Woodbridge Terrace

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho and Regional Manager (RM) Monica Tran arrived unannounced for the purpose of conducting the Required 1 Year Inspection. LPA and RM were greeted and granted entry and met with Executive Director (ED) Christian Otbo after the stating the reason for the visit. The facility is licensed for 180 residents, 40 ambulatory and 140 non-ambulatory. Facility maintains a hospice waiver approved for 20. As of today’s date, the resident census is 140 of which 13 are receiving hospice care. Facility is operating within the conditions and limitations specified on the license. The ED has a valid administrator’s certificate expiring February 8, 2028. At or approximately 9:45am, LPA and RM toured the physical plant including all common areas accompanied by ED Otbo. The facility is a three story property housing Assisted Living (AL) and Memory Care (MC) residents. LPA and RM observed the facility to be clean, sanitary, and in good repair. Hallways were free of clutter. LPA and RM inspected a sample size of 12 resident units of which 2 are memory care units. The resident bedrooms had all required elements with ample lighting. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and slip resistant mats were available. The hot water temperature in the resident bathrooms measured within range between 111.9-120.0 degrees Fahrenheit. All shared bathrooms in the common areas had sufficient supply of soap, toilet paper, and paper towels. The hot water temperature measured within range between 111.5-114.0 degrees Fahrenheit. LPA and RM inspected the kitchen and dining area. Facility maintains ample supply of two day perishables and seven day non-perishable food. LPA and RM observed staff engaged in food preparation wearing gloves and adhering to food sanitation practices. LPA and RM observed medications are centrally stored in the medication room/carts and administered as prescribed per review of the medications and Medication Administration Records (MARs). Toxins, chemicals, cleaning solutions are stored in a locked closet. The Complaint Poster (PUB 475) meets the size requirement and was posted in the entry way. LPA and RM toured the outside grounds. The outdoor passageway is free of obstruction and slip hazards, and there are sufficient seating and shading. The exit gates and delayed egress are operational for the safety of the residents. Facility maintains a working generator, emergency food supply, and 8, 55 gallon water containers. The fire extinguishers are mounted, charged, and serviced on November 11, 2025 per inspection tags. The carbon monoxide detectors were tested and operational. The facility is currently undergoing a comprehensive fire alarm upgrade and replacement and is expected to be completed within the next few weeks per the June 29, 2026 notice. Prior to the upgrade, the fire alarm was last tested on October 1, 2025. The evacuation chairs were observed in each stairwell. Facility staff conducts quarterly emergency disaster training, however the training was not conducted per shift. There are no health and safety hazards observed at the time of inspection. During inspection, LPA reviewed the Infection Control Plan and the Emergency Disaster Plan (LIC610E). LPA conducted a review of 12 residents' and 4 staff files. No discrepancies were noted. LPA interviewed 8 residents and 2 staff. The medications and MARs were reviewed for 4 residents. LPA and RM observed one medication for one resident had extra pills remaining; however upon verifying the Medication Administration Record, the resident was administered as prescribed. Staff indicated that the start date was documented incorrectly. The ED was reminded of the importance of ensuring the start date for medications is documented accurately and for staff to receive emergency disaster training on a quarterly basis per shift accounting different emergency scenarios. Based on the observations made, no deficiencies are being cited. Advisory Note (LIC9102s) are being issued during the visit. An exit interview was conducted with Executive Director Christian Otbo, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Jun 29, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received an Unusual Incident/Injury Report on 01/06/2026 for an incident that occurred with Resident 1 (R1) on 12/27/2025. While at the facility LPA Mendivil requested copies of admission agreement, medication administration records for R1, care notes , physician's report and staff schedule to be emailed to LPA by COB 01/06/2026. LPA toured common areas of the facility. LPA observed Assisted Living residents participating in chair volleyball and Memory Care residents were in the common area watching a movie. LPA did not observe any immediate health and safety concerns during today’s visit. No deficiencies cited at this time. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 6, 2026

Allegation investigated: Staff left resident unattended in soaking wet and dirty diapers for extended periods resulting in multiple UTIs Staff mismanged resident's medication Faciltiy lacks management oversight Insufficient staffing to meet residents’ needs

