425802114-2-8-2023-29-AS-KBUY-CP5S8F-20230217123903

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802114
Report Date: 02/08/2023
Date Signed: 02/08/2023 10:46:27 AM

Substantiated

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
12/21/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20221221090221

FACILITY NAME:	GRANVIDA SENIOR LIVING AND MEMORY CARE		FACILITY NUMBER:	425802114
ADMINISTRATOR:	BRANDY MCCAULEY		FACILITY TYPE:	740
ADDRESS:	5464 CARPINTERIA AVE		TELEPHONE:	(805) 566-0017
CITY:	CARPINTERIA	STATE: CA	ZIP CODE:	93013
CAPACITY:	83	CENSUS: 50	DATE:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Ted Burgess, Executive Director and Ashley Nash, Business Office Director, and Lumana Seide, Resident Care Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff left resident soiled for an extended period of time.
Staff did not provide resident with clean linen.
Staff did not provide a comfortable temperature for resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Olson and Phillips conducted an unannounced follow up complaint visit to issue final findings. LPAs met with Ted Burgess, Executive Director and Ashley Nash, Business Office Director, and Lumana Seide, Resident Care Director and explained the purpose of the visit. LPA Olson interviewed staff, reporting party, and responsible party on 12/29/22 and 3 Witnesses on 1/6/23.

Resident 1 (R1) was re-admitted to the facility on 12/2/22 after being at a Skilled Nursing facility for a few weeks and placed on hospice on 12/6/2022. Interviews revealed that on 12/19/2022 hospice was called because R1 had a bleeding right elbow and skin care after falling out of bed.

LPA Olson reviewed Hospice notes which stated on 12/19/22 at 7pm the Hospice Nurse 1 (N1) documented R1’s skin tear to be 4cmx2cm with no available skin for covering. Nurse noted evidence of bleeding on the bed, clothes and wall but R1 was not actively bleeding. Nurse noted multiple old skin tears on legs, some in the healing stage. Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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 9

Control Number 29-AS-20221221090221

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: GRANVIDA SENIOR LIVING AND MEMORY CARE	FACILITY NUMBER: 425802114
	VISIT DATE: 02/08/2023

NARRATIVE

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Nurse notes also indicate that the patient was cold and shivering so the nurse shut the window. Nurse observed R1’s dinner tray to be upside down on the bed. R1 denied being hungry but stated they were cold. Nurse stated they covered patient in the quilt and bathrobe. Nurse also observed that R1’s shirt and sheets were soiled, which the nurse thinks was due to the overturned dinner tray. Nurse assisted the resident in changing the brief but was unable to change the sheets because the facility did not have any available sheets and couldn’t locate the additional ones. Nurse stated they asked staff to change the soiled bed sheets.

LPA Olson interviewed Medtech on 12/28/22 who stated they were at the facility on 12/19/22 when the nurse came and stated they changed the sheets while Hospice was there after R1 was bandaged up. The MedTech also stated, contrary to N1’s account, they did not have the hospice nurse assist with the brief change because they did it later with the caregiver on shift during their rounds.

LPA Olson interviewed R1’s regular hospice nurse (N2) who stated they have not observed R1 soiled and thinks it was not surprising that R1 tried to get out of bed and fell. N2 stated that R1 was very mobile and would often get up independently and must have tried but couldn’t.

All staff interviewed indicated that during the time of the incident, 12/19/22, the facility was experiencing a large COVID-19 outbreak, and had limited staffing. According to staff interviews and staff schedule, for Assisted Living, the facility only had 2 caregivers on the AM and PM shifts to care for the 50 residents. Staff indicated providing care for residents took a lot longer because of the PPE donning/doffing, and residents needing additional care because they were sick.

On the allegation: Staff left resident soiled for an extended period of time. It was alleged a witness observed R1 to be soiled through to their bedding. LPA Olson interviewed MedTech and staff on 12/28/22, who all stated residents who are incontinent are checked every 2 hours and all staff stated they check on R1 regularly. MedTech stated the sheets were not soiled and had changed R1’s brief with a caregiver after the nurse left. Medtech stated R1 had a second brief on that was partially soiled but R1 was not soaking. LPA Olson interviewed a Witness (W1) who stated on 12/19/22 they observed R1’s tray to be flipped over and think R1 spilled their water/food in the bed and was left in a wet shirt and sheets. W1 stated they tried to change R1 but there were no sheets to be found and when W1 asked the Medtech where extra sheets were they stated “they don’t know, it’s not my job.” Continued on 9099-C (Pg 3)

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 29-AS-20221221090221

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: GRANVIDA SENIOR LIVING AND MEMORY CARE	FACILITY NUMBER: 425802114
	VISIT DATE: 02/08/2023

NARRATIVE

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Witness 2 (W2) stated they visited R1 on 12/19/22 at 2pm and observed R1’s food to be on the table tray next to their bed untouched. On 12/20/22 in the morning, Witness 3 (W3) observed R1’s food to be on the bedside tray untouched. LPA reviewed R1’s Change of Condition/Level of Care Assessment dated 12/2/22 which states by food R1 “requires observation/supervision during meals (7.61).” Based on the information obtained the allegation: Staff left resident soiled for an extended period of time is deemed Substantiated at this time.

