Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that allegations of neglect or inadequate care were not supported by evidence. The facility’s most recent report from September 11, 2025, was a complaint investigation that found no deficiencies and deemed the complaint unsubstantiated. Earlier inspections identified some deficiencies related mainly to staff criminal record clearance and medication documentation, as well as occasional environment and safety issues such as unsecured chemicals and medication carts, some of which posed immediate risks but were corrected promptly. There were no fines, license suspensions, or enforcement actions listed in the available reports. The overall trend shows improvement, with the most recent inspections free of deficiencies after addressing prior issues.
The inspection was conducted as a complaint investigation following an allegation that staff did not ensure adequate supervision, resulting in a resident sustaining injury.
Findings
The investigation found that although the resident did fall and sustain a hip fracture, staff were present and the resident did not require 1:1 supervision. There was insufficient evidence to substantiate the allegation of inadequate supervision, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged that due to lack of supervision, Resident #1 fell resulting in a hip fracture. The investigation included interviews, document reviews, and observations. It was found that staff were present during the incident, and the resident was typically independent with transfers. The allegation was unsubstantiated due to lack of sufficient evidence.
The inspection was an unannounced required annual visit to evaluate the facility's compliance with licensing regulations and health and safety standards.
Findings
The facility was found to be in compliance with all applicable regulations, with no deficiencies cited. The inspection included review of fire safety systems, resident rooms, bathrooms, common areas, grounds, infection control, records, medication management, kitchen, and interviews with residents and staff.
An unannounced case management visit was conducted to issue an amended report related to a previous annual inspection citation for Criminal Record Clearance.
Findings
The report revises a citation issued on 07/23/2024 regarding a failure to obtain a transfer of criminal record clearance for one staff member, posing a potential health, safety, or personal rights risk to persons in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
One staff member did not have a transfer of criminal record clearance prior to working, residing, or volunteering in the licensed facility.
Type B
Report Facts
Deficiency Plan of Correction Due Date: Jul 23, 2024Census: 70Total Capacity: 100
Employees Mentioned
Name
Title
Context
Erica Mosley
Licensing Program Analyst
Conducted the unannounced case management visit and signed the report
Kasandra Lopez
Licensing Program Manager
Named as Licensing Program Manager on the report
Lance Shenk
Administrator/Director
Facility Administrator/Director
Brittany Cramer
Marketing Director
Met with Licensing Program Analyst during the visit
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-03-18 regarding medication protocol, response to resident call pendants, special diet orders, and cancellation of medical appointments at Aegis Living Ventura.
Findings
All allegations were investigated through staff and resident interviews, record reviews, and observations. The investigation found that medication protocols were followed, staff responded timely to call pendants, special diet orders were adhered to, and no staff cancellations of medical appointments occurred. All allegations were deemed unsubstantiated.
Complaint Details
The complaint included allegations that staff did not follow medication protocol, did not respond timely to resident call pendants, did not follow special diet orders, and canceled a resident's medical appointment. After investigation, all allegations were found to be unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Capacity: 100Census: 66Pendant calls: 93Average pendant response time (minutes): 8.05
Employees Mentioned
Name
Title
Context
Esther Cortez
Licensing Program Analyst
Conducted the complaint investigation visit and authored the report
Aleesha Zuniga
Health Services Director
Authorized to review and sign the report during the visit
John Washko
General Manager
Unable to be present during the visit but authorized report signing
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-09-17 regarding staff not ensuring residents' care needs are met, transportation arrangements are provided, and residents are spoken to appropriately.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with residents and staff, and review of records. Residents' care needs were met, transportation arrangements were provided, and no inappropriate language by staff was witnessed. No deficiencies were observed.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not ensuring residents' care needs were met, not providing transportation arrangements, and not speaking to residents appropriately. Interviews and record reviews did not support these allegations.
An unannounced complaint investigation visit was conducted in response to allegations that staff were not properly caring for residents, not checking on residents during the night, and that staff took away residents' medication.
Findings
The investigation found that the allegations were unsubstantiated. Interviews with residents, staff, and family members indicated that residents were checked frequently, including at night, and that staff provided adequate care. The allegation regarding medication was also unsubstantiated as medication management protocols were followed.
Complaint Details
The complaint investigation was triggered by allegations that staff were not properly caring for residents, not checking on residents during the night, and taking away residents' medication. After interviews and file reviews, all allegations were deemed unsubstantiated.
Report Facts
Capacity: 100Census: 82Number of residents interviewed: 3Number of staff interviewed: 6
Employees Mentioned
Name
Title
Context
Esther Cortez
Licensing Program Analyst
Conducted the complaint investigation
Kasandra Lopez
Licensing Program Manager
Named in report as Licensing Program Manager
J.P. Rollet
Acting Administrator
Met with Licensing Program Analyst during the investigation
John Washko
General Manager
Met with Licensing Program Analyst during the investigation
The inspection was conducted as a follow-up on a self-reported incident received on 07/10/2024 regarding a stolen vehicle taken by a staff member.
Findings
No immediate health and safety concerns were observed during the inspection. The Licensing Program Analyst conducted interviews and a physical plant tour as part of the investigation.
