Redwood Senior Living Bakersfield

Type of visit: Case Management - Incident

On 9/6/2023, Licensing Program Analyst (LPA) K.Kaur conducted an unannounced Case Management visit. LPA met with Licensee Representative Anthony Barbato and announced the purpose of the visit. LPA arrived at the facility to conduct case management visit for incident report CCLD received on 8/7/2023 for an incident that happened on 7/31/2023; where Resident (R1) was found at the back of the facility with an open wound on head. LPA conducted a record review on resident’s file and conducted interviews. Resident had a series of incidents in a two-week period. LPA requested additional information in regards to Emergency release follow up orders. No deficiencies cited during this Case Management visit. LPA will review documentation and additional information when received to determine if follow up is necessary. An exit interview was conducted with Licensee Representative Anthony Barbato. Report signed on-site and a copy of report will be emailed due to technical issues.the state’s words, verbatim · CDSS document, Sep 6, 2023

Allegation investigated: Staff is not assisting residents with their care needs. Staff is rude to residents and doesn't treat them with respect.

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent visit and conducted interviews and reviewed records. LPA met with Administrator Beatriz Ponce and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings. The Department investigated the allegations listed above. Administrator and staff were interviewed and did not witness any incident that would indicate staff was not assisting resident with care needs or staff was rude to resident and did not treat resident with respect. Based on interviews conducted with resident; incidents did occur but were not reported to management. Based on observation and interview of staff and residents, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore these allegations are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 19, 2023 · control 24-AS-20230414115426

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 4/20/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA conducted facility tour with Administrator. All pathways, entrances and exits were clear from obstructions. The tour started in the kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Tour continued to Residents Rooms. LPA toured several bedrooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. Fire extinguisher in hallway two was last serviced on 8/16/2022 and was fully charged. Closet full of clean linen supply observed. Cleaning supplies and chemicals are kept locked in hallway closet. Medications are kept in 2 locked Med carts in the staff office. At 2 PM LPA reviewed residents medication with MARS and centrally stored list and observed medication was not disturbed to the resident. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who is CPR certified. LPA observed in the facility front yard sufficient seating and shaded area with trees. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. Continued on next page. LPA is requesting the following documents be submitted to the Fresno CCL office by 4/27/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with appeal rights was provided. .the state’s words, verbatim · CDSS document, Apr 20, 2023

Allegation investigated: Residents are using drugs in the facility.

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent visit and conducted interviews and reviewed records. LPA met with Administrator Beatriz Ponce and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings. The Department investigated the allegations listed above. Administrator, staff and residents were interviewed and denied that drugs were used at the facility. Observation reveled some residents room did contain odor of drugs and interviews reveled resident’s family members complained of odor of drugs coming from resident rooms. Based on observation and interview of staff and residents, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore these allegations are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 30, 2022 · control 24-AS-20220920083013

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Licensee did not prevent resident from having non consensual sexual relations with other residents in care

Licensing Program Analyst (LPA) K. Kaur conducted a subsequent complaint inspection to deliver findings. LPA met with Administrator Beatriz Ponce. Findings were delivered. The Department conducted interviews and reviewed records. Based on interviews conducted and records reviewed, the facility failed to prevent R1 from engaging in non-consensual sexual relations with other residents. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. An Immediate Civil Penalty of $500 is assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. Exit Interview conducted. Appeal Rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Dec 30, 2022 · control 24-AS-20220822090153

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 31, 2022

87411(a) Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, the facility failed to prevent R1 from engaging in non-consensual sexual relations with other residents.the state’s words, verbatim · CDSS document, Dec 30, 2022

Plan of correction: Licensee agrees to ensure enough staff at the facility go ensure provision of care and supervision to meet client needs.

Allegation investigated: Animals pose as a risk to the residents while in care

On 11/10/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a complaint inspection and deliver complaint finding on the above allegation. LPA introduced self, stated the purpose of the visit and met with Administrator Beatriz Ponce and Anthony Barbato, Licensee. During the course of the investigation, the Department conducted interviews and toured the facility. Based on observation and interviews that were conducted, there was insufficient evidence to prove or disprove that stray animals were in area where resident sleeps. The preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided to the Licensee. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 10, 2022 · control 24-AS-20221102153211

Allegation investigated: Facility pressured resident's representative to place resident on hospice.

Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. I met with Beatrice Ponce, Administrator and Licensee, Anthony Barbato and informed them the purpose of the visit. During the course of this investigation LPA reviewed facility files and interviewed persons relevant to the complaint investigation. It was determined that the above allegation: Facility pressured resident's representative to place resident on hospice is UNFOUNDED. Resident R1's hospice documents were developed and signed between family/POA and medical personnel. This agency has investigated the complaint alleging (Facility pressured resident's representative to place resident on hospice). We have found that the complaint was unfounded, therefore we have dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, Sep 22, 2022 · control 24-AS-20211018084025

Type of visit: Case Management - Incident

Licensing Program Analyst LPA K.Kaur conducted a Case Management to follow up on incident that occurred on 7/15/2022. LPA was met by Licensee Anthony Barbato. LPA discussed the purpose of the visit. LPA interviewed staff regarding this incident and toured the resident’s rooms. LPA gathered additional information from Licensee. Facility followed proper procedures. No deficiencies cited An exit interview was conducted with Licensee Anthony Barbato. Report signed on-site and printed copy provided.the state’s words, verbatim · CDSS document, Aug 23, 2022

Allegation investigated: Staff is inappropriately touching resident(s) while in care.

On 8/11/22 at 9:31 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannoucned to conduct a complaint investigation. LPA was greeted by staff and granted entry. LPA met with Licensee (LIC) Anthony Barbato and explained reason for inspection. LPA reviewed records and conducted interviews. R1 no longer resides in the facility and was not interviewed. LIC admitted having physical contact with R1, such as hugs and held R1's hands, but denies it was in a sexual or initimate nature. LIC stated the physical contact was made after R1 requested it and rarey occurred. LIC stated the physical contact was not different from the way LIC physically interacted with any other resident. Therefore, the above allegation is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. A copy of this report was given to Licensee Anthony Barbato, whose signature confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 11, 2022 · control 24-AS-20220610083618

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA) K.Kaur conducted an unannounced complaint visit. LPA K. Kaur met with Staff/Medtech Barbara Martin and discussed the purpose of the visit. In regard to the allegation Unlawful eviction, LPA K. Kaur interviewed staff and reviewed documents. Resident (R1) could not afford to pay monthly rent due to loss of supplemental income from Kern Medical Center therefor other residence was sought and with the agreement of (R1’s) family; resident moved on her own accord. This agency has investigated the complaint alleging Unlawful eviction. We have found that the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis, therefore we have dismissed the complaint. Exit interview conducted. A copy of this report was discussed and provided to Staff/Medtech Barbara Martin, whose signature on this form confirms receipt of this document. Unfoundedthe state’s words, verbatim · CDSS document, Jul 21, 2022 · control 24-AS-20220422114140

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility staff hit resident with broom stick.

Licensing Program Analyst (LPA) K.Kaur conducted an unannounced complaint visit to deliver findings. LPA K. Kaur met with Staff/Medtech Barbara Martin and discussed the purpose of the visit. In regard to the allegation Facility staff hit resident with broom stick, LPA K. Kaur interviewed residents, staff and, reviewed documents. LPA was unable to determine if the accusation occurred after investigation. Although the allegations Facility staff hit resident with broom stick 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 allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report was discussed and provided to Medtech Barbara Martin, whose signature on this form confirms receipt of this document. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 21, 2022 · control 24-AS-20220504083259

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 5/11/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Licensee Representative Anthony Barbato. Visitor log-in/temperature check and disinfection station was observed. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility staff observed with facial coverings. All pathways, entrances and exits were clear from obstructions. The tour started in the kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in kitchen was last serviced on 9/24/2021 and was fully charged. Tour continued to Residents Rooms. LPA toured 4 bedrooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bar. Medications are kept in 2 locked med carts in the staff office. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. It was verified that there is at least two staff on duty who is CPR certified. No deficiencies were observed. LPA is requesting the following documents be submitted to the Fresno CCL office by 5/18/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided.the state’s words, verbatim · CDSS document, May 11, 2022

Allegation investigated: Facility accepted residents who was beyond the level of care that facility could provide

Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced to deliver findings. Upon entry, temperature check was completed by Med Tech Barbara Martin. LPA identified self and asked to speak with Licensee Representative Anthony Barbato. Licensee was contacted via phone by Mrs. Martin. LPA discussed the purpose of the visit and the elements of the allegations. Based on observations, conversations with residents, and records reviewed, the residents are ambulatory and/or can self-transfer. The residents can also communicate their needs to staff. It was determined that the above allegations: Facility accepted residents who was beyond the level of care that facility could provide is UNFOUNDED. Unfoundedthe state’s words, verbatim · CDSS document, Mar 24, 2022 · control 24-AS-20220217145400

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) K.Kaur arrived unannounced for a case management visit regarding the incident report (elopement) that was received. LPA met with Licensee Representative Anthony Barbato. LPA interviewed staff about the incident report. Client files reviewed, per client files, client cannot leave the facility unassisted. See attached LIC 809D for deficiency cited in accordance with California Code of Regulations Title 22. Immediate $500.00 civil penalty was assessed. Exit interview conducted with Administrator. Appeal rights and a copy of the reports provided via email.the state’s words, verbatim · CDSS document, Mar 24, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80078(a) · Plan of correction due date: Mar 25, 2022

80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Based on records review and interview, the licensee did not not ensure that Client 1(C1) was provided proper care and supervision, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 24, 2022

Plan of correction: Administrator agreed to provide a plan of correction to CCLD by POC due date.

Allegation investigated: Facility staff did not notify resident's POA of change of condition. Facility is not providing an opportunity for physical activity for resident in care. Facility has insects.

On 3/17/22 at 9:35 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint investigation and deliver findings. LPA entered the facility and met with staff. Licensee arrived a short time later. During the course of the investigation, LPA made observations, and conducted interviews and records review. Based on the observations, interviews, and records review, LPA found that R1 did not have a change in condition after POA was obtained; R1 admitted denial of physical activity when offered and staff advised R1 would frequently asked to be taken back to bed when R1 was up and about in wheelchair or preferred to be left in bedroom; and although LPA observed flies present in the facility and facility did not obtain pest control to address issue of flies present in the facility, Licensee advised steps were taken to mitigate the flies by ensuring door latches were operating appropriately and window screens were intact, using fly strips in facility, taking trash out more frequently, and adjusting water sprinklers in front yard so there would be a smaller water source for flies. Continue on LIC9099-C. Unsubstantiated Continued from LIC9099. Therefore, the above allegations are unsubstantiated. Exit interview conducted. Due to COVID-19 precautions, a copy of this report was emailed to email on record with Read receipt to confirm receipt of this report. LPA confirmed email on record is current, with Licensee.the state’s words, verbatim · CDSS document, Mar 17, 2022 · control 24-AS-20210917124853

Allegation investigated: Residents has head lice Insufficient food supply

Licensing Program Analyst (LPA) K. Kaur and LPM S. Moua arrived at the facility unannounced to conduct an initial 10-day complaint inspection. Upon entry, temperature check was completed by Med Tech Barbara Martin. LPA and LPM discussed the purpose of the visit and the elements of the allegations. LPM & LPA interviewed Staff, residents. Reviewed records and toured the facility. During the tour LPA & LPM observed an adequate supply of food. Frozen meats and non-perishable and fresh fruits and vegetables were observed. Lunch was also being served LPA & LPM observed fish, salad, rice, bread, and cake on the menu. Based on interviews conducted with staff the facility residents did have head lice however proper protocols were followed to eradicate the issue. Over the counter treatment was first administered and then followed by clinical treatment. The facility has no current cases of head lice at the moment. Therefor the above allegations are UNFOUNDED. Unfoundedthe state’s words, verbatim · CDSS document, Feb 22, 2022 · control 24-AS-20220217151731

Allegation investigated: Staff is not providing adequate care to resident. Staff is not providing hygiene care to resident. Staff is not providing dental care to resident.

