Aegis Living Granada Hills.

Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the Health Service Director (HSD), Yolanda Ramirez, and explained the reason for the visit. The administrator, Lance Shenk, is currently at the Ventura Facility and unable to join. With the assistance of the HSD, a tour of the physical plant was made. The facility has three (3) floors. The fire clearance is for one hundred (100) non-ambulatory residents, of which ten (10) may be bedridden. Hospice waiver is for ten (10) residents. Delayed egress is approved for Dementia Unit (Italy & France). There is a fifteen second delay, or combination code to open the door. The facility's smoke alarms are hard wired. Last testing, which includes the sprinklers, fire door, alarms and exit light was completed on 05/31/25. Fire/earthquake and emergency evacuation drill was last conducted on May 10, 2025. The fire extinguishers throughout the facility hallways are on all three (3) floors, all extinguishers were last serviced on August 1, 2024. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen. Listing for residents that require a special diet is posted on the kitchen wall. Food deliveries from US foods are made twice a week. There were no pesticides or poisons observed near any food areas. Kitchen/food service staff observed with gloves and proper hair cover. Bedrooms: Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Emergency push button was tested for proper function. 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 Bathrooms: Resident bathrooms were properly supplied and had functional fixtures. Hot water temperature in random resident bathrooms on all three floors were checked and measured at a range of 111°F to 114°F. Common Areas : Common areas, including the lobby, activity rooms, movie theater, dining rooms, and library appeared clean and were properly furnished. There is a coffee/hot beverage station at the front entrance. Salon was closed and locked during the day of the visit. Surrounding Grounds : Entry/exits were free of obstruction. The outdoor/patio areas for both the assisted living and dementia wing was clean and free of hazards. Gates for the dementia wing is locked to prevent residents from wandering out. Sufficient staffing was also observed at both dementia wings. Laundry: Both dementia wings have it's own designated laundry area in the dining/activity section of the dementia wing. The assisted living laundry room is located on the first floor, across the kitchen. All three laundry areas were locked during the day of the visit. Staff Office/Work Station: Administrator's office is located on the first floor, by the entrance. Medication room and HSD office on the second floor. Resident Files : LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files : LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications : There are medication carts stationed at both dementia wings, and on each floor. There is a refrigerator, with lock, in the medication room to store medicine that requires cooler temperature. Medicaiton room is also locked at all times. Medication documentation and implementation appeared to be complete. There is a First aid kit on each medication cart. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.

Licensing Program Analyst (LPA) Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20211004100524 . LPA met with the Administrator and explained the reason for the visit. The purpose of the visit is to issue an amended version of the original report created 06-14-2022 after review of a second level appeal which changed the finding of the complaint. New, amended report had been created and previously issued LIC9099-D (deficiency) page will be removed. Exit interview conducted and copy of this report signed and delivered.

Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit to the facility to follow up on an Incident Report received on 12/14/24, pertaining to R1's personal rights. LPA met with the administrator, Lance Shenk, and advised him of the visit. Today's CM visit consisted of interviews with the administrator, staff and Resident 1 (R1). LPA also made a physical plant inspection and conducted a record review. According to the IR, the incident occurred on or around 12/14/24, at approximately 8:10am. R1 was interviewed by administrator and Health Service Director (HSD). Law Enforcement (LE) was also notified and a Battery Report (#24096208) was taken. LE indicated that they will not be conducting any further investigation based on their conversation with R1. Today, interviews made with administrator and Wellness Nurse. Administrator confirms no further interviews from LE based on their initial investigation. R1 is still at the facility. Facility made an internal investigation, which was deemed Inconclusive. R1 was sent immediately to the hospital after the alleged incident on or around 12/14/24. R1 was diagnosed with UTI, which caused some confusion. New orders prescribed at discharge. R1 is back at the facility. Family notified, and no concerns made. Based on the information obtained, it does not appear R1's personal rights were violated. No citations issued as the licensee satisfied their reporting requirements. Administrator was advised and a copy of this report issued.

