Belmont Village Thousand Oaks.

(PAGE 2) Report continued from LIC 9099... During today's visit starting at 10:06 a.m. LPA and DRCS briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Starting at 10:22 a.m. and through the visit LPA conducted five (5) staff interviews, including Staff #1 (S1), interviewed Resident #1 (R1) and obtained copies of pertinent documents relevant to the investigation. On the allegation, Staff inappropriately sprayed a resident, it is the concern of the Reporting Party (RP) that during a shower S1 sprayed R1 in the face and mouth during a shower. To investigate this complaint, LPA conducted in person staff interviews, in person resident interviews, file and record review, and obtained copies of pertinent documentation relevant to the investigation. Interview with R1 revealed that on the alleged incident date of 03/17/2026, during the morning, S1 assisted them with a shower. R1 reported that they were unfamiliar with S1, which was unusual because they are typically familiar with the PALs in the community. They stated that they do not recall what the staff member looked like or their name, noting, “It all happened so fast.” R1 explained that they have sensitive eyes and ears, and water in those areas bothers them. During the assisted shower, they stated that S1 sprayed water into their face and ears. R1 reported, “They didn’t say anything or apologize,” and expressed that while they understand it was a shower, certain areas—specifically the eyes and ears—should be shielded. They described the interaction as rude, and not accidental. R1 stated that they have never had an encounter like this with a PAL before. They shared that “The PALs will bend over backwards to do things for you; they are great.” R1 confirmed that they have not had any additional interactions with S1 since the incident. Interviews with residents revealed that they have not experienced any negative interactions with the PALs during showers. Residents reported satisfaction with the quality of care provided and stated that staff consistently treat them with dignity and respect during bathing assistance. Residents indicated that they are only minimally familiar with S1, noting that they have seen them briefly in the community. Several residents believed that S1 is new to the community, which may explain their limited familiarity. Report continued on LIC 9099-C PAGE 3... 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 (PAGE 3) Report continued from LIC 9099-C PAGE 2... Interview with S1 revealed that on the day of the alleged incident, 03/17/2026, they assisted R1 in getting out of bed. R1 appeared to be struggling to wake up that morning, and the med tech reminded S1 that R1 had an appointment. S1 stated that R1 was cooperative throughout the interaction. S1 assisted R1 to the toilet, then proceeded with the shower, prompting R1 to close their eyes while washing their hair, and completed the shower without issue reported at the time.S1 stated that they “did not act with bad intentions at any point” and believe the situation may be a misunderstanding. Additionally, S1 reported that at no time did R1 verbalize any discomfort or dissatisfaction during the shower. S1 emphasized that they had no ill intent, have never received complaints regarding showers in the past, and were unaware that R1 had any concerns until the allegation was brought forward. Staff interviews revealed that they treat residents with dignity and respect, prioritizing resident safety. Staff reported that they have not received any complaints regarding dissatisfaction during showers; however, they stated that if a concern were to arise, it would be reported to the DRCS immediately. During interviews, staff demonstrated knowledge of resident rights, the different forms of abuse, and reporting procedures. Interview with the DCRS revealed that on the day of the alleged incident 03/17/2026 they received an email from R1’s Power of Attorney (POA) detailing the incident. Once the facility became aware of the allegation, staff followed protocol and initiated an internal investigation. The appropriate agencies, including Licensing, Ombudsman, and Sheriff’s department were notified. The staff was removed from the schedule and was interviewed regarding the allegation and denied any aggressive actions during the shower. It was reported that the staff reported that nothing inappropriate occurred and denied spraying water toward the resident’s face. The staff was removed from the schedule, and will not be placed back on the floor. The staff is redoing all their PAL training and any components included in the initial orientation training. In addition, they will complete 3–4 days of buddy training/shadowing with a lead med tech or caregiver. Following the complaint, the nurse spoke with the resident. The resident stated that the PAL sprayed water into her face and ear. When asked if it might have been accidental, the resident said they did not believe it was. The resident denied pain or injury. A visual assessment was completed, revealing no injuries, and the resident was stable at baseline. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff inappropriately sprayed a resident is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.

Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Incident visit to follow up on two (2) self-reported incidents which took place on 02/23/2026 and 02/28/2026. Upon arrival at 10 a.m. LPA was greeted by the front desk receptionist and explained the reason for the visit. LPA met with Executive Director (ED) Mark Ranno and Director of Resident Care Services Karen Pasten and the reason for the visit was explained. Entrance interview conducted. Incident #1: On 02/23/2026, it was alleged that Staff #1 (S1) called Resident #1 (R1) “stupid” and repeatedly questioned why they were confused. Once the facility became aware of the allegation, staff followed protocol and initiated an internal investigation. The appropriate agencies, including Licensing and Ombudsman, were notified. R1 was interviewed, and S1 was immediately suspended pending the outcome of the investigation. S1 was interviewed and provided in-service training regarding professional interactions with residents with memory impairment. Incident #2 On 02/28/2026 it was alleged that Resident #2 (R2) disclosed to their Power of attorney (POA) that “A man took me downstairs and molested me”. Once the facility became aware of the allegation staff followed protocol and initiated an internal investigation. The appropriate agencies, including Licensing and Ombudsman, were notified. R2 was evaluated by the facility LVN, POA refused transport to the emergency room for further evaluation, however agreed to a virtual telemedicine physician visit. Primary care physician was contacted and provided a copy of the report, and the police were notified #26-26-884. During today's visit, LPA and staff toured the physical plant area inside and out to ensure there were no immediate health and safety concerns. 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 (PAGE 2) Report Continued from LIC 809... Starting at 10:34 a.m. and throughout the visit LPA conducted four (4) in person staff interviews, resident interviews, at 2:15 p.m. attempted to conduct a telephonic interview with POA of R2, file and record review for S1, R1 and R2, facility records review and obtained copies of pertinent documents relevant to the incidents. Incident #1: Documentation revealed that Resident #1’s (R1) Physician’s Report dated 11/25/2024 lists dementia as the primary diagnosis. The assessment and service plan dated 11/18/2025 indicate that R1 receives assistance with medication management, housekeeping, laundry, and hands-on assistance with bathing, dressing, grooming, continence care, toileting, transferring, and fall-prevention interventions. The MDS-COGS assessment dated 08/26/2025 scored 6, indicating low-to-moderate impairment. The Montreal Cognitive Assessment (MoCA) dated 09/25/2025 scored 11/30, indicating significant cognitive impairment. S1 has no history of disciplinary action. On 03/02/2026, S1 conducted an in-service training regarding expectations for professional communication with residents, including appropriate approaches when working with individuals living with dementia. The facility’s internal investigation was completed, and S1 returned to work on 03/03/2026. Interview with the Director of Resident Care Services (DRCS) revealed that A third-party companion reported that R2 stated a staff member had called them “stupid” and repeatedly questioned why they were confused. The facility immediately notified the Executive Director, suspended the staff member, and initiated an investigation. During interviews, the resident stated they did not recall being called “stupid,” though they remembered disliking the staff member’s tone and were unable to identify or describe the individual. A full body assessment on R2 confirmed the resident was safe with no concerns noted. Following interviews with all involved parties, S1 denied the allegation, has no history of misconduct and was reinstated. The resident requested that the S1 not be assigned to them moving forward. Interview with R1 revealed that they did not recall the incident or being called “stupid.” R1 stated they previously disliked the tone of a staff member but could not recall who the staff member was or what they looked like. Resident interviews indicated that residents feel safe within the community and reported that staff treat and speak to them with respect. Residents reported no concerns regarding the quality of care or staff conduct. Staff interviews indicated that they have never witnessed nor engaged in disrespectful behavior toward residents, including calling a resident “stupid.” Report Continued on LIC 809C PAGE 3... 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 (PAGE 3) Report Continued from LIC 809-C PAGE 2... Staff stated they treat residents with dignity and respect. It was noted that during the facility’s internal investigation, S1 denied the allegation, stating that they “would never make derogatory statements toward residents.” Incident #2: Documentation shows that R2’s Physician’s Report dated 10/30/2025 lists dementia as the primary diagnosis. The assessment and service plan dated 10/29/2025 indicate that R2 requires assistance with medication management, housekeeping, and hands-on assistance with bathing, dressing, and grooming. R2 also requires reminders and cues for continence and toileting, reminders to use assistive devices, and occasional redirection and guidance. A Montreal Cognitive Assessment (MoCA) dated 10/29/2025 scored 17/30, indicating moderate cognitive impairment. Telemedicine documentation dated 02/28/2026 shows that R2 was seen for an urgent care visit and presented with dementia accompanied by delusions. The physical exam noted R2 to be healthy, well-nourished, and well-developed, with no acute distress. The assessment included delusions and dementia with psychotic disturbance, with dementia severity and type listed as unspecified. An in-service training was conducted on 03/02/2026 regarding appropriate responses to resident allegations of abuse, neglect, or inappropriate conduct. Interview with the DRCS revealed that R2 reported to their POA that a man had entered thier room at night and attempted to “make out” with them, later describing the event as an attempted sexual encounter but stating they did not believe they were touched, harmed, or assaulted. R2 was unable to describe the individual and provided inconsistent details, at one point saying multiple men were involved and later stating it was one person. A nursing assessment found no injuries, no pain, and no signs of trauma, and the Sheriff’s Department responded and obtained statements from the resident and staff. The resident’s primary care provider, who is familiar with R2 history of dementia with delusions, advised that an ER visit was not necessary and adjusted their medication. The facility completed an in-service training with staff on responding to allegations of abuse, and the POA expressed that they believe the report was related to the resident’s dementia but wanted it documented. During the visit R2 refused to be interviewed. Resident interviews indicated that residents feel safe within the community and reported that staff treat and speak to them with respect. Residents reported no concerns regarding the quality of care or staff conduct. Staff interviews indicated that no residents have ever disclosed abuse to them. Staff stated that if a disclosure were to occur, they are required to report it immediately per facility protocol. No deficiencies were cited at this time. A supplementary report or visit will be conducted if warranted Exit interview conducted. Report was reviewed and a copy was provided.

Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Incident visit to follow up on a self-reported incident which took place on 01/16/2026. Upon arrival at 9:45 a.m. LPA was greeted by the front desk receptionist and explained the reason for the visit. LPA met with Executive Director (ED) Mark Ranno and Director of Resident Care Karen Pasten and the reason for the visit was explained. Entrance interview conducted. On 01/16/2026 it was reported that Resident #1 (R1) exited the community through the front door at approx. 1:30 p.m. and proceed to walk down the side walk with their walker. A bystander observed R1 and proceed to drive into the community to inquired about R1. Upon identification of R1 staff responded and R1 was returned to the community. No injuries or incidents occurred. Physician and Power of Attorney (POA) informed and consented to have R1 placed on Wander Guard. During today's visit, LPA and the staff toured the physical plant area inside and out to ensure there were no immediate health and safety concerns. Starting at 10:10 a.m. and throughout the visit LPA conducted three (3) in person staff interviews, at 11:12 a.m. attempted to conduct a telephonic interview with POA of R1, file and record review for R1 and obtained copies of pertinent documents relevant to the incident. Staff interviews revealed that R1 is well-known within the community and regularly participates in community events and activities. R1 is social, self-aware, and independent. Prior to the incident, R1 had no history of elopement or wandering and had not exhibited any concerning behaviors or indicators suggesting a risk of elopement or wandering. Staff state that on the day of the incident R1 stated they were going to go for a walk around the community but decided to leave the community and cross the street. A bystander drove into the community spoke to concierge staff. 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 (PAGE 2) Report Continued from LIC 809... Concierge staff immediately informed management and ran out to look for R1. R1 was returned to the community with no injuries or incidents. Upon return R1 was assessed by the on duty nurse and noted to be at baseline, alert and oriented to person, place, time and situation. Staff noted that R1 stated they were going for a walk, knew where they were going and how to return. Staff communicated with R1 regarding the the potential risk and hazard of leaving the community unassisted. R1 vocalized remorse to staff stating they did not like the fact that they worried the staff however were unaware that they could not leave unassisted. On the day of the incident R1's Physician and Power of Attorney (POA) were informed and consented to have R1 placed on Wander Guard. Staff state the facility utilizes a photo list to identify which residents are permitted to leave the facility unassisted and which are not. If a resident who is not allowed to leave unassisted wishes to go for a walk or exit the community, staff will either arrange for a staff to accompany the resident or redirect them as needed. Residents in the memory care are never permitted to leave without supervision. When these residents express a desire to leave, staff redirect them, often incorporating physical therapy or other activities to support engagement. All residents whether or not they wear a Wander Guard device are accompanied when leaving the premises. Only a select few residents, evaluated and approved by their Physician, are permitted to leave independently. File and record review confirms that there have been no other incidents involving elopement or wandering for R1. Wandering potential assessment dated 03/24/2025 indicate R1 as a zero (0) no risk for wandering. An updated assessment was conducted on 01/16/2026 with the implementation of Wander Guard. R1's service plan dated 09/01/2025 is listed as no assistance with redirection or guidance. Service plan dated 01/16/2026 is listed as requires interventions with redirection or guidance, Wander risk device left wrist placement, check on each shift, ensure on. No deficiencies were cited at this time. Exit interview conducted. Report was reviewed and a copy was provided.

