Veterans Home of California-Ventura

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management – Incident visit at approx 10:50 a.m. for the purpose of investigating self-reported incident report. Upon arrival LPA met with Supervisor Nazanin Nejad explained the reason for the visit. On 07/21/2026, the Regional Office received a self-reported incident which stated, on 07/20/2026, a staff, witnessed alleged abuse involving Staff #1 (S1), and Resident #1 (R1). According to the report, S1 was guiding R1 with R1's walker towards the lobby. Rather than verbally alerting the resident about a turn, R1 abruptly yanked the walker, causing R1 to stumble, S1 then reportedly became aggressive, raising their voice and stating "You need to turn this way because we are going this way to get to the dining room". Another staff also witnessed the incident. At approx 10:15 am. LPA conducted physical plant, interviewed staff, client and reviewed and obtained copies of pertinent documentation relevant to the investigation. No health and safety concerns were observed during the visit. LPA has determined further investigation is required at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Jul 30, 2026

Allegation investigated: Staff is not preventing resident from being harassed by others while in care. Staff do not safeguard resident's personal belongings. Staff do not treat resident with dignity or respect.

Licensing Program Analysts (LPAs) Emily Peraldi and Kelly Dulek conducted an unannounced subsequent complaint visit to this facility. At 10:37 a.m., the LPAs met with staff and explained the reason for the visit. At 10:49 a.m., Administrator Ray Sena met with the LPAs. During the initial visit conducted on 12/16/2025 between 10:36 a.m. and 2:35 p.m., LPA Peraldi conducted a record review, a brief physical plant tour, interviewed the Administrator and two (2) staff. During today’s visit, at 11:17 a.m., the LPAs conducted an interview with the Administrator. At 11:49 a.m., the LPAs reviewed records and obtained copies of pertinent documents. Between 12:34 p.m. and 1:42 p.m., the LPAs along with the Hospital Administrative Resident II (HAR II) Cynthia “Cindy” Gambill conducted a physical plant tour. Starting at 11:24 a.m., the LPAs conducted interviews with one (1) staff and seven (7) residents. Continued on LIC 9099-C. Unsubstantiated Regarding the allegations: 1.) Staff is not preventing residents from being harassed by others while in care. It was alleged that staff did not prevent Resident #1 (R1) from being harassed by Resident #2 (R2) in the dining room. Interviews with staff revealed that in December 2025, R1 and R2 did have a verbal altercation/confrontation in the dining area and staff immediately intervened and separated both R1 and R2. Interviews with Staff #1 (S1) revealed that staff were aware of the issues between R1 and R2 and did take preventative measures to minimize conflict between R1 and R2 such as asking R1 and R2 for the option of moving rooms to differing hallways. Interviews with staff revealed that staff identify, intervene and deescalate if there are conflicts between residents. The information obtained during the investigation did not include 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 allegation is deemed Unsubstantiated at this time. 2.) Staff do not safeguard resident's personal belongings. It was alleged that staff did not ensure that R1’s personal belongings were safeguarded. Interview with S1 revealed that R1 and R2 had conflict amongst themselves and R2 entered R1’s room and possibly moved items around. S1 stated that facility staff inspected R1’s room after being notified of the issue and it was confirmed that no items were stolen or misplaced when R2 entered R1’s room. Furthermore, S1 explained that conversations and meetings were held with both R1 and R2 regarding their conflict and staff were able to intervene and defuse the conflict. The information obtained during the investigation did not include 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 allegation is deemed Unsubstantiated at this time. 3.) Staff do not treat resident with dignity or respect. It was alleged that staff are not treating R1 with dignity or respect in relation to the above noted incident involving both R1 and R2. Interview with staff revealed concerns regarding staff, R1 and R2 have been resolved. Resident interviews revealed that staff are helpful and treat residents with respect. Interviews with residents did not voice any concerns regarding staff. The information obtained during the investigation did not include 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 allegation is deemed Unsubstantiated at this time. Exit interview conducted with Cindy Gambill. . A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 29-AS-20251209084130

Allegation investigated: Staff abandoned resident.

