Laurel Heights.

Following is a summary of the allegations and investigation finding: Regarding allegation “Staff left resident on floor for an extended period of time” – Information was received that resident #1 had two fall incidents and was left on the floor for an extended time. Also, additional information received that when resident fell (date unknown) R1 contacted the family member who lives close to the facility for help/assistance back into bed. To investigate this allegation, records reviewed revealed that R1 had two falls one on 2/11/2025 and another on 3/23/2025 since admission to the facility memory care on 2/20/2024. Service care plans dated 10/07/2024; 11/24/2024 and 3/26/2025 documented that R1’s level of assistance in mobility/ambulation was minimal to moderate; just prompting and cueing; not required hands on. Records reviewed indicated R1 requiring escort/redirection in the memory care unit and encourage use of walker. Regarding fall incident on 2/11/2025 it was documented that R1 sustained a fall in resident bathroom; R1 fell in the bathroom; R1 had a cell phone which R1 used to call family. The family contacted the facility at which time staff went to assist R1. R1 was found on the floor in R1’s bathroom (incident time documented 8:30pm). The second fall was on 3/23/2025; R1 was out with family; upon returning to the facility R1 sustained a fall transferring out of the family car. Staff were alerted and attended to R1 accordingly. In both fall incidents 911 was contacted and R1 was transferred to the hospital. Staff reported that all residents in memory care are out during the day in the common areas and constantly monitored by staff. Staff stated that when residents are in their room at night, they are checked on at minimum every 2hrs. 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 allegation “Staff left resident on floor for an extended period of time” is deemed unsubstantiated at this time. Regarding allegation “Resident sustained a pressure injury while in care” – Information was received that R1 had a level 1 pressure sore which was do to leaving R1 unattended for long periods each day. R1’s records reviewed did not indicate/note any pressure injury. Interview was conducted with Infinite home Health registered nurse (RN). RN reviewed R1’s records and confirmed that R1 did not have any pressure injury. RN verified through their records that the family took resident to the doctor on 05/08/2025 at which time the doctor provided R1 a referral for home health service; as precaution due to small (dot size) pink rash to R1’s sacral area. RN verified that an LVN from the home health agency evaluated R1 on 5/9/2025, 5/14/202 and on 5/20/2025 and no wound was observed. RN confirmed that they evaluated R1 on 6/2/2025 and no wound was observed to stage. (Continue to 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 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 allegation “Resident sustained a pressure injury while in care” is deemed unsubstantiated at this time. Regarding allegation “Staff leave resident soiled for extended periods of time” - Information was received that R1 was observed continuously found with a full diaper. Records reviewed and interview conducted with staff revealed that for hygiene and toileting, staff wound provide verbal prompts and cues. Staff reported that despite engorgement from staff R1 continuously demonstrated refusal of assistance with hygiene care and showers. Staff state that the family and doctor were informed. Staff reported that despite R1 refusing hygiene care, R1 was reminded and encouraged good hygiene care; family and doctor were aware of the situation. Staff interviewed reported that residents requiring assistance with toileting and showers are always assisted with hygiene care. Staff reported that residents are not left unclean or unsanitary. LPA attempted to interview residents in the memory care however they were unable to interview due to cognitive difficulties. LPA did not observe residents in the memory care unit soiled or unkempt during the initial visit and subsequent visits thereafter for other reasons. Visitors in the memory care unit interviewed during the initial visit expressed satisfaction with the care team services. Assisted living resident interviews were also conducted and five (5) out of five (5) residents interviewed reported no issues with care service provided by staff. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff leave resident soiled for extended periods of time” is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Case Management - Incident visit at the facility today. Upon arrival LPA met with the Business Office Manager, Adriana Castor and reason for the visit was stated. LPA later met with Joey Alvarado, Executive Director (ED). The purpose of today's visit was to conduct interview with staff and resident #1 (R1), review records and obtain pertinent copies of facility records pertaining to a self reported incident involving R1. Facility reported that on 02/16/2026, they were notified by R1's family that a theft incident happened on 2/11/2026. Family stated that they were notified of the incident by R1 on 02/15/2026. R1 did not report the incident to the facility and first contacted law enforcement on 2/13/2026 and later reported to their family on 2/15/2026. ED also contacted law enforcement after being informed of the incident and was told that a case is already open and under investigation with the Ventura County Sheriff's Office. During today's visit LPA reviewed R1's records from approximately 12:30pm-1:15pm; conducted interview with the ED from approximately 1:30pm - 2:15pm, and interviewed R1 along with Sarah Belgard from Adult Protective Services. R1 reported that they were a victim of financial scam. R1 did not report the incident to the facility or their family until after the incident occurred. R1 stated that they filed a police report on 2/13/2026 and later that weekend informed their family. Records reviewed revealed that R1 is responsible for self; able to leave facility unassisted and handles own finances. R1 was a victim of fraud and financial scam. Pending case investigation report from the Ventura County Sheriff's Office, a supplemental report will be issued, if warranted. Exit interview held and copy of report provided.