(PAGE 2) Report continued from LIC 9099... During today's visit starting at 10:20 a.m. LPA and DMC briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Starting at 10:40 a.m. and through the visit conducted nine (9) in person resident interviews, five (5) staff interviews including one (1) med tech, two (2) caregivers also known as PALS within the community and a record review of the call response report / alarm exception report from 11/15/2025 – to 01/06/2026 and excessive delay log. On the allegation, due to lack of staff, call bells are not answered timely, it is the concern of the Reporting Party (RP) that due to the lack of staff residents are waiting over 30 minutes for assistance with toileting. To investigate this complaint, LPA conducted in person staff interviews, in person resident interviews, record review, and obtained copies of pertinent documentation relevant to the investigation. Interviews with the DMC revealed that the facility is staffed according to their acuity report. The facility typically staffs six (6) caregivers/PALS on first shift, five (5) on second shift, and two (2) on NOC shift. To their knowledge, the facility is staffed appropriately and resident needs are being met. Call times may vary; however, all calls are addressed promptly to assist residents. DMC reported that residents are not waiting for extended periods for toileting assistance, and no complaints have been received regarding prolonged wait times. It was noted that the facility does experience call-outs; however, management makes efforts to cover areas of need. Interview with the DRC revealed that the facility resolves all call button requests. They do not have any unresolved requests. The goal is to respond as quickly as possible, ideally within 20 minutes. Interviews with facility staff, including two (2) memory care caregivers/PALS, four (4) assisted living caregivers/PALS, and one (1) med tech, revealed that the facility is at times short-staffed, resulting in longer wait times and a heavier workload. Staff reported that they do their best to address requests as promptly as possible, ideally within 20 minutes. It was noted that when staff are actively assisting residents and additional calls come in, they typically check in with residents to assess the severity of the request and respond accordingly. Assisted living caregivers/PALS reported that, at times, due to limited staffing, residents may wait up to 20 minutes for toileting assistance however are always assisted as promptly as possible. Report continued on LIC 9099-C PAGE 3... 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 (PAGE 3) Report continued from LIC 9099-C PAGE 2... Interviews with residents revealed overall satisfaction with staff; however, they noted a decrease in staffing levels across all departments. Residents are typically attended very promptly, though response times can be slightly longer when fewer staff are present. Residents reported no extended wait times when requesting assistance, with staff generally responding within 10 minutes and sometimes immediately. Residents also reported no extended wait times for toileting assistance and stated they have no concerns at this time regarding call response times. Record review of the call response report/alarm exception report from 11/15/2025 to 01/06/2026, along with the excessive delay log, revealed that all call requests had been resolved. The excessive delay log showed that the most recent extended response time occurred on 11/30/2025 at 7:20 p.m., with a response time of 37 minutes and 15 seconds. It was documented that staff were in the room providing care to a resident and the pull switch had not been restored. Staff were reminded to restore the switch upon entering the room. No other excessive delays were noted in the response times from 11/15/2025 onward. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Due to lack of staff, call bells are not answered timely is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced Case Management visit for the purpose of conducting a full physical plant tour along with reviewing the Stipulation and Waiver; Order adopted by the Department on 09/18/2025. The LPA met with Karen Pasten, Director of Resident Care (DRC) and explained the reason for the visit. The LPA, alongside Karen Pasten, reviewed and discussed the contents of the Stipulation and Waiver; and Order adopted by the Department on 09/18/2025: 2. REVOCATION: STAYED WITH PROBATION: Respondents, Belmont Village Sabre Springs and Belmont Village Thousand Oaks licenses are revoked upon the Department's adoption of this Stipulation as its Order. The revocation of the licenses shall be STAYED for eighteen months during which time Respondents shall be granted probationary licenses subject to the following limitations and conditions: TERMS OF LICENSE PROBATION: 09/18/2025 - 03/18/2027 A. Respondents shall operate the facility in substantial compliance with the regulations and statutes governing the operation of a Residential Care Facilities for the Elderly (RCFE). B. Respondents shall develop and implement the following policies, procedures, and training that Respondents stipulate will be incorporated into Respondents' Plans of Operation. Maintain accurate Medication Administration Records (MARs) for each resident: Include facility-administered and self-administered prescribed and PRN medications. Document medication name, dosage, dates, times, administering staff, missed doses, refusals, and offsite status. Record side effects, errors, and drug reactions on the back of MAR or in nurses' notes. Verify staff training and certification prior to medication administration. Conduct resident evaluations every six months or upon significant change in condition. Report continued on LIC809-C PAGE 2... 