Meadowbrook at Agoura Hills.

Continued from LIC 9099 Regarding allegation “Resident was left in soiled diaper for extended period of time” it was alleged that R1 was left in a soiled diaper for more than ten (10) hours. Interviews conducted reflected the R1’s family was notified by the facility ED that R1 had not been checked since 5:45 P.M. on the evening of 09/29/2025. Information gathered during the course of the investigation reflected that, the ED made a typographical error when corresponding with R1’s family and inadvertently stated P.M. vs A.M. Per the ED, the information was inaccurate as the night shift begins at 10:00 P.M. and ends at 6:00 A.M. the following day. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Resident was left in soiled diaper for extended period of time” is deemed unsubstantiated at this time. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC 9099 It was alleged that “Staff failed to treat resident with dignity or respect”. It was reported that in March 2025, Staff #1 (S1) intentionally fed Resident #1 (R1) dog food, allegedly as a joke. After receiving a formal complaint and speaking to the Reporti ng Party (RP), LPA reviewed the facility’s history and determined that on 04/09/2025 a Case Management (CM) visit had been conducted by LPA E. Cortez regarding the incident involving R1. Evidence reviewed during that visit, including the facility’s incident report and the report of suspected dependent adult/elder abuse form (SOC341) submitted by the ED on 03/21/2025 to Community Care Licensing (CCL), confirmed that the incident had occurred. According to the SOC341, ED acknowledged that S1 fed R1 food from a bowl with paw prints containing dog food, rather than from the community’s kitchen bowl containing Spaghetti prepared for residents. The facility’s internal investigation further confirmed that S1 was laughing about the incident and shared details of their actions with other staff members. R1 did not ingest the dog food and reportedly spat it out immediately. Following the incident, the ED contacted R1’s responsible person and their physician and removed S1 from employment as of 03/31/25. Additionally, all staff were retrained on mandated reporting requirements and abuse prevention procedures. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. As a result, the allegation of “staff do not treat residents with dignity or respect” ha s been SUBSTANTIATED at this time. However, this issue was previously addressed during a case management visit conducted on 04/09/2025, at which time citations were issued. Therefore, no citations will be issued today. Regarding allegation of “Staff failed to meet resident incontinent needs while in care”. It was alleged that facility’s staff left Resident #1 (R1) covered in feces from head to toe in R1’s bed. Interviews conducted reflected that on 09/30/2025, at approximately 8:45 A.M., R1’s family member found R1 covered with urine and feces. Additionally, it was also revealed that prior to this incident R1 was often found in briefs saturated with urine in the morning. Continued on LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued on LIC 9099-C Staff interviews conducted revealed that R1 can be resistant to care at times, becomes easily agitated, and would often refuse showers or care-related assistance. Additionally, even though there is no documentation stating R1 requires frequent monitoring, staff who provide care to R1 stated that due to R1’s condition, R1 requires more frequent monitoring. Additionally, it was revealed that all staff are aware that R1 should be checked at least once every hour. During the interview, staff #2 (S2) reported that on the morning of 09/30/2025, at approximately 6:10 AM, the night shift staff (S3) verbally informed them that R1 had been cleaned and did not require further assistance at that time and proceeded with their regular morning duties, responding to other residents who called for assistance without checking on R1. An interview with the ED revealed that S2 acknowledged that they relied on the information provided by S3 and did not verify R1’s status during the transition between shifts. During today's visit, the LPA reviewed the facility's camera footage from the date of the reported incident. The footage showed that S3 entered R1's room at approximately 5:16 AM and exited at 5:17 AM. The next individual observed entering R1's room was the family member, who arrived at approximately 8:52 AM. Based on the information gathered and record reviewed during the investigation, the department has sufficient evidence to confirm this allegation occurred. As a result, the allegation of “Staff failed to meet resident incontinent needs while in care” has been SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with Executive Director (ED), Joeyvic Alvarado and the reason for the visit was explained. At 11:15 a.m., the LPA along with the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: KITCHEN: The LPA inspected the Memory Care kitchen/food service area and the Assisted Living kitchen/food area. Knives and sharps were stored and inaccessible at the time of the visit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguishers were fully charged and were last serviced 05/06/2025. The LPA observed required postings throughout the common space. The LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA observed an adequate supply of emergency food and water. At 11:15 a.m. the LPA observed a cleaning cart with chemicals accessible to the residents in care left unattended in a hallway inside the Memory Care unit. At 12:15 p.m. the LPA observed a cleaning cart unattended with chemicals accessible to the residents in care in a hallway in Assisted living. (Report will continue on LIC 809-C, 2nd page...) