565850142-9-13-2024-29-AS-DPEA-D9LS2Z-20240930133022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850142
Report Date: 09/13/2024
Date Signed: 09/13/2024 02:54:44 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
04/29/2024 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20240429161933

FACILITY NAME:	CAMARILLO SENIOR LIVING		FACILITY NUMBER:	565850142
ADMINISTRATOR:	GENA GRUNDEIS		FACILITY TYPE:	741
ADDRESS:	6000 SANTA ROSA ROAD		TELEPHONE:	(805) 388-8086
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	140	CENSUS: 84	DATE:	09/13/2024
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Scott Keawekane		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision – Facility resident sustained multiple pressure injuries as a result of facility neglect.
Staff did not address resident's change in condition in a timely manner.
Staff did not ensure that resident's hygiene needs were met.
Facility bathroom(s) is in disrepair.
Staff did not ensure that resident's clothing needs were met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with back-up administrator Scott Keawekane who is the administrator of the skilled nursing facility attached to this property. Administrator Gena Grundes is out on a leave of absence. LPA met with administrator Keawekane and explained the reason for the visit.

On 04/29/2024, the Department received a complaint regarding an allegation for Neglect/Lack of Care and Supervision. Facility Resident #1 (R1) sustained multiple pressure injuries as a result of facility staff neglect. The complaint also alleged staff did not address R1’s change in condition in a timely manner. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Seng.

(continued on LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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 9

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
04/29/2024 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20240429161933

FACILITY NAME:	CAMARILLO SENIOR LIVING		FACILITY NUMBER:	565850142
ADMINISTRATOR:	GENA GRUNDEIS		FACILITY TYPE:	741
ADDRESS:	6000 SANTA ROSA ROAD		TELEPHONE:	(805) 388-8086
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	140	CENSUS: 84	DATE:	09/13/2024
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Scott Keawekane		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not ensure that resident was fed.
Staff isolated resident.
Staff do not ensure that facility is kept in a clean condition.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 29-AS-20240429161933

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: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565850142
	VISIT DATE: 09/13/2024

NARRATIVE

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(continued from LIC9099A)

Regarding the allegations "Staff did not ensure that resident was fed" and "Staff isolated resident", LPA reviewed records for resident #1 (R1) which indicated R1 could eat meals independently. R1 started out eating meals in the dining room but later requested all meals be served in their room. S1 recalled due to R1's condition with edema in their legs and R1's need for constant oxygen, walking was painful appeared to be uncomfortable due to the edema and shortness of breath. S1 suspected that was the reason R1 did not like to get out of their recliner and go to the dining room or participate in activities. R1 was brought trays for each meal. S1 observed R1 ate most of their meals. In addition, R1's physician's report indicated R1 was capable of communicating their needs and feeding themself. Based on this information, these allegations are deemed Unsubstantiated at this time.

Regarding the allegation "Staff do not ensure that facility is kept in a clean condition", LPA interviewed the maintenance director who stated housekeeping cleans the residents' rooms a minimum of once a week or as needed if there is an accident. Trash is removed from the room daily by caregivers. S1 stated they remove trash from residents' rooms at least one time per shift. R2 stated trash was removed from their room three times per week and their room is cleaned by housekeeping once a week. During LPA's visit, LPA observed R2 had a full trash can sitting outside R2's door. R2 stated it had been a couple days since the trash was emptied and R2 called the front desk to let them know the trash can was full. R2 stated they had never done that before and it was very unusual. R2 thinks the caregiver forgot to take the trash out. R2 had no complaints about anything at the facility, including cleanliness. Based on interviews this allegation is deemed Unsubstantiated at this time.