private ambulance company to transport R1 to the hospital, and gave specific instructions for the driver to stay with R1 until admission at the hospital. LPA interviewed R1's family, and they confirmed that the private ambulance company was given specific instructions to stay with R1 until staff at the hospital admits R1. R1's family stated this incident is at no fault of the facility, because of the arrangements made with the ambulance company. Moreover, family stated the driver from the ambulance company not only left R1 unattended, but dropped R1 at the wrong entrance at the hospital. LPA also conducted interviews with residents who do not corroborate with the allegation of ever being left unattended by staff during their medical appointments. Based on the information obtained, there was insufficient evidence to prove that facility staff left R1 unattended at the hospital. Therefore, the allegation is deemed Unsubstantiated at this time. Staff left resident in soiled diapers/clothing: In regards to the allegation, it was reported that when R1 was transported to the hospital, R1 was soiled or covered in their urine. The reporting party (RP) was unable to confirm if R1 left the facility dry, and had an accident while waiting for admission in the hospital, or if R1 had urinated on self in route to the hospital. There were no witnessed provided by the RP to corroborate if the facility staff allowed for R1 to leave the facility soiled in their clothes, in route to the hospital. Interviews with facility staff deny the allegation, stating, when R1 was picked up by the ambulance for hospitalization on 11/27/24, they were dry and not soiled in their clothing. R1 was assessed prior to departure to the hospital. Based on the information obtained, there wasn't enough evidence to prove that staff left R1 soiled in the diapers or clothing. Therefore, the allegation is deemed Unsubstantiated at this time.

Interviews with facility staff, and record review reveal that at admission to the facility, R1 already has an impairment and diagnosis causing for them not to keep hydrated and drink enough water, resulting into the UTI and dehydration. Additional information received from these interviews and record review, also reveal that at admission, R1 already had a history of UTI and kidney stones. R1’s responsible person always had to push for R1 to drink fluids to stay hydrated. Despite the facility’s care plan in addressing R1’s inability to keep hydrated, R1 still showed resistance to drinking and keeping fluids down, due to their mental condition. On or around October 3, 2023, there is documentation of a fall, resulting in medical treatment for dehydration. R1 was discharged and returned to facility 10/05/23, with instructions to encourage frequent hydration. Regarding R1 never regaining the ability to ambulate, interviews made with facility staff and record review reveal that R1 was already non-ambulatory when admitted into the facility, requiring the use of a wheelchair at times. Moreover, R1 was admitted with their own wheelchair. Based on the information obtained, although there was record of a fall caused by possible dehydration, there wasn’t enough evidence to prove that neglect by facility staff caused for R1 to become dehydrated. Therefore, the allegation is deemed Unsubstantiated at this time. Facility staff did not follow admission agreement/ Facility staff did not properly notify resident's responsible person of rate changes. In regards to the allegation, it was reported that since hospice staff have taken over certain responsibilities, the licensee is finding new things to charge for, such as “hospice interface” and continuing to charge for showers on non-hospice days. Moreover, staff are not logging showers to prove showers are being provided to R1. Interviews with facility staff reveal that that on or around January 31, 2024, due to the progression of R1’s condition and diagnosis, their primary physician ordered hospice care. Hospice care plan was initiated for once a week, of which, assistance with showers is included. Although some services, such as incontinence services were dropped from service points on the facility’s care system, there was a hospice collaboration points added to the admission agreement. Hospice and home health collaboration is always explained to the resident, and their responsible person, prior to admission. Moreover, assistance with bathing, which R1 did require, was still in the admission agreement, scheduled for two times per week, which was already agreed upon. Facility did maintain a shower log, as proof assistance with showers were provided and as 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 agreed. Copies of these logs were provided to the responsible person. Copies also obtained by LPA during the investigation. R1’s responsible person was explained of these charges and new charges for both the addition and subtraction for services. R1's responsible person acknowledged, agreed and signed the documentation for the charges. Staff stated that without the responsible persons agreement to the new services and their signatures, hospice service would not have started. Based on the information obtained, there was insufficient evidence to prove that staff did not follow R1’s admission agreement, or the licensee did not notify R1’s responsible person of rate changes. Therefore, the allegation is deemed Unsubstantiated at this time. Facility staff did not answer communications from resident's responsible person. In regards to the allegation, it was reported that R1’s responsible person has attempted to call and email the licensee, trying to get clarification on the facility charges received on a statement dated 2/23/24 for the hospice interface and additional showers, but no response by the licensee was made. These charges were back dated to about 02/01/24. Interviews with facility staff and record review (copies of email interaction) confirm that there was communication between the facility business office, and R1’s responsible person to discuss the order placed by R1’s physician to initiate hospice service, the hospice care plan, changes to R1’s care, and rate charges and subtractions to R1’s admission agreement for services to be provided by the facility. R1’s responsible person acknowledged these changes and services, and the initiation for the hospice care., which they agreed and signed on for these services to start. Without the responsible person’s agreement and signature, hospice services would not have initiated. Based on the information obtained, there was insufficient evidence to prove that staff did not communicate with R1’s responsible person regarding clarification on their hospice service. Therefore, the allegation is deemed Unsubstantiated at this time.