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 BEDROOMS: The LPA observed ten (10) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a sufficient supply of towels and linens. Resident’s cords were tested, LPA observed staff arrive in a timely manner. Smoke detectors were checked in all observed rooms and function properly during the visit. At 11:52 a.m. the LPA observed over the counter super greens 10 gummies, a tube of Voltaren Arthritis pain reliever cream, 2 icy hot lidocaine pain relievers bottles, a tube of triple antibiotic ointment in room 256, per the resident 1's (R1's) LIC602 they cannot store their own medication. At 12:04 p.m. the LPA observed over the counter medication in room 216, per the residents LIC602, it is unclear if they can administer and store own medication, however the LIC602 is from 2022 and resident is diagnosed with Dementia. At 12:11 p.m. the LPA observed a small prescribed bottle of Nystatin 1,000,000 unit/gm in room 177, per the resident 3's (R3's) LIC602, the resident cannot administer or store their own prescribed or over the counter medications. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water temperature was measured in ten (10) random bathrooms between 11:15 a.m. and 1:00 p.m., the temperature measured between 112 – 119.8 degrees Fahrenheit. RECORDS: At 1:30 p.m. a review of facility files was initiated. Facility records are stored in a locked office. The LPA observed documentation of Infection Control, and Emergency Disaster plan . The LPA obtained Client Roster, Staff Roster, and Insurance Liability. The LPA reviewed five (5) resident files. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. The LPA observed the following: R2's LIC602 is from 2022, and there is no documentation of resident's refusal to receive an annual routine visit or their representative's refusal on their behalf. Due to time constraints the LPA will return at a later date to complete the annual inspection. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued.

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Administrator Joeyvic Alvarado and explained the reason for the inspection. On 02/27/2025, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1). Please note report was submitted after hours and LPA did not receive until 02/28/2025. The report stated that on 02/25/2025, while walking on the beach with several residents, R1 lost their balance and fell. R1 was transferred to the hospital for immediate medical treatment. Furthermore, R1 returned to the community on 02/26/2025 with a back fracture. On 02/28/2025, the LPA spoke with Administrator Joey Alvarado regarding the incident. She stated R1 was out on an outing to the beach with other residents and staff, they were walking the board walk and after the fall R1 was sent to the hospital and was diagnosed with a back fracture. The Administrator stated when Staff 1 (S1) was interviewed they conveyed that they were walking holding R1, and another resident (R2) by hands and when a third resident (R3) walked passed them, R2 let go of S1's hand to follow R3. S1 let go of R1 in an attempt to go after R2 and R1 fell. The Administrator stated R1 uses a walker, however S1 did not take R1's walker to the outing as they felt confident that they were going to be able to hold on to them and S1 received a corrective action. During today's inspection, the LPA conducted file review for R1 and S1 beginning at 1:28 PM. File review revealed that per R1's Resident Appraisal (LIC603A) dated 09/24/24, R1 has balance issues, ambulatory with assistance, needs assistance in walking, and is not able to walk without any physical assistance (e.g., walker, crutches, other person), or not able to walk with a cane. Per R1's Physician Report (LIC602) dated 09/24/24, R1 has a history of mechanical fall. Furthermore, R1's file review also revealed that R1 uses a walker and is a high fall risk. Report will continue on LIC809-C, 2nd page. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 File review revealed that on 02/28/2025, S1 received a corrective action notice for allowing residents to get off the bus to walk on the sand during a scenic drive to the beach, and one of those residents was taken off the bus without their assistive device which caused them to fall. Furthermore, S1 received a safety in-service training on 02/28/2025. Based on the information obtained, there is sufficient evidence to support a deficiency is warranted as R1 sustained an injury as a result of S1 taking R1 on an outing to the beach without their assistive device. The following deficiency was cited (See LIC 809-D) from CA Code of Regulations, Title 22, Division 8. Failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $500 was issued. Exit interview conducted. A copy of the report and appeal rights were provided.