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 (PAGE 2) REPORT CONTINUED FROM LIC 809... Ensure medical and behavioral care meets resident needs. Perform quarterly audits of at least 10% of resident files: Review MARs, Physician Reports, Care Plans, admission records, appraisals, incident reports, staff notes, and personal info. Rotate files each quarter and make audit results available to the Department. Perform quarterly audits of at least 10% of employee files: Confirm training, health info, certifications, and personal info are current. Monitor and log call response times: Address excessive delays and provide logs to the Department upon request. Install Wander Guard or similar system within 60 days of effective date. Conduct quarterly elopement in-service training. Maintain an organizational chart of job positions within 60 days of effective date. The Department received the 60 days requested Wander Guard system and organizational chart on 10/09/2025. C. Within 90 days of the effective date of the Stipulation, Respondents shall contract with a telehealth medical provider who can provide telehealth consultation and/or care services to a facility resident who has consented to receive, or will consent to receive in the future, such telehealth services if the resident's personal care physician is unable or fails to respond in a timely manner to a request for care consultation or care. The Department received the 90 days requested telehealth contract on 10/09/2025. D. Respondents shall implement and maintain a consulting arrangement with a medical director to provide guidance and instruction on resident care issues, as needed. E. Each direct care staff actively employed, which is defined as all employees except those who are on a leave of absence and on-call employees who are not actively picking up shifts, will undergo annual training on all of the following topics. In addition, quarterly in-service training will be conducted on one of the following topics- Pressure Injuries; Restricted & Prohibited Conditions; Reappraisal and Observation of Residents; and Use of Belmont's in-house system (Sensys Mobile) for reporting changes of condition and documenting support services completed, as set forth in Paragraph 3.E.iv.: Document all care provided by medical professionals and facility staff in resident files. Accurately update pre-admission appraisals as needed. Observe and document changes in residents’ conditions. Notify physicians and responsible parties of significant changes; call 911 if necessary. Implement and maintain the in-house system for compliance tracking. Maintain records of training attendance: Quarterly for first 18 months, then annually. Include new hires during probationary period. Make records available to the Department. Report continued on LIC809-C PAGE 3... 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 (PAGE 3) REPORT CONTINUED FROM LIC 809-C Page 2... F. Within 30 days following the effective date of the Stipulation, Respondents will develop a documentation and reporting system ("System") for fully complying with the regulations referenced in paragraphs 2(8) and 2(E) above. The protocols underlying the System will be written and provided to the Department within 30 days of the effective date of this Stipulation. The Department received the 30 day requested plan for documentation and reporting system on 10/09/2025. G. The facility Director of Resident Care Services or designee will observe and monitor skin conditions to ensure skin conditions are being properly addressed, that the resident care plan is updated as needed, and that follow-up with the resident's licensed medical provider is done as needed. The Director of Resident Care Services or designee will report to the Area Director of Clinical Services observations of pressure injuries that progress to Stage 3 and/or are covered in eschar and/or are considered unstageable to the Area Director of Clinical Services. H. If Respondents choose to care for a resident with a prohibited health condition, Respondents shall comply with Title 22, California Code of Regulation sections 87616 and 87209, prior to doing so; and, if an exception is granted, Respondents shall address the prohibited health condition in the resident's care plan. I. Respondents shall submit an updated Plan of Operation that demonstrates policies and procedures that will remain in effect during the probationary period in compliance with the terms outlined in paragraph 2, sections A through H, above, to the Department within 30 days of the effective date of this Stipulation for review by the Department. The Department shall review and approve or request modifications to the Plan of Operation within 20 days of receipt of the Plan of Operation. Proof of quarterly audits will be available to the Department upon request, and any revisions to the Plan of Operation shall be submitted to the Department on an ongoing basis. The Department received the 30 day requested updated Plan of Operation 10/09/2025. J. During the period of probation, the Department, in its sole discretion, may conduct unannounced site visits for the purpose of determining whether there is full compliance with the regulations and statutes governing the operation of a RCFE. K. Respondent Belmont Village Sabre Springs does not contest its prior payment of the $10,000.00 civil penalty. L. Respondent Belmont Village Thousand Oaks does not contest its prior payment of the $15,000.00 civil penalty. Report continued on LIC809-C PAGE 4... 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 (PAGE 4) REPORT CONTINUED FROM LIC 809-C Page 3... 3. FUTURE APPLICATION FOR A LICENSE, REGISTRATION , CERTIFICATION OR APPROVAL: A. Licensure, Certification, or Approval: Respondents agree they shall not apply for, receive, or hold any license to operate any facility licensed by the Department of Social Services as defined in sections 1502(a), 1506(c), 1568, 1568.01, 1569.2, 1596. 78, 1596. 750, and 1796.37 of the Health and Safety Code and California Code of Regulations, title 22, section 102352(f)(1)), other than the probationary licenses granted herein... B. Application Denial: Respondents agree that future applications may be denied based on this agreement’s findings, but they retain the right to a hearing if they file a timely appeal or Notice of Defense. 4. TOLLING OF PROBATIONARY PERIOD: The probationary period pauses when the facility isn’t operating and extends accordingly. If a revocation petition is filed, probation continues until the Department issues a final decision. 