated at this time. LPA interviewed staff and residents regarding the facility staffing. Staff indicated the facility is fully staffed and when someone calls out they can find coverage. The residents did not notice any issues with the number of staff at the facility. Therefore, the allegation "Facility does not have enough staff to meet the needs of residents in care" is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report issued.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 29-AS-20230613124133

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 19, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse...This requirement is not met as evidenced by: Based on interviews with residents and staff, the Licensee did not comply with the section cited above as, S1 has been observed multiple times mistreating residents, which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: Licensee will hire an outside vendor to conduct training with S1 regarding personal rights of clients and submit evidence of this training by 7/19/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87 · Plan of correction due date: Jul 19, 2024

87608 Postural Supports (a) ...Postural supports may be used under the following conditions.(1)Postural supports shall be limited to appliances or device to achieve proper body position... to improve a resident's mobility... rather than restrict movement. This requirement is not met as evidenced by: Based on interviews with residents and staff, the Licensee did not comply with the section cited above as, S1 has been observed multiple times using geri-chairs and tables to restrict residents' movement, which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: Licensee will conduct training regarding postural supports with all care staff and provide evidence of training to CCL on or before 7/19/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Jul 19, 2024

87411 Personnel Requirements - General (d) All personnel shall be given on the job training...(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by: Based on interviews with residents and staff, the Licensee did not comply with the section cited above as, S1 has been observed yelling at residents due to a language barrier, which poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: Licensee will counsel S1, provide communication training and provide evidence of training to CCL on or before 7/19/2024.

Allegation investigated: Staff does not treat resident with respect.

Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit. LPA met with administrator Sean Beharry and explained the reason for the visit. During the investigation, LPA conducted interviews with the administrator starting at 11:52 a.m., Resident 1 (R1) at 11:34 a.m., and multiple staff starting at 11:57 a.m. LPA also reviewed and obtained pertinent records at 12:03 p.m. The interviews conducted with R1 and staff, other than Staff 1 (S1) confirmed that S1 forcefully grabs the television remote from R1 while R1 is listening to music in the activity room and changes the channel to movies. None of the other residents complain about the music and nobody asks to watch the movies S1 turns on. Substantiated (continued from LIC9099) In addition, R1 stated they enjoy playing bingo and during bingo S1 goes to get them and take them to the bathroom even though R1 does not need to go to the bathroom. R1 feels this is done by S1 out of spite. Other staff also stated it seemed to them S1's conduct toward R1 was forceful and seemingly spiteful. S1 was interviewed and denied the allegations. However, based on statements from witnesses, the allegation "Staff does not treat resident with respect" is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit Interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 29-AS-20240709103040

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Jul 19, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents... This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as, witnesses stated R1 was treated poorly by S1, which posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: Licensee will conduct training and counseling with S1 regarding residents' rights and S1's conduct with residents. Evidence of this will be provided to CCL on or before 7/19/2024.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Incident visit regarding a self reported incident which took place on or about 7/10/2024. LPA met with administrator Sean Beharry and explained the reason for the visit. Starting at 9:38 a.m. LPA conducted interviews with administrator and two staff. LPA conducted an interview with Resident 1 (R1) at 10:42 a.m. LPA reviewed records during the interview with administrator. On 7/10/2024, at approximately 7:30 a.m. Staff 1 (S1) noticed R1 was not in their room. S1 asked Staff 2 (S2) if they knew where R1 was and S2 did not know R1 was missing. Staff conducted a search of the facility and grounds. S1 noticed a plastic chair was placed near the fence and had a shoe print on it. The police were notified of the missing resident. Staff drove around the neighborhood searching for R1. Administrator stated R1 was last seen by Staff 3 (S3) at approximately 9:30 p.m. on 7/9/2024. Staff located R1 at a nearby shopping center on a bus bench between 7:00-8:00 p.m. on 7/10/2024. A review of R1's records showed R1 was not allowed to leave the facility unassisted by staff. R1 had never displayed any exit seeking behavior. When asked by LPA why they left, R1 stated they were bored and wanted to go get a burger at McDonald's. R1 confirmed they climbed the fence to exit the facility. R1 stated they miss their family and would like to live with their family or closer to their family. R1 also stated they do not want to take medications prescribed by their physician and they are not interested in looking at alternatives to their current medication because they do not feel they need the medications. Administrator stated he is reviewing this with his manager and R1's representative to determine if this is appropriate placement for R1. In the meantime, staff are to keep a closer eye on the courtyard, the chairs that R1 used to climb the fence, and watch for R1 exit seeking. No deficiencies observed at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jul 11, 2024