Licensing Program Analysts (LPAs) Emily Peraldi and Kelly Dulek conducted an unannounced initial complaint visit to this facility. At 10:37 a.m., the LPAs met with staff and explained the reason for the visit. At 11:17 a.m., Administrator Ray Sena met with the LPAs. At 11:17 a.m., the LPAs conducted an interview with the Administrator. At 11:49 a.m., the LPAs reviewed records and obtained copies of pertinent documents. Between 12:34 p.m. and 1:42 p.m., the LPAs along with Hospital Administrative Resident II (HAR II) Cynthia “Cindy” Gambill conducted a physical plant tour. Starting at 12:28 p.m., the LPAs conducted interviews with one (1) staff and seven (7) residents. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Staff abandoned resident. It was alleged that the facility was refusing to accept Resident #1 (R1) back from the hospital. During today’s visit, the LPAs interviewed the Administrator and Staff #1 (S1), in which both confirmed that R1 is returning to the community today, February 20th, 2026. During the visit, the LPAs reviewed and obtained copies of relevant documents related to R1 and their hospital stay. At 02:06 p.m., LPAs observed R1 arrive at the facility and confirmed R1’s return to the community. Record reviews and interviews with staff revealed that during R1’s hospitalization, staff had constant communication with hospital staff and R1’s family regarding R1’s condition, safety and plan of care. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation, as the Administrator and facility staff took appropriate measures and ensured that R1 would safely return to the facility. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted with Cindy Gambill. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 29-AS-20260212114019

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 10:04 a.m., the LPA met with staff and explained the reason for the visit. At 10:07 a.m., Hospital Administrative Resident II (HAR II) Cynthia “Cindy” Gambill met with the LPA. Entrance interview conducted. RECORD REVIEW: Between 10:27 a.m. and 2:36 p.m., the LPA conducted a file review for seven (7) residents and six (6) staff. Resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order. Fire drill was last conducted on 12/18/2025. The LPA observed documentation of the Infection Control Plan and Emergency and Disaster Plan. Administrator certificate for Cindy Gambill is current and valid until 04/13/2027. Administrator certificate for Ray Sena is current and valid until 03/31/2027. The LPA obtained a copy of the resident roster and staff roster. During today’s visit, the LPA had a conversation with Cindy Gambill regarding retaining residents with a diagnosis of Dementia. Currently, the facility’s plan of operation does not include a dementia program. The LPA explained to Cindy Gambill that the plan of operation needs to be updated to include a dementia program as two (2) out of fifty (50) residents have a diagnosis of dementia. Cindy Gambill explained that a dementia program will be added to the plan of operation and will be sent to the Department for review. Continued on LIC 809-C. Due to time constraints the LPA will return to complete the annual at a later date. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Failure to correct deficiency may result in civil penalties. Exit interview conducted with Selena Lopez. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 22, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not address an ongoing rodent issue in the facility.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 10:44 a.m., the LPA met with staff and explained the reason for the visit. At 10:49 a.m., Administrator Ray Sena met with the LPA. At 10:50 a.m., the LPA conducted an interview with the Administrator. At 11:00 a.m., the LPA requested and obtained copies of pertinent documents. Between 11:14 a.m. and 11:49 a.m., the LPA, along with the Administrator conducted a physical plant tour. Starting at 11:24 a.m., the LPA conducted interviews with five (5) staff. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Staff did not address an ongoing rodent issue in the facility. The complainant’s concern is that the ongoing rodent issue in the kitchen is due to the kitchen and food storage area not being properly cleaned or monitored. Interviews conducted with the Administrator and kitchen staff revealed that a rodent was observed and caught inside a rodent trap around November 23rd. The interview conducted with the Administrator revealed that EagleShield Pest Control company conducts monthly pest control and that additional rodent control services were initiated as soon as the rodent issue was identified. The Administrator explained that a rodent inspection was done on November 14th and November 19th in which the inspector set up traps inside of the kitchen storage room. The Administrator stated that the pest control company is scheduled again to do a follow up rodent inspection on December 1st. Record review conducted confirmed that the facility has been receiving monthly pest control services from EagleShield Pest Control and an additional rodent control service. The Administrator provided copies of invoices/ receipts for the monthly pest control for July 2025, August 2025, September 2025, October 2025 and rodent inspections for November 14 and November 19. Interviews with kitchen staff revealed that part of their daily / cleaning tasks are to check all areas of the kitchen and food storage areas for rodent droppings. Kitchen staff interviewed indicated that if they do see rodent droppings, they report it to their supervisor and clean the area immediately. During today’s visit, the LPA observed rodent boxes and traps set in place inside the food storage area. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation, as the Administrator and facility staff have consistently taken corrective measures to ensure that the rodent issue is addressed and eliminated. 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. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 29-AS-20251121163215

