565850243-11-20-2025-29-AS-ZCHN-DNM353-20251120165606

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850243
Report Date: 11/20/2025
Date Signed: 11/20/2025 04:57:12 PM

Document Has Been Signed on 11/20/2025 04:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LAUREL HEIGHTS		FACILITY NUMBER:	565850243
ADMINISTRATOR/ DIRECTOR:	JOHNNY ORTIZ		FACILITY TYPE:	740
ADDRESS:	13960 PEACH HILL DRIVE		TELEPHONE:	(805) 292-0700
CITY:	MOORPARK	STATE: CA	ZIP CODE:	93021
CAPACITY: 112		CENSUS: 72	DATE:	11/20/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	04:49 PM
MET WITH:	Joey Alvarado, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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	Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Executive Director Joey Alvarado and explained the reason for the visit. On 02/11/2025, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a report of the death of Resident #1 (R1). The report noted on 02/01/2025, R1 sustained a fall in their room. R1 was transferred to Los Robles Regional Medical Center Emergency Room (ER) and returned to the facility on 02/02/2025. On 02/04/2025, R1 reported not feeling well and was transported to the hospital and re-admitted. On 02/06/2025, it was reported that R1 passed away due to a brain bleed. On 02/11/2025, the RO referred this case to the Community Care Licensing (CCL) Investigations Branch (IB) Investigations Branch to investigate the allegation of Questionable Death. The case was assigned to Investigator Johnny Canto to conduct the investigation. On 02/11/2025, from 10:15am to 12:45pm, Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management – Incident visit. Upon arrival LPA Chochian met with the Administrator/Executive Director Johnny Ortiz and explained the reason for the visit. The reason for the visit was to follow up on a self-reported incident report. The report pertained to an incident involving Resident #1 (R1) who sustained an unwitnessed fall on 02/01/2025 at the facility and subsequently passed away on 02/06/2025 at Los Robles Regional Medical Center. (Continue to LIC809c)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

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

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAUREL HEIGHTS	FACILITY NUMBER: 565850243
	VISIT DATE: 11/20/2025

NARRATIVE

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Due to the circumstances surrounding the death of R1, the LPA informed the Administrator/Executive Director that the incident was referred to the Community Care Licensing (CCL) Investigations Branch (IB) for further review.

On 03/03/2025, from approximately 11:45am to 3:55pm, Investigator Canto conducted interviews with the Administrator/Executive Director, facility staff, and Resident #2 (R2). In addition, Investigator Canto reviewed Los Robles Regional Medical Center records, Ventura County Clerk Records Office Death Certificate, and facility file documents related to the investigation.

A review of R1’s Physician Report, dated 09/23/2024, listed R1 as ambulatory; able to leave the facility unassisted; able to independently transfer to and from bed; able to store and administer their own medication; able to administer their own oxygen; able to perform their own glucose testing; and able to care for all of their activities of daily living (ADLs).

R1’s Health and Services Evaluation, dated 09/18/2024, indicated R1 was non-ambulatory, listed the mobility/ambulation level of assistance as independent (“resident does not require assistance with mobility/ambulation”); has occasional left knee discomfort when ambulating, relieved by lidocaine patch; does not require supplemental oxygen, has an oxygen concentrator but does not use. The MFS (Morse Fall Scale) evaluation determined R1 was a high fall risk due to a history of falling, uses an ambulatory aid (walker/cane), and has a weak gait. The evaluation indicated to “implement high risk fall risk reduction interventions”. R1 did not require assistance with ADLs, except for help with putting on socks and shoes, and bathing may require reminding or standby assistance.

R1’s Service Plan, dated 10/06/2024, lists diagnosis as diabetes, type II; gastroesophageal reflux disease (GERD); heart disease; atrial fibrillation; congestive artery disease (CAD); congestive heart failure (CHF); spinal stenosis; coronary artery disease; and chronic kidney disease stage 3. The Service Plan includes the same information found in the Health and Services Evaluation.
(Continue to LIC 809c)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAUREL HEIGHTS	FACILITY NUMBER: 565850243
	VISIT DATE: 11/20/2025

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Additionally, the plan documents the potential for high fall risk and indicates “R1 is a high fall risk, encourage to always ambulate with cane or walker, keep room free of clutter, encourage to wear proper shoes”. Medical records reviewed document that on 02/04/2024, R1 was admitted to the Los Robles Regional Medical Center with a chief complaint of respiratory failure. On 02/05/2025, R1’s diagnosis included increasing lethargic and shortness of breath. Further tests and x-rays were completed which indicated “the patient most likely has acute respiratory distress ad hypoxia secondary to COPD exacerbation secondary to pneumonia versus CHF exacerbation as well as AKI and hypoglycemia”. In addition, the records indicated a subdural hemorrhage. R1 was placed on comfort care and passed away on 02/06/2025.

The Department’s investigation revealed on 10/05/2024, R1 was admitted to the Laurel Heights facility. R1’s physician report noted that R1 was independent and not a fall risk. However, the Facility Health and Services Evaluation and Service Plan both noted R1 was a high fall risk, was non-ambulatory, used a cane and/or walker, and was independent with mobility and ambulation. Staff interviews revealed R1 had no history of falls while residing at the facility, was independent, and only needed standby assistance for showering. On 02/01/2025, R1 sustained an unwitnessed fall in R1’s apartment. R1 was discovered on the floor by facility staff when doing rounds. R1 verbalized that they had fallen in their bedroom. Facility staff noted several lacerations to the back of R1’s head. 911 was called, paramedics arrived, and R1 was transported to the Los Robles Regional Medical Center via ambulance. R1 was medically treated and then discharged back to the facility on 02/03/2025. On 02/04/2025, the facility staff noted that R1 appeared lethargic and unable to answer simple questions. The facility staff called 911 again, paramedics arrived, and transported R1 to the hospital. On 02/06/2025, the facility received notification that R1 expired while at Los Robles Regional Medical Center due to a brain bleed. The cause of death was noted as blunt force head injury with subdural hematoma. The Department’s investigation found insufficient evidence to support the facility neglected the care and or safety of R1. Therefore, no citations are being issued at this time.

Exit interview, copy of report given.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC809 (FAS) - (06/04)

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