Woodruff Care Home

Allegation investigated: Insufficient staff to meet the residents needs.

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Administrator Gemma Deoso, who assisted with the visit. Regarding the allegation that there is insufficient staff to meet the residents needs, the investigation consisted of review of resident and staff rosters, including staff schedule, interviews with Resident #1 - Resident #7, Administrator, and Staff #1 - Staff #3. Residents interviewed were unable to corroborate the allegation. Six out of Seven residents interviewed stated that their needs are being met. Administrator and staff interviewed stated that the staff are meeting the residents needs. LPA reviewed staff roster and staff schedule, and observed that the facility appears to have sufficient staff to meet the resident's needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Unsubstantiated Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Ms. Deoso. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 28-AS-20231019153221

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 1, 2023

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met as evidenced by: Administrator, staff and residents interviewed confirmed that the facility has bed bugs. LPA observed Orkin inspection report dated 10/2/23, which also confirms that the facility has bed bugs. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator will send copy of Orkin treatment report for treatment done on 10/25/23 to LPA, by POC due date. Administrator will continue to send reports to LPA until the facility is free of bed bugs.

Allegation investigated: Staff did not administer resident's medication as prescribed. Staff did not provide adequate food service.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the allegations listed above. LPA met with Gemma Deoso, Administrator and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Resident & Staff Rosters, weekly menus (Sep 2023), Resident #1 (R1) files such as; AdmissionAgreement, Physician's report, Identification and Emergency Information, Preplacement Appraisal and Appraisal, Special Incident Reports (dated 2/12/2023 & 8/29/2023), Medication list, Medication Administration Record (MARs) for Jul 2023-Sep 2023, Hospital's discharge papers for R1and letter from R1’s physician stating she can manage her own meds. At 12:30pm, LPA conducted a tour of the facility’s common areas, focusing on the kitchen and dining area. LPA observed that the dining area was closed due to the facility under quarantine. However, LPA observed the food served during lunch consisted of whole grains, nuts, fruit and vegetables. At 1:20pm, LPA reviewed R1’s medication list and MARs. Between 1:40pm-2:45pm, LPA interviewed Staff #1 (S1) - Staff #7 (S7), and between 2:45pm-3:45pm, LPA interviewed Resident #1 (R1) – Resident #9 (R9). *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: " Staff did not administer resident's medication as prescribed.” It is alleged that the facility staff have been mismanaging R1's medication and that the staff are failing to administer it in a timely manner. Facility staff interviewed denied the allegation. Staff stated that resident #1 is medication compliant and staff follow R1's medication directions. Staff stated that R1 is not capable of managing her own medication and being assisted by staff. S3 stated that she received the letter provided by R1 regarding medication administration, however, the letter was incomplete. S3 stated that facility has not received the updated letter that they requested from R1's physician. LPA reviewed Resident #1's medication list and Medication Administration Record (MAR) for Aug-Sep. 2023, and observed that R1's medication has been administered as prescribed. LPA also reviewed R1's Physician's report which stated that R1 is not capable of managing her own medication. (8) out of (9) residents interviewed were unable to corroborate the allegation. Other residents interviewed stated that they are receiving their medication as prescribed and do not have any problems. In regards to the allegation: "Staff did not provide adequate food service.” It is alleged that the staff are failing to provide adequate food service, that on 09/18/2023 R1 did not get any food for dinner. Staff interviewed denied the allegation and stated that residents get their regular meals 3x a day plus snack. And if residents request extra meal, they get it. Staff interviewed also indicated that a resident can easily use the call light in their rooms if they need assistance, whether it's ordering food or other requests. At 12:30PM, LPA conducted a tour of the kitchen and dining area and observed adequate amount of food prepared and packed for lunch. The food was prepared by the cook and the kitchen worker was ready to deliver the food trays (wrapped) to the rooms. Currently, the facility is under quarantine and meals are being delivered to the residents room. The meal included fruit, vegetables, nuts and whole grains. Some meals were labeled to serve residents with dietary preferences. The food is observed to be adequate and sufficient to meet the residents’ nutritional needs. LPA obtained a copy of the weekly menu for the month of Sep. 2023. The menu included different items from each food group and listed alternatives, including snacks on the menu. (8) out of (9) residents interviewed stated that the staff had never missed providing them meals and they do not have problems with the meals being served to them. Other residents stated that they get their meals 3x/day plus snacks. Some residents indicated that they can call a staff by using the call light in their rooms if they want extra food or an alternate menu. LPA also observed the Local Ombudsman contact information posted on the wall in the hallway, next to the elevator and the front office, which was visible to residents in the facility. 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, a copy of this report was provided to the Facility Administrator, Gemma Deoso.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 28-AS-20230919114700

Allegation investigated: Staff not maintaining a comfortable room temperature for residents.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Gemma Deoso, Administrator and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Resident & Staff Rosters, conducted a tour of facility such as common areas, focusing on the residents' rooms, Electrician's contact information and Resident #1 (R1) files such as; Identification and Emergency Information Sheets, Physician Reports, and Resident Appraisal. Between 2:03pm-2:48pm, LPA measured the room temperature using the infrared thermometer in (12) random residents rooms on the ground and 2nd floors, (Room numbers: 107, 110, 111, 113, 119, 126, 235, 236, 239, 240, 242 and 246). LPA also interviewed the Administrator, Staff #1 (S1) - Staff #3 (S3), and Resident #1 (R2) - Resident #10 (R10). ******CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: Regarding allegation: “Staff not maintaining a comfortable room temperature for residents." It is alleged that the residents’ room was hot and uncomfortable and there is no air conditioning in some rooms. During today's visit, LPA toured the entire facility and observed that some resident’s rooms in the ground and 2nd floor have ceiling and stand fans, but no air conditioning. Between 2:03pm-2:48pm, LPA checked the room temperature in twelve (12) random residents’ rooms. Eight (8) out of twelve (12) rooms measured over 85 deg F.(room 107: 89 deg F, room 110: 86 deg F, room 119: 87 deg F, room 235: 86 deg F, room 236: 87 deg F, room 239: 86 deg F, room 240: 86 deg F, room 246: 91 deg F) which did not meet the Title 22 Regulations requirement. Interviews conducted with staff revealed that they have successfully installed portable a/c/s in (2) rooms, however they have not completed the work on other rooms due to an electrical panel breaker is still needed to be installed. Staff also stated that they are providing extra stand fans to the residents upon request and making sure that residents are hydrated by providing drinking water. Six (6) out of (10) residents interviewed stated that their rooms are hot and uncomfortable. Some residents stated that they like their rooms to be cooler and prefer to have air conditioning in their rooms because their rooms get very hot, especially during the day. LPA observed that rooms located in the south side of the building that were exposed to the afternoon sun are uncomfortable and have higher temperature readings than those rooms located in the west side. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Administrator, Gemma Deoso along with the Appeals Rights.the state’s words, verbatim · CDSS document, Jul 17, 2023 · control 28-AS-20230714100240