Complaint Details
The complaint involved Resident #1 reporting a stolen vehicle taken by Staff #1. The investigation included interviews with the administrator and the resident, and review of pertinent documents.
Employees Mentioned
Name
Title
Context
Jeanphilippe Rollet
Administrator
Met with Licensing Program Analyst during inspection and interviewed regarding the incident.
Emily Peraldi
Licensing Program Analyst
Conducted the unannounced Case Management - Incident inspection.
The inspection was an unannounced required annual visit to evaluate compliance with Title 22 regulations and assess the facility's health, safety, and operational standards.
Findings
The facility was generally found to be in compliance with regulations, including proper maintenance of fire safety equipment, clean kitchen and common areas, adequate resident rooms and bathrooms, and proper medication management. However, one deficiency was cited related to a staff member lacking a transfer of criminal record clearance, posing an immediate risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
One staff member did not have a transfer of criminal record clearance as required by CCR 87355(e)(3), posing an immediate health, safety, or personal rights risk to persons in care.
An unannounced Annual Continuation Visit was conducted to continue the annual inspection visit initiated on 07/11/2023, including a medication audit and record review.
Findings
Deficiencies were found related to medication documentation, specifically expiration dates and start dates not properly documented for multiple medications during audits of two residents. Staff corrected the documentation upon observation.
Deficiencies (1)
Description
Failure to comply with medication documentation requirements for centrally stored medications in two out of five resident medication audits, posing potential health, safety, or personal rights risks.
Report Facts
Residents audited: 2Medications with undocumented expiration dates: 15Medications with undocumented expiration dates: 9Medications not documented on centrally stored log: 2Plan of Correction due date: Jan 23, 2024
Employees Mentioned
Name
Title
Context
Lance Shenk
Administrator
Administrator present during the visit
Esther Cortez
Licensing Program Analyst
Conducted the inspection and medication audit
Kasandra Lopez
Licensing Program Manager
Supervisor and Licensing Program Manager named in report
Hannah Robertson
Business Office Manager
Greeted the Licensing Program Analyst and informed of visit reason
The inspection was an unannounced required annual visit to evaluate compliance with health and safety regulations and Title 22 requirements at the assisted living and memory care facility.
Findings
The facility was generally in compliance with regulations, including fire safety and infection control. However, deficiencies were noted including unlocked beauty salon with accessible chemicals posing immediate risk, incomplete staff training hours for some employees, and minor cleanliness issues in bathrooms and furniture condition.
Deficiencies (5)
Description
Beauty salon was unlocked with chemicals and cleaning supplies accessible to residents, posing an immediate health and safety risk.
One out of five staff files reviewed had only 3.5 hours of initial training out of 40 required hours.
Unable to confirm required four hours of postural support and prohibited health training for two out of five staff files reviewed.
Two toilets required cleaning and one bathroom floor was unclean; staff cleaned upon observation.
Four chairs in memory care were in poor condition; new chairs ordered.
The visit was conducted as a complaint investigation following an allegation that facility staff were not meeting the needs of a resident in care.
Findings
The investigation found the allegation unsubstantiated. Interviews with residents, staff, and the resident's family indicated that staff were responsive and providing appropriate care. No citations were issued.
Complaint Details
The complaint alleged that staff were neglecting a resident who was observed hanging off the bed with a leaking cancer wound and other issues. The resident's physician report indicated the resident required extensive assistance but could communicate needs and feed self. Interviews and reviews showed staff were attentive and the resident's family had no concerns. The allegation was deemed unsubstantiated.
Report Facts
Complaint Control Number: 29-AS-20220922164050Capacity: 100Census: 81
Employees Mentioned
Name
Title
Context
Martha Arroyo
Licensing Program Analyst
Conducted the complaint investigation and visits
Desaree Perera
Licensing Program Manager
Named in report as Licensing Program Manager
Mary Sawyer
Marketing Director
Met with during the investigation as Executive Director was unavailable
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 03/28/2022 regarding the facility's alleged failure to respond to residents' responsible persons' correspondence.
Findings
The investigation found insufficient evidence to support the allegation that the facility failed to respond to residents' responsible persons' correspondence. Therefore, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that the facility failed to respond to residents' responsible persons' correspondence. After interviews with facility staff and residents' responsible persons on multiple dates, the allegation was found unsubstantiated.
Report Facts
Complaint Control Number: 29-AS-20220328145922Facility Capacity: 100Census: 83
Employees Mentioned
Name
Title
Context
Joann Rosales
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Lance Shenk
Executive Director
Met with Licensing Program Analyst during investigation and discussed the allegation
The inspection was conducted as a complaint investigation following an allegation of neglect/lack of care and supervision resulting in resident #1 falling and sustaining a fractured wrist.
Findings
The investigation found that resident #1 had two falls, one witnessed and one unwitnessed, resulting in injuries including a fractured wrist and brain bleed. The facility staff denied neglect and reported adequate staffing levels. The evidence did not support the allegation, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged neglect/lack of care and supervision causing resident #1 to fall and sustain a fractured wrist. After interviews, document reviews, and medical record analysis, no neglect or lack of supervision was observed or supported by evidence. The allegation was unsubstantiated.