5. COMPLETION OF PROBATION: If Respondents meet the Stipulation terms, their license conditions will expire after 18 months, and licenses will be fully restored, except for items in the Plan of Operation. Each Belmont Village location will be evaluated separately. 6. VIOLATION OF STIPULATION TERM: Respondents agree that serious violations of probation terms may lead to license revocation, subject to a hearing. If found responsible, the license will be revoked, and notice may be served by certified mail. 7. DEPARTMENT'S AUTHORITY: The Department may delay disciplinary action without waiving its right to act later. If a revocation is filed during probation, the probation period extends until a final decision is issued. 8. MONITORING FEE: Each Respondent must pay a probation monitoring fee equal to the annual license fee during probation. 9. WAIVER OF HEARING RIGHTS: The parties waive their rights to a hearing, presenting evidence, cross-examining witnesses, and further discovery. 10. WAIVER OF APPEAL/MODIFICATION RIGHTS: Respondents waive all rights to challenge, appeal, or seek changes to this action, Stipulation, or its implementing Order. 11. WAIVER OF CLAIMS: The parties waive all legal claims related to this matter, except for civil penalties, monitoring fees, and audit-related actions involving payment adjustments. 12. PUBLIC RECORD: This Sti

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 9:45 a.m. Upon arrival LPA was greeted by the front desk receptionist and explained the reason for the visit. LPA met with Executive Director (ED) Cyntia Dachenberg, and explained the reason for visit was explained. Entrance interview conducted. LPA Mosley and the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common Areas: At approx 10:12 am, the LPA began the physical plant tour, the furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 04/04/2025. The LPA observed required postings throughout the common space. The LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA observed an adequate supply of emergency food and water. The last fire inspection was completed on 09/26/2024 and was found to be in compliance with Fire Code Regulations at the time of inspection. Emergency disaster drills conducted quarterly as per regulation; with the last one conducted on 06/04/2025. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. All records were in order. Interviews: From approx. 10:02 a.m. – 12:20 p.m. LPA conducted random interviews with thirteen (13) residents, ten (10) staff, and one (1) family visitor. Resident interviews revealed that no concerns were noted at the time of the visit. Staff interviews revealed that staff are knowledgeable in their job description, resident rights, different forms of abuse, and reporting procedures. Family visitor interview revealed that no concerns were noted at the time of the visit. Report continued on LIC809-C PAGE 2... 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 (PAGE 2) REPORT CONTINUED FROM LIC 809... Infection Control / Emergency disaster planning : During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control and emergency planning are satisfactory. Bedrooms: Starting at 10:16 a.m. The LPA observed fifteen (15) randomly selected resident bedrooms, of which five (5) were in memory care and ten (10) in assisted living which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a sufficient supply of towels and linens. Restrooms: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water measured between 105.1 – 112.5 degrees Fahrenheit all within the required range. Surrounding Grounds (Outdoors) : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. Kitchen : The LPA inspected the kitchen/food service area at 11:40 a.m. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Medication Audit: LPA conducted a medication review on eight (8) randomly selected residents at approx. 12:25 p.m., The medications are centrally stored in the wellness room located on the third floor. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. No errors observed during review. Records: Resident Records and Personnel records were reviewed starting at approx. 2:45 p.m., Ten (10) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files in order at the time of the visit. Six (6) 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 files in order at the time of the visit. Report continued on LIC809-C PAGE 3... 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 (PAGE 3) REPORT CONTINUED FROM LIC 809-C PAGE 2... LPA obtained the following documents – Census, Staff schedule, and updated Limited Liability insurance. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report provided.

Allegation: “Staff did not seek medical attention in a timely manner:” The complaint alleges that Resident #1 (R1) had an infection in their toe and the facility staff did not obtain medical treatment timely. LPA reviewed medical records and facility documents for R1. R1’s history indicates that R1 had a diagnosis of neuropathy in both feet. R1 was seen by a visiting podiatrist at the facility on 11/14/2023. Podiatrist assessed R1 to have “contusion hallux toe left foot” and “complete onycholysis hallux toe left foot.” Plan of care ordered by the podiatrist on the same date indicated “toenail hallux toe left foot cleansed; antibiotic dressing applied….continue triple antibiotic dressing changes every day for 2 weeks.” An order for triple antibiotic dressing change every day for 2 weeks was given to the facility for treatment of R1’s left toe. Additionally, R1 reported to facility nurse that their right toe was hurting on 12/06/2023. Nurse took a photograph of R1’s right toe and sent it to R1’s physician the same day, which was documented through email correspondence. R1’s medical provider corresponded with the facility on 12/06/2023 and 12/07/2023 related to R1’s toe to assess and provide a treatment plan. On 12/07/2023, R1’s physician indicated for R1 to “see podiatrist ASAP.” R1’s family member took them to the podiatrist/Emergency Department on 12/08/2023. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued related to this allegation. Exit interview conducted. A copy of today’s report was provided.

Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Incident visit regarding a self-reported incident. LPA met with Executive Director (ED) Cyntia Drachenberg and explained the reason for the visit. LPA Dulek received a telephone call from ED at 04:14PM on 11/08/2024. ED informed LPA that Resident #1 (R1) told facility staff on 11/06/2024 that 2 men had entered R1's room and R1 reported they had been sexually assaulted. ED had returned to the community on 11/08/2024 and was informed of the allegation on that day. ED reported to Ventura County Sheriff, R1's medical care providers, and Long Term Care Ombudsman. LPA asked for additional documents to be faxed to the Woodland Hills Regional Office, which were received on 11/12/2024. During LPA's visit today, LPA interviewed ED at 02:37PM, toured the facility with ED at 02:57PM, observed and interviewed R1 and their family member at 03:01PM, interviewed staff at 03:19PM, and LPA obtained copies of pertinent documents. R1 did not make any indication to LPA that the alleged incident had occurred, R1 stated they feel safe, and physical examination by R1's medical provider revealed no indication of the alleged assault. R1 does have a diagnosis of dementia and R1's family member stated they are not concerned about the facility or level of care provided to R1. No immediate health and safety hazards were identified during facility tour. After reviewing all pertinent information, should an additional visit be warranted, LPA will return at a later date to continue the investigation. No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided.

On 08/21/2024, Licensing Program Analyst (LPA), Kelly Dulek met with Executive Director Cyntia Drachenberg for an unannounced Case Management visit to issue a civil penalty per Health & Safety (H&S) Code §1569.49(e). On April 13, 2023, the Department concluded a complaint investigation which alleged the following allegation: Neglect and lack of supervision resulted in injury/death of a resident (R1). The allegation was substantiated, and the licensee was cited under H&S Code §1569.312(a) Basic Services Requirements. The investigation reviewed that on December 20, 2021, Staff (S1) called on their radio for assistance in bringing additional gloves, but the radios were not working properly. R1 was left unattended in the bathroom while S1 exited the room, walked down the hallway, and retrieved the gloves from the laundry room. When S1 returned to R1’s room, R1 was found on the bathroom floor with a cut to their left eyebrow. R1 was assessed, 9-1-1 was contacted and R1 was transported to the hospital. Record review revealed that on December 20, 2021, R1 was admitted to the hospital with a diagnosis of a forehead laceration and traumatic subdural hematoma. R1 was discharged from the hospital on December 22, 2021, back to the facility. Upon discharge, R1 was admitted to hospice care. Per hospice admission records, R1 “fell and hit head and now has subdural hemorrhage” with a terminal diagnosis of, “traumatic subdural hemorrhage.” Ultimately, R1 passed away while at the facility on December 27, 2021. At the time of the complaint visit on April 13, 2023, an immediate civil penalty of $500 was assessed for H&S 1569.312(a), and the licensee was informed that an additional civil penalty might be assessed based on H&S Code §1569.49(e). 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 The Department has concluded an analysis and has determined that a civil penalty is warranted for the death of R1 while under the care of the licensee. This is evidenced by the licensee not ensuring that R1 was afforded with adequate care and supervision in violation of H&S 1569.312(a). R1 sustained a subdural hematoma as a result of blunt force head trauma from a fall resulting in the death of R1. Today, 08/21/2024, the Department is issuing a civil penalty per Health and Safety Code §1569.49 in the amount of $15,000 for a violation that the Department determined resulted in the death of R1. However, since an immediate civil penalty of $500 was previously issued on April 13, 2023, the amount of the civil penalty issued is reduced to $14,500. A copy of the LIC 421D was given to the Executive Director Cyntia Drachenberg and the originals were signed. Exit interview conducted. A copy of the report issued. Executive Director’s signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

Report Continued from LIC 9099... It was alleged that the facility is unsanitary, and facility is malodorous. It was reported that the facility is dirty and smells bad. During the facility walkthroughs, LPAs observed multiple random resident bedrooms and common areas in both assisted living and memory care unit. There were no foul smells observed and facility appeared relatively clean. Record review of facility’s housekeeping operations manual includes daily common area cleaning checklist as well as weekly deep cleaning schedules for housekeeping personnel to follow. Interviews conducted with staff revealed that the common areas are cleaned at least once every day. Additionally, resident bedrooms are cleaned thoroughly once a week and maintained clean throughout the week by both the residents and care staff. Staff stated one of their first tasks every morning is to clean the common areas and pass by one more time before they leave for the day. Staff denied smelling any foul or bad odors in either the common areas or inside the residents’ bedrooms. Interviews conducted with family members revealed that facility is clean when they visit and did not report any bad odors while in the facility. Furthermore, interviews conducted with residents revealed that the facility is maintained cleaned by the staff and stated that they have not had any issues with foul smells and reported no concerns while living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegations of “facility is unsanitary” and “facility is malodourous”. Therefore, these allegations are being deemed Unsubstantiated at this time. It was also alleged that staff do not follow safe sanitation practices. It was reported that many residents were getting sick during the facility outbreak. Record review and Interviews conducted revealed that the facility had a Covid outbreak in December 2023. The positive cases were reported to both Ventura County Public Health (VCPH) and Community Care Licensing Department (CCLD). Additionally, staff stated they were following guidance from both VCPH and CCLD and testing was being conducted on all residents and staff. Furthermore, staff stated they update the facility’s infection control plan as needed and were making sure to follow accordingly. 