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(2) · Plan of correction due date: Jul 31, 2023

87303 Maintenance and Operation ... (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms...between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement is not met as evidenced by: Based on observation and interviews, theAdministrator did not comply with the section cited above in which (8) out of (12) residents rooms measured over 85 deg F and (6) residents stated their rooms are uncomfortable because of hot temperature.the state’s words, verbatim · CDSS document, Jul 17, 2023

Plan of correction: Administrator willl ensure that the facility shall cool rooms to a comfortable range (78-85 deg F) and agreed to install portable a/c to the rooms without a/c. Addiitonally, an electrician will install breaker panels designated for a/c only. Proof will be submitted to CCL/LPA by POC due date.

Allegation investigated: Staff spoke inappropriately to resident in care. Staff is trying to force resident to sign unknown documents. Staff do not provide room cleaning services to resident in care.

Licensing Program Analyst (LPA) Cynthia Chan conducted the complaint investigation for the allegations listed above. LPA arrived unannounced and met with Assistant Administrator, Khrysta Margaros. The purpose for the visit was explained. Administrator, Gemma Deoso, arrived shortly thereafter to assist with the visit. The investigation consisted of the following: LPA obtained copies of the staff and resident rosters, staff in-service training log, and reviewed Resident's #1 (R-1) file. LPA also toured the facility, interviewed the Administrator, Staff #1 - #4, and Residents #1 - #6. The investigation revealed the following: For allegation - Staff spoke inappropriately to resident in care. During the visit today, LPA interviewed the Administrator, Staff, and Residents. Unsubstantiated The administrator and staff denied speaking inappropriately or being rude to residents. Some stated that the residents could misconstrue staff when they are being firm or talking a bit louder due to hearing impairment. Staff indicated they receive training on how to communicate effectively with the residents. 5 out of the 6 residents did not encounter staff being rude or speaking to them inappropriately. They said staff are respectful and one mentioned that the residents are the ones that are rude or yelling at staff. One resident felt that staff are being rude when they ignore the resident's request because they are in a hurry to do something else. For allegation, Staff is trying to force resident to sign unknown documents. The administrator and assistant administrator denied forcing residents to sign documents and stated they always explain to residents what they are signing. They would present the document(s) to the resident and go over each item before they have them sign. For residents in the Assisted Living Waiver (ALW) program, they would request for a social worker from the ALW agency to explain the forms that the residents are signing. 5 out of the 6 residents have not been forced to sign documents they were not aware of. They stated the administrator will explain the forms before requesting for a signature. One of the residents stated the administrator did not disclose all the forms that were signed. For allegation, Staff do not provide room cleaning services to resident in care. Administrator and Staff stated the residents' rooms are being cleaned daily. They stated the rooms get mopped, trash thrown out, and toilets cleaned every day. They also deep clean the rooms once a week. 5 out of the 6 residents stated that staff clean their rooms daily or several times a week. They are satisfied with the cleaning services and have no concerns. One resident stated that staff did not respond to the request to clean the bathroom wall and is still dirty. During the visit, LPA observe staff mopping the floors and cleaning the rooms. LPA did not see any bathroom walls dirty. 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. An exit interview was conducted with the Administrator. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 22, 2023 · control 28-AS-20230613104451

Allegation investigated: Staff are not meeting resident’s medical needs to obtain a prosthetic device as required by a physician.

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Gemma Deoso and explained the reason for the visit. The investigation consisted of: LPA conducted interviews with Administrator Gemma Deoso, Staff 1-2 (S1-2) and Residents 1-6 (R1-6). LPA collected copies of Staff and Resident rosters. LPA reviewed R1-2's facility files and collected copies of documents relevant to the investigation. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff are not meeting resident’s medical needs to obtain a prosthetic device as required by a physician, it is alleged that facility staff did not send paperwork needed for R1's doctor appointment and when asked about the paperwork, staff stated that the paperwork was missing. It is also alleged that the doctor's office stated that the paperwork had not been received from the facility. Facility staff allegedly stated that the paperwork was faxed to the doctor's office and is now misplaced and not located by staff. Interviews conducted with Administrator and S1-2 revealed that facility staff schedule medical appointments for residents and ensure that facility residents keep their medical appointments. They stated that the facility also provides transportation for the resident's to get to their appointments. S1 stated that the paperwork that was needed for R1's medical appointment was faxed to the doctor's office and they have a fax confirmation. S1 stated that the paperwork was not missing and was faxed and also emailed to the doctor's office. S1 stated that when they were made aware by R1 that the doctor's office informed them they did not receive the forms, S1 contacted the doctor's office and was informed that they did not receive the paperwork from facility. S1 stated that they then emailed the forms to the doctor's office on 6/8/23, and confirmed that the forms were received. S1 then had to reschedule another appointment for R1 to 6/9/23 due to the forms not completed timely by the doctor. Interview conducted with R1 revealed that the facility did forward the forms to their doctor on 6/8/23 and rescheduled appointment for them for the following day. R1 stated that facility staff (S1) did inform them of the new appointment and they were able to schedule a transportation appointment. R1 stated that they did go to their appointment and they did not have any additional concerns regarding staff not following through with scheduling appointments. Interviews conducted with 5 out of 6 residents revealed that they do not have any concerns with staff not meeting their medical needs and that staff make their medical appointments as well as provide transportation to their appointments or informing them of appointment information so that they can make transportation arrangements. 1 out of 6 residents stated that they do not have any medical appointments at the moment as they are waiting to be approved for medical insurance and stated that they are satisfied with all other services provided by the facility. LPA reviewed documents which show that the facility forwarded the medical forms to the doctor's office for completion. Based on statements gathered from interviews conducted with staff, residents and LPA review of documents, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Administrator Gemma Deoso.the state’s words, verbatim · CDSS document, Jun 13, 2023 · control 28-AS-20230607152031