Licensing Program Analysts (LPAs) Gary Tan and Michael Cava arrived to this facility today to conduct a One (1) Year Required inspection of the facility. LPAs met with Business Office Manager Andrea Hernandez and explained the reason for the visit. The facility is fire cleared for one hundred (100) non-ambulatory residents, of which ten (10) may be bedridden. Hospice waiver for ten (10) residents. Delayed egress is approved for Dementia Unit (Italy & France). Executive Director Lance Shenk called and designated Ms. Hernandez to sign the report. There is only one entrance being utilized at the facility, the front main entrance door. Screening area is located immediately upon entrance. There is also a sign in sheet, hand sanitizer, gloves and masks available. The facility had submitted and approved Mitigation and Infection plan. There are hand sanitizing stations all over the facility. There are signs of Covid 19 prevention protocol posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in common bathrooms, and the other common areas of the facility. The facility have multiple designated visitors' area in the front entrance and backyard. The facility has sufficient stock of PPE in the storage room. LPA conducted physical plant tour of the facility with Ms. Hernandez, residents' bedrooms on the first, second and third floors were inspected. Common areas, including the activity rooms, movie theater, dining rooms and library appeared clean and were properly furnished. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen, dangerous items are properly stored and inaccessible to residents. The facility menu appears to meet the daily dietary needs of the residents. (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 (continued from LIC 809) There were no pesticides or poisons observed near any food areas. Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. The medications were locked in the medication carts, properly labeled and stored. Medication documentation and implementation appeared to be complete. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked and measured a range of 114.6°F to 118.7°F and within the required range. LPAs observed fire extinguishers throughout the facility hallways on all three (3) floors, all extinguishers were last inspected on 06/06/24. There is a First aid kit on each medication cart stored/parked in the medication room located in the second floor. The facility's smoke alarms are hard wired as back up and tests are done in house on a monthly basis. Facility emergency disaster plan was reviewed. Facility disaster drills are conducted monthly and was last conducted on 07/10/24. A fire protection equipment performance certification was completed on 07/31/24. In addition to the physical plant inspection, residents and staff records were reviewed. LPAs reviewed files of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed. Residents files appear to be complete and updated. Staff present files were also reviewed, staff files appear to be complete and updated. Exit interview conducted and copy of report issued.

Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with staff, Portia Obina and Kimberly Martinez, and explained the reason for the visit. The administrator, Matthew La Vine, joined shortly after. At approximately 9:00am, with the assistance of staff, a tour of the physical plant was made. Facility is fire cleared for one hundred (100) non-ambulatory residents, of which ten (10) may be bedridden. Hospice waiver for ten (10) residents. Delayed egress is approved for Dementia Unit (Italy & France). There are currently five (5) residents receiving hospice care services and one (1) bedridden resident. Required postings were observed in the entry area. The facility's smoke alarms are hard wired as back up and tests are done in house on a monthly basis. Fire drill last conducted August 16, 2023. The fire extinguishers throughout the facility hallways are on all three (3) floors, all extinguishers were last serviced on June 21, 2023 Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen; dangerous items are properly stored and inaccessible to residents. The facility menu appears to meet the daily dietary needs of the residents. There were no pesticides or poisons observed near any food areas. Bedrooms: Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Bathrooms: Resident bathrooms were properly supplied and had functional fixtures. Hot water temperature in random resident bathrooms were checked and measured a range of 105.4°F to 115.8°F and within the required range. 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 Common Areas : Common areas, including the activity rooms, movie theater, dining rooms, pool hall and library appeared clean and were properly furnished. Surrounding Grounds : Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. Resident Files : LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files : LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications : The medications were locked in the medication carts, properly labeled and stored. Medication documentation and implementation appeared to be complete. There is a First aid kit on each medication cart stored/parked in the medication room located in the second floor. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.

towards them. Between 10:30am to 12:30pm, LPA obtained and reviewed copies of R1 and S1's records. A review of R1's records reveal that R1 can be aggressive and verbally disruptive. A review of S1's records do not indicate any history of disciplinary action for job performance during their employment with the facility. Based on the information obtained, there was insufficient evidence to prove that S1 slapped R1. Therefore, the allegation is deemed Unsubstantiated at this time.