Oakmont of Camarillo.

Report Continued from LIC 9099... It was alleged that facility is in disrepair. It was reported that the main elevator near the front lobby had been out of service since 12/20/2025 and that the facility did not order the replacement part needed to repair the elevator in a timely manner. Records reviewed and interviews conducted revealed that the elevator went out of service on Friday, 12/12/2025. A service technician from the vendor, TK Elevator, inspected the elevator on the next business day, Monday, 12/15/2025. On 12/16/2025, the facility contacted the vendor to inquire about the status of the repair. At that time, the facility was informed that the required part—hydraulic packing—would be ordered and that a repair crew would be scheduled to complete the work. Although the necessary part was ordered shortly after the technician evaluated the issue, the delivery of the part and completion of the repair took longer than anticipated. A review of communication records with the vendor confirmed that the part has now been received and that a repair crew is scheduled to complete the repair on 01/30/2026 between 6:00 a.m. and 8:00 a.m. Furthermore, the facility consistently contacted the vendor throughout the process to request updates. During this time, one (1) additional elevator remained fully operational and available for use by residents and staff at all times while the main elevator was out of service. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “facility is in disrepair”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview. A copy of the report was provided.

Report Continued from LIC 9099... A case management visit addressing the same allegation was conducted on 08/06/2025 by LPA E. Peraldi. During the visit, LPA Peraldi interviewed the ED at 11:30 a.m., requested and obtained copies of pertinent documents at 12:00 p.m., and conducted a physical plant tour at 12:15 p.m. During an initial visit on 08/08/2025, between approximately 1:00 p.m. and 2:15 p.m., LPA Chochian conducted a physical plant tour with the Marketing Director (MD), Emilia Ruiz, met with random residents, and interviewed five (5) residents in the assisted living unit and three (3) residents in the memory care unit. Investigator Canto reviewed police records and conducted interviews with residents on 08/21/2025 at approximately 3:38 p.m. and 4:15 p.m. The investigation revealed that on 08/03/2025, R1’s responsible party informed facility staff that R1 had reported being sexually abused twice within the past month. Further statements indicated this was not the first time R1 had made such an allegation. On 05/08/2023, R1 made a similar allegation of being sexually abused by a staff member. An investigation completed on 09/22/2023 found insufficient evidence to support that allegation. A review of R1’s Physician’s Report dated 06/18/2025 listed R1’s primary diagnosis as Alzheimer’s dementia. The report indicated that R1 lacks the capacity for self-care and requires assistance with all Activities of Daily Living (ADLs), including but not limited to bathing, dressing/grooming, feeding, toileting, medication administration, and managing own cash resources. The report also noted that R1 is unable to effectively communicate needs or follow instructions or directions. Per the hospice care plan effective 07/11/2025, R1 was recertified for routine level of care with a primary diagnosis of Alzheimer’s disease. The care plan also documented a medical history that includes hypothyroidism, dementia with psychosis, urinary tract infections (UTIs), and agitation. Interviews further revealed that following the allegation made by R1 on 08/03/2025, R1 was assigned female caregivers only. Staff stated that law enforcement, R1’s Primary Care Physician (PCP), and the hospice agency servicing R1 were notified of the incident. Report Continued on LIC 9099C... 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 9099C... Additional records reviewed and interviews conducted indicated that the Ventura County Sheriff’s Office (VCSO) responded to the facility on 08/05/2025. According to the report, attempts to interview R1 were unsuccessful, as R1 demonstrated cognitive impairment and difficulty providing relevant responses despite repeated redirection efforts. During an interview with R1’s responsible party, they confirmed that R1 had made similar allegations in the past that were determined to be unfounded. R1’s responsible party also stated that they stopped questioning R1 after the report to avoid influencing or any fabricated responses from R1. Furthermore, VCSO was unable to identify a suspect or establish that a crime had occurred. Based on the information obtained and reviewed during the course of the investigation, the Department has insufficient evidence to support the allegation of “staff sexually abused resident in care”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.