Allegation investigated: Staff did not prevent resident from stealing another resident's personal belongings

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced initial complaint investigation visit regarding the above allegation. LPA met with Gemma Deoso Administrator and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of staff/resident roster, face sheet, physician's report, preplacement appraisal information, resident personal property and valuables, for resident #1 (R1) and #2(R2). LPA interview residents 1 - 5 and staff 1-5. The investigation revealed the following: Regarding allegation: Staff did not prevent resident from stealing another resident's personal belongings. It is alleged R2 is continuously stealing R1's personal items; such as phone, debit card, and clothing. R1 stated a phone was stolen from her by R2 and charges to R1's debit card were made for amounts R1 usually does not make. In addition, personal documents have gone missing. Per R1 there was no police report file regarding missing items. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with residents revealed, 4 out of 5 residents interviewed have not experienced losing items while in care at the facility within the last six months. Interviews with staff, revealed 4 out of 5 staff stated R1 has reported missing items. However, staff has assisted resident with searching for items and items were found.1 out of 5 staff stated not to be familiar with any resident reporting missing items. LPA contacted R1's responsible party who stated there was a unknown charge made to the debit card in Utah but was not aware of other charges. Document review revealed, facility has not filed a police report as reported items by R1 had been found. No documents to corroborate the charges to R1's debit card, or ownership of missing items were provided. Due to lack of documentation LPA is not able to determined missing items and/or charges to the debit card. Based on interviews, the preponderance of evidence standard has been met. Although the allegation 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 allegation is UNSUBSTANTIATED. Exit interview was conducted with Gemma Deoso Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2023 · control 28-AS-20230605141305

Allegation investigated: Staff do not ensure hot water is available to residents Staff do not maintain resident bathroom in clean and sanitary condition Staff do not provide soap to resident Staff allow residents to smoke in non-designated areas

Licensing Program Analyst (LPA) Bennette Pena conducted a 10-day complaint visit to investigate the allegations listed above. LPA met with Administrator, Gemma Deoso and explained the purpose of the visit. Administrator and S1 assisted LPA Pena with the visit. The investigation consisted of the following: LPA obtained copies of Resident & Staff Rosters, Plumber's invoice dated 3/16/2023, random resident admission agreement, House rules and Housekeeping job description. LPA toured the facility’s common areas such as residents rooms, bathrooms and designated smoking areas with S1. Between 11am-11:50am, LPA conducted the hot water temperature check in (8) random residents’ rooms on the first and second floor, (Room numbers: 107, 110, 116, 129, 235, 236, 240, 242). At 2:30pm, LPA measured and inspected (3) random residents rooms (Room numbers: 121, 126 & 127) using an infrared thermometer to measure the room temperature (photos taken). LPA interviewed the Administrator, Staff #1 (S1) – Staff #4 (S4), telephonically interviewed Staff #5 (S5) and Resident #1 (R1) – Resident #10 (R10). ***CONTINUED ON LIC9099-C*** Unsubstantiated The investigation revealed the following: Allegation: Staff do not ensure hot water is available to residents. It is alleged that there is no hot water available in the resident’s bathroom sink. Administrator was interviewed at 10:35 am. Administrator indicated that the facility does not have an ongoing issue with hot water. She stated that the boiler was serviced and repaired in March 2023 and has been fixed since. Administrator also stated that she was not aware of any complaints from the residents, staff or family members about the facility not delivering hot water. Maintenance staff was telephonically interviewed and confirmed the hot water was serviced and there is no issues with hot water in the residents rooms. Facility staff were also interviewed, and they indicated that there were no issues with residents' hot water in their rooms. Between 11am-11:50am, LPA tested the hot water in (8) random residents’ rooms on the first and second floor and hot water temperature read between 112.8 deg F-118.3 deg F which is within the required 105 - 120 degrees. LPA interviewed residents between 12:00pm-12:45pm and none of the residents indicated there was an issue with the hot water. LPA also reviewed a copy of the receipt for water heater serviced on 3/16/2023. The receipt indicates that the water heater was cleaned and repaired. Based on observation, statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. · Allegation: Staff do not maintain resident bathroom in clean and sanitary condition. It is alleged that a bathroom inside the resident’s room looks like the toilet has never been cleaned. Additionally, there’s human waste in the toilet and staff said they do not have a housekeeper right now for cleaning. Interviews conducted with staff members indicated that the residents’ rooms are cleaned daily. Administrator stated that the facility has housekeepers maintain overall cleanliness and orderliness of residents’ rooms. Interviews conducted with staff indicated that the housekeepers follow the daily schedule to thoroughly clean the residents’ rooms. Staff members denied the allegation and stated that they help each other and assist the housekeepers with cleaning if needed. At 2:30pm, LPA along with the Administrator checked (3) random residents rooms using an infrared thermometer to measure the residents room temperature. The room temperature measured between 74-78 degrees which is within Title 22 Regulations requirement. LPA observed the rooms to be in a comfortable temperature for residents. Interviews conducted with residents indicated that their rooms are cleaned daily, beddings/linens changed and they don’t have any issues or concerns. LPA observed staff conducting rounds, residents’ rooms, bathrooms, and toilets were clean and did not smell any odors that would indicate that clients urinate or vomit. Based on observation, statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. · Allegation: Staff do not provide soap to resident. It is alleged that the facility does not provide soap for the resident to wash hands and resident has to buy own soap. Interviews conducted with staff members indicated that the facility provides soap, hand soap, toilet paper and other basic hygiene supplies to the residents. Staff members indicated that if residents run out of soap, or those who consume more than normal, residents can come to the office and the items will be provided to them at no extra charge. Interviews conducted with residents indicated that the facility provide soap although some residents prefer to buy their own soap. Residents interviewed also indicated that when the housekeepers clean their bathrooms, they replenish their toilet supplies including soap. Residents stated that they don’t have any issues with the basic hygiene supplies because it is available to them when they request it from the staff. LPA observed the presence of hand soaps and bar soaps in the residents’ bathrooms. LPA also observed sufficient basic hygiene supplies stored in the facility’s office. Staff interviews, resident interviews and LPA's observation do not corroborate this allegation. · Allegation: Staff allow residents to smoke in non-designated areas. It is alleged that residents are smoking cigarettes right outside the front door and as a result, the cigarette smoke comes inside the facility and the resident can smell it inside. Interviews conducted with staff members indicated that the facility has a designated smoking area which is located in the back patio. Staff members stated that residents who smoke are aware of the smoking area. Administrator denied the allegation and stated that the house rules indicated that smoking is not allowed in their rooms or other areas other than the designated smoking patio area. Interviews conducted with residents indicated that they are aware of the designated smoking area in the back of the facility. Residents interviewed did not see anyone smoking in the front door and they do not smell smoke inside their rooms. LPA did not observe residents smoking in the front door during the visit. LPA observed residents smoking in the back patio area (photos taken). Staff interviews, resident interviews and reviewed documentation do not corroborate this allegation. Based on observation, statements and interviews conducted with staff, residents, review of 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. An exit interview was conducted, and a copy of this report was provided to the Administrator, Gemma Deoso.the state’s words, verbatim · CDSS document, Jun 5, 2023 · control 28-AS-20230531105328

Allegation investigated: Staff are verbally abusing residents in care.