On the allegation: Staff did not provide resident with clean linen. It was alleged that R1 did not have extra bedding on 12/19/2022 and laid in soiled linen for hours. Interviews with staff stated they have never had issues with linen not being clean and available. Medtech stated they on were present on the 12/19/22 visit when the hospice nurse came and changed the sheets with the nurse after they finished dressing R1’s wound. LPA Olson interviewed a Witness (W1) who stated on 12/19/22 they asked the Medtech where extra sheets were they stated “they don’t know, it’s not my job” and asked two other caretakers to please find R1’s clean linen and change the sheets. W1 stated they observed 2 caretakers sitting in the common area just talking and asked for help to get clean linen for R1. Staff stated they were working in Memory Care and on break. LPA Olson observed dirty linen to be on the floor of R1’s closet around 2:35 PM on 12/28/22. LPA also observed R1’s pillow did not have a pillowcase. Based on the information obtained the allegation: Staff did not provide resident with clean linen is deemed Substantiated at this time.

On the allegation: Staff did not provide a comfortable temperature for resident in care. It was alleged that R1’s window was left open and R1 was cold. LPA Olson reviewed hospice notes which stated on 12/19/22 around 7pm N1 observed R1 to be cold and closed R1’s window and put a blanket on them. LPA interviewed W2 who visited on 12/19/22 around 2pm and stated they observed R1 to be shaking and freezing and closed the window. Staff interviewed stated that R1 did not like their window open, but staff were hot when working in the room and would ask if they could open it when it was very stuffy/hot, and R1 would say yes. Multiple witnesses observed R1 with no blankets on, and dressed in only a nightgown that went down to the upper thigh, leaving R1’s legs uncovered. LPA interviewed family member on 12/28/22, who stated lately R1 had become less vocal and responsive and wasn’t able to communicate if they were cold or needed something. However, a week or two ago R1 would have been able to call someone and request their window be closed or opened. Staff interviewed agreed R1 had a recent change of condition and responsiveness. Based on the information obtained the allegation: Staff did not provide a comfortable temperature for resident in care is deemed Substantiated at this time. Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 29-AS-20221221090221

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: GRANVIDA SENIOR LIVING AND MEMORY CARE	FACILITY NUMBER: 425802114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/09/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities...the following personal rights: To care, supervision...that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was	1 2 3 4 5 6 7	Administrator agreed to submit a plan to ensure residents care plan are being followed. Administrator will submit plan to CCL by 2/8/23.
	8 9 10 11 12 13 14	not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when R1 was left soiled and not supervised during mealtime, which posed an immediate health, safety, and personal rights risk to residents in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 29-AS-20221221090221

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: GRANVIDA SENIOR LIVING AND MEMORY CARE	FACILITY NUMBER: 425802114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/14/2023 Section Cited CCR 87307(a)(3)(C)	1 2 3 4 5 6 7	87307(a)(3)(C) Personal Accommodations and Services. Clean linen...shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to submit a plan to ensure there is enough clean linen and to train staff on linen protocol and submit to CCL by 2/14/23.
	8 9 10 11 12 13 14	Based on observation and interviews, the licensee did not comply with the section cited above when clean linen for R1 could not be located and when R1 had no pillow case, which posed a potential health, safety, and personal rights risk to residents in care	8 9 10 11 12 13 14
Type B 02/14/2023 Section Cited CCR 87303(b)	1 2 3 4 5 6 7	87303(b) Maintenance and Operation. A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to hold a training in regards to this regulation and submit training to CCL with staff name, date and topic by 2/14/23
	8 9 10 11 12 13 14	Based on observation and interviews, the licensee did not comply with the section cited above when staff left R1’s window open when they knew R1 didn’t like it open, which posed a potential health, safety, and personal rights risk to residents in care	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 9

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
12/21/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20221221090221

FACILITY NAME:	GRANVIDA SENIOR LIVING AND MEMORY CARE		FACILITY NUMBER:	425802114
ADMINISTRATOR:	BRANDY MCCAULEY		FACILITY TYPE:	740
ADDRESS:	5464 CARPINTERIA AVE		TELEPHONE:	(805) 566-0017
CITY:	CARPINTERIA	STATE: CA	ZIP CODE:	93013
CAPACITY:	83	CENSUS: 50	DATE:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Ted Burgess, Executive Director and Ashley Nash, Business Office Director, and Lumana Seide, Resident Care Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Due to staff neglect resident fell while in care resulting an injury.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Olson and Phillips conducted an unannounced follow up complaint visit to issue final findings. LPA Olson met with Ted Burgess, Executive Director and Ashley Nash, Business Office Director, and Lumana Seide, Resident Care Director and explained the purpose of the visit. LPA Olson interviewed staff, reporting party, and responsible party on 12/29/22 and 3 Witnesses on 1/6/23.

