Every finding on record at New Life Venture Corp

The following reflects the findings of the California Department of Public Health during a recertification survey conducted on January 20, 2026, through January 23, 2026. Census: 72 Unduplicated Admissions: 165 Home Visits with Record Review: 3 Record reviews without home visits: 4 Sample size: 7 All Emergency Preparedness conditions of participation were met No deficiency issued.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted on January 20, 2026, through January 23, 2026. Census: 72 Unduplicated Admissions: 165 Home Visits with Record Review: 3 Record reviews without home visits: 4 Sample size: 7 All conditions of participation were met There was 1 deficiency issued

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure medication reconciliation and administration were conducted for one of seven sampled patients (Patient 1) when a Licensed Vocational Nurse (LVN 1) administered an expired insulin (a synthetic hormone that turns food into energy and manages the blood sugar level). This failure had the potential to cause ineffective drug therapy to Patient 1, significant side effects, and noncompliance with the treatment. During a review of Patient 1’s face sheet (a document that gives a summary of patient’s information), it indicated a start of care date of November 4, 2025, with a recertification period of January 3, 2026, to March 3, 2026. Patient 1 had diagnoses that included Type 2 diabetes mellitus (a chronic condition where the body cannot effectively use insulin). During a home visit on January 21, 2026, at 10:00 AM, with LVN 1, an observation of Patient 1’s medications available at home were compared with Patient 1’s most current Medication Profile (MP). During a concurrent observation and interview on January 21, 2026, at 10:15 AM, with LVN 1, LVN 1checked Patient 1’s rapid acting insulin (starts working within 15 minutes, peaks in 1-2 hours, and lasts 2-4 hours) Insulin pen (a disposable, pre-filled, insulin pen used to mange blood sugar levels in patients with type 2 diabetes). The label on the pen indicated, “(brand name) KwikPen…EXP (expiration): 2025-DEC-19 (December 19, 2025-medication had been expired for 33 days)”. LVN 1 then checked Patient 1’s MP which indicated “(name of brand) (short acting insulin) per sliding scale 3X (times) day breakfast/lunch/dinner with meals BS (blood sugar) less than 99mg/dl (unit for milligrams per deciliter): HOLD/ BS (blood sugar) level of 100-200mg/dl administer 1 unit subcutaneously / BS level of 201-300mg/dl administer 3 units subcutaneously / BS level of more than 300mg/dl call M.D (Medical Doctor).” LVN 1 proceeded to administer 1 unit of insulin on Patient 1’s abdomen, without checking the expiration date. During an interview on January 21, 2026, at 10:30 AM, with LVN 1. LVN 1 stated, “I should have checked the insulin pen expiration date prior to administering insulin to patient (patient 1), I did not check it”. The LVN 1verified and confirmed insulin pen had been expired for 33 days, the LVN 1 further stated that administering expired insulin will put Patient 1 at risk of ineffective blood glucose control. During a follow up interview and record review on January 21, 2026, at 3:00 PM with Designated Administrator (D-ADMIN), the agency’s policy and procedure (P&P) titled, “Identification of Medications for Administration”, dated April 2018, was reviewed. The P&P indicated …"PROCEDURE 2. The nurse will review the written physician (or other authorized licensed independent practitioner) order prior to medication administration. 4. Medications should be properly labeled with that patient’s name, an additional patient identifier, name of drug, dosage, diluent date of preparation, expiration date, initial of preparer, and any special instructions, as applicable”. The D-ADMIN stated that LVN 1 should have checked the expiration date of the Insulin pen prior to administering insulin to Patient 1. D-ADMIN further verified and confirmed that insulin pen has been expired for 33 days, and the patient may not receive the intended dose, even if the correct units are administered which can lead to poor blood glucose control and LVN 1 did not follow the P&P by administering expired insulin to Patient 1. During a concurrent interview and record review on January 22, 2026, at 1:30 PM with Quality Coordinator (QC), the agency P&P titled, “Identification of Medications for Administration”, dated April 2018, was reviewed. The P&P indicated …"PROCEDURE 2. The nurse will review the written physician (or other authorized licensed independent practitioner) order prior to medication administration. 4. Medications should be properly labeled with that patient’s name, an additional patient identifier, name of drug, dosage, diluent date of preparation, expiration date, initial of preparer, and any special instructions, as applicable”. The QC stated LVN 1 did not check the expiration date on the insulin pen (expired 33 days) and administered it to Patient 1. The QC further stated that administering expired medication is a medication administration error, it reflects failure to follow the “five rights” of medication administration and standard nursing practice.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted January 23, 2023 through January 25, 2023. Representing the Department: Surveyors: 35183, 44841, 45388, 46119 Census: 92 Unduplicated Admissions: 176 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All Conditions of Participations were met.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the 2021 and 2022 years reviewed, in a universe of 92 patients. This failure had the potential to cause the EPP to indicate ineffective procedures and outdated information. The agency’s “Emergency Management Plan,” binder, undated, contained a form titled, “Annual Review of Emergency Program for Home Health Agencies,” undated. A review of the form indicated the following: “Purpose: The home health agency must review its emergency preparedness program at least annually. Instructions: Complete this review at least annually. Emergency Program Component: Policies & Procedures Emergency Preparedness Comprehensive Assessment Risk Assessment Follow-Ups Medical Documents Volunteers Review Date: (this area was blank) Comments (document changes required): (this area was blank) Emergency Program Component: Communication Plan Review Date: (this area was blank) Comments (document changes required): (this area was blank) Emergency Program Component: Contact Information Staff /Contract services Physicians Volunteers Emergency preparedness officials / other assistance Review Date: (this area was blank) Comments (document changes required): (this area was blank) Emergency Program Component: Training and Testing Review Date: (this area was blank) Comments (document changes required): (this area was blank) Emergency Program Component: Program updates (Integrated Healthcare Systems Only) Review Date: (this area was blank) Comments (document changes required): (this area was blank) …” A review of the agency’s “Governing Body Meeting Minutes,” for years 2021 and 2022, was conducted. There was no documented evidence to show the EPP had been reviewed and updated. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on January 25, 2023, at 9:15 AM, the Admin/DPCS stated he was responsible for the Emergency Preparedness Program. The Admin/DPCS stated he was a member of the Governing Body. The Admin/DPCS stated he had not filled out the “Annual Review of Emergency Program for Home Health Agencies,” form. The Admin/DPCS stated he could not show documented evidence that the Emergency Preparedness Program had been reviewed and updated in the past two years. A review of the agency’s policy and procedure titled, “Emergency Management Plan,” dated April 2018, indicated, “POLICY: The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. …PROCEDURES: … Communication Plan: The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated annually. … Training and Testing: The training and testing program is reviewed and updated at least annually. …”