Licensing Program Analysts (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above allegation. LPA met with Staff #1 (S1) and explained the reason for the visit. The investigation consisted of the following: LPA obtained Resident & Staff Rosters, In-service training/meeting record (Report suspected Abuse of Dependent Adults & Elders/Mandated Rights, Personal Rights). LPA also toured the facility with the Asst.Administrator which included all the common areas and a random sample of resident bedrooms. LPA also interviewed Staff #1 - Staff #5 and Resident #1 (R1) - Resident # 6 (R6). LPA attempted to interview night shift Staff #6 (3x), (2:15pm, 3:54pm and 4:17pm) and left a voice mail message, but S6 did not return the call. *****CONTINUED ON LIC9099-C***** Unsubstantiated Investigation revealed the following: Regarding allegation: "Staff are verbally abusing residents in care." All of the staff interviewed denied the allegation. Staff members stated that they treat all residents with respect and do not verbally abuse residents. Interviewed staff indicated they have not seen, heard or observe staff verbally abusing residents. 3 out of 5 staff members interviewed indicated that it was the residents who were verbally abusive to staff and not the other way around. Interviewed staff also indicated that hey are trained in Resident Rights, Personal Rights and Mandated Reporting. Interviewed residents indicated that staff are not verbally abusive. All 6 of the residents interviewed stated that the staff are not verbally abusing them nor have observed any staff verbally abusing other residents in care. S5-S6 stated that staff in the facility are pleasant and attend to their needs. Staff interviews, resident interviews and reviewed documentation do not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview and a copy of this report were provided to the Facility Assistant Administrator, Gemma DeOso.the state’s words, verbatim · CDSS document, Mar 29, 2023 · control 28-AS-20230328111454

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Carmen Galicia. There are currently 58 elderly residents 60 years and older residing in the facility. One resident (1) is receiving hospice care. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. Room # 232 is designated as a COVID-19 isolation room if needed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. The facility does not have a Dementia Waiver in place. A Hospice Waiver for 8 is approved. A fire clearance for 20 ambulatory and 68 non-ambulatory residents is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 1/1/2024. Surety bond of $10,000.00 is current. Physical Plant/Environment Safety: The facility is a 2-story building located that is licensed for 88 elderly residents ages 60 and older. It consists of 45 resident rooms, 2 administrative offices, medication room, kitchen, dining room, caregiver room, 2 shower rooms janitor rooms, laundry room, electrical room, boiler room, 2 courtyards, and an activity patio located in the rear of the property. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. On 9/27/2022 LA County Fire Department conducted a fire inspection. Fire clearance was denied pending corrections. Corrections were submitted on 11/4/2022, but facility has not obtained fire clearance verification. A call was placed during this visit. The fire inspector did not return the phone call. On 10/16/2022, R4 Fire Testing Services Inc. conducted an inspection to correct the violations identified in the Fire Department report. The sprinkler system, alarms, fire connections, and kitchen hood system were inspected. The facility has eight (8) fully charged fire extinguishers. Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 101.6 - 109.9 degrees Fahrenheit. Maintenance staff cleaned the boiler during the inspection. However, circulation pumps need replacement. Rooms 108, 112, 127, 233, and 239 were missing window vertical blinds. Room 242's floors were dirty. Rooms 109 & 112 did not have Oxygen posters on the door. Signs were posted during the visit. Staffing: A total of 32 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificates expires 12/3/2023. Staff have criminal background clearance and training. Five (5) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training are current. Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted in the 1st floor hallway. The Incident report binder was reviewed. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted by the dining room. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. See next page Residents with Special Health Needs: Nine (9) residents are receiving home health services. One (1) resident receives hospice care. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in some resident beds. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. "No smoking In Use" signs were not posted on the resident doors. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Carmen Galicia. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Mar 14, 2023

Allegation investigated: Staff did not provide timely medical attention to resident

Licensing Program Analysts (LPA) Kimberly Ramirez and LPA Tena Herrera conducted an announced subsequent complaint visit stemming from initial complaint visit dated 11/22/2021. LPA’s met with Administrator Carmen Galicia and explained the purpose of the visit. The investigation consisted of the following: A physical plant inspection of the facility was conducted at 10:02 am. Staff (S1-S5) and residents (R1-R4). LPA’s requested a copy of LIC 500, resident roster, Resident R1 face sheet, R1 Emergency contact sheet, R1 Physician orders, R1 medical records, LIC 624, Post Discharge Plan of Care and Outside Agency Documentation log. See LIC 9099-C for continuation. Unsubstantiated Allegation: Staff did not provide timely medical attention to resident. It is alleged that R1 was observed with a mass on her eye with maggots. Staff (S1 – S5) all deny this allegation. S1 stated they assist residents with all medical needs and try their best to arrive to assist in a timely manner. R2 stated when he/she needs assistance, staff arrives quick and assist him/her. R1 was not available for an interview and has since passed away. Review of R1’s Outside Agency Documentation log, shows a wound care specialist was arriving to the facility once a week from 10/01/2021 to 11/15/2021 to provide wound care. S1 -S4 all acknowledge that R1 would refuse medical treatment and would require coaching to allow staff to groom R1. R2 confirmed that R1 would refuse medical treatment for wound care. LIC 624 dated 11/16/2021 indicates R1 was sent by non-emergency ambulance to Norwalk Community Hospital for treatment of wound to left eye. Based upon records review and interviews conducted, and observations made the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was held with Administrator Carmen Galicia. A copy of this report was issuedthe state’s words, verbatim · CDSS document, Feb 16, 2023 · control 28-AS-20211117125615