Report Continued from LIC 9099... It was alleged that staff did not ensure medication was inaccessible to resident. It was reported that Resident #1 (R1) had taken THC gummies that were allegedly left in their room due to staff not properly cleaning the room. Record review and interviews conducted revealed that R1 was taken to the hospital on 10/02/2025 after feeling dizzy and weak. According to the incident report, R1 was transported to the hospital after care staff called 911. R1 returned to the facility the same day with a diagnosis of syncope. Interviews with staff indicated that all medications are kept in locked medication carts located inside the medication room. Staff stated that the medication room remains locked at all times when medications are not being administered or when staff are not present. Staff also reported that they assist residents with maintaining clean bedrooms and denied observing medications in any resident’s room. Interviews with R1’s family revealed that the facility communicates well with them regarding R1’s condition and needs. They stated that they had no concerns about R1 receiving the correct medications when ordered by a physician, noting that R1 was not on any medications until recently. Furthermore, during an interview, R1 denied eating any candy or taking any gummies. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not ensure medication was inaccessible to resident”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff spoke inappropriately to resident in care. It was reported that staff were observed being mean and yelling at Resident #2 (R2), telling R2 to stop crying. Interviews conducted with staff revealed that R2 often asks to speak with a specific family member. Staff stated that although they attempt to redirect R2, they sometimes call R2’s family to help calm R2. Staff added that R2’s family has stated they do not mind being contacted, as they want to ensure R2 is safe. Further staff interviews indicated that they have not observed other staff members disrespecting residents and denied ever having disrespected residents themselves while working and providing care. During interviews with R2’s family, they stated that facility staff are great and patient with R2 and expressed no concerns regarding how staff treat R2. Interviews with other residents’ family members revealed that they have not witnessed staff mistreating residents during their visits. Additionally, family members did not report any concerns about facility staff or the way residents are treated, stating that staff have been wonderful to both residents and visitors. Based on interviews, the Department has insufficient evidence to support the allegation of “staff spoke inappropriately to resident in care”. Therefore, this allegation is deemed Unsubstituted at this time. Exit interview conducted. A copy of the report was issued.

Report Continued from LIC 9099... It was alleged that staff did not ensure resident took medication as prescribed. It was reported that Resident #1 (R1) did not take their medications for several weeks, which resulted in R1 being hospitalized. Additionally, when R1 moved out of the facility, medications were found scattered throughout their apartment. The LPA conducted a medication review on 11/20/2025 and observed three (3) randomly selected residents centrally stored medications. Medication review revealed that medications were being properly documented on the Centrally Stored Medications and Destruction Record (CSMDR). The LPA and staff conducted a pill count, and the quantities matched the documentation. Staff also noted when residents did not take their medications as prescribed due to being away from the facility or refusing to take them. Interviews with staff revealed that they had not experienced any problems with R1 refusing medications or administering their prescribed medications. Staff stated that R1 understood the importance of taking their medications as prescribed. Staff explained that during medication administration, they provide residents with a cup of water and wait for the resident to take the medication and return the empty cup. Staff also stated that they have not had issues with residents hiding medications instead of taking them. Further interviews revealed that staff are familiar with residents who refuse medications or have difficulty taking them, and they stated that R1 was not one of those residents. Staff added that R1 was adamant about receiving their medications on time and that they had no concerns regarding R1’s medications. Staff also reported that R1’s family had never expressed any concerns. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not ensure resident took medication as prescribed”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi conducted an unannounced annual inspection today. Upon arrival, LPAs met with Executive Director (ED), Mark Cortes and explained the reason for the visit. Entrance interview. During today’s inspection, the LPAs along with the Executive Director and Maintenance Director 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: Resident Rooms / Bathrooms: The LPAs observed six (6) random resident bedrooms in the assisted living and memory care unit. All resident rooms were furnished appropriately, with appropriate furnishings, and sufficient lighting. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature measured between the required range per regulations at the time of the visit. The facility also maintains a monthly hot water temperature log to ensure compliance. Kitchen: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. 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 809... Common Areas: The LPAs observed common areas to be clean and in good condition. There are games and/or activity supplies in the activity rooms. There was sufficient space to accommodate both indoor and outdoor activities. An adequate amount of emergency food and water was observed; properly stored. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Fireplaces observed in various rooms; adequately covered. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 12/23/2024. Outdoor Space: The LPAs observed the outdoor garden which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. No bodies of water accessible to residents noted at the time of the visit. Record Review: The LPAs reviewed ten (10) resident records and ten (10) staff records starting at 12:20 p.m. Ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Ten personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were in order. During today’s visit, LPAs conducted interviews with five (5) staff and five (5) residents. No concerns were noted. 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... Medications Review: The LPAs reviewed medications at approximately 12:15 p.m. The medications in assisted living are centrally stored in a medication room on the 1st floor. Medications in memory care unit are centrally stored inside the memory care unit near the dining room. Medications appear to be given as prescribed at the time of the visit. Infection Control / Emergency Disaster Planning: During today’s visit, the LPAs reviewed the facility's infection control policy as well as their emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. The last fire safety inspection was completed on 08/21/2025 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 09/13/2025. Exit interview conducted. Report was reviewed and copy provided.

