Inspection Reports for Varenita of Simi Valley

The visit was an unannounced case management legal/non-compliance inspection to ensure the facility is maintaining substantial compliance with licensing requirements.

The facility was toured to check for health and safety hazards and compliance with Title 22 Regulations. Resident bedrooms, common areas, fire safety equipment, and food service areas were inspected. Some expired cereal boxes were noted, but the facility had sufficient food supplies and planned to order more non-perishable items.

An unannounced case management – legal/non-compliance visit was conducted to ensure the facility is maintaining substantial compliance, focusing on medications and Centrally Stored Medications and Destruction Records (CSMDR) compliance with Title 22 Regulations.

The medication review revealed that 3 out of 5 residents had routine medications started but not documented on the CSMDR, and 2 out of 5 residents had medications missing start dates on both the CSMDR and medication labels. Additionally, Resident #1 had prescribed bedtime medications missing one dosage each without documented staff observation notes.

The visit was an unannounced case management – legal/non-compliance inspection to ensure the facility is maintaining substantial compliance, focusing on records being in order and compliant with Title 22 Regulations.

The Licensing Program Analyst reviewed ten resident files and ten personnel files, finding all files complete with no deficiencies issued. An exit interview was conducted and a report copy was issued.

An unannounced annual inspection was conducted to evaluate compliance with Title 22 regulations, infection control policies, emergency disaster plans, and other regulatory requirements.

The facility was generally found to be in compliance with infection control, fire safety, kitchen, common areas, and medication storage regulations. However, deficiencies were cited related to staff criminal record clearance and incomplete annual training for some staff members.

The visit was an unannounced case management – legal/non-compliance inspection to ensure the facility is maintaining substantial compliance and there are no health and safety hazards.

The inspection found that resident rooms and bathrooms were appropriately furnished and stocked, hot water temperatures were within required ranges, fire extinguishers were fully charged, and there were no obstructions or hazards observed. The facility's new resident Admissions Agreement and Assessment Tool need updating to meet Title 22 Regulations. No deficiencies were issued.

The inspection was an unannounced complaint investigation triggered by allegations received on 07/24/2024 regarding mishandling of residents' incontinence needs, unmet dental needs, and unmet hygiene needs at the facility.

The investigation found no sufficient evidence to substantiate the allegations. Interviews with staff and families, as well as physical plant observations, indicated that residents' incontinence, dental, and hygiene needs were being met appropriately. Therefore, all allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included mishandling of residents' incontinence needs, failure to meet dental needs, and failure to meet hygiene needs. Interviews with eleven staff members and five families revealed no concerns or evidence supporting the allegations.

The inspection was an unannounced complaint investigation conducted in response to allegations received on 07/29/2024 regarding inadequate supplies, unmet residents' diapering needs, and use of expired COVID tests.

The investigation found the allegations of inadequate supplies and unmet diapering needs to be unsubstantiated due to insufficient evidence. However, the allegation that staff used expired COVID test kits was substantiated, with evidence confirming expired test kits were used on August 9, 2024.

The complaint investigation was unannounced and initiated due to allegations of inadequate supplies, unmet diapering needs, and use of expired COVID tests. The first two allegations were unsubstantiated, while the use of expired COVID tests was substantiated based on interviews, document reviews, and confirmation from the test kit manufacturer and FDA records.

The visit was an unannounced complaint investigation triggered by an allegation that staff were not following physician's orders for a resident, specifically not using a waist belt on the resident's wheelchair as prescribed.

The investigation found insufficient evidence to substantiate the allegation. Although the resident's POA obtained a physician's order for use of a waist belt at a Skilled Nursing Facility, the facility did not use it due to non-compliance with Title 22 and lack of a physician's order for use at this facility. Therefore, the allegation was deemed unsubstantiated.

The complaint alleged that staff were not following physician's orders by not using a waist belt on Resident #1's wheelchair. The investigation included interviews, record reviews, and a physical plant inspection. The allegation was found unsubstantiated due to insufficient evidence.