Allegation investigated: Staff did not seek timely medical attention for a resident. Staff did not address a resident’s scabies infection.

Licensing Program Analysts (LPAs), Martha Arroyo and Valeria Conway conducted a subsequent visit to the facility to issue findings for the above allegations. The initial visit was conducted on 06/13/2023 by LPA M. Arroyo. During today's visit, LPA met with the Administrator, Sean Beharry and the reason for the visit was explained. Entrance interview. During the initial visit on 06/13/2023, at 10:52 a.m., the LPA conducted a tour of the facility to ensure there are no health and safety concerns, conducted interviews with two Administrators, two staff, and four residents between 11:04 a.m. and 12: 40 p.m., conducted a file review at 11:35 a.m., and obtained copies of pertinent documents relevant to the investigation. Hospice records were requested and reviewed. Continued on LIC 9099C... Unsubstantiated Continued from LIC 9099... It was alleged that staff did not seek timely medical attention for a resident. It was reported that in October 2022, Resident #1 (R1) was observed on several occasions to have dry palms with skin peeling off, but even after applying ointment, on December 2022, R1 had developed open cracks diagnosed as cellulitis. It was also reported that in February 2023, R1 had fungus on their fingernail which resulted in R1 having their fingernail removed; however, the fungus was still there. Records review of Re-Cert Assessment dated 11/15/2022, noted R1 with atopic dermatitis on bilateral hands with skin treatments in place; and on the Re-Cert Assessment dated 01/12/2022, it stated that R1’s chronic bilateral palm dermatitis was not responding to topical treatments on 12/02/2022, which caused it to worsen into cellulitis of skin and the doctor ordered oral antibiotics Keflex 500mg x7 days started on 12/09/2022. Additionally, review of communication log dated 02/11/2023, noted R1 with left middle finger fungal sore. New orders and initial treatment was started same day to treat x 14 days and then to re-evaluate. Treatment was started again on 03/07/2023 for Lamisil 250mg x6 weeks with Fungi-Nail solution topical treatment and consultations with a podiatrist and recommendations were made after. Furthermore, both facility staff and hospice were continuously treating R1’s dermatitis and fingernail fungus. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of, “staff did not seek timely medical attention for a resident”. Therefore, this allegations is being deemed Unsubstantiated at this time. It was also alleged that staff did not address a resident’s scabies infection. It was reported that in April 2023, R1 had bites and a rash on their skin which was reported to being a skin condition and not scabies; however, it was not until June 2023, when R1 was finally diagnosed and treated for scabies. Information obtained during the course of the investigation revealed that R1’s skin rash was being treated by Hospice Care of the Valley and facility staff as both hospice and facility staff were following skin treatment orders to relieve R1’s skin rashes for several weeks. Although R1’s skin rashes seemed to be flaring up even after being treated, hospice continued to prescribe different types of topical skin treatments to try and alleviate R1’s skin rashes. Continued on LIC 9099C... Continued from LIC 9099C... Records review revealed that between April 2023 and June 2023, hospice had prescribed different skin treatments such as Elimite, Zeasorb Powder and Triamcinolone cream to continue to find a treatment that would work for R1’s skin rashes. Furthermore, the facility had conducted a skin sweep assessment in April 2022 that had resulted in negative results. This ultimately swayed the facility to hire a dermatology company to come out to the facility and assess the resident at the facility. However, even after all the testing, hospice staff stated R1’s skin rash was never diagnosed. Additionally, hospice added that although they were unable to find a cause, they did alternate between different treatments to try and control the skin rashes as well as give as much comfort to R1. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “staff did not address a resident’s scabies infection”. Therefore, this allegation, is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued. Continued from LIC 9099... It was alleged that staff did not provide adequate supervision, resulting in a resident falling and sustaining injuries. It was reported that Resident #1 (R1) is wheelchair dependent, and on 09/04/2022, R1 was injured after falling out of the wheelchair. It was also reported that after the fall, R1 had a large welt on their forehead with some skin scraped off, and bruises were observed on R1’s arms and knees. Information obtained during the course of the investigation revealed that R1 was admitted to Hospice Care of the Valley on 01/20/2022; and Comprehensive Nursing Assessment dated, 01/20/2022 stated R1 was bed and chair bound as well as required total assistance with activities of daily living (ADL). Additionally, the LPA reviewed hospice nursing notes that included the communication log between facility staff and hospice staff regarding R1 dated 01/24/2022 – 06/13/2023. Communication log from 09/04/2022 stated that facility staff informed hospice that R1 had an unwitnessed fall in the dining room. R1 was found next to their wheelchair with a large bump ecchymosis (bruise) on their left forehead and a bruise with swelling on R1’s right knee lower shin area. Thereafter, hospice nurse instructed facility staff to place R1 on bed rest and ice both sites three times a day. Additionally, hospice staff educated facility staff on fall safety precautions to which facility staff expressed understanding. Furthermore, R1 required assistance with all ADL’s as well as staff supervision at all times. For this reason, because R1 was left unattended, R1 suffered a fall from their wheelchair resulting in R1 sustaining injuries while in the dining room. Therefore, based on the information obtained and reviewed, the allegation of, “staff did not provide adequate supervision, resulting in a resident falling and sustaining injuries” is being deemed Substantiated at this time. It was further alleged that staff did not ensure a resident’s medical equipment was maintained. It was reported that R1 suffered a fall on 09/04/2022 and it was determined that the wheelchair brakes were not working. Records reviewed that included the communication log between facility staff and hospice staff dated 09/05/2022, revealed that hospice spoke with the facility administrator and staff to inquire about R1’s unwitnessed fall from 09/04/2022 in the dining room which left R1 with forehead laceration and right knee swelling. Continued from LIC 9099... Continued from LIC 9099C... During this conversation, facility staff stated that incident occurred after lunchtime when R1 was wheeled to the dining table, but wheels unlocked and must have backed away from table causing R1 to slide down to the floor. However, R1’s wheelchair was not reported faulty to hospice until after the fall incident from 09/04/2022 when hospice called the facility to obtain more information on the incident the following day. Additionally, interviews conducted with staff revealed that hospice is usually good about replacing medical equipment and added that facility staff typically observes if equipment is malfunctioning as they are the ones assisting the residents on a daily basis. Furthermore, hospice ordered a new reclining wheelchair for R1 the following day to prevent another accident. Based on the information obtained and reviewed, the allegations of, “staff did not ensure a resident’s medical equipment was maintained” 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, Feb 22, 2024 · control 29-AS-20230608141637

