Broadview Residential Care Center

Allegation investigated: Facility staff did not arrange a reappraisal meeting. Facility staff restrained a resident in care. Facility staff handle residents in a rough manner. Facility staff do not dispense medications according to physician's orders.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Administrator Betsy Davis and explained the purpose of the visit. It was reported that staff did not arrange for a reappraisal meeting. To investigate this allegation on 9/14/2023 between 12:00pm and 12:30pm, staff interviews were initiated. Interviews revealed that Resident #1 (R1) had a sudden and steep decline in their health. According to staff, R1 appeared weak, had increase impulsiveness, inaudible speech, decrease attention to safety, a fall risk, an over active bladder, and an inability to self-feed. R1's family was immediately made of aware of R1's change in medical condition. Between 1:00pm and 2:00pm. LPA reviewed facility records. Records revealed that on 9/05/2023, R1 was reappraised. On 9/04/2023 R1's needs and services plan was updated and on 9/07/2023 R1's physician report was updated as well. Per physicain report it was recommended by the doctor that R1 be sent to a skilled nursing facility due to requiring a higher level of care as their condition had worsened. Unsubstantiated Based on interviews and records review, there is not sufficient information to support this allegation. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. It was alleged that facility staff restrained a resident in care by placing chairs around their bed. To investigate this allegation on 9/14/2023 between 12:00pm and 12:30pm, staff interviews were initiated. Interviews revealed that Resident #1 (R1) was a fall risk due to a worsening of their medical condition. In order to make sure that R1 did not fall, staff were asked to check on them every fifteen minutes. In addition, one chair was placed next to the bed so that R1 could be transferred in and out of their bed. The chair was not used to restrain R1. Based on interviews there is not sufficient information to support this allegation. Thus, this allegation is UNSUBSTANTIATED at this time. It was reported that staff handle residents in a rough manner. To investigate this allegation on 9/14/2023 between 12:00pm and 12:30pm, staff interviews were initiated. Interviews revealed that staff are cordial and helpful towards residents. Residents personal rights are respected. Between 3:00pm and 3:35pm, resident interviews were initiated. Interviews revealed that staff are kind and assist when called upon. Based on observation and interviews, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. It was alleged that facility staff do not dispense medications according to physician's orders. Between 2:45pm and 3:00pm, R1's medical administration record (MAR) was reviewed. LPA did not note any discrepancies. Medications that were administered were initialed by the facility medical technicians. R1's MAR showed that medications were being dispensed daily. Between 3:00pm and 3:30pm, staff were interviewed. Interviews revealed that medications are being dispensed in a timely manner daily and on schedule. Between 3:00pm and 3:35pm, resident interviews were initiated. Interviews revealed that they are given their medication on time and do not report any issues. Based on records review and interviews, there is not sufficient information to support this allegation. Thus, it is deemed UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 14, 2023 · control 31-AS-20230907153007

Allegation investigated: Staff are not allowing residents to participate in activities

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Administrator Betsy Davis and explained the reason for this visit. LPA conducted physical plant tour at 9:48 AM, requested copy of facility documents relevant to the investigation at 10:10 AM and interviewed residents and staff between 10:15 AM to 1:00 PM. It was alleged that the Administrator took a card game away from Resident #1 (R1) because there must be 10 players to play. LPA's interview with the administrator today at 10:15 AM revealed that she did not take away any card game from any resident but only changed the card game activity to another form of activity so more residents could participate. LPA's observation during physical plant tour at 10:00 AM revealed that the card game that was supposed to be taken by the administrator was at R1's room as it has always been per LPA's interview with the Activity Director at around 10:43 AM. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Further interview with the Activity Director also revealed that while it was scheduled on the Activity Calendar, the card game activity that R1 would like to play attracts only a few residents to participate as it did on prior weeks it was scheduled and played. Further, the card game was bought and owned by the facility but it was always R1 who would like to keep it after every game which is why it was on R1's room. LPA's interview with another staff also revealed that it was explained to R1 by the Activity Director hours prior to the allotted time for the card activity game that the card activity game will be changed to another activity to encourage more residents to participate and R1 agreed. LPA's interview with seven (7) residents or 10% of the current census revealed that seven (7) out of seven (7) residents participate in the Activity of their choosing and no staff or anyone stop them from participating nor anyone forced them to participate in any Activity that they do not like. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 15, 2023 · control 31-AS-20230811092041

