<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850366
Report Date: 08/21/2025
Date Signed: 08/21/2025 10:16:06 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/18/2025 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20250318122806
FACILITY NAME:MAJESTIC RESIDENTIAL CAREFACILITY NUMBER:
565850366
ADMINISTRATOR:OSILESI, KEMIFACILITY TYPE:
740
ADDRESS:2036 CUTLER STTELEPHONE:
(310) 503-2515
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kemi OsilesiTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate supervision to resident in care resulting in a fracture

Staff mismanaged resident's medication

Staff did not provide a proper rate increase notice to resident or resident's authorized representative

Staff did not provide resident records to resident's authorized representative
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Kemi Osilesi and explained the reason for the visit.

On 03/18/2025, the Woodland Hills Adult and Senior Care Regional Office (RO) received a complaint alleging Resident #1 (R1) fell and sustained a fractured femur due to lack of supervision of the facility staff. The case was referred to Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Douglas Real.

On 03/19/2025, from 03:07pm to 5:00pm, Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit for the allegation listed above. Upon arrival LPA Balisi met with staff and explained the reason for the visit, Administrator Kemi Osilesi arrived shortly after.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
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 4
Control Number 29-AS-20250318122806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MAJESTIC RESIDENTIAL CARE
FACILITY NUMBER: 565850366
VISIT DATE: 08/21/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099

At approximately 03:10pm the LPA conducted a physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings.

On 04/01/2025, at approximately 10:30am, Investigator Real conducted interviews with R1’s resident representative; on 04/17/2025, from approximately 11:30am to 2:00pm, with R1, staff, and residents; on 06/13/2025, at approximately 12:25pm, with the Administrator; on 06/17/2025, at approximately 12:30pm, with the overnight staff; and on 07/01/2025, at approximately 12:50pm, with R1’s resident representative. In addition, Investigator Real reviewed Los Robles Regional Medical Center medical records and facility file documents related to the investigation.

According to the facility file documents reviewed, R1 was admitted to the facility on 06/15/2024. R1 had a history of falls and was considered a fall risk. R1’s Appraisal Needs and Services Plan, updated 12/27/2024, noted confusion and agitation at night, with R1 attempting to walk without supervision. The plan noted safety measures were put in place and staff encouraged R1 to use the call button at night.

A review of the Unusual Incident/Injury Report related to R1’s fall on 02/07/2025 revealed the overnight staff checked on R1 at 12:26am and at that time R1 was in bed. At 12:40am the staff heard the safety mat alarm and saw R1 on the floor in R1’s room with leg pain. R1 did not request assistance prior to getting out of bed. The Administrator was notified and 911 was called. Paramedics transported R1 to the hospital.

A review of the Los Robles Regional Medical Center medical records revealed R1 was admitted to the hospital on 02/07/2025 with a diagnosis of femur fracture. Surgical procedure was performed to repair the fracture. R1 was discharged from the hospital on 02/14/2025.

The Department’s investigation revealed the facility provided a sufficient level of care and supervision for R1. R1, who suffered from dementia, did not have 24/7, one on one supervision. R1 wore a call button alarm that R1 could use to contact facility employees when R1 wanted to get out of bed and was consistently reminded by staff to use the alarm so that staff could assist R1 out of bed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20250318122806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MAJESTIC RESIDENTIAL CARE
FACILITY NUMBER: 565850366
VISIT DATE: 08/21/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099-C

In addition, floor alarm mats were placed on the floor around R1’s bed at night to alert the night staff if R1 got out of bed without contacting them for help. The overnight staff spent the night in a chair outside R1’s room, which allowed them to respond in a prompt manner to incidents or accidents that might occur in the residents’ rooms. The staff working on the night of R1’s fall properly responded as well as assessed R1 after the fall and 911 was called when R1 reported pain. Interviews were conducted with R1’s resident representatives, R1, facility residents and staff. The information obtained during the Department’s investigation did not sufficiently support the allegation. While R1 did sustain a fall which resulted in a fracture, the investigation did not provide sufficient evidence to substantiate neglect/lack of supervision. Therefore, the allegation is deemed Unsubstantiated at this time.

It was reported that “Staff mismanaged resident’s medication” as it was alleged that the Administrator was administering medications that were discontinued. Interviews and record reviews revealed that on 02/07/2025, R1 was admitted to Los Robles Regional Medical Center. The discharge orders directed to stop administering the medication Amlodipine Besylate (NORVASC 5 mg) daily and to consider resuming blood pressure medication only if systolic blood pressure exceeded 160–170 mmHg. On 02/24/2025, R1 was admitted to Kaiser for hypertension and mild chronic kidney disease. The Primary Care Physician (PCP) ordered R1 to start Amlodipine for blood pressure control. On 02/25/2025, during a scheduled visit at the Kaiser Geriatric Clinic, R1 was discharged with instructions to stop taking Amlodipine. Between 02/26 - 03/06/2025, R1’s blood pressure readings were as follows: 149/88, 164/88, 172/80, 167/81, 157/83, 149/89, 164/89, 156/90, and 168/90. On 03/06/2025, the facility administrator notified R1’s PCP of these readings. The PCP recommended restarting Amlodipine. According to the administrator’s interview, the facility requested the POA to order and provide the medication, as has been done in the past. The POA declined to order Amlodipine, citing the 02/07/2025 recommendation from Los Robles advising against its use. As a result, R1 did not receive Amlodipine from March 6 until March 11, 2025, when R1 relocated from the facility. Medication Administration Records (MARs) confirm that R1 was not administered Amlodipine from February 7 through March 11, 2025. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff mismanaged resident’s medication” is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20250318122806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MAJESTIC RESIDENTIAL CARE
FACILITY NUMBER: 565850366
VISIT DATE: 08/21/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099-C

It was reported that "Staff did not provide a proper rate increase notice to resident or resident's authorized representative" as it was alleged that the Administrator informed the POA of R1 of a $500 rent increase without giving at least 30 days’ notice. Interviews and records review revealed that R1 was admitted to the facility on 06/15/2024, with a monthly rent of $4,000. On 12/27/2024, a notice of a $500 rent increase, effective April 2025, was provided to R1’s Power of Attorney (POA) at that time. Following the death of the POA on 01/16/2025, a family member was designated as the new POA. On 02/28/2025, the new POA was informed of the upcoming rent increase. On 03/07/2025, the facility provided the new POA with an updated Admission Agreement reflecting the increased monthly rent of $4,500. However, the updated agreement was never signed, and the rent increase was not implemented. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff did not provide a proper rate increase notice to resident or resident's authorized representative” is deemed Unsubstantiated at this time.

It was reported that “Staff did not provide resident records to resident’s authorized representative” as it was alleged that Administrator did not provide requested medical records in a timely manner. Interviews conducted and records reviewed revealed on 03/11/2025, upon R1’s discharge from the facility, a family member / responsible party of R1 was provided facility records. LPA’s records review revealed all relevant records were given to the family member / responsible party of R1. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff did not provide resident records to resident’s authorized representative” is deemed Unsubstantiated at this time.


Exit interview conducted, copy of this report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4