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 22, 2024

(f)Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on the information obtained and reviewed, the Licensee did not comply with the section cited above as, R1 was left unsupervised resulting in R1 falling off their wheelchair and sustaining injuries, which posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee will submit a plan on how the facility will ensure residents will be supervised based on their individual needs. Submit to CCL by 02/29/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 22, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on the information obtained and reviewed, the Licensee did not comply with the section cited above as, staff failed to report faulty wheelchair brakes to hospice causing R1 to have an unwitnessed fall in the dining room, which posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee will submit a plan on how the facility will ensure all medical equipment is maintained and report any faulty equipment to the proper agencies. Submit to CCL by 02/29/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20230608141637). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation. During the complaint investigation of complaint # 29-AS-20230608141637, the following deficiency was observed: On 09/04/2022, Resident #1 (R1) had an unwitnessed fall in the dining room after R1’s wheelchair wheels unlocked. R1 was found next to their wheelchair in the dining room with a large bump ecchymosis (bruise) on their left forehead and a bruise with swelling on their right knee lower shin area. Hospice instructed facility staff to place R1 on bed rest and ice both sites three times a day. However, records review revealed that facility did not submit an incident report (LIC 624) to Community Care Licensing (CCL) reporting the unusual incident for R1. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit Interview. Citation issued. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Feb 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 29, 2024

(a)Each licensee shall furnish to the licensing agency reports…within seven days of the occurrence of any of the events specified in (A) through (D). (D)Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as, R1 had an unwitnessed fall causing a forehead bruise and right knee swelling which prompt hospice to have R1 placed on bed rest, which posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: The Licensee will read regulation 87211 on Reporting Requirements and submit a statement of understanding to CCL no later than 12/29/2024.

Allegation investigated: Staff did not address an outbreak

Licensing Program Analysts (LPA) Esther Cortez arrived unannounced at 10:00 a.m. to conduct an initial 10-day complaint visit. The LPA met with Administrator Sean Beharry and explained the reason for the visit. During today's visit, the LPA obtained documents, conducted a file review, and conducted staff interviews from 10:00 a.m. - 12:30 p.m. It was alleged that Staff did not address an outbreak. It was reported that residents and staff have visible rashes and residents are constantly itching. It was further reported that this has been going on for months and that the rash is contagious. Interviews conducted with staff revealed that there are residents and staff who are currently experiencing rashes and itchiness and it has been ongoing for months. Report will continue on LIC9099-C. Substantiated Additionally, administrator Sean stated that two residents (R1, R2) had recently been taken to urgent care and diagnosed with suspected Scabies. However, Incident reports regarding the Infectious disease for R1 and R2 were not submitted to CCLD and Ventura County Public Health (VCPH) was not notified. Review of documents revealed that R1 had been diagnosed with presumed scabies and prescribed Permethrin on 02/07/2024. Furthermore, R2 had been prescribed Permethrin on 1/31/2024. Administrator stated they had not notified CCLD or Public Health due to other residents who were presenting with rashes and itchiness being diagnosed with contact Dermatitis and were waiting for a Dermatologist who was scheduled to visit the facility and test the residents and staff for scabies and confirm if they had scabies. During today’s visit Administrator Sean notified VCPH of the two residents with presumed scabies and possible scabies outbreak and obtained guidance on how to move forward. VCPH will be meeting with the facility this week to address the outbreak. Based on the information obtained during the course of the investigation, the allegation of “Staff did not address an outbreak.” is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the appeal rights and report was issued.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 29-AS-20240205083319

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Feb 13, 2024

87211 Reporting Requirements (a)(2) Occurrences, such as epidemic outbreaks, ...or major accidents which threaten the welfare, safety or health of residents...shall be reported within 24 hours either by telephone or facsimile to the licensing agency 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 R1 and R2 were diagnosed with suspected/presumed scabies, yet CCL and VCPH were not notified, which poses a potential health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: During todays visit the administrator contacted VCPH who will be visiting the facility this week and adressing the outbreak and has agreed to submit to Incident Reports to CCL in the timeline reflected in section 87211. Will submit Incident Reports for R1 and R2 by 2/13/2024.