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Executive Director Joey Alvarado and explained the reason for the visit. On 02/11/2025, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a report of the death of Resident #1 (R1). The report noted on 02/01/2025, R1 sustained a fall in their room. R1 was transferred to Los Robles Regional Medical Center Emergency Room (ER) and returned to the facility on 02/02/2025. On 02/04/2025, R1 reported not feeling well and was transported to the hospital and re-admitted. On 02/06/2025, it was reported that R1 passed away due to a brain bleed. On 02/11/2025, the RO referred this case to the Community Care Licensing (CCL) Investigations Branch (IB) Investigations Branch to investigate the allegation of Questionable Death. The case was assigned to Investigator Johnny Canto to conduct the investigation. On 02/11/2025, from 10:15am to 12:45pm, Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management – Incident visit. Upon arrival LPA Chochian met with the Administrator/Executive Director Johnny Ortiz and explained the reason for the visit. The reason for the visit was to follow up on a self-reported incident report. The report pertained to an incident involving Resident #1 (R1) who sustained an unwitnessed fall on 02/01/2025 at the facility and subsequently passed away on 02/06/2025 at Los Robles Regional Medical Center. (Continue to LIC809c) 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 Due to the circumstances surrounding the death of R1, the LPA informed the Administrator/Executive Director that the incident was referred to the Community Care Licensing (CCL) Investigations Branch (IB) for further review. On 03/03/2025, from approximately 11:45am to 3:55pm, Investigator Canto conducted interviews with the Administrator/Executive Director, facility staff, and Resident #2 (R2). In addition, Investigator Canto reviewed Los Robles Regional Medical Center records, Ventura County Clerk Records Office Death Certificate, and facility file documents related to the investigation. A review of R1’s Physician Report, dated 09/23/2024, listed R1 as ambulatory; able to leave the facility unassisted; able to independently transfer to and from bed; able to store and administer their own medication; able to administer their own oxygen; able to perform their own glucose testing; and able to care for all of their activities of daily living (ADLs). R1’s Health and Services Evaluation, dated 09/18/2024, indicated R1 was non-ambulatory, listed the mobility/ambulation level of assistance as independent (“resident does not require assistance with mobility/ambulation”); has occasional left knee discomfort when ambulating, relieved by lidocaine patch; does not require supplemental oxygen, has an oxygen concentrator but does not use. The MFS (Morse Fall Scale) evaluation determined R1 was a high fall risk due to a history of falling, uses an ambulatory aid (walker/cane), and has a weak gait. The evaluation indicated to “implement high risk fall risk reduction interventions”. R1 did not require assistance with ADLs, except for help with putting on socks and shoes, and bathing may require reminding or standby assistance. R1’s Service Plan, dated 10/06/2024, lists diagnosis as diabetes, type II; gastroesophageal reflux disease (GERD); heart disease; atrial fibrillation; congestive artery disease (CAD); congestive heart failure (CHF); spinal stenosis; coronary artery disease; and chronic kidney disease stage 3. The Service Plan includes the same information found in the Health and Services Evaluation. (Continue to 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 Additionally, the plan documents the potential for high fall risk and indicates “R1 is a high fall risk, encourage to always ambulate with cane or walker, keep room free of clutter, encourage to wear proper shoes”. Medical records reviewed document that on 02/04/2024, R1 was admitted to the Los Robles Regional Medical Center with a chief complaint of respiratory failure. On 02/05/2025, R1’s diagnosis included increasing lethargic and shortness of breath. Further tests and x-rays were completed which indicated “the patient most likely has acute respiratory distress ad hypoxia secondary to COPD exacerbation secondary to pneumonia versus CHF exacerbation as well as AKI and hypoglycemia”. In addition, the records indicated a subdural hemorrhage. R1 was placed on comfort care and passed away on 02/06/2025. The Department’s investigation revealed on 10/05/2024, R1 was admitted to the Laurel Heights facility. R1’s physician report noted that R1 was independent and not a fall risk. However, the Facility Health and Services Evaluation and Service Plan both noted R1 was a high fall risk, was non-ambulatory, used a cane and/or walker, and was independent with mobility and ambulation. Staff interviews revealed R1 had no history of falls while residing at the facility, was independent, and only needed standby assistance for showering. On 02/01/2025, R1 sustained an unwitnessed fall in R1’s apartment. R1 was discovered on the floor by facility staff when doing rounds. R1 verbalized that they had fallen in their bedroom. Facility staff noted several lacerations to the back of R1’s head. 911 was called, paramedics arrived, and R1 was transported to the Los Robles Regional Medical Center via ambulance. R1 was medically treated and then discharged back to the facility on 02/03/2025. On 02/04/2025, the facility staff noted that R1 appeared lethargic and unable to answer simple questions. The facility staff called 911 again, paramedics arrived, and transported R1 to the hospital. On 02/06/2025, the facility received notification that R1 expired while at Los Robles Regional Medical Center due to a brain bleed. The cause of death was noted as blunt force head injury with subdural hematoma. The Department’s investigation found insufficient evidence to support the facility neglected the care and or safety of R1. Therefore, no citations are being issued at this time. Exit interview, copy of report given.

Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management – Incident visit in conjunction with the annual continuation inspection today. LPA met with Executive Director (ED) Johnny Ortiz and discussed the reason for the case management visit/report. The purpose of today's visit was to investigate, review records and obtain pertinent copies of facility records pertaining to a self reported incident on 09/15/2025, of alleged resident to resident sexual abuse. During today's visit the LPA conducted interview with the staff and requested copies of pertinent documents. Further investigation is needed regarding the alleged sexual abuse. Exit interview held. Copy of report provided.

Licensing Program Analysts (LPA) Zabel Chochian initiated a required annual visit today at approximately 3pm. LPA and Executive Director Johnny Ortiz toured the physical plant areas inside the assisted living and memory care unit to ensure there are no health and safety hazards. 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 furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguishers are fully charged and were last serviced 01/14/2025. Due to time constraints, the annual inspection will be completed on a follow-up visit. No deficiencies cited at this time. Exit interview conducted and a copy of report provided.

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to this facility and met with Executive Director, Johnny Ortiz. The case management visit is being conducted due to deficiencies observed during the investigation of complaint control # 29-AS-20241230123842. During the complaint investigation, the following deficiencies were observed: During today’s visit LPA reviewed and compared the Personnel Report (LIC500), LIS system and the Guardian System. During the audit, LPA observed two (2) staff members listed on the Personnel Report (LIC500) that have passed a criminal background clearance, however, they were not properly associated to the facility. LPA was able to look-up employee information in the LIS system and found that Staff #1 has been working at the facility since 06/13/2022 and Staff #2 (S2) has been working since 05/16/2024. Both staff members were separated from facility named above. S1 separation date was 07/01/2023 and S2 was separated on 05/22/2023. ED stated that S1 is not longer an employee for the facility since 03/16/2025 and during today's visit S2 was associated to the facility. Additionally, LPA requested the Personnel Report (LIC 500) for the month of December 2024. However ED was unable to produce this information stating that they were not aware that the facility is required to keep a current roster of all facility personnel. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Citations issued, civil penalty issued, exit interview, appeal rights given.

Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management – Incident visit. Upn arrival LPA met with Executive Director (ED) Johnny Ortiz. Reason for visit was explained. The reason for today's inspection is to follow up on a self reported incident report received on 02/10/2025. The report pertains to an incident involving Resident #1 (R1) . It was reported that on 2/01/25, R1 sustained an unwitnessed fall at the facility. R1 sustained a bump on the back of the head therefore 911 was called and resident was transferred to Los Roblas Hospital ER; 02/02/2025, R1 was discharged from ER at approximately 3am. R1 was put on a 72 hour monitoring upon return from the hospital. On 02/04/2025, R1 was observed not feeling well therefore 911 was contacted and resident was transferred to ER again. On 02/06/2025, facility was notified by R1's responsible person that R1 had passed way. Per the information received, the circumstances surrounding the death of R1 on 02/06/2025 may be questionable. During today's visit, the LPA conducted interview with the ED and facility's Health Service Director-Pricila Bosdoganian; copies of pertinent documents requested including but not limited to a copy of the death certificate/report. LPA informed ED that this incident was referred to Community Care Licensing Investigations Branch (IB) for review and that further review is required. An LPA will return at a later date to issue findings. Exit interview conducted. A copy of the report was

(Report Continued from LIC 9099...) It was alleged that the Administrator is not on the premises for a sufficient number of hours. It was reported that the Administrator is always away from the facility. Interviews conducted with staff revealed that the Administrator is seen coming into the facility everyday Monday through Friday. Staff stated that the Administrator typically comes in the morning and added that the Administrator leaves the facility after they have left for the day themselves. Additionally, during resident interviews it was revealed that six out of six residents often see the Administrator walking through the hallways talking with both residents and staff. Furthermore, interviews with residents and staff corroborated that the Administrator is regularly seen at the facility during normal business hours. Based on the interviews conducted with staff and residents, the Department does not have sufficient evidence to support the allegation of “administrator is not on the premises for a sufficient number of hours”. Therefore, this allegation is deemed Unsubstantiated at this time. It was further alleged that a qualified staff is not designated to operate the facility during the administrator’s absence. It was reported that the facility has designated a receptionist to cover the facility in the Administrator’s absence and they are not qualified. Interviews conducted with staff revealed that the Administrator is regularly at the facility Monday through Friday. However, on weekends when the Administrator is not scheduled, there is management available at the facility. At any time, if the Administrator is unavailable, the facility has a Business Director, Health Services Director, and Marketing Director that are able to assist when needed. Furthermore, interviews conducted with staff revealed that management is available and willing to help whenever the Administrator is not present. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “a qualified staff is not designated to operate the facility during the administrator’s absence”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued at this time. A copy of the report was provided.