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 29-AS-20240429161933

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: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565850142
	VISIT DATE: 09/13/2024

NARRATIVE

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(continued from LIC9099)

On 05/01/2024, from 9:15 a.m. to 10:47 a.m., LPA Kelly Dulek conducted an initial complaint visit. During the visit, from 9:18 a.m. to 10:05 a.m., the LPA interviewed and toured the facility with the Executive Director (ED) and reviewed and obtained copies of documents pertinent to the investigation. No immediate health and safety concerns were observed during the facility tour. On 05/15/2024, from approximately 11:35 a.m. to 3:39 p.m., Investigator Seng conducted interviews with R1’s Resident Representatives; on 05/16/2024, from approximately 1:03 p.m. to 3:09 p.m., with the facility Administrator, Director, Wellness Nurse, Med Tech, caregivers, and residents; on 07/05/2024, at approximately 4:24 p.m., with R1; on 08/09/2024, at approximately 3:23 p.m., with St. John’s Hospital Case Social Worker Supervisor; and on 08/23/2024, at approximately 3:27 p.m. with the Long Term Care Ombudsman (LTCO). In addition, the investigator reviewed St. John’s Hospital medical records, photos of R1’s pressure injuries, and facility file documents related to the investigation.

According to R1’s Preplacement Appraisal conducted on 06/05/2024, R1 suffered from COPD, Congestive Heart Failure (CHF), Anxiety, High Cholesterol, High Blood Pressure, Type Two Diabetes, had thyroid and gallbladder removed, and used a walker or wheelchair. R1 was listed as non-ambulatory as R1 was able to use their walker to walk for short distances only. R1 required assistance with putting on and removing R1’s compression socks. The report also documented R1 showed signs of forgetfulness. Per R1’s Physician’s Report completed on 06/16/2023, R1 required assistance with showering, was non ambulatory, able to administer own oxygen, able to dress and groom self, feed self, take care of own toileting needs, but was unable to shower self, requiring showers with assistance. R1 had no history of skin breakdown. Because R1 had a history of CHF, this caused edema which resulted in R1’s legs swelling, thus the need for medication, leg elevation and compression socks to alleviate the swelling. The facility file records indicated R1 was admitted to the assisted living portion of the facility on 06/30/2023.

(continued on LIC9099C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 29-AS-20240429161933

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: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565850142
	VISIT DATE: 09/13/2024

NARRATIVE

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(continued from LIC9099C)

A review and summary of the medical records documented on 04/23/2024 at approximately 5:52 p.m., R1 was admitted to St. John’s Hospital for treatment of a severe cough. The diagnosis included Congestive Heart Failure (CHF), Gait instability, Edema, Hypertension (HTN), Hyperlipidemia (HLD), Gastroesophageal Reflux Disease (GERD), Hypothyroidism, Restless leg, Dementia, Agitation due to dementia, and Dyspnea. R1 was seen for a consult on 04/25/2024 at approximately 6:32 a.m. by the Registered Nurse (RN) for shortness of breath (SOB), bilateral lower extremity (BLE) edema, venous stasis, HTN, dementia, obesity, incontinence, weakness, and agitation. R1’s pressure injuries consisted of multiple decubitus ulcers. R1 had several wounds and skin breakdowns on the sacral area, abdominal fold, feet, and breasts. R1 was discharged from the hospital on 05/02/2024.

The investigation revealed R1 suffered from congestive heart failure (CHF) and was told to elevate R1’s legs. R1 was only able to do this on R1’s bed. Staff made multiple attempts to try and convince R1 to lie on R1’s bed to do this; however, R1 refused and instead sat in R1’s recliner, where R1 was unable to elevate R1’s legs. This sustained sitting caused R1 to develop pressure injuries to R1’s lower back and coccyx. Staff offered to bathe and change R1’s clothing multiple times; however, R1 also refused their assistance. As staff was unable to assist, they could not conduct body checks on R1 to determine whether R1 sustained any pressure injuries. Although the facility maintains R1 was independent and did not require any assistance, according to R1’s preplacement appraisal completed at the time of admission June 2023, R1 needed staff to assist R1 with R1’s compression socks. By February 2024, the facility noted that R1 was starting to show signs of dementia and depression, R1 began to withdraw and stayed in their room, yet R1’s level of care was not increased. Staff were aware that R1 would lie in R1’s recliner and was sleeping in it as well, but there is no indication the facility notified R1’s doctor or conducted a reappraisal to address this issue. While R1 has a personal right to sleep in R1’s chair overnight, allowing R1 to do so likely contributed to the development of R1’s pressure injuries. The facility’s failure to intervene also likely contributed to R1’s venous/stasis ulcers.