On the allegation, "Staff are not responding to resident's call button in a timely manner"; it is the concern of the reporting party that in case of an emergency a resident can die due to pendant calls not being answered in a timely manner. It was further reported that on 02/09/25 resident 1 (R1) around 7:30 a.m. pressed their call button and no one went, R1 then called the front desk and left a message, and waited for an additional 30 minutes until someone went to their room. Interviews conducted with staff revealed that caregivers are primarily the ones that respond to the resident’s call buttons and try to respond as quickly as they can but MedTechs and other staff will assist as well with the pendant calls to ensure they are answered in a timely manner. However staff interviews revealed that even though it does not happen often, residents have waited over 15 minutes to be assisted, it all depends if they are short staffed and how busy they are. Interviews conducted with ten (10) randomly selected residents revealed that four (4) out of the ten (10) residents do not use their pendant button as they are independent. Two (2) residents revealed staff gets to them as timely as possible, and four (4) residents revealed that it can take staff a long time to respond to their pendant calls with some revealing that they have waited over 30 minutes for assistance. Additionally, a review of the pendant call log response times revealed that on 2/09/25, R1 did not have a registered pendant call around 7:30 a.m., however, R1 did have two (2) pendant calls that took over 25 minutes to respond to on that same date. Furthermore, the pendant call log revealed that in about 21 pendant calls from various residents on 02/09/25, residents waited over 20 minutes for assistance including 12 calls that were answered after 30 minutes of waiting. Based on the information gathered through interviews, and file review, the allegation Staff does not respond to resident's call button in a timely manner is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).Civil penalty was issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.

On the allegation " Licensee did not provide the facility with an up to date and readily available emergency disaster plan"; it is the concern of the reporting party (RP) that the community had no evacuation plan, and that it was complete chaos during an evacuation. To investigate the allegation the LPA conducted file review and interviews. Information obtained revealed that on 01/09/2025 the community had to evacuate due to the Kenneth Fire. File review revealed that the community has an Emergency and Disaster Plan (LIC610E) on file. A review of the LIC610E indicated that the community had temporary shelter locations, evacuation procedures and staff assignments during an emergency disaster. File review also revealed that the community conducts monthly emergency and fire drills with their last drill conducted on 12/03/2024. Eleven (11) out of thirteen (13) randomly selected residents that were interviewed revealed that they had no concerns regarding the evacuation, it was well handled, they were well taken care of, the staff did the best they could, and that the staff were knowledgeable on the evacuation process. All staff interviewed revealed that the community trained them and has a third-party individual that comes and educates them on what to do during an emergency and/or disaster such as a fire. Additionally, staff interviewed that were present during the evacuation revealed that considering the emergency they were prepared to the best of their ability, the community was getting ready for an evacuation days prior, all residents had evacuation bags ready to go, and they ensured the safety of the residents. Based on the information gathered, the above allegation is deemed unsubstantiated at this time. Exit interview conducted and report issued. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On the allegation, “Facility staff are unable to provide medication as prescribed to residents during an evacuation”; it is the concern of the reporting party (RP) that residents had no medication or care during an evacuation. To investigate the allegation the LPA conducted interviews and a medication audit for three residents. Information obtained revealed that on 01/09/2025 the community had to evacuate to three relocation sites and several residents left with family members due to the Kenneth Fire. Staff interviewed revealed that medications and incontinence supplies were relocated to the relocation sites, and/or provided to family members that took residents home with them. Eleven (11) out of thirteen (13) randomly selected residents that were interviewed revealed that they had no concerns regarding the evacuation, it was well handled, they were well taken care of, the staff did the best they could, and medications were provided. However, two (2) out of thirteen (13) residents revealed that they were not provided medications during the evacuation. On 01/15/2024, the LPA conducted a medication audit for three residents and observed the following; Resident 1 (R1) had their evening medications, Eliquis 2.5 MG and Potassium CL ER 20MEQ , still in the bubble pack for 01/09/2025 and 01/10/2025. Resident 2 (R2) had their evening medication, Xarelto 20MG medication still in the bubble packs for 01/09/2025 and 01/10/2025. Additionally, based on a pill count for Resident 3 (R3) conducted by the Memory Care Director, the LPA observed that R3 was not provided their morning Letrozole .25MG medication on 1/10/2025. R1 and R2 were evacuated to one of the relocation sites, and R3 went home with family. An interview conducted with R3’s family member revealed that they were not given R3’s medications during the evacuation. Based on the information gathered through interviews, and medication audit, the allegation above is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Exit interview was conducted and a copy of the report and Appeal Rights were issued.