Report Continued from LIC 9099... Records review and interviews conducted revealed Resident #1 (R1) was admitted to the facility on 08/31/2024. Per R1’s physician’s report dated 06/19/2025, R1’s primary diagnosis include dementia and a recurrent sacral pressure ulcer, with a noted lack of capacity for self-care. Per updated Resident Assessment dated 01/28/2025, it indicates that R1 requires hands-on assistance with all grooming and hygiene tasks. This includes assistance with showering or bathing 1–2 times per week, dressing and undressing twice daily, as well as toileting needs. It was alleged that staff are not meeting resident’s oral hygiene needs and staff are not meeting resident’s grooming needs. It was reported that R1 had significant buildup on their tongue and their skin appeared extremely dirty. Records review and staff interviews revealed that R1 was receiving services from Buena Vista Hospice. According to staff interviews, hospice staff provided R1 with showers twice a week, while facility staff gave sponge baths on the other days. Staff also stated that R1’s teeth were brushed daily and that R1 did not refuse oral hygiene care. They also added that any refusals of care are typically documented and communicated between staff; however, there were no refusals reported during the visit. Additional interviews revealed that R1 had specific preferences regarding which staff members assisted with their oral hygiene and grooming. Furthermore, an interview with R1’s family indicated that they visited R1 frequently—several times a week—and consistently observed that R1 was clean and well cared for and reported no concerns regarding R1’s care while residing at the facility. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “staff are not meeting resident’s oral hygiene needs” and “staff are not meeting resident’s grooming needs”. Therefore, these allegations are deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was issued.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident visit. At 11:30 a.m., the LPA met with the Executive Director (ED), Mark Cortes and explained the reason for the visit. The reason for today's visit is to follow up on a self-reported incident report and Suspected Dependent Adult/ Elder Abuse (SOC 341) report received on 08/05/2025. The reports pertain to possible sexual abuse of Resident #1 (R1) by unknown staff. During today’s visit, at 11:30 a.m., the LPA conducted an interview with the ED. At 12:00 p.m., the LPA requested and obtained copies of pertinent documents. At 12:15 p.m., the LPA, along with the ED conducted a physical plant tour. No immediate health and safety concerns were observed during today's inspection. A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). Further investigation is needed, and an additional report may follow. Exit interview conducted. A copy of the report was provided.

Report Continued from LIC 9099... It was alleged that facility staff speaks inappropriately to residents. It was reported that staff is bullying residents by intimidation, foul language and threats, and has created an unsafe environment for residents. Interviews conducted with residents revealed that the staff is friendly and pleasant whenever they assist. Residents mentioned that staff greet them and all other residents when passing through the common areas and are always ready to help if needed. Additionally, residents stated that they have never witnessed or heard staff using inappropriate language when interacting with other residents or staff, and they have not observed any instances of staff being rude or disrespectful. Furthermore, residents reported having no concerns about living at the facility. Based on interviews conducted with residents, the Department has insufficient evidence to support the allegation of “facility staff speaks inappropriately to residents”. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Report was reviewed and copy issued.