Licensing Program Analyst (LPA) K. Kaur and LPM S. Moua arrived at the facility unannounced to conduct follow up inspection. Upon entry, temperature check was completed by Med Tech Barbara Martin. LPA and LPM discussed the purpose of the visit and the elements of the allegations. LPM & LPA interviewed Staff, residents. Reviewed records and toured the facility. Based on interviews conducted the resident as on Hospice and receiving hygiene care two to three times a week. Facility staff deny that hygiene and dental care were not provided. LPA did not discover any specific incidents related to the allegations. Based on the interviews conducted and records review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.Exit interview was conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 22, 2022 · control 24-AS-20220131155034

Type of visit: Case Management - Other

Licensing Program Manager (LPM) S. Moua and Licensing Program Analyst (LPA) K. Kaur conducted a joint inspection to the facility on this date. The purpose of the inspection was to conduct an Informal Meeting with the Licensee regarding the number of complaints that the facility has received since licensed on 5/18/2021. LPM and LPA met with Licensee Representative, one of the managing partners of the LLC - Anthony Barbato. LPM discussed that since licensed, the facility has received 11 complaints. Discussion took place regarding the following areas: 1. Proper assessment of potential residents 2. Age acceptance and retention and compatibility of residents 3. Hospice Care Waiver and Hospice residents with Total Care 4. Staffing 5. Facility's protocols/procedures on un-witness falls LPM discussed what may be the ramifications if the facility is non-compliant. LPM discussed that the Department and the facility's LPA is available to assist with questions and concerns, that ultimately, the goal is the health and safety of the residents. Exit Interview was conducted. No deficiencies were issued.the state’s words, verbatim · CDSS document, Feb 22, 2022

Allegation investigated: There was no heat at the facility. RP was pressured to sign paperwork.

Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced to conduct an initial 10-day complaint inspection. Upon entry, temperature check was completed by Med Tech Barbara Martin. LPA identified herself and asked to speak with Licensee Anthony Barbato. Licensee was contacted via phone by Mrs. Martin. LPA discussed the purpose of the visit and the elements of the allegations. LPA interviewed Staff, residents. Reviewed records and toured the facility. Based on observation; heat was operational at the facility. Records review and staff interview determined RP came to the facility and signed the admission paperwork in her own accordance. It was determined that the above allegations: There was no heat at the facility and RP was pressured to sign paperwork are UNFOUNDED. Unfoundedthe state’s words, verbatim · CDSS document, Feb 10, 2022 · control 24-AS-20220131155034

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

LPA K. Kaur conducted an unannounced complaint inspection on this day to open the complaint investigation. LPA met with Administrator and stated the purpose of the visit. During the course of the investigation, LPA reviewed records for R1. The Needs and Services Plan for R1 was incomplete. Deficiency is being cited based on records review in accordance with the CCR Title 22 on the attached 809-D. An exit interview was conducted with Licensee Representative Anthony Barbato and a copy of this report with appeal rights will be provided to the licensee via email. A read receipt confirms the Licensee received these documents.the state’s words, verbatim · CDSS document, Feb 10, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87459(a) · Plan of correction due date: Feb 15, 2022

87459 Functional Capabilities (a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. This requirement is not met as evidenced by: During the course of the investigation, LPA reviewed records for R1. The Needs and Services Plan for R1 was incomplete.the state’s words, verbatim · CDSS document, Feb 10, 2022

Plan of correction: Administrator agreed to complete Needs and Services plan for R1 by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts LPAs K.Kaur and S. Doucette conducted a Case Management to follow up on incidents that occurred on 11/21/21 . LPA was met by Staff Barbara Martin and discussed the purpose of the visit. LPAs and Licensee representative Anthony Barbato began the tour at the front entrance/office of the facility. Upon entrance of the facility LPAs smelt a strong odor of urine. Regarding incident facility contacted hospice nurse to notify of R1's medical condition. Facility did not submit incident report within the 7 days. Deficiencies are being cited based on LPA's observation, interviews conducted, and record review in accordance with the CCR Title 22. See LIC 809D. An exit interview was conducted with Licensee Representative Anthony Barbato and a copy of this report with Plans of Corrections and appeal rights was provided.the state’s words, verbatim · CDSS document, Dec 3, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 17, 2021

87303 Maintenance and Operation, (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met evident by: Based on observation, the Licensee did not ensure the facility was free of urine odor which poses a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Dec 3, 2021

Plan of correction: Plan of correction POC Licensee agrees to ensure facility is free of urine odor by POC due date 12/17/2021. LPA will return to facility to ensure POC was completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a) · Plan of correction due date: Dec 3, 2021

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met evident by: Based on observation of documentation licensee did not submit report within 7 days which poses a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Dec 3, 2021

Plan of correction: Plan of correction POC Licensee agrees to submit in writing understanding of this regulation by POC due date.