The inspection visit was conducted as a complaint investigation regarding allegations that staff increased resident fees without providing new additional services.

The allegation that staff increased resident fees without providing new additional services was substantiated. Records showed residents were charged increased fees without updated admission agreements reflecting the changes, and no additional services were provided to justify the fee increase.

The complaint alleged that staff increased resident fees without providing new additional services. The allegation was substantiated based on document review and interviews.

The visit was an unannounced case management - other visit conducted to obtain pertinent information regarding an incident that occurred on 01/01/2024.

During the visit, the Licensing Program Analyst met with staff, conducted a record review, and obtained copies of pertinent documents. An exit interview was conducted and the report was reviewed and issued.

The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure the facility meets health and safety standards.

The facility was generally found to be in compliance with regulations including kitchen safety, common areas, bedrooms, restrooms, medication storage, and infection control. However, a deficiency was noted regarding expired non-perishable food items which were discarded and replaced during the inspection.

The visit was an unannounced case management investigation to conclude an incident that occurred on 2024-01-01 involving staff and a resident.

The investigation found that Staff #1 slapped Resident #1 while providing care after being slapped by the resident, which violated residents' personal rights and posed an immediate safety risk.

The visit was complaint-related, investigating an incident where Resident #1 slapped Staff #1, who then slapped the resident back. The incident was substantiated based on evidence obtained.

The visit was an unannounced complaint investigation triggered by multiple allegations received on 2023-05-22 regarding staff behavior and care at the facility.

The investigation found all allegations except one to be unsubstantiated, including inappropriate staff communication, unsafe environment, improper medication training, causing resident to bleed, eating resident food, and improper cleaning. One allegation that a staff member was under the influence at work was substantiated.

The complaint investigation was unannounced and involved multiple allegations against staff behavior and care. After interviews with staff, residents, family members, and review of records, all allegations except the one regarding staff under the influence at work were deemed unsubstantiated. The allegation of staff under the influence was substantiated based on admission by the staff member and evidence provided.

The visit was an unannounced Case Management – Incident inspection to investigate a self-reported incident involving staff and a resident that occurred on 2024-01-01.

During the visit, the Licensing Program Analyst conducted interviews, toured the Memory Care Unit, and reviewed relevant documents. Further investigation was deemed necessary and a follow-up visit will be conducted.

The complaint involved an incident where Resident #1 slapped Staff #1, who then responded by slapping the resident. Staff #2 witnessed the event. The investigation is ongoing.

The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2023-05-30 that a staff member was using illegal drugs at the facility.

The investigation substantiated the allegation that Staff #1 was under the influence of marijuana (THC crystals) while on duty, posing an immediate health and safety risk to residents. Staff #1 was terminated and a civil penalty was issued.

The complaint alleged that Staff #1 was using illegal drugs (suspected crystal methamphetamine or cocaine) on the premises. The investigation found Staff #1 admitted to being under the influence of marijuana while working. The allegation was substantiated.

The visit was conducted as an unannounced complaint investigation following allegations that the facility was unsanitary, staff did not provide a safe and comfortable environment for residents, and that the facility was malodorous.

The investigation found the allegations that the facility was unsanitary and staff did not provide a safe and comfortable environment for residents to be unsubstantiated based on observations and interviews. However, the allegation that the facility was malodorous was substantiated due to a lingering smell of pet urine in a resident's bedroom, resulting in a cited deficiency.

The complaint investigation was triggered by allegations received on 07/31/2023 regarding unsanitary conditions, unsafe and uncomfortable environment, and malodor in the facility. The allegation of malodor was substantiated, while the others were unsubstantiated.

The visit was an unannounced complaint investigation conducted due to allegations that staff do not ensure residents are receiving their medications as prescribed and that staff are not properly managing residents' medications.

The allegation that staff do not ensure residents receive medications as prescribed was found unsubstantiated based on record review and interviews. However, the allegation that staff are not properly managing residents' medications was substantiated due to missing narcotics from inventory, posing an immediate health and safety risk.