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. Upon arrival, LPAs were greeted by the front desk receptionist and explained the reason for the visit. The Executive Director, Mark Cortes arrived shortly after. Entrance interview. The LPAs along with the Executive Director, 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: KITCHEN: The LPAs inspected the kitchen/food service area at 10:15 a.m. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be clean and in good condition. The facility maintained a comfortable temperature. LPAs observed required postings throughout the common space. Stairwells were observed to have emergency evacuation chairs. LPAs observed fireplaces in the first floor dining area, library/reading room, the Bistro, and the formal sitting room, all were observed to be adequately screened at the time of the visit. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. 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 809... BEDROOMS: The LPAs observed two (2) random resident bedrooms in memory care and seven (7) random resident bedrooms in assisted living. All resident bedrooms were furnished appropriately and had sufficient lighting. RESTROOMS: The LPAs observed nine (9) random resident restrooms during the inspection. All 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. Starting at 10:24 a.m., the hot water temperature was measured in seven (7) random assisted living bathrooms and two (2) random memory care bathrooms, and the temperature measured between 110.4 – 114.6 degrees Fahrenheit. RECORDS: LPA’s reviewed Resident Records at 11:45 a.m. and Personnel Records at 1:00 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. LPAs conducted interviews with five (5) staff and three (3) residents during the inspection. MEDICATIONS: Medications review in Memory Care began at approximately 12:25 p.m. and medications review in Assisted Living began at approximately 1:50 p.m. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medication appeared to be given as prescribed at the time of the visit. 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... INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced 12/17/2023. Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on 10/10/2024. No citations issued at this time. Exit interview conducted. A copy of the report was issued.

Allegation “Resident sustained injury while in care:” It was alleged that due to lack of care and supervision, Resident #1 (R1) fell and sustained an injury while in care. Record review revealed that R1 was admitted to the facility on 07/18/2022. R1’s physician’s report upon admit indicated R1 was ambulatory and had a diagnosis of vascular dementia; care plan assessment indicated that R1 “wanders only within the common areas of the secured community.” Incident report reviewed revealed that R1 sustained a fall on 07/31/2022, resulting in a hip fracture. According to incident report, staff and family member interview, R1 was sitting in a chair in the Memory Care outdoor area. R1 scooted their chair out and into a recessed garden bed, resulting in R1 losing their balance and falling as they attempted to stand up. At the time of the fall, R1 did not require 1:1 supervision, nor did R1 require an escort when ambulating about the secure memory care unit. Incident report and staff interview revealed that staff were nearby when the fall occurred, and that staff followed the proper protocol for obtaining additional medical care and reporting the incident. Therefore, based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred; the allegation that “resident sustained injury while in care” is deemed UNSUBSTANTIATED at this time. Allegation “Staff do not respond to call button timely:” It was alleged that on occasion, R1’s family member stayed at the facility with R1 overnight and that R1’s call button was not responded to timely. LPA reviewed Care Point Server records for R1. Record review revealed response times recorded within the identified appropriate time frame reported by facility staff. Interview revealed that there are few residents in the Memory Care unit utilizing the pendant call system. When a resident presses the pendant, the alerts go to the front desk console as well as the staff pagers. Staff then will respond to the resident’s room for assistance. Interview revealed that there are times when staff are busy with other residents, but that the staff work together and communicate with one another to ensure all calls and residents’ needs are met timely. During facility visits throughout the complaint inspection, LPA observed staff tending to residents’ needs and no additional residents identified any concerns related to timeliness. Based on interview, observation, and record review revealed that at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff do not respond to call button timely” is deemed UNSUBSTANTIATED at this time. Allegation “Staff do not seek medical attention timely:” The complaint alleges that a witness observed another resident (Resident #2 – R2) who resides in Memory Care sitting outside on the patio and according to the complaint, R2 appeared overheated and in need of Report 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 medical care. LPA spoke with facility Management as well as facility staff that were present at the time of the alleged incident. Staff indicated that R2 enjoys sitting outside in the fresh air and in the sun. On the date of the alleged incident, according to staff interviewed, R2 had not been outside for longer than about 15 to 20 minutes when staff escorted R2 back inside. R2 was tired when staff brought them back into the facility, so staff assisted R2 to bed. There was no medical treatment necessary for R2 relating to their time spent outside and therefore no incident report was needed. LPA observed R2 in the facility during the initial complaint visit; R2 appeared happy and healthy. Based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff do not seek medical attention timely” is deemed UNSUBSTANTIATED at this time. Allegation “Facility in disrepair:” The complaint alleges that the sensors in R1’s room are non-functional. LPA reviewed motion sensor logs for R1’s room for the relevant time period, which did indicate multiple reports of motion in R1’s room. During the initial compliant visit, LPA tested the motion sensors in R1’s room and they were functional at the time of the visit. Staff interviewed indicated that R1’s motion sensors do function. LPA toured the facility during the initial complaint visit and both subsequent complaint visits, as well as multiple other unrelated visits throughout the course of the investigation and no concerns were observed during any visits. Based on interview, record review, and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that “facility is in disrepair” is deemed UNSUBSTANTIATED at this time. Allegation “Staff are not trained for the job assigned to them:” The complaint alleges that new staff are not trained properly and therefore are unable to care for the residents. LPA reviewed training logs for various facility staff, including medication technicians and care staff. Interviews revealed that the facility utilizes computer training, including videos and quizzes as well as shadowing and in-person training prior to staff working in the facility with residents. Residents interviewed indicated their needs are met, and that staff are providing adequate care. Training records reviewed revealed that staff are trained in accordance with regulation. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff are not trained for the job assigned to them is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today’s report was provided.