Allegation investigated: Facility is dirty. Unlawful eviction. Resident was sexually assaulted by another resident. Staff not maintaining residents hygiene. Staff not providing assistance to resident in a timely manner. Resident sustained bladder infection while in care. Staff did not provide 60-day notice prior to rent increase.

Licensing Program Analysts (LPA)s Shawna Doucette and Kamaldeep Kaur contacted the facility to commence a complaint investigation. LPAs took COVID-19 pre-cautionary measures. LPA's were met at the entrance by Licensee Representative Anthony Barbato. LPAs identified themselves and discussed the purpose of the visit and the elements of the allegations to deliver findings with Licensee Anthony Barbato. LPA's interviewed Staff and residents, reviewed records and toured the facility. Based on observation, facility was dirty however this allegation was addressed on another complaint 24-AS-20210728164232 on 11/4/21. Licensee completed Plan of Correction. Based on records review and interviews, facility did issue an unlawful eviction, however the allegation was addressed on a previous complaint 24-AS-20210831165239. Licensee completed Plan of Correction. Based on interviews of Staff and Residents and records review the allegation of resident sexually assaulted by another resident was unable to be determined whether it happened or not. After intervewing staff, it was found that this incident occured over a year ago prior to the current Licensee taking over the facility. Unsubstantiated Based on resident interviews and staff interviews the allegation Staff not maintaining residents hygiene it was stated facility does not keep a log of residents ADL's but has a written policy that staff will check every resident every 30 minutes or as needed. After interviewing residents, it was found their hygiene needs were being met. It is unknown if there was an incident where R1's needs were not met. Based on interviews of staff and residents, it is found staff are providing care in a timely manner. It is unknown if there was an incident where staff did not provide R1 care within a timely manner. Based on records review and interviews resident did sustain a bladder infection while in care, however facility followed proper procedures by obtaining medical care for R1. Based on records review and interviews, facility did provide 60-day notice prior to rent increase. Although the allegations listed above 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 allegations are UNSUBSTANTIATED. LPA took R1's records to make copies and will return the records to the facility on 12/3/21. An exit interview was conducted with Licensee Representative Anthony Barbato and a copy of this report was provided via email.the state’s words, verbatim · CDSS document, Dec 1, 2021 · control 24-AS-20210920122813

Allegation investigated: Residents sustained injuries while in care. Facility has pest infestation. Facility is not clean.

On 11/29/2021, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to deliver complaint findings. LPA met with Licensee Anthony Barbato and announced the purpose of the visit. During the course of the investigation, the Department reviewed records, conducted interviews, and inspected the facility. Based off of records reviewed and interviews, there were no injuries sustained by residents which were the result of inadequate care or supervision. During facility inspection, the facility was free from pests and there were no signs of infestation. Staff and residents stated that there were no pests other than flies. Staff had taken measures to control the number of flies in the facility. The facility appeared to be clean. Bathrooms were clean and odor free. The above allegations are Unsubstantiated. No deficiencies were cited during the visit. A copy of the report was provided via email and exit interview conducted with the Licensee. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 29, 2021 · control 24-AS-20210907140249