Allegation investigated: Staff did not accord dignity to resident Staff did not maintain resident’s medical information confidential

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with Administrator Ray Sena and explained the reason for the visit. At 12:15 p.m. LPA discussed the allegations with the Administrator. At 1:03 p.m. LPA conducted a telephone interview with the nursing supervisor Selena Lopez, RN. The nurse who was the subject of this complaint was not in as she works the NOC (overnight) shift. However, the nursing supervisor had already spoke with the nurse regarding this alleged incident and provided LPA with the information from their meeting. (continued on LIC9099C) Unsubstantiated (continued from LIC9099) Resident 1 (R1) had alleged that Staff 1 (S1) had medical information about them and asked R1 about it. R1 felt their privacy was violated. R1 stated the incident happened in their room. After speaking with nursing staff and a social worker, LPA decided not to approach R1 regarding this incident as it might be upsetting to R1 and cause psychological setbacks. During the course of this investigation, it was stated by staff R1 has a history of hallucinations. These hallucinations primarily occurred after R1 had a hospital stay due to a fall. During R1's time at the hospital R1 was prescribed a medication which the nurses felt caused R1 to have hallucinations. The nursing supervisor notified R1's primary care physician (PCP) and since R1's PCP discontinued the medication, R1 is doing better. The nursing supervisor stated she spoke with S1 about this alleged incident. S1 stated they didn't say anything to R1 about the hallucinations. S1 stated they didn't even recall going into R1's room that night. The nursing supervisor stated R1 had reported other instances of hallucinations and not recalling conversations with staff. The nursing supervisor stated she believed S1 as she has not had issues with S1; no complaints from other residents. Based on interviews, these allegations are deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 29-AS-20250311152417

