Ocean Hills Assisted Living & Memory Care.

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Sheryl Johnston. During today's visit, LPA observed residents in care and reviewed facility records. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. LPA was away from the facility for approximately one hour between 12:05pm and 1:05pm. No deficiencies were cited on today's date. An exit interview was conducted with Business Office Manager Kristin Mulligan, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management to complete the annual inspection from 4/17/2025. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Sheryl Johnston. The facility is licensed for a maximum capacity of 123 non-ambulatory residents, 10 of which may be bedridden. The facility has a waiver for 20 hospice residents. During today’s visit, the facility had a census of 108 residents. The Administrator for the facility is Sheryl Johnston and their certificate was valid and current. During visits on 4/17/2025 and 4/25/2025, LPA toured the facility and inspected a random sampling of resident rooms, private and common bathrooms, facility kitchen, common areas, and outside space. No bodies of water were observed on the premises. LPA observed delayed egress in the facility's memory care. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured within requirements across a random sampling of resident rooms and common bathrooms. The facility’s internal temperature was measured at 74, 75, and 76 degrees Fahrenheit across the facility. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Sheryl Johnston, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. Continued on LIC809-C page… 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, initial medical assessment, updated annual reappraisal, documents regarding safeguarding personal property and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Sheryl Johnston. During today's visit, LPA observed residents in care and reviewed facility records. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. No deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Sheryl Johnston and Resident Care Director Dennis Prejusa, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to conduct follow up regarding an incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Sheryl Johnston. On 3/14/2025, the Department received an incident report from the facility that described that on 3/5/2025, Resident 1 (R1) complained of pain during the overnight shift. [Executive Director was provided with an LIC811 Confidential Names list to identify R1] Facility staff offered R1 PRN pain medication, which R1 did not want, resulting in staff calling emergency services. R1 was transported to the hospital where R1 received medical attention and was diagnosed with multiple health conditions, including two injuries. R1 returned to the facility on 3/10/2025. During today’s visit, LPA conducted a health and safety check, observed residents in care, and reviewed and obtained copies of facility records. No deficiencies were cited on today’s date and no immediate health or safety concerns were observed. An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).

Review of Resident 1’s (R1's) documents revealed that R1 was had two assessments conducted in September 2020 and an additional care assessment in November 2020 due to increasing care needs. In September 2020, R1’s care needs included standby assistance for bathing, reminders for meals, and noted that R1 was a fall concern. During the November 2020 assessment, R1’s care needs increased to require full assistance from staff for all activities of daily living due to a fall. R1 was also placed on the facility’s waitlist for memory care, and communications between R1’s responsible party and physician dated October 2020 agreed that it was in R1’s best interest to be placed on the waitlist instead of relocating to a different facility. Additionally, R1’s responsible party had arranged for R1 to have a third party caregiver provide 1 on 1 supervision, which interviews with outside sources confirmed. R1 also began receiving hospice services sometime between November and December 2020. Review of fax communications revealed that R1’s physician and responsible party were kept informed of and were in agreement with R1’s increasing care needs. Interviews with outside sources revealed that there were some concerns regarding supervision, however, the concern was with the third party agency that was hired by R1’s responsible party and outside sources denied concerns with the facility staff's ability to meet R1's increasing care needs. Review of Resident 2’s (R2's) assessment records for October 2020 revealed that R2 required reminders for meals and dressing and required 1 person assistance for bathing. Review of R2’s physician report for December 2020 revealed that R2 had a diagnosis of major cognitive impairment, was confused and disoriented, had auditory and visual impairment and was occasionally incontinent. R2 was reassessed in January 2021 and review of R2’s physician report and needs and services plan from January 2021 revealed that R2 began receiving hospice services, required reminders for meals and toileting, required 1 person assistance for bathing and was at risk for falls. Review of fax communications between the facility and R2’s physician revealed that the facility maintained communication regarding R2’s changes in condition including falls. Review of Resident 3’s (R3's) physician’s report from August 2019 revealed that R3 had a diagnosis of mild cognitive impairment, was not confused or disoriented, was able to follow directions and communicate needs and was able to manage their medications independently. Review of fax communications revealed that beginning in September 2020, R3 was observed to have increasing confusion and agitation. Review of R3’s needs and service plans dated April 2021 revealed that while R3 did not have any increasing care needs, R3 required reassurance from staff to prevent agitation and distrust of staff. Review of assessment documents for R1, R2, and R3 did not reveal evidence that supported the allegation that residents were not appropriately assessed or that resident's appraisals were not updated to meet resident's care needs. Continued on LIC9099-C page... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Review of the staff schedule for November 2020 revealed that the facility scheduled between 4 and 5 care staff including medication technicians per shift and scheduled between 2 and 3 care staff including medication technicians scheduled for the overnight shift. Interviews with residents did not reveal evidence that staff were not able to meet resident care needs and residents stated that staff were very attentive and helpful. Evidence obtained during interviews with outside sources corroborated that staffing level was sufficient to meet resident care needs. Interviews with staff were inconsistent regarding the ability of staff to meet the care needs of residents. Staff interviews provided conflicting information, with some interviews stating that the staff level during shifts matched the November 2020 staff level and other interviews revealed that there were multiple instances where there were approximately 3 caregivers during a shift, with one caregiver per floor in assisted living and one caregiver in the facility’s memory section. Review of the admission agreement used by the facility in 2019 and 2020 revealed that the facility agreed to provide residents with meals three times a day and in-between meal snacks. The admission agreement stated that meals would be provided "restaurant-style" in the facility's dining room or via tray service due to temporary sickness or at an additional fee. Additionally, the facility offered catering services to a resident's apartment or to a common area with prior notice and at an additional fee. Interviews with staff and residents did not reveal any concerns regarding the food quality, variety of options, or the facility’s ability to accommodate special diets. Review of the admission agreement revealed that the facility did not promise to provide a certain quality or level of dining experience to residents beyond providing meals in a restaurant like setting. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22). 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 Review of a random sampling of residents’ assessment records, needs and services plans, and additional care assessment documents did not reveal residents who had wandering or exit seeking behavior that could not be managed by staff redirection. Review of incident reports submitted to the Department by the facility and review of licensing reports between September 2020 and December 2021 did not reveal any instances of resident elopements or wandering that resulted in injury. The Department has investigated the above-mentioned allegation and based on record review, this allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

Review of medical and assessment records dated 2019 revealed that Resident 1 (R1) had a diagnosis of mild cognitive impairment, was confused and disoriented, was able to follow directions and communicate with staff, and required 1 person assistance with bathing, grooming, dressing, and transfers, and required standby assistance for toileting care, and required wheelchair escorting to meals and activities. Interviews with staff and outside sources revealed that R1 was hospitalized and transferred to a higher level of care sometime in late 2019 to early 2020. After R1 returned to the facility, R1’s care needs had increased and R1 had a diagnosis of major cognitive impairment and required 2 person assistance and additional time for toileting, bathing, and transfers, as confirmed by interviews with staff and outside sources and review of medical and assessment records dated 2020. Review of R1’s medical records dated 2020 revealed that R1 was receiving physical therapy services for weakness in their lower extremities and difficulty with ambulation. Additionally, R1’s needs and service plan dated 2020 revealed that staff were instructed to provide bathing and incontinence care in bed during the evening and overnight if R1 felt too weak to be transferred out of bed for care. Interviews with staff and outside sources confirmed that R1 was provided with incontinence and bathing care while in bed after R1 returned from the higher level of care. Interviews with staff and outside sources revealed that R1 used incontinence briefs and was not able to consistently communicate their needs following hospitalization, and staff would check on R1 multiple times a day and respond to call lights for incontinence care. Interviews with staff and outside sources provided conflicting information regarding if R1’s incontinence needs were being met overnight but confirmed that staff would respond to call lights and check R1 for soiled briefs during the night. Interviews with staff and outside sources revealed that staff would assist R1 with transferring by lifting R1 with the use of a gait belt and while holding onto R1’s arms. Interviews with staff denied any bruising or injuries from transferring. Interviews with outside sources provided conflicting information regarding bruising on R1’s arms and stated that R1 may have sustained bruising due to a fall in the shower. Outside sources stated during interviews that there were instances where staff were not available to transfer R1 and outside sources would assist R1 with transferring. Interviews with outside sources and staff revealed that R1 received medication management from facility staff. Interviews with staff revealed that R1’s spouse was an active participant in R1’s care and would frequently speak with R1’s physician to change R1’s medication orders, resulting in medications being discontinued without facility staff notice. Continued on LIC9099-C page... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Interviews with staff confirmed that medications for R1 had been changed or discontinued by R1’s spouse without a written notice provided to the facility, and staff would explain to R1’s spouse that the facility needed an updated written order to administer medication differently. Review of communications between the facility and R1’s physician in 2020 confirmed multiple communications where medication orders were requested to be changed due to a request by R1’s family. Additionally, those communications and interviews with staff and outside sources revealed that R1’s spouse would occasionally refuse to allow staff to administer medications to R1 due to requested changes in how the medication was prescribed or if R1’s spouse believe the medication was not given at the exact time. Interviews did not reveal any specific descriptions of medications that were administered incorrectly or missed for R1. Review of pest control records in 2020 revealed that the facility had an ongoing contract with a pest control company who provided pest control services to the facility on a monthly basis. Review of those records revealed that due to the COVID-19 pandemic, services were only provided on the exterior of the building, but pest control staff would verify any concerns with facility staff prior to services being provided. The pest control company provided bait and extermination services for rodents and insects and provided the facility with best practices to prevent insects or rodents. Interviews with staff and outside sources revealed that when the facility first opened in 2019, there was an issue with insects, however, those interviews did not provide the Department with the severity of the insect issue or which portions of the facility were impacted. Interviews with staff revealed that due to the COVID-19 pandemic, meals were provided to residents in boxes at their room doors. Staff stated that due to the number of residents requiring meals and the facility still serving hot meals, some meals would get soggy or cold. Staff stated that caregivers assisted dining staff with delivering meals to get meals to residents more quickly, and attempted to serve meals that were supposed to be cold more often. Staff denied any issues with quality of ingredients or meal amounts during interviews, but stated that it was possible that residents felt limited in meal choice due to the delivery system. The Department was unable to interview R1 due to being unable to locate R1's whereabouts after R1 moved out of the facility. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Receptionist Lindsey Sherrod. LPA was later joined by Executive Director Sheryl Johnston, Assistant Director Jiovani Anderson Diaz, and Business Office Manager Jamie Colon. According to the facility’s license, the facility has a maximum capacity of one hundred twenty-three (123) residents, all of whom may be non-ambulatory. During today’s inspection, there were a total of one hundred and sixteen (116) residents in care. This facility does not feature a secured perimeter but has delayed egress doors in memory care unit. LPA, accompanied by Johnston and Anderson Diaz toured the interior and exterior of the facility, and inspected resident rooms. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant. There was at least two (2) days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to residents. Medications were labeled, as required, and stored in locked areas. (CONTINUED ON LIC809-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 LIC809) No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Confidential records were stored in locked areas. Johnston also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Sheryl Johnston and Jiovani Anderson Diaz to whom a copy of this report and the Licensee/AppealRights(LIC9058 03/22) were provided during the visit.

Review of R1’s medical assessment and appraisal documents dated September 2023 did not reveal any history of inappropriate, aggressive, Sundowning, or wandering behaviors. Review of R2’s medical assessments dated May 2023 revealed that R2 had a diagnosis of major cognitive impairment, was confused, disoriented, and able to follow directions, but was unable to communicate needs. R2’s medical assessments denied any history of inappropriate, aggressive, Sundowning, or wandering behaviors. Interviews with staff and outside sources and review of admission records revealed that R1 was admitted to the facility on 10/14/2023 and occupied a shared double room with R2 within the memory care portion of the facility. Interviews with staff and outside sources and review of documents received by the Department from the facility on 10/20/2023 revealed that on 10/18/2023, R2 reported to facility staff that they were uncomfortable around R1 and that R1 had attempted to kiss and touch R2’s body. Facility staff relocated R1 to another room within the memory care the same day as R2’s statements. Review of documents received by the Department revealed that facility management followed reporting requirements and submitted an incident report and report of suspected elder abuse to the Department on 10/20/2023 as well as notified R1 and R2’s responsible parties. Interviews with staff stated that R1 would occasionally yell at or become upset with staff when they entered R1’s room to provide care, but that R1 was able to be redirected. Interviews with outside sources stated that R1’s personality could be described as “affectionate”, but those interviews did not indicate that R1 had a history of any aggressive, inappropriate, or sexual behaviors, or had a history of physically interacting with others in an affectionate manner. Review of progress notes and interviews with staff and outside sources denied any physical aggression or any additional altercations between R1 and any other residents, including R2. Interviews with outside sources revealed that R2 had complained to outside sources about R1’s behavior prior to R2’s report to the facility on 10/18/2023, but those previous complaints were not reported to facility staff. Interviews with staff and facility management did not reveal any knowledge of R1’s kissing and touching behavior prior to R2’s report on 10/18/2023. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with ED Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Sheryl Johnston. Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/04/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a facility tour / welfare check, collected copies of pertinent records, and interviewed R1 and relevant staff. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Johnston, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow up on an incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit to Business Office Manager Jamie Colon. The Department received an incident report from the facility on 10/20/2023 stating the Resident 1 (R1) had eloped from the facility and sustained an injury requiring hospitalization on 10/16/2023. During today's visit, LPA toured the facility, conducted a health and safety check, observed residents in care, and reviewed and obtained copies of facility records. No deficiencies were cited or observed on this date. An exit interview was conducted with Business Office Manager Jamie Colon, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).