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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850112
Report Date: 03/26/2026
Date Signed: 03/26/2026 04:32:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2025 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20250325145942
FACILITY NAME:REGENCY PALMS OXNARDFACILITY NUMBER:
565850112
ADMINISTRATOR:KENNETH MAHLERFACILITY TYPE:
740
ADDRESS:1020 BISMARK WAYTELEPHONE:
(805) 247-0227
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:127CENSUS: 93DATE:
03/26/2026
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Stephani Smith TIME COMPLETED:
04:50 PM
ALLEGATION(S):
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9
Facility staff do not respond to residents call buttons in timely manner.
Facility staff are not dispensing medication as prescribed.
Facility staff did not seek timely medical attention for resident in care.
Facility staff do not ensure resident's hygiene needs are met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility. At 1:20 p.m., the LPA met with the Interim Executive Director (ED) Stephani Smith and explained the reason for the visit.

During the initial visit on 03/27/2025 between 12:30 p.m. and 2:35 p.m., LPAs Peraldi and Barutyan conducted a physical plant tour and interviews with the ED, three (3) residents and one (1) staff. During today’s visit starting at 1:36 p.m., the LPA conducted a physical plant tour and interviewed the Interim ED and five (5) staff. During both visits, the LPA reviewed and obtained copies of pertinent documents during the visit.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 29-AS-20250325145942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: REGENCY PALMS OXNARD
FACILITY NUMBER: 565850112
VISIT DATE: 03/26/2026
NARRATIVE
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Regarding the allegation:1.) Facility staff do not respond to residents call buttons in timely manner. It was alleged that Resident #1 (R1) had waited for more than 30 minutes to get assistance, leading to R1 being left in soiled clothing. The LPA was provided with pictures dated 12/29/2024, of R1 being left in soiled diaper and clothing. During the time of R1 being left in soiled diapers, it was brought up to the Wellness Director (WD) at the time, Gloria Morales and the ED at the time, Ken Mahler. Interviews conducted with staff revealed that during the time of the complaint, there were staff shortages and response times were longer than 20 minutes. Interviews with staff confirmed that R1 had been left in soiled pull ups on occasions. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff do not respond to residents call buttons in timely manner” is deemed Substantiated at this time.

2.) Facility staff are not dispensing medication as prescribed. It was alleged that facility staff were not properly assisting Resident #1 (R1) with their medication, as R1’s medication was found on the floor multiple times. During the initial visit, the LPA could not conduct a medication audit for R1, as R1 no longer resided at the facility. The LPA requested R1’s medication records. Per record review, on 12/26/2024, R1’s physician ordered R1 to start taking Macrobid 100 mg (twice daily for 7 days) and Phenazopyridine 200 mg (three times daily for 5 days). On 12/27/2024, it was noted on R1’s medication pass history that R1 only took Macrobid 100 mg once and Phenazopyridine 200 mg twice. The medication pass history did not document the reason for the missed medications. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff are not dispensing medication as prescribed” is deemed Substantiated at this time. The same deficiency was cited for another complaint on 03/26/2026 therefore it will not be duplicated on this complaint.

3.) Facility staff did not seek timely medical attention for resident in care. It was alleged that during December 2024, R1 was not receiving timely medical attention which resulted in the hospitalization of R1. Per record review, on 12/27/2024, R1’s physician ordered “Urgent Home Health (HH) order to administer suppository and blood sugar checks” as well as “blood sugar checks once daily in the morning before breakfast.” During the initial visit, LPA Peraldi conducted a file review of R1’s records. There were no HH documents or plan of care for R1. Interviews with the previous ED and WD revealed that they were not aware of R1 needing HH in December 2024. Interview with R1’s family member revealed that they believed R1’s blood sugar was not getting checked. Continued on LIC 9099-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20250325145942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: REGENCY PALMS OXNARD
FACILITY NUMBER: 565850112
VISIT DATE: 03/26/2026
NARRATIVE
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 R1 was sent to the hospital soon after (no specific date or reason was provided) and returned to the facility on 01/22/2025 under hospice. The facility did not produce proof that R1 was getting their blood sugar check per physician order. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff did not seek timely medical attention for resident in care” is deemed Substantiated at this time.