Allegation investigated: Staff do not ensure resident's personal hygiene needs are met

Licensing Program Analysts (LPA) Esther Cortez arrived unannounced at 9:45 a.m. to conduct a subsequent compliant visit. The LPA met with MedTech (MT) Jennifer Diaz and explained the reason for the visit. Administrator Sean Beharry could not be at the facility during today's visit and authorized MT Hazel Esaspillaga to sign and receive the report. On 08/23/23, the LPA toured the facility, obtained documents, and conducted staff and resident interviews from 8:50 a.m. - 6:00 p.m. During today's visit, the LPA conducted a file review, obtained documents, and interviewed staff and Individual #1 (I1) who cared for R1 in 2023 from 9:45 a.m. to 1:00 p.m. Report will continue on LIC9099-C. Unsubstantiated This report was amended for privacy reasons. It is alleged that ‘Staff do not ensure resident's personal hygiene needs are met.’ The concern of the RP is that resident #1 (R1) smelled of feces, had feces on their clothes and was not wearing any underwear. It was further reported that R1 was disheveled and unkempt. During this investigation LPA Cortez conducted interviews with facility staff, R1, Individual #1 (I1) who cared for R1 in 2023, and a family member of the resident. In addition, R1’s records were reviewed. Staff Interviews revealed that R1 refuses to shower or change and gets aggressive with the staff when they attempt to assist. Staff also indicated that when residents are observed with soiled clothing they are changed. During LPA's interview with R1, it was learned that R1 does not like anyone in their room and states that they are independent and do not want any help. Interview with I1, revealed that they have attempted to assist with showering R1, however R1 refused, was abusive, resistant, and had a tendency to hit. Interview with R1's family revealed that they have no concerns with the care the facility is providing at this time, based on R1’s behavior. R1’s family member acknowledges R1 can be aggressive and in addition tends to pack away or lose their clothes. R1’s family member also revealed they visit R1 once or twice a week, and even though they have observed stains on R1’s clothing they have been old stains and have never seen R1 with feces or fresh stains. The LPA observed documentation of R1’s shower refusals while they were receiving Hospice care in previous years. During today’s visit, at 10:50 a.m. the LPA observed a MedTech attempt to assist R1 with changing, however R1 threw the clothes and started to yell and yelled at the MT to get out of their room. Based on the information gathered through the interviews, and observation there is insufficient evidence to support the above allegation. Therefore, although the allegation may have happened, or may be valid, this allegation is deemed Unsubstantiated at this time. Administrator was available over the phone to review report. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 29-AS-20230818091916

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cortez conducted a case management - deficiencies visit inspection due to a deficiency observed during the investigation of complaint control #29-AS-20230818091916. The LPA met with MedTech (MT) Jennifer Diaz and explained the reason for report. Administrator Sean Beharry could not be present during the visit today and authorized MT Hazel Aspillaga to review and sign the report. During the complaint investigation, the following deficiencies were observed: During today's visit, LPA interviewed Staff #1 (S1). During the interview S1 admitted to forcing Resident #1 (R1) and other residents to shower after their refusal. In addition S1 stated that other staff force residents to shower as well after refusal. S1 revealed, that there's is residents who always refuse to shower and that is the only way to get them to shower, however they do not document any shower refusal. The LPA did not observed a complete and current documentation of shower refusals for Resident #1. Administrator was available over the phone to review report. Citations Issued. See LIC 809-D. Appeal Rights discussed and copy of report issued.the state’s words, verbatim · CDSS document, Jan 26, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Feb 9, 2024

87468.1(a)(16) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement is not met as evidenced by: Based on interviews, the licensee did not allow R1 the personal right to reject the service of showers, as R1 and other residents are being forced to shower which posed a potential person right risk to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Administrator agrees to conduct personal rights trainning with all staff and submit proof to LPA no later than POC due date of 2/09/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Feb 9, 2024

87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. Based on record review, the licensee did not have a complete and current record of shower refusals for R1 which poses a potential person right risk to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Administrator will review Title 22, Section 87506-Resident Records and ensure that all the required documents are in the resident files. Licensee will submit a signed written statement that Section 87506(a) was read and understood by 2/09/24