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on 08/14/2023 and the initial 10 day visit was conducted on 08/22/2023 by LPA Tirre. LPA Tirre obtained copies of pertinent documents such as physicians report. LPA Mendivil conducted interviews with staff and residents. Regarding the allegations Staff left resident unattended in soaking wet and dirty diapers for extended periods resulting in multiple UTIs ,Staff mismanged resident's medication, Faciltiy lacks management oversight ,Insufficient staffing to meet residents’ needs the investigation revealed the following: It was alleged that Resident 1 (R1) was left unattended in soaking wet diapers for extended periods of time. Per review of R1's physician report dated 02/20/2023 R1 was diagnosed with Vascular Dementia. Unsubstantiated Per physican report R1 did not have issues with bowel or bladder impairment and was able to care for own toileting needs. Based on care plan from May 2023 resident was not incontinent in either bowel or bladder. R1 was able to ambulate with the use of a walker and was able to communicate their needs. Based on internal chart notes, after R1's hospital stay on 08/14/2023 staff was providing assistance with incontinent care. It was alleged the facility left resident unattended in soaking wet and dirty diapers for extended periods resulting in multiple UTIs, based on interviews with 4 out of 4 staff stated they do not leave residents in dirty diapers for extended periods. Per interviews staff stated all residents are checked at minimum every two hours unless resident's care plan requires more frequent checks. Interviews with Current Executive Director (ED) Christian Otbo stated that if residents are refusing services such as incontinent care or showers staff will document and reach out to family for assistance. Based on interviews conducted 4 out of 4 staff stated although the residents can be difficult and not want to be changed they will utilize another caregiver in hopes that will ease the resident and allow for the service to be provided. Per interview with Med-tech stated if residents refuse medications it will be documented and the physician will be notified. Med-tech staff stated once they provide medication to the resident they are trained to remain with residents until medications are taken and will check for cheek pocketing of medications. Per review of R1's medication administration records medications were refused by R1 on multiple occasions in August 2023 and were documented. Per ED stated they were no complaints about facility management oversight in 2023 or currently. Per interviews with 3 out of 4 staff stated they do not have concerns about management oversight, 1 staff member was not asked about management oversight. Per interview with ED stated the facility has used staffing agency to fill shifts they could not cover. Interviews with 4 out of 4 staff stated they did not feel they were understaffed. Interviews with 4 out of 4 residents stated their needs are met. Therefore based on the preponderance of evidence through records reviewed and interviews the allegations Staff left resident unattended in soaking wet and dirty diapers for extended periods resulting in multiple UTIs ,Staff mismanaged resident's medication, Facility lacks management oversight ,Insufficient staffing to meet residents’ needs are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 22-AS-20230814153307

Type of visit: Case Management - Incident

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver case management findings. LPA was greeted and granted entry and explained the reason for the visit. The Department received an Unusual Incident/Serious Injury Report on September 12, 2025, for an incident that occurred on September 10, 2025, with Resident 1 (R1). LPA Mendivil conducted a case management visit on September 16, 2025, and gathered admission agreement, medication administration records for R1, care notes and staff schedule. The course of the investigation revealed the following: R1 was admitted to the facility on January 12, 2025. Per review of R1’s level of care effective on August 31, 2025, stated R1 is a fall risk and staff were to provide safety checks and remind R1 to use their walker when ambulating. R1 has a diagnosis of senile dementia, hypertension and falls based on R1’s physicians report dated January 11, 2025. On September 10, 2025, around 6:30pm, R1 had an unwitnessed fall in the Memory Care common tv room. Staff 1 (S1) reported they were assisting another resident that pressed the egress door at the time of the fall, approximately 20 feet away from R1. When S1 came back into the living room area they observed R1 to be on the floor next to the recliner they were previously sitting on. It was reported that S1 asked for assistance from other staff to assess R1. R1 was observed to have a small skin tear on elbow and expressed pain upon moving their right leg. It was then reported that the facility called 911 and the resident was taken to the hospital where they were diagnosed with a hip fracture. Prior to hospitalization, incident reports reviewed showed R1 had six separate falls which resulted did not result in any serious bodily injuries until the fall on September 10, 2025. Based on interviews with Executive Director Christian, it was reported that R1 had 2 assessments one at admission and once again in August of 2025. Per review of incident reports for falls on January 28, 2025; March 17,2025; March 25, 2025; April 16, 2025; May 14, 2025; May 18, 2025; July 07, 2025; August 02, 2025; and September 10, 2025; staff assessed R1 following falls. In addition, R1’s family and physician were notified. Per interviews with R1’s physician assistant (PA) it was reported R1 had significantly more falls at their previous facility and the PA stated they did not feel facility staff were neglectful or provided inadequate care for R1. Therefore, based on evidence through records reviewed and interviews, the Department could not corroborate if neglect/lack of care and supervision caused R1’s fall and injuries. No deficiencies are being cited. An exit interview was conducted, and a copy of this report was provided to Executive Director.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Case Management - Incident