Allegation investigated: Staff did not provide timely medical attention to resident

This is a corrected verison of previous complaint report dated 02/16/2023. Verbiage was corrected on LIC 9099. Licensing Program Analysts (LPA) Kimberly Ramirez and LPA Tena Herrera conducted an announced subsequent complaint visit stemming from initial complaint visit dated 11/22/2021, conducted by LPA Gonzalez. LPA’s met with Administrator Carmen Galicia and explained the purpose of the visit. The investigation consisted of the following: A physical plant inspection of the facility was conducted at 10:02 am. Staff (S1-S5) and residents (R1-R4) were interviewed. LPA’s requested a copy of LIC 500, resident roster, Resident R1 face sheet, R1 Emergency contact sheet, R1 Physician orders, R1 medical records, LIC 624, Post Discharge Plan of Care and Outside Agency Documentation log. See LIC 9099-C for continuation. Unsubstantiated Allegation: Staff did not provide timely medical attention to resident. It is alleged that R1 was observed with a mass on her eye with maggots. Staff (S1 – S5) all deny this allegation. S1 stated they assist residents with all medical needs and try their best to arrive to assist in a timely manner. R2 stated when he/she needs assistance, staff arrives quick and assist him/her. R1 was not available for an interview and has since passed away. Review of R1’s Outside Agency Documentation log, shows a wound care specialist was arriving to the facility once a week from 10/01/2021 to 11/15/2021 to provide wound care. S1 -S4 all acknowledge that R1 would refuse medical treatment and would require coaching to allow staff to groom R1. R2 confirmed that R1 would refuse medical treatment for wound care. LIC 624 dated 11/16/2021 indicates R1 was sent by non-emergency ambulance to Norwalk Community Hospital for treatment of wound to left eye. Based upon records review and interviews conducted, and observations made the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was held with Administrator Carmen Galicia. A copy of this report was issuedthe state’s words, verbatim · CDSS document, Feb 16, 2023 · control 28-AS-20211117125615

Allegation investigated: Staff mismanaged resident's medication Staff do not respond to resident's call for assistance

On 02/02/23 at 9:26 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Carmen Galicia (Administrator) and explained the purpose of the visit. During today’s visit LPA and administrator toured the facility and tested the call button in rooms 110, 113, 119, 129, 132, 233 and 246. LPA obtained resident/ staff roster, Resident #1 Physicians report, Photo of R1's medication and Resident #1 Physicians orders. LPA also interviewed: Administrator and a total of two (2) staff who shall be referred to as S1, and S2. LPA interviewed a total of 6 residents who shall be referred to as: R1 through R6. Report continued 9099c Unsubstantiated The investigation reveals the following: Regarding " Staff mismanaged resident's medication", it is alleged that the facility is not administering resident medication correctly. During the visit LPA reviewed R1’s physicians orders and confirmed the medications orders state the starting time for the medication to be given, but do not specify how much time the medication should be given before meals. LPA also observed the medication bottle states before meals and at bedtime. Administrator and 1/2 staff interviews confirmed R1 receives the medication but refuses when it is not exactly 1 hour before meals. Administrator and staff explained to resident that the orders state before meals, but not 1 hour before meals. Although it does not state 1 hour before staff has accommodated the resident. 1/2 staff do not work with R1 and medications. 4/6 residents stated they do not have any issues with there medications. 1/6 residents stated the facility has made mistakes in the pass with their medication but has always adjusted when brought to their attention. 1/6 residents stated the facility has recently administered the medication right, but in the past the facility was not administering the medication 1 hour before meals. The investigation reveals the following: Regarding "Staff do not respond to resident's call for assistance “, it is alleged that the facility is not answering the call light. During the tour LPA tested the call button and all was in working condition. During the test the facility staff responded in three (3) minutes or less. The administrator stated when a resident pulls the cord, an alarm tells the staff which room need assistance. The administrator further stated that they never had any residents complain about staff not responding. 2/2 staff stated they have always responded to the residents and have not heard the residents complain about not getting assistance. 5/6 residents confirmed the facility staff has always responded in a timely manner when they need assistance. 1/6 residents stated staff do not come when they pull the cord for assistance. Based on LPA's observation, interviews, and file review the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Carmen Galicia and a copy of this record provided.the state’s words, verbatim · CDSS document, Feb 2, 2023 · control 28-AS-20230125151435

Allegation investigated: Resident's behavior poses as a risk while in care.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent complaint visit at the facility for the purpose of investigating the above mentioned allegation. LPA Maldonado met with Administrator Carmen Galicia and explained the purpose for the visit. On 04/27/20 at 8:48 AM the LPA Arterberry interviewed a resident who shall be referred to as R1. On 04/27/2020 at 11:25 AM the LPA also interviewed the administrator. The following documents were supplied by the administrator for R1: Woodruff Care Home Identification Page/Face Sheet, 30-Day Notice of Eviction dated 03/31/2020, House Rules, Psychiatric Progress Notes dated 04/20/2020, Individualized Service Plan (ISP), Resident Assessment Form, Lakewood Regional Medical Center Discharge Instructions and Unusual Incident Reports (SIR). (Report Continued on LIC9099-C...) Unsubstantiated During today's visit, LPA Maldonado requested a copy of the resident/staff roster and a copy of the previously requested documents for review- these documents were not available for review prior to this visit. The investigation revealed the following: Regarding allegation- Resident's behavior poses as a risk while in care. It is alleged that the behaviors of R1 pose a risk while in care due to R1 drinking to excess and not adhering to house rules. This caused R1 to become aggressive to the point of police being called on 04/14/2020. Per R1's ISP and Resident Assessment, R1's level of awareness consists of frequent agitation, aggressiveness by using foul language and threatening, depression, and hallucinations/delusions. After review of the hospital discharge documents for R1, it was discovered that R1 was admitted to the hospital on 4/14/20 due to acute alcohol intoxication. Facility staff assisted resident in trying to de-escalate the situation and took action by calling 911. Then, a final eviction notice was issued to R1 on 03/31/20, for non-compliance with the house rules. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the complaint investigation of the allegation is unsubstantiated. Per California Code of Regulations, Title 22, no deficiencies will be cited. An exit interview was conducted with administrator Carmen Galicia and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2022 · control 28-AS-20200421112512