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Teresa Camara and Martha Arroyo conducted an unannounced annual inspection. LPAs met with Administrator/Hospital Administrative Resident II (HAR II) Cindy Gambill and Administrator Ray Sena. Entrance interview conducted. Beginning at 9:40 a.m., LPAs started reviewing records. The facility's emergency disaster plan was complete and last reviewed for accuracy by the Administrator on 2/1/2024. The facility conducts evacuation drills quarterly for each shift, the last one was conducted on 10/17/2024. The State Fire Marshall's report was last done on 8/22/2023 and there were no deficiencies. The last sprinkler inspection was done 12/17/2024 with no deficiencies. The annual fire panel inspection was done 3/19/2024 with no deficiencies. The fire doors were inspected 10/11/2024, the fire damper was inspected 9/22/2024, the fire hydrants were inspected 9/24/2024; all had no deficiencies. The facility's liability insurance is up to date with the current policy expiration date as 2/14/2025. Beginning at 11:15, LPAs along with Administrators, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers throughout the facility appeared fully charged and were last inspected 3/28/2024. Fire extinguishers are inspected by staff monthly. RESIDENT ROOMS/RESTROOMS: The facility consists of 36 resident rooms, including both single and double occupancy. Each room contains a restroom. 10 resident rooms and their accompanying restrooms were observed during today's facility tour. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. All resident restrooms observed contained grab bars and non-skid surfaces. Water temperature was measured in various resident restrooms, and measured between 112.8 degrees Fahrenheit to 113.9 degrees Fahrenheit, which is within the required range. KITCHEN: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. COMMON AREAS: This includes 2 (two) libraries, a gym, 2 (two) lounges, dining room, spa, laundry rooms, and common restrooms. LPAs observed a fireplace, which was adequately screened, in the dining area. LPAs observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Other required postings were observed in the common hallways. OUTDOOR SPACE: LPAs and Administrators toured the outside area of the facility. There are various outdoor gardens, a common courtyard, parking areas, as well as multiple shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. RECORD REVIEW: LPAs reviewed records beginning at 12:35 p.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All five (5) staff files and five (5) resident files observed were in compliance with regulation except the criminal record clearance for Staff 1 (S1) was not associated to the facility. INFECTION CONTROL: During today’s visit, the LPAs reviewed the facility's Infection Control Plan which appeared adequate. There are hand washing signs posted throughout the facility and hand sanitizer stations throughout the facility. MEDICATION REVIEW: Beginning at 11:45 a.m. LPAs reviewed medications for two residents. The January 2025 centrally stored medication and destruction record (CSMDR) for Resident 1 (R1) in the medication room on the 300 block of rooms was missing. The CSMDR was complete for Resident 2 (R2) in the medication room on the 200 block of rooms. Medications appear to be given as prescribed. INTERVIEWS: During today's visit, LPAs interviewed four (4) staff and four (4) residents. No concerns noted. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D). Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jan 23, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced case management visit regarding a self-reported incident on the relocation of three (3) residents from Veterans Home of California – West Los Angeles (License #197607966) to Veterans Home of California – Ventura (License #565801637) located at 10900 Telephone Road, Ventura, CA 93004 due to wildfire evacuation orders. LPA met with Administrator Cynthia Gambill and explained the reason for the visit. During the visit, LPA conducted a health and safety check and no concerns were observed. The Administrator confirmed three residents have been temporarily relocated to Veterans Home of California – Ventura. At 11:38 LPA conducted a brief facility tour and met with two of the three residents evacuated to this facility. Resident 1 (R1) was taken to a local hospital this morning due to viral symptoms but is due back at the facility later today. Resident 2 (R2) shares a room with R1 and is quarantining, although R2 has no symptoms at this time. Resident 3 (R3) shares a room with another resident at this facility. Each room has a shared full bathroom. R1, R2 and R3 all self administer their medications. They each have a night stand to store their medications. Each of them have a bed with clean linens, room to store their belongings, and sufficient supplies of hygiene items. They are all non-ambulatory. The residents were all sent with records including the face sheet, physician's report, POLST, insurance cards, and medications lists. At 11:55 a.m. LPA inspected the food supply which had a sufficient amount of two-day perishable and seven-day non-perishable food supplies. LPA reviewed resident and staff rosters, the facility's Emergency Operations Plan, as well as the last fire inspection and fire system testing dated 12/17/2024. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jan 13, 2025

Allegation investigated: Staff is verbally abusing residents

Licensing Program Analyst (LPA) Teresa Camara conducted a complaint investigation visit regarding the above noted allegation. LPA met with administrator Cindy Gambill and explained the reason for the visit. LPA interviewed ten (10) residents starting at 10:20 a.m. LPA interviewed dining room staff at 11:37 a.m. and the food service manager at 11:39 a.m. Based on interviews, one resident stated that Staff 1 (S1) seemed to not be catching on to the job as food server and needed extra training. The resident was not aware of S1 yelling at residents. None of the other residents observed or experienced any staff yelling or otherwise being rude to residents, nor had the dining room staff or manager who had been interviewed. Based on interviews, the above noted allegation is deemed Unsubstantiated at this time. Exit interview conducted and report issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 23, 2024 · control 29-AS-20241016084837

Allegation investigated: Neglect/Lack of Supervision: Resident #1 (R1) used illegal drugs at the facility while under the care of the facility