(continued on LIC9099C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 29-AS-20240429161933

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: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565850142
	VISIT DATE: 09/13/2024

NARRATIVE

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(continued from LIC9099C)

Based on files obtained and interviews conducted, the Department found sufficient evidence to prove that the facility was responsible for the neglect leading to R1 sustaining multiple pressure injuries. This included the facility not conducting a reappraisal for R1 to address R1’s change of condition. Therefore, the allegations “Neglect/Lack of Care and Supervision – Facility resident sustained multiple pressure injuries as a result of facility neglect” and “Staff did not address resident's change in condition in a timely manner” are deemed Substantiated at this time.

During LPA Camara's visit on 9/13/2024, LPA interviewed staff 1 (S1) at 11:11 a.m. S1 has been a caregiver at this facility for approximately eight (8) months and recalled providing care to R1. LPA also reviewed facility records pertaining to R1. The facility assessment completed on 7/31/2023, indicated R1 needed minimal assistance with clothing and required stand-by assistance with showering. S1 recalled when arriving in the mornings and R1 was already dressed sitting in their recliner. S1 would sometimes need to assist R1 with getting dressed, especially if R1's clothing was not smelling fresh. R1 would sometimes refused assistance with changing clothing. S1 did not work on R1's shower days but S1 recalled other caregivers stating R1 frequently refused showers. Caregivers would notify the facility nurses if R1 refused care. As stated previously in this report, there was no indication facility management contacted R1's physician regarding R1's refusal of care (self-neglect). Therefore, the allegations "Staff did not ensure that resident's hygiene needs were met" and "Staff did not ensure that resident's clothing needs were met" are deemed Substantiated at this time.

(continued on LIC9099C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 29-AS-20240429161933

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: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565850142
	VISIT DATE: 09/13/2024

NARRATIVE

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(continued from LIC9099C)

S1 also recalled observing R1's toilet had overflowed at least twice. One time maintenance was there and fixed it immediately. Another time, S1 arrived in the morning and observed the toilet had overflowed. S1 was told it had overflowed the night before but maintenance staff was not at the facility during the night so R1 was told it would have to wait until the next day. S1 believes the staff at night did not know they should have called someone so maintenance could come and fix the toilet that night. LPA Camara had interviewed the maintenance director over the phone at 10:50 a.m. during LPA's 9/13/2024 visit, and the maintenance director stated they would come to the facility at night to fix an overflowing toilet as that is considered an emergency. Based on these interviews, the allegation "Facility bathroom(s) is in disrepair" (regarding R1's toilet), is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 29-AS-20240429161933

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: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565850142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/25/2024 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	§1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan how they will ensure appropriate care and supervision to meet the needs of residents. Submit to CCL by 9/20/2024.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff neglect led to R1 sustaining multiple pressure injuries, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1)
Type B 09/25/2024 Section Cited CCR 87463(a)(3)	1 2 3 4 5 6 7	87463(a)(3) Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan how they will ensure reappraisals are conducted to address a resident’s change of condition. Submit to CCL by 9/20/2024.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff did not conduct a reappraisal to address resident's change in condition, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 29-AS-20240429161933

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: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565850142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/25/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan how they will ensure all staff understand how to ensure the facility is properly maintained and what constitutes a maintenance emergency. Submit to CCL by 9/20/2024.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above. Facility staff left R1's toilet inoperable overnight, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC9099 (FAS) - (06/04)

Page: 9 of 9