(Report Continued from LIC 9099...) It was alleged that facility has mold. It was reported that there is an issue with mold in the basement as well as certain resident bedrooms. During the plant tour on 08/31/2023, LPA observed the basement and specific bedrooms throughout the facility. Upon observation, the LPA did not see any signs of mold on the bedroom walls, behind, or around the bathroom doors. Additionally, there was no smell that indicated there is a mold problem in the facility. Information obtained and reviewed revealed the facility had a leak due to heavy storms; however, the facility had Nu-Cal Pipeline Corp. come out to the facility and do water intrusion repairs where needed. Interviews conducted with staff also indicated the facility had water damage due to water from the rain getting through the walls. Additionally, certain services are provided and offered to residents in the basement which include the salon, movie theater, and fitness center. Interviews conducted with random residents revealed they often visit the basement to take advantage of the services offered downstairs and they did not report smelling mold while being in the basement. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility has mold”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that facility is in disrepair. It was reported that the stairwell leading to the basement is detaching from the foundation and the stairs shift when in use. Document review revealed the facility had contracting company Nu-Cal Pipeline Corp. do water intrusion repairs due to heavy rains that had caused water damage at the facility. The facility had the pipes sealed, walls, and baseboards replaced. Additionally, during the plant tour on 08/31/2023 and 12/05/2023, the stairwell leading to the basement did not move or shift while the LPA and staff went downstairs. Interviews conducted with staff revealed that neither residents nor family members have reported the facility being in disrepair. Based on LPA observations and record review, the Department does not have sufficient evidence to support the allegation of “facility is in disrepair”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff do not ensure kitchen is clean. It was reported that the kitchen staff leave the kitchen unkempt, dirty dishes piled up, food that needs to be refrigerated is being left out, and counters are left dirty. During the plant tour on 08/31/2023 and 12/05/2023, the LPA toured both the kitchen and food service area. (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...) The LPA observed clean and newly washed dishes on a cart. The sink was empty as all dishes had been recently washed. Kitchen counters appeared clean at the time of the visit. Additionally, all food was observed inside both the refrigerator and freezer and not laying on any counter. Furthermore, interviews conducted with staff revealed that the kitchen is cleaned immediately after all meal services and maintained clean throughout the day. Based on LPA observations, the Department does not have sufficient evidence to support the allegation of “staff do not ensure kitchen is clean”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff are feeding residents food that is not of good quality. It was reported that chunky milk that has been expired is left in the refrigerator and expired food is being served to the residents. During the facility walkthrough on 08/31/2023, the LPA observed the facility’s food supply in the kitchen, pantry, and refrigerator. The LPA observed food from all groups such as meats, dairy, eggs, breads, fresh fruit, and vegetables. Additionally, the LPA inspected the food labels and checked for expiration dates. All food labels had dates clearly marked and no expired food was observed. Interviews conducted with staff revealed the facility’s food is usually ordered to be delivered twice a week and perishables are ordered as needed. Interviews conducted with random residents revealed the food prepared at the facility is better than other places they have been to. Furthermore, residents reported to LPA during interviews that the facility offers a variety of different foods, they had no concerns about the food being served at the facility. Based on LPA observation and interviews conducted, the Department does not have sufficient evidence to support the allegation of “staff are feeding residents food that is not of good quality”. Therefore, this allegation is deemed Unsubstantiated at this time. It was further alleged that staff dispensed incorrect medication to resident. It was reported that one resident’s half pill was found in another resident’s bedroom. During the visit on 08/31/2023, LPA conducted a medication audit for four (4) random residents and no discrepancies were observed. Review of centrally stored medication and destruction records indicate medications are being administered as prescribed. Interviews conducted with staff revealed medication audits are performed to maintain accuracy and make sure medication is being administered correctly to residents. (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...) Additionally, staff stated medication technicians are trained before they are able to assist residents with medications. Interviews conducted with random residents revealed that their medication is administered by staff around the same time every day and reported having no issue with their medications while living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff dispensed incorrect medication to resident”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued. Report was reviewed and a copy was issued.