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 12/21/2023. The LPA was greeted by MedTech Jennifer Diaz and informed them of the reason for the visit. Administrator Sean Beharry could not be present during the visit today and authorized MT Hazel Aspillaga to review and sign the report. Today the LPA conducted a medication audit, interviewed three staff, and finished the record review initiated on 12/21/2023. Interviews: During today’s visit, the LPA conducted three (3) staff interviews. Medications: At 1:45 p.m. a medications review was initiated for three out of five residents and the following was observed. The medications were stored in the medication room, which is locked and inaccessible to the residents. During Resident #3 (R#3's) audit, the LPA observed Donepezil HCL 5MG Tab still in the bubble pack, however the plastic bubble was punched out but medication not successfully poured out. MT Jennifer Diaz stated that when medication is not given it will be documented on the Medication Administration Record (MAR). However there was no documentation on R3’s MAR that the medication was not given. Record Review: The LPA observed documentation of Infection Control plan, Disaster prevention and Insurance liability. The LPA reviewed five (5) out of thirty-seven (37) resident files. The LPA was not able to review any of the five residents’ admissions agreements, due to them being stored in a separate file in the Administrators office. The administrator was not available for todays visit, and staff does not have access to the office. Out of the five files reviewed, the LPA identified that three files were missing the safeguards for property/valuables form, (SPV), two residents (R2,R5) did not have signed resident rights forms (LIC613), and three residents (R2, R3, R4) did not have their appraisal/needs and services form (LIC625) signed by the resident and/or their responsible party. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 26, 2024

The state marks this report as 10 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At 09:10 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Sean Beharry and informed them of the reason for the visit. At 09:35 a.m. the LPA conducted a tour of the physical plant with Administrator Sean to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of twenty-five (25) resident rooms, seven (7) half bathrooms, five (5) full bathrooms, activity room, common sitting area, dining room, and kitchen on the first floor. The second floor consists of three (3) staff rooms, one (1) office and is only for staff use and inaccessible to resident in care. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 02/07/2023. Smoke alarms and carbon monoxide detectors were tested and functioned properly. Kitchen: During the facility tour at 9:36 a.m., kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Bedrooms: During today’s visit, the LPA observed ten (10) randomly selected resident units. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding. At 11:07 a.m. the LPA observed a camera in room #17. The Administrator stated that the responsible party requested a baby monitor to be placed in the resident’s room (R1) due to R1 being a fall risk. The baby monitor was removed from R1’s room during the visit. At 10:49 a.m. the LPA observed a dresser and a nightstand with missing knobs in room #20 and the floor to be unkept with residue. At 10:55 a.m. the LPA Observed a nightstand with missing knobs in room #21. Report will continur on LIC809-C. Bathrooms: The LPA toured five (5) of twelve (12) resident bathrooms and checked to make sure bathrooms were clean and in good repair. The LPA observed appropriate grab bars and non-skid mat and/or material in each bathroom. Water temperature was tested randomly in bathrooms. The water temperature measured in the restrooms ranged between 124.0 degrees Fahrenheit and 127.5 degrees Fahrenheit between 10:07 a.m. and 10:33 a.m. Common Areas: These included the dining areas and activity room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Record Review: At 12:15 p.m. a review of facility files was initiated. The LPA reviewed five (5) of twenty four (24) staff files. Out of the five files reviewed, the LPA identified that one out of five staff (S1) does not have any annual training on file, and three out of five staff (S2, S3, S4) are missing 15.5 annual training hours including four (4) hours of which shall be specific to postural supports, restricted health conditions, and hospice care. Otherwise, the staff files were in order. Interviews: During today’s visit, the LPA conducted four (4) resident interviews. No concerns voiced during the interviews. Due to time constraints the LPA will return to complete the annual at a later date. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Sean Beharry.the state’s words, verbatim · CDSS document, Dec 21, 2023

The state marks this report as 10 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.