Allegation investigated: Resident was assaulted while in care Facility staff did not safeguard resident's personal belongings

On 03/21/2023 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Agard was met by Besty Davis, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. The investigation consisted of the following: On 02/12/2023, LPA Agard conducted a 10-day visit, toured the physical plant and requested documents. LPA Agard requested the following documents: 1) staff and resident roster, 2) incident reports from the past 30 days and 3) R1’s physician report. All documents were received at the time of visit. On 03/21/2023, LPA Agard conducted interviews with residents, staff and a witness. LPA delivered findings on the same day. Cont. on 9099C Unsubstantiated The investigation revealed the following: Regarding the allegation… Resident was assaulted while in care. It’s being alleged a resident in care was possibly drugged and raped during the night. LPA Agard interviewed 2 staff out of 29. 0 out of 2 confirmed the allegation. S1 states, R1 has presented with a recent onset of memory loss, confusion and delusions. “R1 was just diagnosed with a cognitive impairment so that is where all this is coming from. R1 complained that staff were stealing their things. I would go to the room and find the missing items. The night that resident came back from a (offsite) home visit, they completed their activities of daily living independently, forgot to put on their undergarments and alleged they had been assaulted because of this. Ultimately, R1 was not reporting correctly. R1 requested for a rape kit but the hospital denied it because they did not observe any signs or indications of rape.” During interviews with residents, LPA Agard attempted interviews with 6 out of 63 residents. 0 out of 5 confirmed the allegation. R1 was unable to be interviewed due to resident’s cognitive impairment. All residents interviewed unanimously denied the allegation. Citing only positive experiences while living at the facility. R2 states, “I love living here. So does my spouse. They love it too. The staff treat me very nice. I don’t know about that allegation. Never heard about that but could you please tell S1 that we love it here.” R3 states, “It’s absolutely wonderful here. The staff are very caring, they keep the place clean and take care of me just the way I like. I’m very fortunate to be here. I don’t know about anyone being assaulted.” LPA interviewed one witness that also denied the allegation. W1 states, “R1 was taken to the hospital and was checked by the Obstetrician Gynecologist (OBGYN) during the hospitalization. They told us there was no signs of R1 being attacked.” Regarding the allegation… Facility staff did not safeguard resident's personal belongings. It’s being alleged items and clothing has been stolen from a resident in care.” During interviews with staff, 0 out of 2 confirmed the allegation. S1 states, “no one was stealing from R1. They would report stuff missing, but I would find it. Many of the things they reported missing had all been there. We found so many things that were doubles and triples.” S2 states, “Many residents might say something is missing but is just misplaced and is usually in their room.” cont on 9099C During an interview with residents, 0 out of 5 confirmed the allegation. R1 was unable to be interviewed. All residents interviewed unanimously denied the allegation. R2 states, “My belongings are safe. People give me a lot of things all the time. I’ve never had anything go missing.” R3 states, “Absolutely. I never had an issue with my stuff going missing.” R5 states, “My personal belongings have always been safe. We don’t have theft issues here.” LPA interviewed one witness that also denied the allegation. W1 states, “The truth is, I know R1 always says things were disappearing, but I can tell you they lose everything. For example, R1 would say someone took their phone. Not remembering they gave their phone to me to charge. This continues even while they live with me now.” During a record review, LPA observed the following: an incident report dated 10/14/2022 stating R1 had been experiencing signs of paranoid behavior, reporting staff wanting to harm them, and steal from them. LPA reviewed a physician report dated for 12/09/2021 that identified a mild cognitive impairment in R1. On 02/05/2023, R1 was admitted to Keck Medicine of the University of Southern California for signs and symptoms of dementia and alleged assault. Resident was diagnosed with an Acute Urinary Tract Infection (UTI), confusion and delusions. Most recently, R1 had an evaluation on 03/09/2023 due to residents’ recent changes in health condition. The assessment identifies a diagnosis of moderate dementia with other behavioral disturbances, and a decline in cognition complicated by anxiety, depression and psychosis. Based on LPA’s record review and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Mar 21, 2023 · control 28-AS-20230207091758