The following reflects the findings of the California Department of Public Health during a recertification survey conducted January 23, 2023 through January 25, 2023. Representing the Department: Surveyors: 35183, 44841, 45388, 46119 Census: 92 Unduplicated Admissions: 176 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All Conditions of Participations were met.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patients' initial assessment was completed within 48 hours of the patients’ referral order for one of seven sampled patients (Patient 7). This failure had the potential to cause a delay in the determination of Patient 7’s immediate care and support needs. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of October 17, 2022, with a certification period of October 17, 2022, to December 15, 2022. Patient 7 had diagnoses that included Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 7’s referral order dated October 13, 2022, indicated to evaluate patient for admission to home health services. A review of Patient 7’s initial assessment dated October 17, 2022, indicated the initial assessment had been conducted on October 17, 2022. (The initial assessment had been completed four days after the physician’s referral order.) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on January 23, 2023, at 3:48 PM, the Admin/DPCS stated Patient 7’s initial assessment had not been conducted within 48 hours of the physician’s referral order and should have been. The Admin/DPCS stated the agency’s policy and procedure titled, “Initial and Comprehensive Assessment,” dated April 2018, had not been followed. A review of the agency’s policy and procedure titled, “Initial and Comprehensive Assessment,” dated April 2018, indicated, “PURPOSE: To provide guidelines for the initial assessment of patients admitted to service and for completing the plan of care. POLICY: An initial patient assessment will be performed and documented in the patient's clinical record by a registered nurse, physical therapist, or speech therapist. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient's return home, on the start of care date ordered by the physician (or other authorized licensed independent practitioner), or at the patient/family request with the approval of the physician (or another authorized licensed independent practitioner). …”