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management visit. LPA was granted entry into the facility by staff and explained the reason for the visit. The Department received an Unusual Incident/Injury Report on 09/12/2025 for an incident that occurred with Resident 1 (R1) on 09/10/2025. LPA Mendivil obtained copies of LIC 602 and Care Plan via email on 09/12/2025. While at the facility LPA Mendivil requested copies of admission agreement, medication administration records for R1, care notes and staff schedule to be emailed to LPA by COB 09/16/2025. LPA toured common areas of the facility. LPA observed Assisted Living residents participating in chair volleyball and Memory Care residents were in the common area watching a movie. LPA did not observe any immediate health and safety concerns during today’s visit. No deficiencies cited at this time. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2025

Type of visit: Required - 1 Year

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Fred Arias made an unannounced visit to conduct a required annual. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During today’s visit, LPA Mendivil along with Daisy Gonzales, Hospitality Service Director toured the facility and inspected the physical plant, including but not limited to testing hot water temperature in six bathrooms. The hot water temperature measured between 115 and 120 degrees Fahrenheit. The facility’s last fire drill was conducted on May 15th, 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA Arias observed medication storage and reviewed the centrally stored medications for three residents. Per review completed medication appear to be being given as prescribed. LPA Mendivil observed activities in the form of group exercise, hair salon and gym. LPA Arias reviewed six out of six staff records. LPA Arias conducted a complete review of seven resident records. LPA Mendivil confirmed that administrator has a current administrator certificate which expires on 02/09/2026 Based on the observations made during today’s visit no deficiencies cited on this date. An exit interview was conducted with facility staff and copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 18, 2025

Allegation investigated: Staff are mishandling the residents' level of care assessments.

On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Executive Director Christian Otbo and explained the reason for the visit. The Department received the complaint on 09/06/2023 and LPA Mendivil conducted the initial 10 day visit on 09/12/2023. LPA Mendivil interviewed staff and obtained copies of blank assessments. Regarding the allegation that staff are mishandling the resident's level of care assessments, the investigation revealed the following: It was alleged faciltiy is mishandling resident's level of care assessments. Based on interviews with 2 out of 2 staff on 09/12/2023 both staff stated due issues with internal systems they were not able to update assessments electronically, but were providing all services required for each resident. Unsubstantiated Interview conducted with current Executive Director (ED) Christian stated once a resident has placed a room deposit and completed the LIC 602 Physician's Report the facility will set up an appointment to conduct the assessment. ED stated will conduct assessment with resident and family and ensure everyone is aware of the level of care that was assessed. Interviews with staff that assist with Assisted Living care assessments stated the residents are involved and can ask for their care plans. Interviews with 8 out of 8 residents stated they cannot specifically remember their care assessments but were present for conversations about their care. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation staff are mishandling the residents' level of care assessments is determined to be UNSUBSTANTIATED,meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2025 · control 22-AS-20230906145516

Allegation investigated: Medication not being administered as prescribed Staff did not treat resident with dignity and respect Facility is charging for services not agreed upon admission

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Executive Director Christian Otbo and explained the reason for the visit. The Department received a complaint on 10/18/2022 and the initial 10 day visit was conducted on 10/25/2022 by LPA Mendivil. During the initial visit LPA Mendivil obtained copies of pertinent documents such as staff schedule, resident assessments and physician reports. LPA Mendivil also interviewed staff and residents. Regarding the allegations medications not being administered as prescribed, staff did not treat resident with dignity and respect and facility is charging for services not agreed upon admission, the investigation revealed the following: It was alleged that Resident 1 (R1) had to wait for over 2.5 hours to receive their medication. CONT on LIC 9099-C dated 05/29/2025 Unsubstantiated Based on interviews with 5 out of 5 staff stated residents get their medications as prescribed. Former Executive Director Myra Aragones stated the facility does not withhold resident's medications and notates when resident's refuse medications. Current Executive Director Christian Otbo stated has not heard of any issues with residents receiving their medications as prescribed. Review of R1's medication administration record indicated resident received their medications as prescribed. Interviews with 6 out of 8 residents indicated they receive their medications as prescribed. The remaining 2 residents manage their own medications. It was alleged that due to R1 waiting for 2.5 hours for their medication staff did not treat resident with dignity and respect following the medication incident. Based on interviews with 6 out of 6 staff stated they treat residents with dignity and respect. Staff stated they are aware and trained on resident's personal rights. Interviews with 8 out of 8 residents stated they are treated with dignity and respect by all staff. It was alleged the facility is charging for services that were not agreed upon at admissions. Per interview with former Executive Director Myra Aragones stated that the facility can reassess residents based on a change of condition and provide the services currently needed. Myra stated as residents age they may have change in condition so the facility will provide assistance with Activities of Daily Living (ADLs) as needed. Interviews with 8 out of 8 residents stated they cannot specifically remember their care assessments but were present for conversations about their care. Therefore based on the preponderance of evidence through interviews and records reviewed the allegations medications not being administered as prescribed, staff did not treat resident with dignity and respect and facility is charging for services not agreed upon admission are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided.the state’s words, verbatim · CDSS document, May 29, 2025 · control 22-AS-20221018111730