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... Record review of facility’s housekeeping training & operations manual revealed that facility has a response plan as well as disinfecting protocols for infectious diseases including norovirus and covid-19 which is expected to be followed by all staff. Staff added that common area are cleaned and disinfected every morning as well as before heading out for the day. Furthermore, interviews conducted with residents revealed that the facility is maintained clean by facility staff and stated they had no concerns while living at the facility. Based on record review and interviews conducted, the Department does not have sufficient evidence to support the allegation of “staff do not follow safe sanitation practices”. Therefore, this allegations is being deemed Unsubstantiated at this time. It was further alleged that staff are not providing adequate supervision to residents and staff are not meeting the residents’ needs. It was reported that residents sit for hours with long strings of snot hanging out of their noses. Interviews conducted with staff revealed that they have not had any staffing concerns as they have been fully staffed. Additionally, staff stated that they walk through the common areas during the day when not assisting residents to make sure the residents are okay. As far as the residents that prefer to stay in their bedrooms, staff conduct status checks throughout the day to make sure they are fine, and their needs are being met. Interviews conducted with family members revealed that there is always staff nearby whenever they visit the facility. Family members stated that they felt facility staff provide the supervision the residents need and added that facility staff are taking good care of the residents as well. Interviews conducted with residents revealed that facility staff assist whenever resident call for them and have not reported any issues with staff not being able to assist when needed. Residents also stated that staff come by their bedrooms to check on them and make sure they are doing fine a few times throughout the day. Furthermore, residents and their family members have not reported any concerns with facility not having enough staff to meet the residents needs and displayed no concerns with facility staff. Based on the information obtained during the investigation, the Department does not have sufficient evidence to support the allegations of “staff are not providing adequate supervision to residents” and “staff are not meeting the residents’ needs”. Therefore, these allegations are being deemed Unsubstantiated at this time. Exit interview. Copy of the report was issued.

Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Cyntia Drachenberg was contacted and met with LPA. Reason for the visit was stated. Administrator designated staff to assist LPA with the physical plant tour. Physical plant tour was conducted with staff. Areas inside and outside were toured to ensure that there are no health and safety hazards. COMMON AREAS: Units designated for assisted living residents are on all four floors and there is a separate unit on the second floor designated for memory care residents. The LPA toured all four floors and common spaces in both the assisted living and memory care unit. Memory care delayed egress doors were tested for operational need. Activity rooms and common spaces were clean and in good repair. No obstructions and/or safety hazards observed during the tour. Fire extinguishers were charged and serviced on 04/24/2024. BEDROOMS: The LPA observed a random selection of resident rooms (on all floors), and rooms were observed furnished appropriately with clean linens, furnishings and sufficient lighting. LPA also conducted interview with random residents during the resident room checks. RESTROOMS: The LPA observed a random selection of resident restrooms. Restrooms were clean, sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms were stocked with soap and paper towels. Hand washing signs promoting good hand hygiene were observed in the common restrooms. KITCHEN: Kitchen observed clean and appliances in operable condition. Facility food supply observed sufficient during todays visit (three (3) day perishable and seven (7) day non-perishable food supply). EXTERIOR: The facility has outdoor seating for residents on the first, second and third floor. Due to time constraints, the annual inspection will be completed on a follow-up visit. No deficiencies cited at this time. Exit interview conducted. Copy of report provided.

Continued from LIC 9099... It was alleged that facility is trying to persuade resident and/or their responsibly parties to change physicians or home health agency to one’s preferred by administration. It was reported that certain home health companies and physicians are self-referring clients for money and having facilities change the resident’s Primary Care Physician (PCP). Interviews conducted with staff revealed that many residents that are admitted to the facility have come from other neighboring facilities. These residents when admitted to the facility already have a PCP which they utilize. Additionally, staff added that sometimes family members may ask for a local doctor to establish care for their family member when the resident is hard to ambulate or be taken out of the facility. In which, the facility provides a list with different doctors in the area and a contact number. However, it is ultimately the family’s choice as they call themselves to get more information and decide between what the insurance covers and which provider can meet the needs of the resident. Interviews with staff further revealed that residents discharged from the hospital already come with a home health agency that their doctors recommended. If a resident requires any service from a home health agency, the facility contacts the resident’s PCP, and they will assign whichever home health agency they use or is covered by their insurance. Interviews conducted with family members revealed that they have not felt pushed or forced to select a certain doctor or home health agency by the facility. Family members stated that the resident’s doctor has not changed in years and added that it would not change even if the facility suggested it. Interview conducted with resident revealed that changing doctors was a decision made only by themselves and no one else. Furthermore, resident denied the facility persuaded them to making that change at any time while living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility is trying to persuade resident and/or their responsibly parties to change physicians or home health agency to one’s preferred by administration”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued. Report was reviewed and a copy was issued.