Allegation investigated: Staff sexually abused resident

On 11/03/2022 at 9:15 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Administrator Carmen Galicia and explained the reason for the visit. The initial complaint visit was conducted on 9/20/2022. During the initial visit LPA Baptiste conducted a health and safety check. LPA conducted a tour of the facility, inside and out. LPA requested copies of staff and resident roster along with Resident #1 (R1) Face sheet, Psychiatric assessment dated 5/12/2020, Physicians’ orders dated 7/12/22, Resident assessment, Individualized service plan and Physicians report. LPA also obtained Resident #2 (R2) Face sheet, Physician’s report dated 7/06/2022, Resident assessment, Individual Service Plan, Comprehensive assessment dated 5/13/22, Physicians orders dated 8/7/022 and Order Summary Report from Valley Convalescent Hospital. Report continued on 9099c Unsubstantiated Investigation consisted of the following: CDSS IB investigator accepted the complaint as an assignment. The investigator interviewed Resident # R1 and R2. On today’s visit LPA obtained a copy of in-service training for mandator reporting and LPA interviewed administrator and Staff #1 through Staff#3. LPA also interviewed Residents# 3 through Residents#5. Per IB Investigator, it was revealed that resident/victim(R1) denied abuse by anyone within the facility. R1 further stated to the investigator that they feel safe and happy living in the facility. IB investigator interviewed R2 and it was revealed that R2 never witness abuse at the facility but was told by R1 that they do not like when a male care staff changes their diaper. LPA interviewed administrator and confirmed that the facility was made aware from a resident that they have reported abuse to CCLD. The administrator stated that they immediately investigated, and the resident denied any form of abuse. The facility then conducted in-service training with staff on mandatory reporting. 3/3 staff denied the allegation and confirmed that male care staff have a female care staff with them during diaper changes. 5/5 residents interviewed denied witnessing or experiencing any form of abuse at the facility. 3/3 residents further confirmed that male care staff has a female care giver in the room during diaper changes. 4/5 residents stated they felt safe at the facility. Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Carmen Galicia and a copy of this record provided.the state’s words, verbatim · CDSS document, Nov 3, 2022 · control 28-AS-20220916162018

Type of visit: Case Management - Incident

On 10/21/2022 at 1:27p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Case Management visit for an incident report and SOC341 received by CCLD on 10/10/2022. Carmen Galicia, Administrator faxed the Special Incident Report and SOC341 to the CCLD office as indicated on reporting requirements. Upon arrival LPA met S1 and explain the reason for the visit. At 1:37 Administrator Carmen Galicia arrived, and LPA explained the reason for the visit. During the visit LPA toured the facility. LPA interviewed administrator, and Residents R1 through R3. LPA obtained a copy of staff roster, Resident roster, Incident report dated 10/10/22, SOC341 dated 10/11/2022, R1’s psychiatric evaluation dated 10/14/2022, R2’s psychiatric evaluation dated 10/14/2022, house rules, and S2 internal incident report. Report continued on 809c The Special Incident Report indicates that the incident occurred on 10/08/2022 at approximately 10:10 am and involved a physical altercation between Resident #1 (R1) and Resident #2 (R2). According to the report R1 struck R2 with bare hands because R2 taunted R1. Interview with Administrator revealed there was a witness Resident #3(R3). LPA interviewed R3 to obtain more information. According to R3, R2 wanted a lighter, to which R1 asked R2 where was R2’s other Lighters. R2 then became verbally aggressive and threaten R1. R1 then proceeded to become agitated and walked closer to R2. R2 tried to kick R1 in the groin but missed and R1 then struck R2. Staff then proceeded to break up the altercation. Staff #2 (S2) was not available for interview, but per S2 internal incident report, S2 did not witness how the incident started but heard the residents arguing. S2 stated they saw R1 grab R2’s face and intervened to stop the confrontation. R1 stated that R2 was verbally aggressive and then R1 hit R2. R2 stated that they do not remember what happened during the altercation. R1 stated that they are getting along with R2. The administrator confirmed both residents was laughing together days after altercation. Psychiatric evaluation for R1 stated R1 is not a danger and is fine to stay in the facility. R2 is currently undergoing psychiatric evaluations. Per discussion with Administrator both residents will be given a warning as they broke house rule number #1 and the facility will create a plan of supervision for the residents during there smoke breaks. During today’s visit, there were no deficiencies cited, per Title 22 regulations. Exit interview conducted and a copy of the report was given to Administrator Carmen Galicia during the exit interview.the state’s words, verbatim · CDSS document, Oct 21, 2022

Allegation investigated: Staff will not take resident to the doctor Staff are not following physician's orders Staff are not washing residents clothes/sheets properly

On 9/29/2022 at 9:00 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Administrator Carmen Galicia and explained the reason for the visit. The initial complaint visit was conducted on 8/30/2022. The investigation consisted of the following: During the initial visit, LPA toured the facility with the administrator and obtained the resident/ staff roster, R1's discharge paperwork dated 7/25/22, 8/19/22, 8/24/22, and 8/26/22. LPA received a copy of Incident reports dated 7/25/22, 8/1/22, and 8/19/2022, Pest control reports dated 8/10/22 and 8/17/2022, Laundry schedule, list of R1’s medications, and a copy of R1's MAR. LPA interviewed residents R1 through R6. LPA Interviewed administrator and staff S1. During the subsequent complaint, LPA received written notice from R1's primary care provider confirming that R1 is negative for scabies. Report continued on 9099c Unsubstantiated The investigation revealed the following: regarding “Staff will not take the resident to the doctor”, it was alleged that the facility would not send R1 to the doctor. R1 was admitted into the facility on 7/20/22. R1 was sent to the hospital on 7/25/22, 8/1/22, and 8/19/22. The facility sent SIRs via fax to Licensing office for all of R1’s hospital visits. LPA interviewed the administrator and confirmed that R1 was sent to the hospital upon request. S1 confirmed that the facility sends residents to the hospital when they request it or when there is a change in the residents’ condition. 5/6 residents confirmed that the facility have sent residents to the hospital when needed. R1 confirmed seeing a doctor since the complaint. The investigation revealed the following: regarding “Staff is not following physician’s orders”, it was alleged that R1 was prescribed scabies cream and staff is not putting it all over the body as directed. LPA reviewed R1's MAR and confirmed R1 was prescribed permethrin for history of parasitic disease. The facility administered the medication on 8/25/22 per R1’s MAR. The administrator stated the cream was not for scabies and was prescribed to R1 because R1 complained of bed bugs. The administrator also stated that the resident never complained of scabies. Staff 1 indicated the medication was a one-time use and was given as prescribed. 5/6 residents stated they have always received their medications from the facility with no problems. LPA also reviewed discharged paperwork from Kaiser dated 8/24/22 and confirmed a scabies test was not performed on R1. The primary care provider for R1 issued a letter to the facility confirming that R1 does not have scabies. The investigation revealed the following: regarding “Staff is not washing residents’ clothes/sheets properly”, it is alleged that the facility is not washing R1’s clothes properly to clear scabies. R1's primary care provider stated that R1 does not have scabies. The administrator stated that R1's bedroom has bed bugs and is currently being treated. 5/6 residents stated that staff wash their clothes once a week without any issues. 1/6 of the residents stated that the facility should follow a certain procedure while washing residents' clothes to remove scabies. For the bed bugs allegation please refer to complaint # 28-AS-20220912122555 dated 9/12/22. Based on LPA's interviews, and file review the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Carmen Galicia and a copy of this record provided.the state’s words, verbatim · CDSS document, Sep 29, 2022 · control 28-AS-20220823114418