Allegation investigated: - Staff did not intervene when visitor caused injury to resident

Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to deliver findings for the allegation mentioned above. LPA met with Woodbridge Staff Danna Dsaachs. It was alleged that staff did not intervene when visitor caused injury to the resident. During the investigation LPA interviewed Resident 1 (R1), staff, and witnesses; checked R1’s files; and reviewed R1’s physician report, needs and services plan, identification form and incident reports from the last 3 months of R1. The investigation determined the following: During the investigation LPA asked R1 if their spouse ever hurt them before, R1 denied their spouse hurt them despite being impatient. When asked about the staff at Woodbridge Terrace, R1 replied they were very helpful, great, and provided the care and supervision they needed. Despite R1’s diagnoses and physical limitations, R1 tries to do things independently without any assistance. Witnesses and staff Unsubstantiated interviewed during the investigation all agreed that R1 is a bit stubborn and oppositional creating some minor friction between R1 and their spouse. Since the alleged incident occurred, Executive Director (ED) Christian Otbo explained the staff have been monitoring R1 and their spouse. The Irvine Police Department (PD) were contacted right away by the facility when the alleged incident was first reported to facility management staff, acknowledging how serious they took the situation. Irvine PD talked to R1 and their spouse and let the facility know nothing criminal occurred after their investigation, concluding there are no indications the spouse intentionally harms R1 and the fact the complaint of pain could be due to a prior rotator cuff injury. Based on the police report LPA obtained from Irvine PD, the facility always had personnel/caregivers typically stayed around the couple when they were together prior to the incident occurring. In the police report, the investigator also reported the facility placed enough safeguards to deter further harm toward R1 afterwards, in which a caregiver is always present with them when R1’s spouse visits. The police investigator noted in the report the facility continually follows up and document’s R1’s shoulder pain. 3 out of 3 facility staff interviewed indicated that the facility did keep a close eye on R1 and their spouse after the incident. Assisted Living Director (ALD) Rose Alcantara explained that the pair have supervised visits at the facility bistro and library where generally there are a lot of people and staff present. If they go to R1’s room a caregiver is always present with them to ensure safety measures for R1. ALD Alcantara also mentioned the facility did safety checks, checked up on R1 every hour and did a medical assessment, where x-rays indicated no evidence of a fracture or injury. Therefore, based on LPA Tea's observation and interviews conducted and records review the allegation the staff did not intervene when visitor caused injury to resident has been determined to be unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited at this time and an exit interview was conducted and a copy of the report and confidential names list was provided to the facility.the state’s words, verbatim · CDSS document, Apr 25, 2025 · control 22-AS-20240212114038

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today's visit was to conduct a case management. LPA Tea was greeted and granted entry into the facility by Executive Director (ED) Christian Otbo. On this day LPA Tea amended LIC9099 dated 01/16/2025. LPA reviewed amended report with executive director. An exit interview was conducted with the ED Otbo. A copy of this report and amended LIC9099 was provided to the facility.the state’s words, verbatim · CDSS document, Jan 16, 2025

Allegation investigated: Facility is accepting bedridden residents, but do not have an approved fire clearance for it. Facility is not adhering to physician reports