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with pending Administrator Ray Sena and explained the reason for the visit. On 02/28/2024, the Woodland Hills North Adult and Senior Care office received a complaint of neglect/lack of supervision. Resident #1 (R1) used illegal drugs at the facility while under the care of the facility. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Laarni Santiago. On 03/06/2024, from 9:30am to 1:15pm, Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA Dulek arrived at the facility at 9:30am and met Continued on LIC 9099-C Unsubstantiated with the Administrator/Hospital Administrative Resident (HAR) II Cynthia Gambill and the pending Administrator Ray Sena. An entrance interview was conducted. During the visit, the LPA interviewed both members of the Management team at 9:36am, reviewed and received copies of pertinent documents, and toured the facility at 11:50am. No immediate health and safety hazards were identified during the visit. The LPA determined further investigation was needed to determine findings for the above allegation. Management was made aware that the allegation was referred to and accepted for investigation by the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Laarni Santiago. Investigator Santiago conducted interviews on 03/22/2024, at approximately 10:41am, with the Assistant Administrator; on 04/05/2024, from approximately 2:01pm to 3:00pm, with the Administrator, Resident #1 (R1), and a facility resident; on 05/31/2024, from approximately 10:53am to 12:00pm, with Supervising Registered Nurse, Supervising Psychiatric Social Worker, a facility resident, and Registered Nurse Infection Preventionist; on 06/04/2024, from approximately 10:02am to 6:11pm, with facility attorney, Witness #1 (W1), the Long-Term Care Ombudsman (LTCO), and the facility attending physician. In addition, the investigator reviewed Ventura County Medical Center (VCMC) records, Community Memorial Hospital (CMH) records, and facility file documents related to R1. A review of R1’s preplacement appraisal, dated 09/09/2021, revealed R1 denied that they had a history of substance abuse but reported that they last used cocaine “2 years ago.” R1 had a history of substance use disorder (SUD) treatment. R1’s physician report, dated 03/09/2022, listed the diagnosis as A-fib, Hypertension, Diabetes Type II, Ambulatory, independent with all capacities of self-care and medication management, able to leave the facility unsupervised, able to follow instructions, and able to communicate needs. According to the VCMC medical records, the records documented that R1 tested positive for amphetamine on 08/07/2023. The CMH lab results indicated R1 tested positive for amphetamine on six (6) different dates from the period of 08/27/2023 to 01/30/2024. The Department’s investigation revealed R1 was admitted to the facility on 06/09/2022 but the staff were unaware of R1 being under the influence until R1 tested positive for amphetamines in August 2023. On Report Continued on LIC 9099-C 08/05/2023, R1 was admitted to the VCMC for heart failure, blood clot in leg and testicular pain. As part of the evaluation and management of acute conditions, a urine toxicology screen was done by the hospital team, and R1 tested positive for amphetamine on 08/07/2023. Interviews with staff and outside sources revealed that the facility was not aware of R1’s substance abuse until R1 was admitted to the hospital. The facility referred R1 to a substance use disorder (SUD) treatment program multiple times and conducted random weekly drug screenings. When R1 declined to attend an SUD treatment program and continued to test positive for meth/amphetamine, R1 was given a Code of Conduct letter and warned of a possible eviction. The facility staff sought the California Department of Veterans Affairs (CalVet) legal team to work on R1’s eviction procedures and R1 was served an eviction notice on 03/13/2024. However, the legal team revealed that R1 could not be evicted without going through the court and legal proceedings. Furthermore, that “CalVet is limited by law and regulations for the reasons to which they could evict.” The facility staff and CalVet’s legal team did not have supporting evidence to prove that R1 was using drugs in the property as R1 was independent and could leave the facility unsupervised. Staff denied that they allowed R1 to use illicit drugs at the facility but advised that they wanted to give R1 an opportunity to get help before evicting R1. The facility took steps to initiate the eviction process which was filed by the Superior Court of California County of Ventura on 04/15/2024. A settlement was reached in court and R1 was allowed to remain at the facility if R1 did not violate the stipulations written in the Terms of Agreement dated, 05/23/2024 (Last Chance Agreement). As of 05/31/2024, R1 remained at the facility and staff interviews revealed that R1 had been testing negative for illegal drugs since R1 was served their eviction notice. During today's visit, pending Administrator informed LPA that R1 was admitted this morning to a SUD treatment program where R1 will remain for a minimum of 30-day treatment. Based on interviews conducted and records reviewed, although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation “Neglect/Lack of Supervision: Resident #1 (R1) used illegal drugs at the facility while under the care of the facility” is deemed Unsubstantiated at this time. Exit interview conducted, copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 12, 2024 · control 29-AS-20240228090830

Allegation investigated: Facility is not maintained clean and sanitary Residents' rooms are so cluttered that it is a safety hazard Housekeeping staff do not receive training