Type of visit: Case Management - Incident

On 6/14/2022 at 9:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced case management inspection at the facility. LPA met with Administrator Carmen Galicia to discuss the purpose of the visit, which is to gather additional information regarding the SIR/UIR (unusual incident report) dated 6/10/22 for an incident involving Resident #1(R1) and Resident #2(R2). According to the incident report, R1 struck R2 in the head with an aluminum cane. The incident resulted in R2 receiving a half-inch scar on the right side of the head. The facility called the police, and R1 was taken into custody. During today's visit, LPA interviewed Administrator, staff (S1), R1, R2, R3 and R4. LPA reviewed R1 and R2 files and toured the facility with administrator. LPA did not observe signs of neglect, abuse, or other immediate health and safety threats. LPA obtained copies of the following documents: Report continued on 809c · Staff roster · Resident roster · Police report · R1 individual service plan · R1 Assessment Form · R1 and R2 physicians report · Copy of incident reports · In service training record · SOC 341 Interviews confirmed that R2 will go to R1’s room to visit R1’s roommate. R1 stated R2 stole $80 and 2 wallets from the room. LPA interviewed S1 who was present during the incident. S1 confirmed hearing a hollow noise but did not see the altercation because S1 was removing the trash. S1 confirmed calling for assistance when the altercation happened, and staff arrived with in 2 mins. Administrator stated facility called the police, completed SOC341, send incident report’s to CCLD, completed a physic evaluation for R1 (which will be faxed to LPA) and had an Inservice with staff. Administrator confirmed both residents had never exhibited aggressive behavior. Administrator plan to keep residents separated and to relocate R1 to a different room tomorrow 6/15/22. Administrator also stated R1 will use a walker and not a cane in the facility. LPA file review confirmed both residents do not have aggressive behavior as stated in the physician’s report. During today’s visit, there were no deficiencies cited, per Title 22 regulations. Exit interview conducted and a copy of the report was given to Administrator Carmen Galicia during the exit interview.the state’s words, verbatim · CDSS document, Jun 14, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Annual visit using the infection Control Evaluation Tool. LPA arrived unannounced and met with Receptionist Khrysta Margaros and Activity Coordinator Rosa Villalpando. The purpose of the inspection was discussed. The Administrator Chanel Sanchez , arrived shortly after to assist with the visit. During today's visit, LPA used the infection control tool to evaluate the facility. The facility is licensed for eighty eight (88) residents of which (20) can be ambulatory and (68) non ambulatory. The facility has a hospice waiver for eight (8) and currently has three (3) resident on hospice. LPA and administrator toured the facility at 9:30 am. Areas inspected included but are not limited to: Dining room, activity room, TV room, common areas, eight (8) residents bedrooms - four (4) on each floor, kitchen, medication room. There are forty four (44) resident rooms. 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. The outdoor activity area is free of visible hazards and debris. 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, 107, 117, 122 were inspected on the first floor, rooms 236, 239, 340, 242 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. The emergency call light was tested on (3) rooms and was operating at the time of the visit. LPA observed the laundry room which contained 3 washers and 3 dryers. Activity room and TV room was also observed. Continue 809C The facility has a sprinkler system with wired alarm. 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. The hallways and stairways were inspected and were free of any obstructions. 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. LPA reviewed 6 resident files to confirm emergency contact is updated. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. LPA randomly chose some residents' medications to review. Medications are documented properly and stored appropriately. 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, Feb 17, 2022

Allegation investigated: Resident left in soiled diapers Residents bed linins are not being changed timely Residents personal belongings are missing Staff are not answer residents call button timely

Licensing Program Analyst (LPA) Christine Wong conducted an unnnounced complaint visit to the above facility and investigateed the abvoe allegations. LPA met with Janitor- Reynaldo Apostol and explained the reason of the visit. At around 9:20am, the adminsitrator Chanel Sanchez arrived and assisted with the visit. The investigation consisted of the following: On today's visit, LPA interviewed seven (7) residents, administrator and four (4) staff. LPA also obtained copy of documents for Resident#1 and #2 (R1 and R2) The investgiation revealed of the following: Allegation#1 "Resident left in soiled diapers." LPA interviewed seven (7) residents and five residents reported they never left in soiled diapers. The caregiver usually come regularly to change them or residents would use the call light/call button and ask the caregivers to change them if needed. LPA interviewed staff and staff denied the allegation and reported they never left residents in soiled diapers from a long time. They always tried to keep them clean and dry. (See LIC9099C for continuation) Unsubstantiated Allegation#2 "Residents bed linins are not being changed timely" LPA interviewed seven (7) residents and five (5) residents reported the staff usually changed their bed linen daily or every two to three days. The bed linens are always clean. LPA interviewed staff and denied the allegation and reported they usually changed residents' bed linens depends on their daily condition but for regular base, the residents' bed linens usually changed once or twice weekly. Allegation#3 "Residents personal belongings are missing" LPA interviewed seven (7) residents and five (5) residents reported they never lost anything in the facility. They all feel safe living in the facility. LPA asked staff and reported they usually would assist resident to locate the missing items or sometimes residents belongings are still in their bedroom or laundry bag which they did not recognize. Allegation#4 "Staff are not answer residents call button timely." LPA interviewed seven (7) residents and six (6) residents reported that the caregiver always answered the call light/call button in a timely manner. The longest time that the caregiver would usually take about ten minutes. They do not have any issues with the call button/call light. LPA interviewed staff and denied the allegation. The staff usually responded the call button right away. The administrator reported if the caregivers are busy with the residents, other staff in the facility would step in and help out too. Based upon interviews conducted, record review, and observations made the findings indicate that, although the allegations may have happened or are 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 with Administrator Chanel Sanchez. A copy of the report was provided. Based on interviews conducted, observation and records review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit Interview was conducted with the Administrator, Chanel Sanchez and a copy of report and appeal right was provided.the state’s words, verbatim · CDSS document, Dec 9, 2021 · control 28-AS-20211206123535