This unannounced investigation inspection by Licensing Program Analysts (LPAs) Dwayne Mason Jr. and William Vanegas is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPAs arrived at the facility and were greeted by facility staff. LPAs met with Daizy Gonzalez, Residents Relations Director and explained the nature of the inspection. The department received a complaint on 10/28/2024 stating the facility is accepting bedridden residents, but do not have an approved fire clearance for it and that the facility is not adhering to physician 's reports. During the investigation, the Department interviewed staff and residents in care. (continued on LIC9099-C) Unfounded (continued from LIC9099) On 11/5/2024 LPAs conducted a visit to the facility. LPAs obtained copies of the personnel report, resident roster, physician's reports and physician's orders. LPAs toured the facility, interviewed staff, made observations of resident rooms and reviewed records. LPAs observed 4 residents (R1, R2, R3, R4). It was reported that R1 is bedridden. Based on record review, it was found that R1 is non-ambulatory. R2, R3 and R4 were observed with hoyer lifts in their rooms. LPAs reviewed current physician's orders for hoyer lifts for R2, R3 and R4. Based on records reviewed and observations made, LPAs determined that the facility is not accepting bedridden residents. Based on records reviewed and observations made, LPAs determined that the facility is adhering to physician reports. Based on LPAs' observations and review of documents obtained, these allegations are UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, Nov 5, 2024 · control 22-AS-20241028120627

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced Required One Year visit to ensure substantial compliance with Title 22 regulations. According to the facility’s license, the facility has a maximum capacity of 180 non-ambulatory clients ages 60 and over, of which 140 may be non-ambulatory. Facility also has a hospice waiver for 20. LPA was granted entry into the facility and was met by Executive Director (ED) Christian Otbo whom LPA discussed the purpose of the visit. LPA was accompanied by ED Otbo, during a tour of the facility, which was conducted inside and out including a sample of resident units, the dining area, recreation rooms, outside grounds, and food storage areas.. Exterior and interior passageways were free from obstructions. Pathways were free of obstruction and slip hazards. Smoke and carbon monoxide alarms are hard wired to a central location. All doors and elevators were operational. Emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Each resident had clean and sufficient bed linens. Linens are kept in the individual rooms and extra linens towels, and washcloths are kept at facility in store room. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted and also available through a monthly community bulletin. Central cleaning supplies were stored in a locked closed room. Centrally stored medications were properly stored and locked on medication carts. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records are complete and compliant. All direct care staff have First Aide/CPR certificates, and staff training. Resident records reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted, this report was discussed with ED Otbo. The report along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Executive Director,Otbo.the state’s words, verbatim · CDSS document, Aug 21, 2024

Allegation investigated: Staff refused to transport resident for doctors visit. Staff did not prevent covid outbreak.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegations listed above. LPA met with Assistant Administrator Susie Mora and explained the reason for the visit. The investigation into the allegation, staff refused to transport resident for doctors visit, revealed the following. It was alleged that Resident 1 (R1) complained about an ongoing cough from July 8, through July 13, 2024, and asked staff to assist them with seeing a doctor about their cough. R1 reported they did have a cough but they did not report to staff that they wanted to see a doctor. 5 out of 5 staff interviewed reported they did not notice R1 coughing or displaying symptoms of Covid-19. It was reported that R1's family requested a Covid-19 test for R1 on July 12, 2024 but staff did not administer a Covid-19 test. 5 out of 5 staff interviewed could not corroborate that report. On July 15, 2024 R1 tested positive for Covid-19. Staff tested R1 for Covid-19 on that day at the family's request. R1's primary care physician was notified and prescribed new medication for R1. A review of facility records and 7 out of 7 witnesses interviewed, verifies this information. None of the evidence gathered supports the allegation. Unsubstantiated Based on the evidence the allegation, is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, staff did not prevent covid outbreak revealed the following. It was alleged that the facility did not follow the infection control plan when a resident had obvious Covid-19 symptoms and when residents tested positive for Covid-19. A review of records shows that 9 residents tested positive for Covid-19 from July 1, 2024 until July 25, 2024. The facility has a census of 132 residents. The Assistant Administrator reported that once a resident is tested positive for Covid-19 they contact Orange County Health Care Agency, Community Care Licensing (CCL), the resident's physician and their responsible party. The Assistant Administrator reported that once a resident is tested positive they self isolate in their room and staff interacting with them follow all the guidelines regarding the use of PPE. It was reported that R1 was exposed to Covid-19 from Resident 2 (R2) and R2 had obvious symptoms of Covid-19. 5 out of 5 staff interviewed could not verify this report. R1 could not verify this report. R2 could not be reached to be interviewed. R2 tested positive for Covid-19 the day after R1 tested positive. It was reported that the facility was slow to act when R1 tested positive for Covid-19. The Assisted Living Director reported that once R1 tested positive they notified the family and the physician and R1 agreed to isolate in their room. All 7 witnesses interviewed and R1 verified this report. It cannot be determined where R1 or R2 caught Covid-19. All 5 staff interviewed and the Assisted Living Director and the Assistant Administrator reported that all residents who tested positive for Covid-19 were isolated and the facility followed their infection control plan. There is no evidence to support the allegation, therefore the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 22-AS-20240716153403