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to complete and deliver investigation finding. Upon arrival LPA met with Administrators Cynthia Gambill and Ray Sena. Reason for the visit was explained. On 02/06/2024, Community Care Licensing Division received the above complaint allegations. Investigation into the allegations consist of facility physical plant tour; staff, and resident interviews on 02/14/2024; and records review on 5/13/2024. Following is a summary of the allegations and investigation finding: Allegation) Facility is not maintained clean and sanitary. It was alleged that resident rooms have not been cleaned for months; some for probably years and facility kitchen is also dirty. (Continue to LIC9099c). Unsubstantiated During the initial visit on 02/14/2024, facility physical plant tour was conducted. Facility kitchen, common areas, and six (6) resident rooms were randomly inspected. LPA observed the kitchen to be clean with staff working with gloves and hair nets on while in the kitchen. Interview with staff revealed that the kitchen, common areas are cleaned daily. Resident rooms (206, 303, 322, 323, 326,329) were toured and residents were interviewed on 02/14/2024. Staff and residents reported that the rooms are scheduled for cleaning once a week and daily trash pickup. Residents interviewed did not have any issues with facility housekeeping and expressed that the housekeeping staff do a good job. Some of the residents expressed that they don’t like their personal belongings touched however would allow housekeeping to clean if they are in the room. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility is not maintained clean and sanitary” is deemed unsubstantiated at this time. Allegation) Residents' rooms are so cluttered that it is a safety hazard. It was alleged that there is so much clutter in some of the resident rooms that it is a safety hazard. It was also reported that some residents have belongings stacked so high it blocks the windows. During the initial visit on 02/14/2024, six (6) resident rooms were randomly inspected (rooms 206, 303, 322, 323, 326,329) and residents were interviewed. Residents reported that the rooms are cleaned once a week by staff. Residents interviewed expressed that they have a lot of personal belongings in their rooms and try their best to arrange everything to avoid any safety hazards. Some of the residents did have boxes in the middle of the room and reported to LPA that they are in the process of going through the boxes at the moment and will move things around once they are done. Residents expressed that they have sufficient space to get around in their room and did not feel that there is any safety issues. LPA did not observe any immediate safety hazard in resident rooms toured at the time. Administrator reported that they do their own random inspections of resident rooms and identify residents who my need assistance to avoid any safety hazards. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Residents' rooms are so cluttered that it is a safety hazard” is deemed unsubstantiated at this time. Allegation) Housekeeping staff do not receive training. It was reported that the housekeepers that work here are not properly trained. Administrator and staff denied the allegation. Housekeeping staff training records were reviewed on 05/13/2024 and no discrepancies were observed at this time. Random residents interviewed on 02/14/2024 expressed that the housekeeping staff are well trained and do a good job. Residents interviewed did not report any issues with housekeeping staff. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Housekeeping staff do not receive training” is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, May 13, 2024 · control 29-AS-20240206161748

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 9:55 a.m., LPA met with Hospital Administrative Resident (HAR) II Cynthia Gambill and explained the reason for the visit. The reason for today's inspection is to follow up on a self-reported incident dated 04/22/2024. The report pertains to Resident #1 (R1) reporting physical abuse by Staff #1 (S1). At 9:58 a.m., the LPA conducted an interview with HAR II. At 10:10 a.m., the LPA requested and obtained copies of pertinent documents. At 10:45 a.m., the LPA and HAR II conducted a brief physical plant tour. No immediate health and safety concerns were observed during today's inspection. Additional report may follow if warranted. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 2, 2024

Allegation investigated: Staff does not keep residents rooms free from odor.

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 09:30AM for an unrelated visit and met with Hospital Administrative Resident (HAR) II Cynthia Gambill and pending Administrator Ray Sena. Entrance interview conducted. As this complaint was received during the unrelated visit, LPA discussed this allegation with HAR II 12:54PM. During today's visit, LPA interviewed both members of the Management team at 09:36AM and HAR II again at 12:54 PM and toured the facility at 11:50 AM. The following was then determined: During facility tour, LPA did not note any odors in the facility common areas nor in the rooms toured, which included a selection of those listed in the complaint allegation. Interview with management revealed that residents are responsible for maintaining their own personal living space, but the facility does offer Report Continued on LIC 9099-C Unsubstantiated housekeeping services daily to include vacuuming, emptying trash and cleaning resident restrooms. Residents do maintain the right to refuse housekeeping services, however, the facility does have a code of conduct which includes a statement that "each resident is required to maintain or cooperate with staff in maintaining his or her living area in a safe, clean, neat and sanitary condition." Interview with management revealed that when residents do not comply with the Code of Conduct, they are issued a violation and encouraged to participate in a compliance plan. At the time of today's visit, no odors were observed in the facility and Management indicated there have been no noticeable odors brought to their attention recently. Based on interview and observation, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that "staff does not keep residents rooms free from odor" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 29-AS-20240306122033