The complaint investigation was triggered by allegations that staff do not ensure residents receive their medications as prescribed and that staff are not properly managing residents' medications. The first allegation was unsubstantiated, while the second was substantiated due to missing narcotics. The investigation included interviews, record reviews, and audits of narcotic inventory.

The visit was conducted as a Case Management - Deficiencies inspection in conjunction with a complaint investigation (Complaint Control # 29-AS-20230801143754) to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation, it was found that Resident #1's centrally stored medication and destruction record was not updated with medication expiration and start dates. Staff interviews confirmed that these records were not being completely filled out for all residents' centrally stored medication.

The visit was triggered by complaint # 29-AS-20230801143754. The deficiency was substantiated as the centrally stored medication records were incomplete and not updated as required.

The visit was an unannounced complaint investigation conducted in response to allegations received on 08/31/2022 regarding resident care concerns including residents being left soiled, incontinence needs not addressed, improper monitoring of medical condition changes, and unmet hygiene needs.

Based on interviews, observations, and records review, there was insufficient evidence to substantiate the allegations. The resident's condition changes were communicated appropriately, care was provided according to observed needs, and no residents were purposely left in soiled clothing. The allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included a resident being left soiled, staff not addressing incontinence needs, failure to monitor a resident's medical condition change, and unmet hygiene needs. Investigations included interviews with staff and residents, record reviews, and observations. No evidence supported the allegations.

The inspection was conducted as an unannounced complaint investigation following a report received on 2023-05-30 alleging that the licensee was not addressing a flea outbreak at the facility.

The investigation found that the facility had promptly engaged a pest control company to inspect and treat the facility. Staff interviews and pest control records showed no evidence of fleas, and the allegation was deemed unsubstantiated due to insufficient evidence.

The complaint alleged that a staff member entered the facility with fleas on their clothes, and some staff and residents had flea bites or fleas on their clothes. The facility responded with pest control measures. Interviews and inspections found no fleas present, leading to the complaint being unsubstantiated.

An unannounced complaint investigation visit was conducted following a complaint received on 08/31/2022 regarding the failure to update a resident's care plan.

The investigation found that the care plan for resident #1 was not updated or signed by the responsible person during a period of change in the resident's condition from 02/2022 to 03/2022. This deficiency was substantiated and cited under CCR 87463(c).

The complaint alleged that the resident care plan was not updated. The investigation substantiated this allegation based on interviews and record reviews. The failure to update the care plan posed a potential health, safety, and personal rights risk to residents in care.

The inspection was an unannounced Required Annual inspection with a specific emphasis on infection control practices and procedures.

The facility was found to be in compliance with Title 22 Regulations, with adequate infection control practices including symptom screening, PPE supply, and cleaning protocols. Fire extinguishers were recently serviced and smoke and carbon monoxide detectors were tested and cleared.

An unannounced complaint investigation visit was conducted due to an allegation that the facility was not following COVID-19 protocols.

The investigation found that staff and residents were not properly wearing face masks during a COVID-19 outbreak, with staff observed wearing masks on their chins. The allegation that the facility was not following COVID-19 protocols was substantiated.

The complaint was substantiated. The facility was found not to be following COVID-19 protocols during an outbreak, with improper mask usage by staff and residents.

A pre-licensing unannounced visit was conducted to evaluate the facility's readiness for licensure and compliance with applicable regulations.

The facility was inspected for fire safety, personal accommodations, services, and food service. All areas including bedrooms, memory care rooms, kitchen, common areas, and outdoor areas were found to be clean, properly furnished, and compliant with regulations. No corrections were needed at this time.

Initial licensing evaluation for a new construction Residential Care Facility for the Elderly with dementia care.

The applicant and administrator successfully completed the Component II evaluation, demonstrating understanding of Title 22 regulations, facility operations, staff qualifications, program policies, and application document requirements.