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Deficiencies inspection due to deficiencies observed during the investigation for Complaint control #29-AS-20240826174337 which were unrelated to the complaint allegation. the LPA met with Business Office Manager II Michelle Greenberg and Director of Resident Services I, Lauria Gallagher and explained the reason for the visit. During the complaint investigation of complaint # 29-AS-20240826174337, the following deficiency was observed: The Operations Specialist/Interim Administrator stated they have worked at the facility for a couple of months and work Monday through Friday from 9:00am to 9:00pm, however was not found to be finger printed cleared and associated to the facility per the Licensing Information System report and Guardian online system. An Immediate $500 Civil Penalty is assessed today. Citation issued, Immediate $500 Civil Penalty issued, exit interview, appeal rights given.

On the allegation, "Staff are not responding to resident's call button in a timely manner"; it is the concern of the reporting party (RP) that resident 1’s (R1’s) pendant that they push for help is not being answered promptly consistently. RP revealed that R1 has waited 40 minutes to an hour for help. Interviews conducted with staff revealed that caregivers are the ones that respond to the resident’s call buttons and try to respond as quickly as they can; however, if the caregivers are assisting other residents, residents have waited over 15 minutes to be assisted. Staff revealed that residents have also waited over 30 minutes for assistance. Interviews conducted with two (2) residents revealed that they use the pendant for assistance and there have been occasions where they had to wait over 30 minutes, and it has happened constantly. Additionally, a review of the pendant call log response times revealed that 26 times that pendants were pressed on 12/01/2024, residents waited over 30 minutes. Furthermore, a resident had pressed their pendant during the interview with the LPA and after waiting over 30 minutes the LPA left and staff had not responded to the resident’s pendant. Based on the information gathered through interviews, file review, and observation the allegation Staff does not respond to resident's call button in a timely manner is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 10:45 a.m. Upon arrival, the LPA met with Operation Specialist Diane Lugar and the reason for the visit was explained. Entrance interview conducted. Executive Director Jeff Labelle joined mid visit. At 11:35 a.m., the LPA along with the Operation Specialist toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: KITCHEN: The LPA inspected the Memory Care kitchen/food service area and the Assisted Living kitchen/food area. Knives and sharps were stored and inaccessible at the time of the visit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 1:04 p.m the hot water in the Kitchen of Assisted Living measured at 129.9 degrees Fahrenheit, and the LPA did not observed the required sign. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguishers were fully charged and were last serviced 05/08/2024 and 05/22/2024. The LPA observed required postings throughout the common space. The LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA observed an adequate supply of emergency food and water. BEDROOMS: The LPA observed eleven (11) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a sufficient supply of towels and linens. Resident’s cords were tested, LPA observed staff arrive in a timely manner. At 12:31 p.m. the LPA observed the smoke detector in the living room of resident room #274 (AL) inoperable and at 1:30 p.m. the LPA did not observed a smoke detector in resident room #103 in memory care. (Report Continued on LIC 809...) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Report Continued from LIC 809...) At 11:45 p.m., the LPA observed a Lysol spray bottle, and a bottle of Maximum Strength Blue-Emu pain relief spray in resident room #150, and per the residents physician's report they cannot store or managed medications. At 11:49 p.m. the LPA observed a can of Lysol disinfectant spray, a bottle of Lysol hydrogen peroxide spray, and a Resolve pet stain and odor remover bottle in resident's room #156. At 11:52 p.m. in the same room the LPA observed prescribed medication on the residents counter, and per the residents physician's report they cannot store or managed medications. At 12:14 p.m. the LPA observed Lysol, Pinesol, Febreze, and a bottle of Lysol power toilet bowel cleaner in residents room #165. At 12:18 p.m. the LPA observed an unlocked storage room that contained a bottle of LA's totally Awesome all purpose cleaner, a bottle of carpet cleaner, a bottle of Magnum Blue Degreaser, a bottle of WanoX stain remover spray, a bottle of Zep all purpose carpet shampoo, and machines accessible to the residents in care. At 12:21 p.m. the LPA observed Imodium multi-symptom relief, Pepto bismol, Aleve pain relieving lotion, hydrocortisone cream, and prescribed Arthritis Pain Reliever Topical gel, and per the residents physician's report they cannot store or managed medications. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water temperature was measured in ten (10) random bathrooms between 11:45 a.m. and 2:00 p.m., the temperature measured between 108.9 – 125.6 degrees Fahrenheit. RECORDS: The LPA initiated record review at 3:15 p.m. However, due to time contraints the LPA will return at a later date to complete the annual inspection. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued.