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 09:15AM for an unannounced annual inspection. Upon arrival, the LPA met with Administrator/Hospital Administrative Resident II (HAR II) Cindy Gambill. Entrance interview conducted. Beginning at 09:54AM, LPA along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Annual fire inspection was completed on 08/22/2023. No deficiencies were noted at that time. Fire extinguishers throughout the building were observed to be fully charged and inspected monthly. RESIDENT ROOMS/RESTROOMS: The facility consists of 36 resident rooms, including both single and double occupancy. Each room contains a restroom. 10 resident rooms and their accompanying restrooms were observed during today's facility tour. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. All resident restrooms observed contained grab bars and non-skid surfaces. Water temperature was measured in various resident restrooms, and measured between 114.7 degrees Fahrenheit to 115.4 degrees Fahrenheit, which is within the required range. KITCHEN: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPA observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. COMMON AREAS: This includes 2 (two) libraries, a gym, 2 (two) lounges, dining room, spa, laundry rooms, and common restrooms. LPA observed a fireplace, which was adequately screened, in the dining area. LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Other required postings were observed in the common hallways. Report Continued on LIC 809-C OUTDOOR SPACE: LPA and Administrator toured the outside area of the facility. There are various outdoor gardens, a common courtyard, parking areas, as well as multiple shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. RECORD REVIEW: LPA reviewed records beginning at 10:35AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All five (5) staff files and five (5) resident files observed were in compliance with regulation. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's Infection Control Plan and the Emergency Disaster Plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency Disaster Plan was observed to be complete and updated annually as required. Fire drills are conducted monthly, with the last fire drill documented on 12/12/2023. Last earthquake drill was conducted on 10/19/2023. MEDICATION REVIEW: Beginning at 01:35PM, LPA reviewed Medication Administration Records (MAR) for 3 (three) residents. All items observed were in compliance with regulation. INTERVIEWS: During today's visit, LPA interviewed four (4) staff and four (4) residents. During today's visit, LPA obtained a copy of the facility's liability insurance as well as an updated Personnel Roster. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jan 9, 2024

Allegation investigated: Resident not being treated with dignity and respect

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced amended report to correct an error in the 10/27/2023 Complaint Investigation Report and to add additional information to the report. Licensing Program Analyst (LPA) Esther Cortez arrived unannounced to conduct an initial 10-day complaint visit. The LPA met with Administrator Selena Garcia Lopez and explained the reason for the visit. Administrator Selena had to leave and instructed Cindy Gambill, Hospital Administrative Resident 2 (HOR2) to sing and review the report. Today, the LPA interviewed two (2) staff and four (4) residents and reviewed documents between 10:50 a.m. and 3:30 p.m. Report will contnue on LIC9099-C Substantiated Regarding the allegation, Resident not being treated with dignity and respect, it was alleged that on 08/20/2023, Staff #1 (S1) told Resident #1 (R1) that they were trying to fall to sue the facility. It was further alleged that R1 reported the incident to S2 and S2 reported the incident to management. The LPA observed that the Administrator had submitted an Unusual Incident Report (UIR) to document the above-mentioned interaction and/or incident. After review of the incident, on 08/28/23 the Administrator informed the LPA that they were in the process of reviewing the event. During the investigation, a written charting note made by S1 regarding the incident was provided to the LPA. S1 wrote that R1 had approached them and requested for R1’s walls to be checked for leaks, and no leakage was found. Later R1 had gone outside as they were “concerned about the downspout flooding outside”. S1 stated that they requested R1 to go back inside, which they did, and R1 later went back outside. S1 wrote they told R1 “maybe you are trying to hurt yourself here, so you can sue the home,” after they had requested for R1 to come inside again. Additionally, Licensing Program Manager KaSandra Lopez conducted a telephone interview with S1 on March 13, 2024. Based on record review, and interviews there is sufficient evidence to support the allegation that Resident not being treated with dignity and respect. The allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted and copy of the report and appeal rights provided to HOR2 Cindy Gambill. Regarding the allegation, Staff threatened resident, it was alleged that on 08/20/2023 S1 threatened R1 to go inside their room or that they would contact the sheriff. It was further alleged that R1 reported the incident to S2 and S2 reported the incident to management. The LPA observed that the Administrator had submitted a Special Incident Report (SIR) to document the above-mentioned interaction and/or incident. To investigate the allegation, the LPA reviewed pertinent documents, and conducted resident and staff interviews. Interviews and record review revealed that S1 told R1 “if you don’t follow my directions, I’m going to call the Sheriffs.” However, interviews with S1 and R1 revealed that S1 had told R1 to step away from blocked off areas due to water leaking multiple times, and R1 had been asked to go inside their room multiple times due to safety concerns due to the hurricane and heavy rain on that day. Interview with one witness (W1) revealed that even though S1 did tell R1 to go inside their room or they would contact the sheriff, it was due to safety concerns. Lastly, all additional residents interviewed revealed that they feel safe and have no concerns regarding S1. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Staff threatened resident”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 29-AS-20231025114008

