Inspection Reports for
Elms Residential Home Care

The complaint investigation was unsubstantiated for allegations related to drug use, illness mitigation, food service, safeguarding resident funds, and hygiene. The allegation regarding inaccurate resident records was substantiated based on incomplete and missing documentation in resident files.

The investigation found insufficient evidence to substantiate allegations regarding drug use, illness mitigation, food service, safeguarding resident funds, and hygiene. However, the allegation that staff do not maintain accurate records for residents was substantiated due to incomplete and missing documentation in resident files.

The inspection identified several deficiencies including non-functional fire sprinklers, an outdated and inoperable call button system, incomplete personnel and resident records, lack of documented emergency drills, and missing annual staff training. The facility is undergoing a change of ownership and has plans to correct these deficiencies by specified due dates.

The complaint investigation was substantiated for inadequate staff training but unsubstantiated for pest infestation and cleanliness issues. The facility had no current bedbug evidence and maintained pest control services until June 2025.

The allegation that staff were not adequately trained was substantiated due to lack of medication training documentation for four staff members. The allegations regarding pest infestation and poor cleanliness were unsubstantiated based on facility tour, interviews, and pest control records.

The Licensing Program Analyst conducted interviews, a health and safety tour, and met with staff and the administrator. No deficiencies were cited during this visit.

During the visit, Licensing Program Analysts and Managers interviewed the administrator, reviewed resident files, and participated in a telephone call with other relevant parties. An entrance and exit interview were conducted, and a copy of the report was provided.

The Licensee was informed about the Health and Safety Code 1569.682 requirements for closure, including the need to submit a closure plan and provide a 60-day notification to residents. The Licensee acknowledged understanding of these requirements and has assistance from a consultant and Ventura County Behavior Health for the closure process.

The complaint was substantiated based on evidence that residents missed medications due to the facility's inability to pick up medications from the pharmacy. Two residents reported missed medications on one occasion. The allegation regarding facility disrepair was unsubstantiated after resident interviews and confirmation of extermination service for bed bugs.

The allegation that staff mismanaged residents' medications was substantiated due to missed medications and failure to provide medication pickup services, with two out of five residents confirming missed doses. A separate allegation regarding facility disrepair, including bed bugs and toilet issues, was investigated and found unsubstantiated.

The inspection identified multiple deficiencies including expired and improperly labeled food items, unsanitary conditions in resident bedrooms and bathrooms, improper storage of cleaning supplies, expired staff CPR/first aid certifications, missing resident pre-appraisals and admission agreements, lack of quarterly emergency drills, and incomplete medication records.

The complaint investigation was substantiated for allegations that facility staff do not serve nutritious meals and do not provide basic laundry service. The allegation that staff do not meet residents' dietary needs was unsubstantiated.

The investigation substantiated that the facility failed to provide adequate fresh fruits and vegetables during meals and did not provide timely basic laundry services due to staffing issues. However, the allegation that staff do not meet residents' dietary needs was unsubstantiated.

The visit was conducted in conjunction with a complaint visit (Complaint Control #29-AS-20230405151719). The deficiencies cited were not related to the complaint.

The facility was cited for failure to have an administrator or designee present during the visit to assist the Licensing Program Analyst, and staff was unable to provide necessary documentation for the investigation.

The complaint was substantiated. The allegation was that staff do not provide adequate meal service, specifically that food was served cold and residents lacked variety in fruits, vegetables, and breakfast items. The investigation confirmed insufficient perishable fruit supply and occasional cold meals.

The investigation found that the facility did not have a sufficient supply of perishable fruit for the census of 42 residents, and residents confirmed they do not receive fresh fruit every day. Some residents also reported occasionally receiving cold meals. There was no evidence supporting insufficient vegetable supply or breakfast variety complaints.

The complaint investigation revealed the facility was short staffed and an individual without fingerprint clearance was asked to work at the facility and help with laundry. The deficiency was substantiated by record review and interviews.

The inspection found that an individual (I1) worked at the facility without having the required criminal record clearance and fingerprinting, posing an immediate health, safety, and personal rights risk to persons in care. Civil penalties of $100 were assessed.

The complaint alleged neglect and lack of supervision led to Client #1 being hit by Client #2. After interviews with clients, staff, residents, and a case manager, the allegation was found unsubstantiated due to insufficient evidence.

The investigation found conflicting accounts of the incident between the involved clients. Staff were not in the immediate area during the incident, and no evidence supported lack of supervision. Residents felt safe and staff reported appropriate intervention practices. The allegation was deemed unsubstantiated.

The inspection found deficiencies including hot water temperature exceeding regulatory limits, accessible disinfectants posing health risks, and inadequate supply of nonperishable fruit. Civil penalties of $250 were issued.

The complaint investigation was unsubstantiated according to the report delivered on 09/16/2021.

The Licensing Program Analyst conducted a physical plant inspection and staff interviews. The allegation was deemed unsubstantiated as of the report date.

The complaint was substantiated. The allegation was that the Administrator increased rental rates without proper notice. Interviews and document review confirmed that residents did not receive the required 60 days prior written notice.

The investigation found that the Administrator did not provide proper written notice of the rental rate increase to residents, which was a violation of regulation 87507(g)(4). The allegation was substantiated based on interviews and document review.

The inspection found that several resident admission agreements were incomplete or missing, and medications were not stored securely, posing health risks. Specifically, resident #1's medication was accessible to residents despite the resident being unable to self-administer or store medications.

The complaint involved allegations that resident #1 intimidated residents, verbally abused residents, and violated house rules by smoking in their room. The investigation concluded the allegations were unsubstantiated.

The investigation found that the resident did verbally intimidate and verbally abuse staff and residents during behavioral episodes and violated house rules by smoking in their room. However, the allegations were deemed unsubstantiated at this time. The administrator committed to ensuring resident health and safety and to providing staff training on handling behavioral episodes.

The complaint was substantiated. The allegation was that facility staff did not assist resident #1 with medications as prescribed, specifically PRN Ondansetron 4 mg. The investigation confirmed missed doses during the PM shift on 1 or 2 days the prior week.

The investigation substantiated the allegation that staff failed to assist resident #1 with PRN medications as prescribed, specifically Ondansetron 4 mg, which posed an immediate health risk. The facility was cited for not assisting residents with self-administered medications as required.

During the facility tour, the Licensing Program Analyst observed bleach and bed bug killer stored in an unlocked closet accessible to residents, which posed an immediate health risk. A deficiency was cited for failure to store disinfectants and poisons where inaccessible to clients.

The facility was found to be in compliance with Title 22 regulations with no health or safety hazards observed. Infection control practices were adequate, with sufficient PPE supplies and cleaning protocols. No citations were issued during the visit.

The complaint was substantiated. The allegation was that staff failed to keep the facility clean. Interviews with residents and staff confirmed that rooms and restrooms were not cleaned frequently, with some residents reporting their rooms had not been cleaned in 2-3 weeks. Staffing shortages were noted as a contributing factor.

The investigation found sufficient evidence to substantiate the allegation that staff failed to keep the facility clean, with multiple residents and staff reporting that rooms and restrooms were not cleaned regularly, posing potential health and safety risks.