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 06/26/2024. LPA was greeted and granted entry by Reception Rosa Leaning and explained the reason for the visit. Executive Director Christian Otbo arrived during the visit. Incident report dated 06/26/2024 indicated Resident 1 (R1) had reported that the resident's private caregiver (PC) had hit the resident. Irvine Police responded, case #24-06954, and determined no criminal activity had occurred. Facility interviewed Resident who changed the story upon interview. Facility interviewed private caregiver who denied the accusation stating that the private caregiver had placed his hand on the resident's neck to guide him to restroom. Facility contacted staffing agency to request the private caregiver not be placed in facility again due to allegation. Per physician report dated 02/09/2024, R1 is diagnosed with Metabolic Encephalopathy and Mild Cognitive Impairment. Physician report indicates resident is confused/ disoriented. LPA is unable to interview resident as resident has moved out of the facility. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 11, 2024

Allegation investigated: Staff handled resident in a rough manner.

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Memory Care Director Susie Mora and explained the reason for the visit. The department received a complaint on 08/25/2023 and the initial 10 day visit was conducted on 08/31/2023 by LPA Mendivil. During the visit on 08/31/2023 LPA Mendivil obtained copies of pertinent documents including needs and services plan, physician’s report, and behavioral assessment. Regarding the allegation staff handled resident in a rough manner, the investigation revealed the following: It was reported by a witness that Resident 1 (R1) was observed with bruises on hip and thighs while they were being assessed for a new facility. Based on R1’s physician report dated 02/20/2023 it was noted that R1 does not require continuous bed care and is able to ambulate with a walker. CONT on LIC 9099-C Unsubstantiated Based on interviews with 6 out of 6 staff indicated they did not handle R1 in a rough manner. 6 out of 6 staff stated R1 would become combative which results in them backing away. Review of 6 out of 6 staff file indicate staff have trained on Dementia and challenging behaviors. Per interviews with 3 out of 3 residents indicate the staff is not rough with them when assisting with activities of daily living. LPA Mendivil attempted to interview R1 at their current facility but R1 would not respond to LPA Mendivil's questions. Therefore based on evidence through records reviewed and interviews the allegation Staff handled resident in a rough manner is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 22-AS-20230825114411

Allegation investigated: Facility did not ensure residents receive their medications Facility did not secure medication from residents in care

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Susie Mora, Assistant Executive Director/Memory Care Director and explained the reason for the visit. The department received a complaint on 09/22/2023 and LPA Mendivil conducted the initial visit on 09/29/2023. During the visit LPA interviewed staff and residents and obtained copies of pertinent documents including: medication records and staff training records. Regarding the allegations facility did not ensure residents receive their medications and facility did not secure medication from residents in care, the investigation revealed the following: It was alleged on 08/16/2023, 08/17/2023 and 08/20/2023 that 5 residents did not receive their medications. Based on interviews with Memory Care Director/Assitant Executive Director Susie Mora, the missed medication issue was brought to her attention on or around 09/21/2023. CONT on LIC 9099-C Unsubstantiated Susie stated they did an medication audit and were able to determine the medications were not missed but refused by residents and not properly documented by staff. Susie stated that staff has been retrained on medication refusal and how to properly document. Susie reported the physicians' of the residents were notified and no residents had adverse reactions. During the visit LPA Mendivil observed a locked medication cart in Memory Care and a secured medication room. LPA observed a cabinet above med-tech desk which is not locked but contains paperwork and is secured by either a med-tech present or a locked door when staff is not in the room. Based on interviews with 1 out of 1 staff indicate they received updated training on how to mark refusals in their system and denied residents missing medications due to their errors. Based on interviews with 3 out of 4 residents indicated they receive their medications without issue and are able to refuse medications if they want. The 4th resident stated that they did not receive medications. Therefore, based on evidence through records reviewed and interviews the allegations Facility did not ensure residents receive their medications and Facility did not secure medication from residents in care are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 22-AS-20230922134701