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility is filthy

Licensing Program Analyst (LPA) Darius Williamd conducted a follow up complaint visit to deliver findings. LPA Williams met with Licensee, Anthony Barbato and discussed the purpose of the visit. LPA Williams has condcuted observations of the facility and interviews. On 11/4/2021, LPA Williams observed cluster of brown spots, which looked to be grease, totaling an approximate area of 4 feet wide by two feet high, on the kitchen backsplash wall behind the sink and on the window sill. Additionally, the drywall behind the sink is damaged, which looks to be from water. Based on the LPA's observation, the preponderence of evidence standard has been met. Therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation Title 22, Division 6, Chapter 8, Article 5, Section 87303(a), is being cited on the attached LIC 9099D. Plan of correction was reviewed with Licensee. Exit interview conducted and a copy of this report and appeal rights were provided. Substantiated In regards to the allegation, staff did not administer resident's medication, LPA Williams reviewed R1's Medication Administration Record Sheet for July and August 2021. All medications were initialed, which according to the Licensee means the medications were administered to R1. In regards to the allegation, residents wheel chair is in disrepair, LPA Williams observed a wheel chair that the Licensee identified as R1's. The wheel chair rolled and the breaking system was functional. In regards to the allegation, residents bed is not comfortable, LPA Williams observed a bed in room 16. LPA Williams observed the mattress to be clean, good repair, and had structure. In regards to the allegation, patio furniture is in disrepair, LPA Williams observed chairs and tables in the front and backyards. All furniture supported the weight of an individual and were not missing any pieces. In regards to the allegation, facility has exposed wires, LPA Williams toured the facility common areas and did not observe any exposed wires in the floor, walls, or ceilings, that would pose a health and safety risk. Although the above allegations 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 allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 4, 2021 · control 24-AS-20210728164232

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 11, 2021

87303 Maintenance and Operation, (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met evident by: Based on observation, the Licensee did not ensure the kitchen backsplash was clean and sanitary, which poses a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Nov 4, 2021

Plan of correction: Licensee has agreed to clean and paint the backsplash. Additionally, the Licensee has agreed to repair the drywall damage by Plan of Correction due date of 11/11/2021. Licensee has agreed to submit photo of corrections the Department by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Darius Williams conducted a facility visit in response to information on Resident 1’s (R1) physician report. LPA Williams met with Licensee Anthony Barbato and discussed the purpose of the visit. LPA Williams conducted record reviews. R1 was admitted to the facility on 4/16/2021. According to R1’s physician report, dated 4/13/2021, R1 required total assistance with all activities of daily living, which is a prohibited health condition. R1’s hospice services was initiated until 5/21/2021. Based on record reviews, the Licensee admitted and retained R1 with a prohibited health condition (residents who depends on others to perform all activities of daily living), between 4/16/2021 and 5/21/2021. Title 22, Division 6, Chapter 8, Article 11, Section 87615(a)(5), is being cited on the attached LIC 9099D. LPA Williams discussed plan of correction with Licensee. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 4, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87615(a)(5) · Plan of correction due date: Nov 8, 2021

87615 Prohibited Health Conditions. (a) Persons who require health services...those specified below shall not be admitted or retained..., (5) Residents who depend on others to perform all activities of daily living... This requirement was not met evident by: Based on record reviews, the Licensee did not ensure an exception was obtained prior to accepting Resident 1 who had a prohibited health condition, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 4, 2021

Plan of correction: Resident 1 no longer resides at the facility. Licensee has agreed to review Sections 87611 through 87617 regarding health restrictions. Licensee will submit document acknowleding reading and understanding of the regulations to the Department by Plan Of Correction due date of 11/8/2021.

Allegation investigated: Resident was sexually assaulted while in care Staff did not complete an individual written admission agreement with the resident or the resident's responsible person.

Licensing Program Analyst (LPA) Darius Williamd conducted an unannounced Complaint visit to deliver findings. LPA Williams met with Licensee Anthony Barbato and discussed the purpose of the visit. The Department has investigated the above allegations. In regards to the allegation, resident was sexually assaulted while in care, based on the Department's conducted interviews and records reviews, the preponderance of evidence standard has been met, therefore the allegation has been SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Article 8, Section 87468.1(a)(3) is being cited on the attached LIC 9099D. *Continued on LIC 9099C* Substantiated In regards to the allegation, staff did not complete an individual written admission agreement with the resident or the resident’s responsible party, LPA Williams reviewed R1’s records and the current admission agreement on file was from a prior facility, Rose Garden, License #157202405. There was not an Admission Agreement for Rosewood Senior Living Bakersfield on file. Based on record review the preponderance of evidence standard has been met, therefore the allegation has been SUBSTANTIATED. Title 22 California Code of Regulation, Division 6, Chapter 8, Article 9, Section 87507(c) is being cited on the attached LIC 9099D. LPA discussed plan of correction with Licensee. An exit interview was conducted and a copy of this report and appeals rights was provided. In regards to the allegation, residents were left in soiled clothing, according to R1’s physicians report, R1 is able to care for their own toileting needs. According to Resident 2 and Resident 3, staff conduct approximately 30 minute checks and will assist with toileting as needed. LPA Williams did not observe any residents in soiled clothing. Although the above allegations 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 allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided. This agency has investigated the complaint alleging, facility did not have telephone service. We have found that the complaint was UNFOUNDED, meaning the allegation could not have happened or is without a reasonable basis, therefore we have dismissed the complaint. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 21, 2021 · control 24-AS-20210701091250

