complaint·April 9, 2026

Continued from 9099 On 06/11/2025, medical records from Adventists Health – Simi Valley were reviewed. Between 07/07/25 and 09/15/25, The Department interviewed current and former facility staff, R1’s Responsible Party (RP) and other relevant parties. R1’s charting notes covering periods from 01/28/25 through 07/06/25 were also reviewed. On 11/26/2025 between 09:30 a.m. to 12:30 p.m., LPA Balisi conducted a subsequent complaint visit. At approx. 09:45 a.m. LPA conducted physical plant tour, interviewed staff and reviewed and obtained additional copies of pertinent documentation relevant to the investigation. It was reported that due to neglect/ lack of care and supervision R1 had toxic levels of a prescribed medication identified by medical providers. Interviews conducted and records review revealed that R1 was transported to the hospital on 04/21/2025 for evaluation of a skin rash and blistering. During that hospitalization, medical staff identified toxic levels of the prescribed medication Depakote in R1’s system. Hospital discharge instructions directed that Depakote be held, pending follow-up with R1’s primary care provider. Upon R1’s return to the facility, the discharge instructions were provided to facility staff by R1’s family and private caregiver, and staff were verbally informed of the medication hold. On 05/14/2025, R1 was again transported to the hospital, at which time laboratory results showed Depakote levels that were higher than those recorded on 04/21/2025. A review of facility medication records indicated that on 04/28/2025, staff began administering a newly prescribed medication, Keppra, but did not discontinue Depakote as directed in the hospital discharge instructions. As a result, from 04/28/2025 through 05/14/2025, R1 received both Depakote and Keppra. Based on the information obtained during the investigation, the allegation of neglect / lack of care and supervision, related to the continued administration of a medication that had been ordered to be held, has been deemed substantiated at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Executive Director was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided. It was reported that “Due to lack of supervision, resident fell resulting in a bruise” as It was alleged that Resident 1 (R1) sustained a bruise to the abdomen as a result of a fall. Interviews conducted and records reviewed reflected that that R1 experienced a fall on 04/27/2025. On 05/09/2025, staff observed a bruise on the right side of R1’s abdomen. No fall involving R1 was documented on 05/09/2025, and R1 was unable to identify how the bruise occurred. A review of facility records indicated that no additional falls involving R1 were documented between 04/27/2025 and 05/09/2025.LPA’s interview with Staff revealed that, based on the circumstances of the fall on 04/27/2025, the observed bruise did not appear consistent with that fall. Staff reported that following the fall, R1 were found lying on their back with their head on a pillow and were not positioned against or in contact with any object at the time they were found. It was further revealed that R1 uses a scooter and has been observed leaning forward onto the scooter handles. Staff also stated that the bruise may have resulted from contact with two exposed metal poles on an attachable bed rail when the rail is in the lowered position. Staff explained that the poles are exposed when the bed rail is lowered. A review of R1’s charting notes indicated that since 01/28/2025, R1 has experienced a total of five unwitnessed falls. No significant injuries were reported as a result of these falls. Following R1’s first three falls, charting notes dated 05/01/2025 indicated that Home Health recommended R1 receive assistance with all upright activities due to increased fall risk. Records further revealed that R1 experienced two additional unwitnessed falls on 06/05/2025 and 06/10/2025. Both incidents occurred in R1’s room. 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 “Due to lack of supervision, resident fell resulting in a bruise” is deemed Unsubstantiated at this time. It was reported that “Staff did not notify authorized representative of bruise on resident”, as It was alleged that R1’s responsible party was not notified in a timely manner of a bruise observed on R1. Interviews were conducted and records reviewed reflected that on 05/09/2025, Staff #1 (S1) observed a bruise on the right side of R1’s abdomen. According to charting notes, S1 informed R1’s private caregiver of the observed bruise. The private caregiver is listed in R1’s records as Emergency Contact #2. The charting notes further indicated that the private caregiver requested Tylenol for R1 and stated they would notify R1’s Power of Attorney (POA) of the bruise. LPA’s interview with S1 revealed, S1 stated that they asked R1’s private caregiver, who was present in R1’s room at the time, to send a text message to R1’s POA regarding the bruise. Continued from 9099-C S1 further stated that after assessing R1, they also directly contacted R1’s POA to report the observed bruise. Interviews with R1’s POA and R1’s private caregiver revealed that both individuals stated they did not recall being notified of the bruise. Interviews were conducted with seven (7) facility staff. All seven staff stated that when a bruise or change in condition is observed, the med tech or appropriate staff are notified immediately, the resident is assessed, and notifications are made to the resident’s family or responsible party, the primary care physician, and any involved home health agencies. None of the staff interviewed reported concerns regarding untimely notification to required parties when a bruise or change in condition is observed. 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 notify authorized representative of bruise on resident” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.