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 03/03/2024. LPA met with Executive Director (ED) Bradlee Foerschner. LPA explained the reason for today's visit. On 03/04/2024, ED sent an email to the LPA, which included an Incident Report and suspected abuse report related to an altercation involving Resident #1 (R1) and Resident #2 (R2) who reside in Traditions. The altercation resulted in injury to R2, so R2 was sent to the hospital for medical treatment and subsequently moved out of the facility. During today's visit, LPA interviewed ED related to the incident and LPA toured the facility at 02:25PM. No immediate health and safety hazards were identified during today’s visit. LPA will return at a later date to continue the investigation into the incident. No citations issued. Exit interview conducted. A copy of today's report was provided.

Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek arrived at the facility at 09:40AM for an unannounced annual inspection. Upon arrival, the LPAs met with Executive Director (ED) Bradlee Foerschner. Entrance interview conducted. Beginning at 10:20AM, LPA Camara, along with facility Executive Director, 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 11/04/2022 and pull stations were inspected on 05/24/2023. No safety concerns were noted at that time. Fire extinguishers throughout the building were observed to be fully charged and last serviced 12/20/2022. COMMON AREAS: The facility is a two story building. Facility has 2 working elevators and 3 stairwells. On the first floor, there are the kitchen facilities, dining room, Bistro, laundry rooms, medication room, bar/lounge area, library, activity rooms, formal sitting areas, beauty salon, fitness center, Wellness Center, office rooms, and common restrooms. On the second floor, there is a media room, laundry rooms, and common restrooms. LPA observed fireplaces in the first floor dining area, library/reading room, the Bistro, and the formal sitting room, all were observed to be adequately screened at the time of the visit. 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 large activity room on the first floor. OUTDOOR SPACE: LPA Camara and ED toured the outside area of the facility. There are two outdoor gated courtyards: one is designated for Memory Care residents and the other one is designated for Assisted Living residents. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Report Continued on LIC 809-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 KITCHEN: The main kitchen and dining room are located on the 1st floor. Food is prepared in the main kitchen and delivered to the dining area and the Memory Care dining room. 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 three-day and seven-day emergency supply of food and water. RESIDENT ROOMS/RESTROOMS: Memory Care is located on the first floor and has 36 rooms. Out of the 36 rooms, 4 are identified for double occupancy. The Memory Care Unit has all studio apartments with no appliances. There are 54 Assisted Living units and can be found on the first and second floors of the building. Assisted Living units are either studio, one, or two bedroom units and rooms and are equipped with a refrigerator, sink, and microwave. All rooms in both the Memory Care and Assisted Living Units are complete, with properly installed grab-bars in resident bathrooms and non-skid surfaces in shower/tubs and sufficient furniture and bedding/linens. Water temperature was checked in randomly selected rooms in both the Assisted Living and Memory Care units and measured between 107 to 117.6 degrees Fahrenheit, within the required range. RECORD REVIEW: LPA Dulek reviewed records beginning at 10:40AM. 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 Dulek 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. Last emergency disaster drill was conducted on 09/12/2023. MEDICATION REVIEW: LPA Camara reviewed medications for three (3) residents during today's visit. All medications observed were labeled, stored, and properly documented at the time of the visit. INTERVIEWS: During today's visit, LPA Camara interviewed four (4) staff and four (4) residents. No citations issued. Exit interview conducted. A copy of today's report was provided.