Staff are not following a resident's physician's order. On the allegation that staff are not following a resident’s physician order; the Reporting Party (RP) stated that on 8/6/2024, a staff removed the bed rails from the resident's (R1) bed because the facility's corporate office stated that bed rails are prohibited at the facility. LPA Urena interviewed the RP on 08/12/2024 from 2:49 p.m. to 3:20 p.m. The RP stated that R1 had a physician’s order for the half bed rails since October 2023; the bed rails were ordered by the physician due to R1 having a history of falling, and R1 is currently receiving hospice care and have a hospice care plan that specifies the need for half bed rails. Furthermore, the RP stated that facility’s corporate office staff made a visit to the facility and ordered bed rails to be removed as of August 6, 2024. The facility’s corporate office staff made the decision to return the bed rails and installed them back on R1’s bed. However, the RP stated that they have witnessed on several occasions that the bedrails are always in the lower position, versus the raised position to prevent R1 from falling out of the bed. R1 stated that they are not aware of the facility’s policy on prohibiting bed rails. The admission agreement signed by the RP does not have the facility’s policy stated on the agreement. To investigate the allegation, the LPAs reviewed R1’s physician report (LIC 602A), Admission Agreement (LIC 604A), Hospice Plan, physician’s order for bedrails, facility policy on bedrails and/or notification to residents in care about the facility’s bedrail policy. The record review revealed that R1 has a physician’s order for half bed rails dated 12/26/2023. The Admission Agreement (21 pages) does not specify the facility’s policy on bed rails. Based on the information obtained through interviews and record review; the information revealed that although the half bed rails were removed only temporarily and have been re-installed on R1’s bed, the facility staff failed to inform the R1’s responsible parties of the facility’s policy implementation, and the facility staff failed to follow the resident's physician's order. Therefore, this allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.

(Report Continued from LIC 809...) During the interview with the Administrator Joeyvic Alvarado, she stated Resident #1 (R1) had a fall on 08/15/2022 and went to the hospital. When the resident was discharged the family opted to move them to a board and care and where R1 subsequently passed away. The Administrator showed the LPA surveillance footage of R1 when they fell. The LPA observed the resident to be walking in the hallway when they pulled on their sweater causing them to lose their balance and fall. Video footage went on to show that staff was nearby the resident when they fell and provided aid to the R1 right away. The Administrator was not aware of R1 having any other recent falls. Interview with a staff present near R1 when they fell stated R1’s fall had nothing to do with staffing. They said R1 was agitated that day and they just happened to fall. Additional interviews with all four staff revealed that there are times when there are only two caregivers during the day shift which makes it difficult to care for the residents, especially when assisting residents who are a two person assist. Interviews also revealed there are some days three caregivers is not enough either to assist residents because that only leaves one person on the floor. The Administrator stated there are always three caregivers scheduled on shift during the day but there are times when a staff will call out sick and there will be only two caregivers on shift. The Administrator stated it may take an hour or two for agency staff to arrive although a manager will stay and assist, or the medication technician will assist until more staff are available. Based on the information obtained, although there is not sufficient evidence to support insufficient staffing resulted in resident falls, staff interviews revealed there are times when they only have two caregivers on shift which is insufficient to meet the residents needs. Therefore, the allegation of Insufficient staffing at the time the complaint was filed is deemed substantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.