4.) Facility staff do not ensure resident's hygiene needs are met. It was alleged that R1’s hygiene needs were being neglected as R1 did not receive assistance with showers. The LPA was provided with text messages and pictures of R1’s hygiene concerns from 2024. The text messages demonstrate R1’s hygiene concerns being brought to the WD at the time and no direct response was given to R1’s family. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff do not ensure resident's hygiene needs are met” is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). The Interim ED was informed that failure to correct deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20250325145942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: REGENCY PALMS OXNARD
FACILITY NUMBER: 565850112
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2026
Section Cited
CCR
87625(b)(2)
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87625(b)(2) Managed Incontinence...the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement is not met as evidenced by:
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The Interim ED will conduct an in-service training with all staff regarding regulation 87625 Managed Incontinence. Submit proof to the LPA.
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Based on interviews and record review, the licensee did not comply with the section cited above, as they did not ensure R1’s incontinence was properly managed, which poses an immediate health and safety risk to residents in care.
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Type A
03/27/2026
Section Cited
CCR
87465(a)(1)
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87465 (a)A plan for incidental medical and dental care shall be developed…(1) The licensee shall arrange...medical and dental care appropriate to the conditions&needs of residents.This requirement is not met as evidenced by:
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The Interim ED will conduct an in-service training with all staff regarding regulation Submit proof to the LPA.
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Based on interview and record review, the licensee did not comply with the section cited above as the Licensee failed to seek medical attention in a timely manner to R1 which posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20250325145942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: REGENCY PALMS OXNARD
FACILITY NUMBER: 565850112
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2026
Section Cited
CCR
87464(f)(4)
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(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...indicated in the pre-admission appraisal, with those activities of daily living such as dressing,... bathing... This requirement is not met as evidenced by
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The Interim ED will conduct an in-service training with all staff regarding regulation. Submit proof to the LPA.
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Based on interviews, licensee did not comply with the above section by not providing R1 basic services such as bathing and grooming which poses potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2025 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20250325145942

FACILITY NAME:REGENCY PALMS OXNARDFACILITY NUMBER:
565850112
ADMINISTRATOR:KENNETH MAHLERFACILITY TYPE:
740
ADDRESS:1020 BISMARK WAYTELEPHONE:
(805) 247-0227
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:127CENSUS: 93DATE:
03/26/2026
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Stephani Smith TIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
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9
Facility staff do not keep resident rooms clean and orderly.
INVESTIGATION FINDINGS:
1
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3
4
5
6
7
8
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10
11
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13
Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility. At 1:20 p.m., the LPA met with the Interim Executive Director (ED) Stephani Smith and explained the reason for the visit.

During the initial visit on 03/27/2025 between 12:30 p.m. and 2:35 p.m., LPAs Peraldi and Barutyan conducted a physical plant tour and interviews with the ED, three (3) residents and one (1) staff. During today’s visit starting at 1:36 p.m., the LPA conducted a physical plant tour and interviewed the ED and five (5) staff. During both visits, the LPA reviewed and obtained copies of pertinent documents during the visit.

Continued LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20250325145942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: REGENCY PALMS OXNARD
FACILITY NUMBER: 565850112
VISIT DATE: 03/26/2026
NARRATIVE
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Regarding the allegation: 1.) Facility staff do not keep resident rooms clean and orderly. During physical plant tours, the LPA observed multiple resident rooms and restrooms which appeared clean. Interviews with staff and interim ED explained that there are three (3) housekeepers, one (1) for the Memory Care (MC) side and another for the Assisted Living (AL) side, and another part time housekeeper. Interviews with housekeepers revealed that they have a schedule and are assigned to clean different rooms each day. Housekeeping staff explained that each resident room gets cleaned once a week or as needed. Interviews with residents during the time of the complaint did not reveal any concerns regarding the cleanliness of their rooms and facility. 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.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7