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 10/01/2023. LPA met with Executive Director (ED) Bradlee Foerschner. LPA explained the reason for today's visit. On 10/02/2023, ED had called and left a voicemail message for the LPA indicating Resident #1 (R1) who resides in Traditions had been found outside about a block away from the facility. R1 does have a diagnosis of dementia and is unable to leave the facility unassisted. During today's visit, LPA interviewed ED related to the incident, LPA along with ED toured the facility at 12:45PM, all delayed egress points were tested, and LPA obtained copies of documents pertinent to the incident. ED had informed LPA that last night, one of the delayed egress points had malfunctioned and the facility has provided staff to observe the identified gate until needed repairs are made. All other delayed egress points functioned properly during today's visit. ED indicated the written incident report related to the 10/01/2023 incident would be faxed to the Regional Office within the appropriate time frame. LPA will return at a later date to continue the investigation into the incident that occurred once all written documentation has been received. No citations issued. Exit interview conducted. A copy of today's report was provided.

Allegation: “Facility staff did not properly assist resident with transfers, resulting in resident falling:” It was alleged that during the overnight shift, Resident #1 (R1) who requires assistance with transfers, was not assisted properly and R1 fell as a result. Review of R1’s resident assessment dated 08/27/2021 revealed that R1 requires one-person physical assistance with transfers and resident has not fallen within the past year. Interview revealed that Monday through Friday during daytime hours, R1 has a private caregiver assisting them with all transfers and all ADL needs during that time. Facility staff provide assistance to R1 Monday through Friday at night only, as well as all day Saturday and Sunday. Interview with R1’s family member revealed that although a one-person transfer is sufficient, facility care staff are not adequately trained, and therefore a 2-person assist with transfers is needed often. While R1’s family member did indicate a 2-person transfer is more appropriate, Resident Assessment indicating R1 requires a 1-person transfer was reviewed and signed for by R1’s family member on 08/27/2021. Interview with staff revealed that they are trained annually on assisting residents with transfers. Based on interview and record review, 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 “facility staff did not properly assist resident with transfers, resulting in resident falling” is deemed UNSUBSTANTIATED at this time. Allegation: “Facility is understaffed:” It was alleged that during the evening, overnight and weekend shifts, the facility is understaffed. During the initial visit, LPA arrived at 6:19PM to observe evening staffing. When LPA arrived, there were 2 care staff and one medication technician present in Assisted Living, as well as one care staff and one medication technician in Memory Care. Staff interviewed indicated that medication technicians are trained and assist in meeting resident care needs and that there were 2 Memory Care caregivers present, but one was on their assigned break time when LPA arrived. Interview revealed that although the facility was experiencing some staffing concerns, the facility is utilizing agency staff to cover vacant shifts. Additionally, the facility is hosting job fairs as needed to recruit new staff. Staff interviewed did state that they are short staffed “all the time,” they also indicated that staff work double shifts and stay late to cover the vacant shifts. Staff schedule reviewed appeared to be adequate. Based on interview and record review, 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 “facility is understaffed” is deemed UNSUBSTANTIATED at this time. Report 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 Allegation: “Licensee failed to provide necessary hygiene items for resident(s):” It was alleged that R1 had run out of toilet paper and when R1 asked for a replacement roll, that facility staff indicated the facility is no longer providing needed hygiene items for residents. LPA interviewed residents and staff and reviewed the facility’s policy related to hygiene items. Interview revealed that housekeeping staff replace the roll during their regular cleaning services. Care staff interviewed were unsure whether it is the facility’s policy to provide items such as toilet paper to the residents, but all staff interviewed indicated they do provide items when residents request them. Residents interviewed indicated that normally residents purchase their own toilet paper or their families provide their preferred items, but when they ask for hygiene items, facility staff do provide them timely. Based on interview and policy review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation; therefore, the allegation that “licensee failed to provide necessary hygiene items for resident(s)” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.