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Ashley Calderon conducted an unannounced Annual - 1 Year Required visit to this facility. Upon arrival, LPA met with Assistant Administrator / Dennise Alonso and later with Administrator Betsy Davis who assisted with the visit. During today's visit, LPA used the infection control tool to evaluate the facility. The facility has a hospice waiver for two (2) and currently has no residents on hospice. LPA and Davis toured the entire physical plant of the facility, the facility is a two-story building. Areas toured: the front lobby, dining area, activity spaces / common lounge areas, medication room, storage/ disaster rooms, resident common restrooms, laundry room, outside gardens, five (5) residents bedrooms and kitchen area. LPA observed that the facility does not have a swimming pool or other large body of water, small fountains were observed and were secured and fenced. All indoor and outdoor passageways were free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located and hand sanitizers are placed throughout the facility. All staff were observed to be wearing mask during this visit and facility had enough PPE supplies. LPA toured randomly selected resident rooms. Rooms 108, 118 were inspected on the first floor, rooms 222, 240 and 244 were inspected on the second floor. All bedrooms were furnished with required furniture. The resident's bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. Common resident restrooms were observed. One common restroom on the second floor was observed having a disinfectant bottle accessible to resident's, a deficiency was observed and cited on LIC809D . The hot water temperature was tested and measured within Title 22 Regulations guidelines, all were in measured between 110.5 - 118.9 Fahrenheit. Smoke detectors are present throughout the facility and in resident bedrooms. Fire extinguishers are fully charged and present throughout the facility, oxygen monoxides are operable, and fire alarms are wired to the Glendale Fire Department. Continuation 809-C... The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods, food menu was posted and no foods were expired. Common areas were observed clean and properly furnished. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Deficiencies were noted during this visit on LIC 809D per Title 22 Regulations. A copy of the report was provided to the administrator and appeal rights were given.the state’s words, verbatim · CDSS document, Dec 27, 2022

Type of visit: Office

Licensing Program Analyst (LPA) Ashley conducted an announced informal Teams meeting visit regarding COVID 19 recommendations and guidelines. LPA Calderon conducted the visit virtually with Administrator Besty Davis, Department of Public Health Outbreak Management Branch Representative, Alan Garcia, Brenna De Leon, and Dr. Al-Ahmad. LPA Calderon, conducted a tour of the facility with Alan Garcia, Brenna De Leon and Betsy Davis and observed the following: Entrance had thermometer, hand sanitizer and Covid-19 symptom log in book. Facility is currently following Covid-19 (infection control) recommendations. No vaccination shots / booster issues. Staff were observed wearing face masks and no staff shortages. . Residents are placed in green zone – 35 residents, yellow zones- 1 resident and red zone- 18 residents. Staff do not have direct contact with residents in the yellow and red zones, residents are independently living residents. Sufficient PPE for 60 days and PPE located outside of rooms and trash cans with lids in the rooms. Facility has appropriate Covid-19 signs throughout the facility as well as hand sanitizing stations. Kitchen uses disposable utensils, plates and cups for meals, getting delivered to yellow and red zones. Dining room area open only to green zone residents. Laundry is done by staff, wear PPE while washing residents’ clothes, each resident gets individual washing services. Recommendations from Public Health: change air filter and leave on air conditioner 24/7 to help viral partials and help with the air flow. No deficiencies were given during this visit. Exit interview was conducted with Betsy Davis and a copy of this report will be mailed to the facility.the state’s words, verbatim · CDSS document, Nov 9, 2022