Licensing Program Analysts (LPA’s) Martha Arroyo and Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:45 a.m. Upon arrival, the LPAs met with the Executive Director (ED), Joeyvic Alvarado and Health and Wellness Director (HWD), Alex Alvarado and at this time the reason for the visit was explained. Entrance interview conducted. At 10:20 a.m., the LPA’s along with the ED and HWD toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: KITCHEN: The LPA’s inspected the Memory Care kitchen/food service area at 10:20 a.m. and the Assisted Living kitchen/food area at 11:13 a.m. Knives and sharps were stored and inaccessible at the time of the visit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 11:45 a.m., the LPA’s observed several non-perishables that were expired, these items included two (2) containers of Imperial Apple Juice Concentrate and two (2) cans of Corned Beef Hash (expired – May 2023). Items were discarded at the time of the visit. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 05/31/2023. The LPA’s observed required postings throughout the common space. The LPA’s observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA’s observed an adequate supply of emergency food and water. (Report Continued on LIC 809...) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Report Continued from LIC 809...) BEDROOMS: The LPA’s observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPAs observed a sufficient supply of towels and linens. Resident’s pendant were tested , LPAs observed staff arrive in a timely manner. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. At 10:28 a.m., the LPA’s observed accessible items inside a memory care bathroom that included a Dove body soap, Herbal Essence Conditioner, Pert Plus Shampoo, and Cetaphil cream. The ED locked the cabinet immediately. The hot water temperature was measured in four (4) random memory care bathrooms between 10:29 a.m. and 10:37 a.m., the temperature measured between 108.9 – 120.2 degrees Fahrenheit. Between 10:47 a.m. and 11:29 a.m., the hot water temperature was measured in nine (9) random assisted living bathrooms and the temperature measured between 108.7 – 122 degrees Fahrenheit. Staff adjusted the water temperature at the time of the visit. The LPA’s observed several resident trash cans and waste baskets without covers/lids. During the walkthrough, the LPA’s observed the facility has trash cans with lids in storage. The ED stated the trash cans will be replaced. RECORDS: LPA’s reviewed Resident Records at 11:59 a.m. and Personnel Records at 1:15 p.m. Eight (8) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Eight (8) personnel files and the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. The last fire inspection was completed on 08/15/2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Fire and earthquake drills conducted within the last 6 months as per regulation; the last one conducted 08/26/2023. (Report Continued on LIC 809C...) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Report Continued from LIC 809C...) The LPA’s conducted interviews with two (2) residents and six (6) staff between 12:30 p.m. and 1:30 p.m. At the time of the visit, the LPA’s obtained the following documents: LIC500 Personnel Report, Staff Schedule, Census/Resident Roster, and a copy of the liability insurance. MEDICATIONS: Medications review began at 1:20 p.m. The medications are centrally stored in the medication room. Medications are labeled and checked for expiration dates. Medications including PRN’s are properly documented on the centrally stored medications and destruction record. The LPA’s observed PRNs to have physicians order on file. No errors observed during the medication review. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued.

Allegation: Licensee did not report resident's change of condition to the responsible party timely. The allegation alleges on 11/15/2021, Resident #1's (R1) leg was red and needed medical attention and R1's Responsible Party (RP) was not notified until 11/19/2021. Record review revealed on 11/16/2021, the physician of R1 was faxed notifying them of insect bites on R1’s leg that were getting bigger and requesting advice. On 11/19/2021, the physician responded via fax requesting photos or to schedule a visit. Email correspondences between the RP and facility nurse Staff #2 (S2) revealed on 11/19/2021, S2 emailed RP requesting RP to take R1 to the urgent care due to R1’s physician not responding back to them. Based on the information obtained, there is sufficient evidence to support R1’s Responsible Party was not notified timely of R1’s change of condition. Therefore, the allegation of licensee did not report resident's change of condition to the responsible party timely is deemed substantiated at this time. Allegation: Insufficient staffing The allegation alleges there is only one med tech on staff on shift which is not sufficient. Review of the staff schedule from 11/14/2021 through 12/11/2021 revealed frequently there is only one med tech on the AM and PM shift instead of two med techs for each shift like on the other days. Interviews with four med techs who worked around the time the complaint was filed, revealed having only one med tech on shift in assisted living is not sufficient and as a result medications are being delivered late to the residents. A review of the current staff schedule revealed there is one med tech and one half day med tech during the AM and PM shift. The half day med tech works during peak hours from 6:00 AM-10:00 AM and 4:00 PM – 8:00 PM. Interviews today revealed staff are able to meet the resident’s needs under the current schedule. Based on the information obtained, there is sufficient evidence to support the allegation of insufficient staffing occurred at the time the complaint was filed. Therefore, the allegation is deemed substantiated at this time. The following deficiencies were cited from the CA Code of Regulations. See LIC 9099-D. Exit interview and report reviewed with Business Office Manager Michelle Greenberg. A copy of the report and appeal rights provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During the interview with S1, S1 denied ever yelling or being rude to R1 and denied ever slamming a door in R1’s face. Based on the information obtained, there is insufficient evidence to support the allegation of staff are verbally abusive to residents occurred. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview and report reviewed with Michelle Greenberg. A copy of the report and appeal rights provided.