Report Facts
Facility capacity: 100Resident census: 83Dates of falls: Resident #1 had a witnessed fall on 2021-12-12 and an unwitnessed fall on 2022-03-06
Employees Mentioned
Name
Title
Context
Lance Shenk
Administrator
Met during investigation and interviewed regarding complaint
Kelly Dulek
Licensing Program Analyst
Conducted complaint investigation and authored report
Hannah Robertson
Business Office Manager
Met during investigation and interviewed
Mark Brassfield
Health Services Director
Met during investigation and interviewed
Douglas Real
Investigator
Conducted interviews and reviewed records during investigation
Angel Ascencio
Licensing Program Analyst
Conducted unannounced complaint visit and entrance interview
The visit was an unannounced complaint investigation conducted to investigate allegations of lack of supervision resulting in resident eloping from the facility and failure to report the elopement incident.
Findings
The investigation found that Resident #1 resides in the Assisted Living section and is able to leave the facility unassisted. Records and interviews confirmed the resident is self-responsible and able to leave the facility unassisted. The allegations were deemed unfounded.
Complaint Details
The complaint investigation was triggered by allegations of lack of supervision resulting in resident eloping and failure to report the elopement incident. The allegations were found to be unfounded.
Report Facts
Capacity: 100Census: 77
Employees Mentioned
Name
Title
Context
Zabel Chochian
Licensing Program Analyst
Conducted the complaint investigation visit
Karen G. Goroyan
Executive Director/Administrator
Met with Licensing Program Analyst during investigation
Mark Brassfield
Health Service Director
Met with Licensing Program Analyst during investigation
An unannounced Required - 1 Year inspection was conducted to evaluate the facility's compliance with regulations including infection control, safety, and medication storage.
Findings
The inspection found several deficiencies related to unsecured medication carts, accessible scissors in the activities director's office, and toxic substances accessible to residents with dementia, all posing immediate health and safety risks. The facility took corrective actions during the visit and planned staff training.
Deficiencies (3)
Description
Unsecured medication cart in the Creekside memory care activity room accessible to residents.
Scissors observed in an unlocked activities director's office accessible to residents.
Toxic substances accessible to residents with dementia.
Report Facts
Deficiencies cited: 3
Employees Mentioned
Name
Title
Context
Karen Gary Goroyan
Administrator
Met with Licensing Program Analyst during inspection and involved in corrective actions.
Mark Brassfield
Staff present during inspection when unsecured scissors and personal care items were observed.
Joann Rosales
Licensing Program Analyst
Conducted the inspection and authored the report.
Kristin Heffernan
Licensing Program Manager
Supervisor overseeing the inspection.
Inspection Report Original LicensingCensus: 69Capacity: 100Deficiencies: 1Jul 2, 2021
Visit Reason
Pre-licensing visit conducted as part of a change of ownership application from Aegis of Ventura #565800683, including inspection of fire safety, personal accommodations, medication procedures, and food service.
Findings
The facility was inspected and found to have adequate supplies, proper fire safety equipment, and appropriate accommodations including private bathrooms and approved bedridden rooms. However, the physical plant was not in compliance with Title 22 regulations at the time of inspection, with some medications and cleaning supplies accessible to residents.
Deficiencies (1)
Description
Physical plant is not in compliance with Title 22 regulations at this time.
Report Facts
Capacity: 100Census: 69Hot water temperature readings: 112.1Hot water temperature readings: 108.4Hot water temperature readings: 112.9Hot water temperature readings: 109.6Number of bedridden residents approved: 18Number of bedridden rooms: 18
Employees Mentioned
Name
Title
Context
Sam El-Rabaa
Administrator
Administrator present during pre-licensing visit and named as applicant representative
JoAnn Rosales
Licensing Program Analyst
Conducted the pre-licensing visit and inspection
Ana De La Cerda
VP Regulatory Affairs
Applicant who designated the Administrator as applicant representative
Kristin Heffernan
Licensing Program Manager
Named in report header and footer
Inspection Report Original LicensingCapacity: 100Deficiencies: 0May 7, 2021
Visit Reason
The visit was conducted as part of the original licensing process involving a telephone call with the Community Care Licensing analyst to complete Component II of the application process and verify the applicant and administrator's understanding of Title 22 regulations.
Findings
The applicant and administrator successfully completed Component II, demonstrating understanding of facility operation, staff qualifications, program policies, grievance procedures, physical plant, and application document requirements. They were advised to submit required documentation including signed LIC 809 and photo ID.
Report Facts
Capacity: 100
Employees Mentioned
Name
Title
Context
Sam El-Rabaa
Administrator
Named as facility administrator participating in licensing process
Ana De La Cerda
Met with during the visit
Julia Kim
Licensing Program Manager
Named in report header
Nicole Rouse
Licensing Program Analyst
Named in report header and analyst conducting the licensing call
Loading inspection reports...
Need Help?
Let us help you or a loved one find the perfect senior home.