Licensing Program Analyst (LPA) Dulek conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Kailey Vanderwall and explained the reason for the visit. On 05/11/2023, from 8:48am to 10:25am, Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 05/08/2023. LPA Dulek initially met with Business Office Director Kailey Vanderwall. The Executive Director (ED) Bradlee Foerschner arrived at 9:00am and the LPA explained the reason for the visit. On 05/08/2023 at 04:10pm, LPA Dulek received a telephone call from the ED indicating Resident #1 (R1) who resides in the memory care unit, had made an allegation of abuse against Staff #1 (S1). The LPA requested that an incident report and suspected abuse report be sent to the Woodland Hills Regional Office. The written report was faxed and received on 05/09/2023. Additionally, the ED informed the LPA that notifications were made to R1's resident representative, primary care physician, the local police department, and the Long-Term Care Ombudsman (LTCO). During the visit, the LPA along with the Business Office Director toured the facility at 8:51am, interviewed the ED at 9:04am, and obtained copies of pertinent documents. No immediate health and safety hazards were identified during the visit. The ED was informed that Investigator Ryan Miles from CCLD's Investigations Branch would follow up regarding the incident. On 06/03/2023, at approximately 2:01pm, Investigator Miles conducted an interview with the Director of Memory Care; on 06/04/2023, at approximately 1:40pm, with R1; and on 07/05/2023, from approximately 10:54am to 11:18am, with S1 and the ED. In addition, the investigator reviewed facility file documents related to R1 and S1, and obtained and reviewed the Ventura County Sheriff’s Department (VCSD) Report #2023-58367. The investigation revealed that on 05/08/2023, R1 reported to the Director of Memory Care that S1 inappropriately touched them. R1 stated “a couple of weeks ago” S1 penetrated their vagina with S1’s finger when S1 came to R1’s room to provide personal care. The ED also interviewed R1. Throughout the interview the timeline changed of when the alleged incident occurred ranging from 2 days to a few weeks ago. Report Continued on LIC 809-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 During the interview with the ED, R1 stated “there was construction being done in R1’s room, with white chalk on the ground caused by the construction, and the bathroom walls have been moved”. The ED notified R1’s physician of the allegation and delusions. R1’s physician conducted an examination of R1 and found no physical signs of a sexual assault. When interviewed by the police, R1 stated the incident happened a few months ago; and did not recall being inappropriately touched by S1 when interviewed by Investigator Miles. S1 denied touching R1 inappropriately. S1 was placed on administrative leave during the facility internal investigation. S1 was allowed to return to work on 05/10/2023. A review of R1’s physician report, signed on 07/26/2022, lists the primary diagnosis as altered mental status: Dementia. Other conditions listed included confused/disoriented, and sundowning behavior. Additional information obtained from interviews and medical reports revealed that R1 also suffered from delusional thoughts and hallucinations at times. According to the supporting documents, when R1 resided at a Skilled Nursing Facility in July 2022, the notes documented on 07/06/2022 to “monitor R1’s hallucinations such as sexual contact with roommate or staff”. R1’s resident representative also confirmed R1 experienced “delusions involving sexual allegations”. According to the VCSD report, Deputy Turner contacted R1 to ask a few questions to assist in assessing R1’s cognitive ability and comprehension. During the initial questioning and duration of the conversation, R1 “expressed observable cognitive impairment”. Based on R1’s cognitive mental status it was determined that R1 would not be able to provide additional accurate information. S1 was contacted and denied the allegation. The report concluded that the VCSD was unable to determine a crime occurred and the case was closed. Based on the interviews conducted and supporting documents, the Department does not have sufficient evidence to support the allegation of sexual abuse. Therefore, the allegation “Sexual Abuse – Resident allegedly was inappropriately touched by a staff member” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of report of the report was provided.

team then released R1's records via email to the requesting party on Monday 09/11/2023 at 12:33PM. Interview with ED further revealed that these documents were previously requested by R1's family member on 07/03/2023, with a deadline for receipt on 07/06/2023, however ED had provided R1's family member with the documents early on 07/05/2023. Email receipt was provided to LPA during today's visit. Based on interview and record review, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation " Licensee did not provide resident's records as requested" is deemed UNSUBSTANTIATED at this time. Exit interview conducted. No citations issued. A copy of the report was provided.

outside, LPA observed that when turning the door handle from inside R1's room, the lock disengages and the door can be opened. LPA took photos and video of the door opening from the inside, even when the door was locked. Interview with ED revealed that the doors can be locked to ensure resident privacy and to secure a resident's personal belongings. Residents can exit their rooms safely at any time of their own choosing, regardless of the door lock. Therefore, based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred; as thus the allegation that " Staff locked resident in their facility bedroom" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted with Executive Director. A copy of the report was provided.