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patients' plan of care was followed for one of seven sampled patients (Patient 7) when a Certified Home Health Aide did not make visits as ordered in Patient 7’s plan of care. This failure had the potential to cause Patient 7 not to receive needed assistance with activities of daily living. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of October 17, 2022, with a certification period of October 17, 2022, to December 15, 2022. Patient 7 had diagnoses that included Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 7’s CMS 485 (a form provided by the Centers for Medicare and Medicaid Services-CMS-which documents a patient’s plan of care and physician’s orders) dated October 17, 2022, to December 15, 2022, indicated, the CHHA was to make visits to Patient 7, one time a week for one weeks and two times a week for eight weeks. A review of Patient 7’s physician’s order dated November 16, 2022, indicated to cancel the CHHA visits. A review of Patient 7’s CHHA visits from October 17, 2022, to November 15, 2022, was conducted. There was no documented evidence to show CHHA visits had been conducted during this time frame. A review of Patient 7’s Care Coordination notes from October 17, 2022, to November 15, 2022, was conducted. There was no documented evidence to show notification to the physician or reasons why the visits had not been conducted. During an interview with a Care Coordinator (CC 1) and the Administrator/Director of Patient Care Services (Admin/DPCS) on January 23, 2023, at 3:30 PM, CC 1 stated she had endorsed CHHA 2 to schedule visits with Patient 7. CC 1 stated she had followed up with CHHA 2 about the scheduling and CHHA 2 told her the family scheduled the visit but would then call back and reschedule repeatedly. CC 1 stated since the family kept refusing to follow through with the CHHA visits a physician’s order was put in on November 16, 2022, to cancel CHHA visits. CC 1 stated she was supposed to do a communication note on the missed visits and forward the communication note to the physician for notification but had not. The Admin/DPCS stated CC 1 should have followed the agency’s policy and procedure titled, “Missed Visits,” dated April 2018 and had not. A review of the agency’s policy and procedure titled, “Missed Visits,” dated April 2018, indicated, “PURPOSE: To ensure that missed visits are documented and does not affect the quality of patient care. POLICY: Missed visits will be communicated to the clinical supervisor and the patient's physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. PROCEDURE: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the physician and clinical supervisor of the missed visit and reason for missed visit B. Document in the patient's clinical record the following information: 1. Patient name, 2. Date and type of visit that was missed, 3. Reason for the missed visit, 4. Description of any unmet needs and how the patient's needs were met, 5. Physician notification including date, time, physician name, method of notification and the staff reporting the information, 6. Other person(s) that were notified of the missed visit, 7. Any other follow-up needed, 8. Signature of staff member reporting the information. 3. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. 4. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. 5. If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and physician.”

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a Registered Nurse (RN) provided supervision of care provided by a Licensed Vocational Nurse (LVN) for one of seven sampled patients (Patient 5). This failure had the potential to cause substandard LVN care practices to go unrecognized. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 16, 2022, with a certification period of November 16, 2022 to January 14, 2023. Patient 5 had diagnoses that included Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 5’s CMS 485 (a form provided by the Centers for Medicare and Medicaid Services-CMS-which documents a patient’s plan of care and physician’s orders) dated November 16, 2022 to January 14, 2023, indicated, the skilled nurse (SN- a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) was to make visits to Patient 5, one time a week for nine weeks. A review of Patient 5’s LVN visit notes indicated visits were made on November 22, and 28, 2022, December 5, 12, 19, and 26, 2022, and January 2, 2023. A review of Patient 5’s RN visit notes from November 16, 2022, to January 14, 2023, was conducted. There was no documented evidence to show an RN supervisory visit for the LVN had been conducted. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on January 24, 2023, at 2:37 PM, the Admin/DPCS stated an RN was supposed to conduct a supervisory visit for the LVN every 30 days. The Admin/DPCS stated the LVN that visited Patient 5 had not received a supervisory visit within the 30-day time period and should have. A review of the agency’s policy and procedure titled, “Responsibilities/Supervision of Clinical Services,” dated April 2018, indicated, “PURPOSE: To define the process for supervision of clinical services provided by [name of agency]. …PROCEDURE: …B. Licensed practical/vocational nurses will be supervised by a registered nurse making a visit to the home with or without the LPN/LVN every thirty (30) days unless state regulation requires more frequently. …”