Resident 1 (R1) was re-admitted to the facility on 12/2/22 after being at a Skilled Nursing facility for a few weeks and placed on hospice on 12/6/2022. Interviews revealed that on 12/19/2022 hospice was called because R1 had a bleeding right elbow and skin care after falling out of bed.

LPA Olson reviewed Hospice notes which stated on 12/19/22 at 7pm the Hospice Nurse 1 (N1) documented R1’s skin tear to be 4cmx2cm with no available skin for covering.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 29-AS-20221221090221

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: GRANVIDA SENIOR LIVING AND MEMORY CARE	FACILITY NUMBER: 425802114
	VISIT DATE: 02/08/2023

NARRATIVE

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The skin tear is referenced in the hospice nurse’s notes from 12/19/22 and indicated the skin tear was 4cm x 2cm. LPA Olson interviewed R1’s Hospice Nurses and a Family member who all believed R1 fell on accident and not due to neglect. Nurse noted evidence of bleeding on the bed, clothes and wall but R1 was not actively bleeding. Nurse noted multiple old skin tears on legs, some in the healing stage. Nurse notes also indicate that the patient was cold and shivering so the nurse shut the window. Nurse observed R1’s dinner tray to be upside down on the bed. R1 denied being hungry but stated they were cold. Nurse stated they covered patient in the quilt and bathrobe. Nurse also observed that R1’s shirt and sheets were soiled, which the nurse thinks was due to the overturned dinner tray. Nurse assisted the resident in changing the brief but was unable to change the sheets because the facility did not have any available sheets and couldn’t locate the additional ones. Nurse stated they asked staff to change the soiled bed sheets.

LPA Olson interviewed Medtech on 12/28/22 who stated they were at the facility on 12/19/22 when the nurse came and stated they changed the sheets while Hospice was there after R1 was bandaged up. The MedTech also stated, contrary to N1’s account, they did not have the hospice nurse assist with the brief change because they did it later with the caregiver on shift during their rounds.

LPA Olson interviewed R1’s regular hospice nurse (N2) who stated they have not observed R1 soiled and thinks it was not surprising that R1 tried to get out of bed and fell. N2 stated that R1 was very mobile and would often get up independently and must have tried but couldn’t.

On the allegation: Due to staff neglect resident fell while in care resulting an injury. It was alleged that on 12/19/2022 hospice was called for Resident 1 (R1) because R1 had a bleeding right elbow skin tear and was found on the floor by staff on 12/19/2022. Interviews revealed that R1 was very mobile and would get out of bed independently often and must have tried to get up and fallen. Interviews also revealed R1 was able to press and use their pendant for assistance but recently hadn’t been pushing it. LPA reviewed R1’s call logs from 12/10/22 through 12/30/22. LPA noticed that R1 presses their pendant multiple times throughout the day. Facility Progress Notes for R1 state on 12/18/22 at 4:51PM “Resident fell around 1:10PM. We are assuming (R1) was trying to get out of bed but was unsuccessful. Was found on back with a pillow under (R1’s) head. No bruises or cuts are noticeable.” Progress notes on 12/19/22 at 5:16AM state “Resident had a fall at 2am, (R1) seems to be confused, (Medtech 2) asked (R1) if anything hurt or if (R1) needed to be seen by the doctor. (R1) seemed in good spirits, refused pain and no visible wounds. We got (R1) up and into bed notified POA and Staff 1 (S1)" Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 29-AS-20221221090221

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: GRANVIDA SENIOR LIVING AND MEMORY CARE	FACILITY NUMBER: 425802114
	VISIT DATE: 02/08/2023

NARRATIVE

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MedTech interviewed stated the AM staff called hospice on 12/19/22 due to a skin tear sustained during the 2AM fall. The skin tear is referenced in the hospice nurse’s notes from 12/19/22 and indicated the skin tear was 4cm x 2cm. LPA Olson interviewed R1’s Hospice Nurses and a Family member who all believed R1 fell on accident and not due to neglect.

The Facility Progress Notes do not indicate any skin tear for R1 on 12/19/22. There is a noted discrepancy between the Facility Progress Notes, and the hospice notes and MedTech interview which indicate a skin tear was present on 12/19/22. In addition, the facility did not submit an Incident Report to CCL for the unwitnessed fall and injury which was addressed in a Case Management visit. Based on the information obtained the allegation: Due to staff neglect resident fell while in care resulting an injury is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed and printed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 29-AS-20221221090221

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: GRANVIDA SENIOR LIVING AND MEMORY CARE	FACILITY NUMBER: 425802114
	VISIT DATE: 02/08/2023

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	Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted, copy of report and appeal rights were emailed and printed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 9 of 9