Allegation investigated: Staff are inappropriately restraining the residents while in care

Licensing Program Analyst (LPA) Christine Wong conducted an initial complaint investigation for the above allegation listed aboved. LPA met wtih the receptionist Arlene Cirera and explained the purpose of the visit. Then LPA met wtih Administrator Betsy Davis and assisted witht visit. The investigation consisted of the following: LPA interviewd administrator, four staff (S1-S4) and six residents (R1-R6) and obtained resident and staff roster, resident sign in out sheet from March 11 to March 25, 2022, residetns exercise attendence sheet and outbreak line list and incident reports. The investigation revelaed of the following: Allegation "Staff are inappropriately restraining the residents while in care." LPA interviewed six residents and six out of six residents denied the allegation. They reported that they were able to go out during the pademic. They never felt the facility were inapproproately restraining them. (See LIC 9099C for continuation) Unsubstantiated The residents reported they can still go to their doctor appointments and families can come and visit them during the pandemic. LPA interviewed staff and all denied the allegation. Staff reported residents have their right to go outside of their rooms and the building if they have no symptoms with good health. Administrator reported two weeks ago, the facility had another outbreak (Norovirus) in the facility and facility consulted with the Department of Public Health and its better to lock down the facility due to the virus is very contagious as they have about 8 residents and 2 staff were getting infected. Currently the facility has been cleared from the outbreak. LPA also reviewed the resident sign in and out sheet and residents were able to go in and out from the building. LPA also reviewed the exercise class attendance sheet and residents do attend the exercise class during the time of the outbreak which is meant that resident were not locked in the room. Based on statements and interviews conducted with staff, residents and record reviews, there was not enough supportive evidence to concur with the reported allegations. 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 allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report and appeal right was provided to the administrator Batsy Davis.the state’s words, verbatim · CDSS document, Mar 29, 2022 · control 28-AS-20220323161606

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced Annual - 1 Year Required visit to this facility. Upon arrival, LPA met with Assistant Administrator / Dennise Alonso and Administrator Betsy Davis who assist with the visit. During today's visit, LPA used the infection control tool to evaluate the facility. The facility is licensed for one hundred and eighty residents (180) and currently has sixty two (62) residents in care. The facility has a hospice waiver for two (2) and currently has no residents on hospice. LPA and administrator toured the facility at 10:00 am. Areas inspected included but are not limited to: the lobby, activity spaces, tea room, common areas, six (6 ) residents bedrooms -three (3) on each floor, kitchen, medication room and gardens. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways were free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit. LPA toured randomly selected resident rooms. Rooms 108, 142,149 were inspected on the first floor, rooms 220, 242, 244 were inspected on the second floor. All bedrooms were furnished with required furnitures. The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water temperature was tested and measured within Title 22 Regulations guidelines. Smoke detectors are present throughout the facility and in resident bedrooms. Fire extinguishers are present through the facility and are fully charged. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods. Common areas were observed clean and properly furnished. LPAs observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the administrator.the state’s words, verbatim · CDSS document, Jan 24, 2022

Allegation investigated: Facility is in disrepair. Resident has not been adequately hydrated resulting in dehydration. Staff continued to provide discontinued medication to the resident.