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 10, 2023

Personal Rights. Each resident shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Administrator stated S1 will be issued a letter of Instruction and received training on residents personal rights. Administrator agrees to submit proof by 11/10/23

Allegation investigated: Staff inappropriately spoke to a resident while in care

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced initial 10-Day complaint visit to the facility at 12:20 p.m. the LPA was greeted by Cindy Gambill, Hospital Administrative Resident 2 (HOR2), and discussed the reason for the visit. Administrator Selena Garcia Lopez arrived shortly. During today's visit the LPA obained copies of pertinent documents at 12:45 p.m. and interviewed three (3) residents, two (2) staff and the administrator between 01:00 p.m. and 3:15 p.m. Report will continue on LIC9099-C Substantiated Regarding the allegation, Staff spoke inappropriately to resident in care, it was alleged that on 09/16/2023, Staff #1 (S1) began yelling at Resident #1 (R1) as R1 walked towards the nursing station and yelled “They don’t give a shit about you!” It was further alleged that R1 reported the incident to S2, and S2 intervened and told S1 to stop yelling. During the investigation, R1 informed the LPA that S1 had yelled at them from the hallway and woken them up and confirmed that S1 yelled “They don’t give a shit about you.” A written statement made by S1 regarding the incident was provided to the LPA. S1 wrote that he spoke to the resident, “we don’t care about your shitty attitude. I am passing out meal orders and ensuring that you are safe and getting your meals.” Based on record review, since S1 admitted to speaking inappropriately to R1, there is sufficient evidence to support the allegation that staff spoke inappropriately to resident in care. The allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC9099-D). Exit interview was conducted with the Administrator. A copy of the report and Appeal Rights were issued. Regarding the allegation, Staff yelled at residents while in care, it was alleged that on 9/16/2023 Staff #1 (S1) began yelling at Resident #1 (R1) as R1 walked towards the nursing station and yelled “They don’t give a shit about you!” It was further alleged that R1 reported the incident to S2, and S2 intervened and told S1 to stop yelling. During the investigation, R1 informed the LPA that S1 had yelled at them from the hallway and woken them up and confirmed that S1 yelled “They don’t give a shit about you.” The LPA was unable to interview S2, however was able to interview two additional residents. When asked if they have ever heard staff yelling at residents or to them, they stated that they had not heard staff yelling, nor had they been yelled at while in care. They stated, “staff is real great” and that staff are “pretty mellow”. In addition, Administrator Selena stated that even though S1 had admitted to speaking inappropriately to R1, S1 denied yelling at S1. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Resident was yelled at while in care”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of the report was provided to Administrator Selena.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 29-AS-20230920135710

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 6, 2023

87468.1(a)(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...This requirment was not met as evidence by: Based on interviews and record review, the licensee did not comply with the section cited above when staff (S1) spoke to R1 inappropiately which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Administrator has agreed to review with staff (S1)the regulation 87468.1 (a)(1)-and send proof orself-verification via a letter to the CCLD department by 10/06/2023.