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Oct 22, 2021

87468.1 Personal Rights of Residents in All Facilities; (a) Residents...shall have all of the following personal rights:; (3) To be free from punishment, humiliation, intimidation, abuse, or other actions... This requirement was not met evident by: Based on interviews and record reviews, the Licensee did not ensure Resident 1 was free from being sexually assualted by another resident, which poses an immediate health and safety risk to person's in care.the state’s words, verbatim · CDSS document, Oct 21, 2021

Plan of correction: POC was corrected on the spot. Resident 1 and the suspect no longer reside at the facility. Additionally, The Licensee is conducting interviews on 10/21/2021, and 10/22/2021, to hire additional staff to increase supervision. Licensee has agreed to submit documentation to CCLD regarding the number of staffed hired and schedule on 10/25/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Oct 29, 2021

87507 Admission Agreements; (c) Admission agreements shall be signed and dated, ...by the resident or the resident’s representative,...no later than seven days following admission. This requirement was not met evident by: Based on interview and record reviews, the Licensee did not ensure an admission agreement was signed by Resident 1 or authorized representative, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2021

Plan of correction: Resident 1 moved to another facility June 2021. Licensee has agreed to audit files for current Admission Agreements, and the reasoning if an agreement is not current, by POC due date of 10/29/2021.

Allegation investigated: Facility is charging resident for services not provided. Staff are not administering medication(s) to resident according to physician's orders.

Licensing Program Analyst (LPA) Lady Cabrera conducted the complaint investigation visit to the facility. LPA met with Licensee to deliver the findings of the complaint. During the course of this investigation, LPA interviewed facility staff, resident (R1) and PACE Program Staff. It was determined that the above allegations: Facility is charging resident for services not provided and Staff are not administering medication(s) to resident according to physician's orders are UNFOUNDED. Based on interviews and records review, the facility continues to provide R1 with services. R1 was not admitted to PACE Bakersfield and was not attending the program every day. Per interviews and records review, the facility is providing the R1’s medication and pain medications. Unfounded This agency has investigated the complaint alleging (Facility is charging resident for services not provided. Staff are not administering medication(s) to resident according to physician's orders). We have found that the complaint was unfounded, therefore we have dismissed the complaint. Exit interview was conducted. Licensee was provided with a copy of this report.the state’s words, verbatim · CDSS document, Oct 20, 2021 · control 24-AS-20210930171438

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unnanounced to conduct the 10 day complaint visit. LPA explained the purpose of the visit and elements of the allogation with Licensee, Anthony Barbato. The Department has investigated the complaint alleging: Unlawful Eviction. Based on interview with the Licensee and record review of the 30 Day Notice of Eviction issued to R1 on 8/31/2021 it was determined that the Notice was not complete and therefore, unlawful. The preponderance of evidence standard has been met, therefore the allegation has been found to be SUBSTANTIATED. The following deficiencies were observed and noted on the attached LIC 809D. A copy of this report along with Appeal Rights were provided to Licensee Anthony Barbato. An exit interview was conducted with Licensee Substantiatedthe state’s words, verbatim · CDSS document, Sep 10, 2021 · control 24-AS-20210831165239

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(1) · Plan of correction due date: Sep 17, 2021

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph 5. This requirement was not evidenced by: Licensee issued a 30 Day Notice of Eviction to R1 on 8/31/21 that did not include the reason for eviction, Nonpayment of the rate for basic services within ten days of the due date. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2021

Plan of correction: Licensee has agreed to revise the 30 Day Notice of Eviction to include the reason for eviction as specified along with cooresponding documentation. Licensee will submit a written statement to include the revisions to the notice to include 1. Reason for Eviction and 2. That a copy of the Notice will be provided to CCLD within 5 days if issue date. Licensee will submit the revised 30 Day Notice of Eviction and written statement to CCLD via email by 9/17/21.