Licensing Program Analyst (LPA) David Sicairos conducted an subsequent unannounced complaint visit regarding the above stated allegations. LPA met with Administrator Betsy Davis and explained the reason for the visit. The investigation revealed the following: during the intial televisit conducted on 09/11/20, LPA interviewed the Administrator. LPA also requested via email copies of documents for Resident #1 (R1) such as Physician's Report, Identification and Emergency Information, Resident Appraisal, Progress Notes, MAR's for the last 3 months, and any recent Incident Reports. During today's visit, LPA toured the facility including common areas and interviewed Staff #1 - Staff #5 and Resident #1 - Resident #9. LPA also interviewed Dr. Hoang over the phone. The investigation revealed the following: in regards to the allegation "facility is in disrepair", it is alleged that the common areas in the facility do not have air conditioning and the facility will get too hot. During today's visit, LPA toured the common areas with the Administrator and observed the common area thermostats in the first floor read between 75F - 76F and 72F - 77F in the 2nd floor. (CONTINUED ON 9099C) Unsubstantiated 9 out of 9 residents interviewed indicated that they feel that the temperature in the common areas of the facility is always at a comfortable temperature. Residents interviewed also indicated that they have individual A/C units in their rooms and they are able to adjust the temperature and turn on and off the unit as they please. 5 out of 5 staff members interviewed indicated that the facility is always set at a comfortable temperature. Staff members indicated that they will assist residents with their A/C units and room temperature adjustments as necessary. LPA obtained a "Temperature Log" for R1 dated 09/03/20 - 09/11/20 monitoring R1's room temperature. Room temperature ranged from 72F - 76F. Therefore there was insufficient evidence to corroborate with this allegation. In regards to the allegation "resident has not been adequately hydrated resulting in dehydration", it is alleged that R1 was moved to the first floor closer to the nurse’s station so that they could monitor her water intake. Resident was offered to be moved downstairs, however R1's Responsible Party declined. Reporting Party is concerned that the residents are not being properly hydrated. 9 out of 9 residents interviewed indicated that the facility always has drinking water available for residents. Residents indicated staff members will pass out pitchers of waters with ice to all residents throughout the day as needed. Residents are also provided with liquids during each meal. 5 out 5 staff members interviewed indicated that residents are provided with pitchers of waters throughout the day. Residents can request as much water as they want. Staff members indicated that they will prompt and remind residents to drink fluids as they pass out meals and water. During today's visit, LPA observed staff members passing out pitchers of waters to residents. LPA obtained a "Fluid Intake Log" for R1 dated from 09/03/20 - 09/11/20 monitoring R1's water intake. Therefore there was insufficient evidence to corroborate with this allegation. In regards to the allegation "staff continued to provide discontinued medication to the resident", it is alleged that facility staff found some R1's discontinued pills after being discharged from the hospital and administered them to the resident. On 08/03/20, Clobazam was put "on hold" for R1 by Dr. Hoang. R1 was hospitalized between 08/24/20 - 08/26/20. Upon discharge from the hospital, Clobazam 10mg was listed as part of the discharge medication orders for R1. Based on Doctor's Orders received from the hospital, facility staff administered Clobazam to R1 on 08/27/20. R1 then refused the medication on 08/28/20. Around 6:30pm on 08/28/20, Administrator received Doctor's Orders from Dr. Harutunian instructing facility to discontinue use of Clobazam on R1. Facility proceeded to discontinue medication based on doctor's written orders. R1 has not been given Clobazam since the date facility received written doctor's orders to discontinue the medication. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 14, 2021 · control 28-AS-20200903103643

Allegation investigated: Resident sustained unexplained injuries while in care

Licensing Program Analyst (LPA) Christine Wong conducted a complaint investigation for the allegation listed above. LPA met with Betsy Davis, the Administrator and explained the purpose of the visit. During today’s visit, LPA interviewed the Administrator, one staff and obtained a copy of the staff and resident roster. LPA also interviewed the Administrator from the Broadway Manor (skilled nursing home) at 605 W. Broadway Glendale 91204 and obtained the resident roster for Broadway Manor. Based on interview and document reviewed, Resident #1 (R1) did not reside at this facility but at the Broadway Manor. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted. A copy of the report was provided to to the adminsitrator Betsy Davis Unfoundedthe state’s words, verbatim · CDSS document, Sep 3, 2021 · control 28-AS-20210827123656

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.