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Dec 23, 2021

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility(2)The licensee shall provide assistance in meeting necessary medical and dental needs. The requirement is not met ad evidenced by : record review and R1's interview, LPA reviewed R1 phyisican report and discharge paper and R1 required insulin Lispro Sliding scale and finger stick blood sugar and there's no discontinuation paper from doctor in R1's file and facility is not following doctor's orderthe state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: The administrator will ensure the provide assistance in meeting necessary residents' medical needs. The administrator will retrain the staff and ensure each resident has a plan for their incidental medical and dental care and send the staff training log to LPA by POC due date.

Allegation investigated: Facility has lice.

Licensing Program Analyst (LPA) Christine Wong conducted a unannounced complaint visit to address the above allegation. LPA met with Administrator, Chanel Sanchez and explained the reason for the visit. The investigation consisted of the following: On today's visit, LPA interviewed five staff (S1-S5), six residents (R2-R6). LPA also reviewed Resident#1 (R1)'s file and obtained copy of staff and resident roster, R1's face sheet and physician report. The investigation revelaled of the following: Allegation: "Facility has lice". LPA interviewed six (6) residents and four residents reported the facility has lice. They reported they either knew some residents had it or they are currently on the head lice treatment now. LPA interviewed five staff and all reported some residents had head lice and some of them are in the treatment now or they already had finished the head lice treatment. (See LIC 9099C for continuation) Substantiated Based on LPA’s interviews which were conducted, the preponderance of evidences standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) are being cited on the attached LIC 9099D. Exit interview conducted and a copy of the report and the appeal rights were given to the administrator Chanel Sanchezthe state’s words, verbatim · CDSS document, Oct 13, 2021 · control 28-AS-20211004120039

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 27, 2021

87468.1 Personal Right of Residents in All facilities. (a)(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment The requirement is not met as evidenced by LPA's interviews and recorded review, four out of six residents reported that facility has head lice, either they heard about it or either they are on lice treatment now. Staff also reported facilty has head lice and residents are on treatment now which posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 13, 2021

Plan of correction: The administrator will ensure residents to be accorded safe and healthful and comfortable accomendations..etc. The administrator will send a plan to LPA about how to prevent head lice in the facility by POC due date.

Allegation investigated: Staff threw away resident’s belongings without permission.

Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation. The purpose of the visit was discussed with Administrator Chanel Sanchez. The investigation consisted of the following: A physical plant tour of the interior and exterior physical plant was conducted. LPA observed Resident (R1's) room. Staff (S1-S4) and Residents (R1- R10) were interviewed. R1's file documents were reviewed and obtained: [Identification and Emergency Information, Admission Agreement, Client/Resident Personal Property and Valuables, Additional Valuables Inventory List, Bed bug policy, House Rules, Resident Acknowledgement of Room Safety Inspection, Bed Bug procedures, LIC 500 Personnel Report, resident roster, and pest control service contract-in-voice. RTC Pest Control company was present during the visit treating a total of 5 rooms and common areas for cockroaches. Pictures of R1's room belongings during the clean-up and furniture removal were reviewed. Two (2) pictures were obtained. **** See LIC 9099C for continuation of report. Unsubstantiated Allegation: "Staff threw away resident’s belongings without permission." Based on record review and interviews conducted, on September 7, 2021 facility staff went into resident's rooms to remove furniture and personal belongings that were infested with cockroaches. A previous complaint dated 8/16/21 addressing cockroaches in the facility was substantiated. As a result facility Administrator and staff inspected rooms that had cockroaches and bed bugs and discarded infested furniture. Resident (R1) was out of the facility when staff went into the room to clean it and threw away an alleged new rocking chair. Per observation, the rocking chair has not been replaced. Administrator stated that if R1 provides a receipt of R1's alleged "new" rocking chair that was thrown away the facility will purchase a replacement chair. Residents interviewed confirmed some of their belongings and furniture were thrown away because they had a lot of cockroaches. Four (4) out of 10 residents stated their furniture and personal belongings were thrown away without permission due to cockroaches in their room. However, the facility gave notification of clean-up and removal of furniture [if needed] on August 25, 2021 during a resident meeting held outdoors. Facility provided residents a Resident Acknowledgement of Room Safety Inspection form that they signed. The facility has a pest control contract in place. Pest services are being conducted weekly. As a result, staff remove items prior to pest heat treatment. Any furniture that is infested with cockroaches and bed bugs is discarded into the temporary commercial trash bin outside. Pest services found cockroach infestation and bed bugs in Resident (R1's) room. Nine (9) pictures were obtained. Staff interviewed stated they were instructed to throw away R1's belongings as a remediation plan to the cockroach infestation. During today's visit, LPA observed staff prepping, cleaning, and throwing away items from another resident's room that will be receiving pest services today. Many cockroaches were observed in the furniture that was being thrown away. Per facility Bed Bug Procedure and House Rule protocols state that "personal belongings sanitized or disposed" and "residents will allow staff to dispose of items that are not safe, could cause a pest problem, or could be a fire hazard." Based upon interviews conducted, record review, and observations made the findings indicate that, although the allegations may have happened or are 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 with Administrator Chanel Sanchez. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2021 · control 28-AS-20210910160143

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1 · Plan of correction due date: Sep 16, 2021

UNSUBSTANTIATED- NO deficiencies cited. Page created and final printed in error.the state’s words, verbatim · CDSS document, Sep 16, 2021

Allegation investigated: Staff did not ensure facility was free from cockroaches

Licensing Program Analyst's (LPA's) Linda Almaraz and Luis Mora conducted a complaint visit to investigate the allegations listed above. LPA met with Office Assistant, Margarette Cartera and discussed the reason for todays visit. Later during the visit, Assistant Administrator Aurora Tecson arrived. The investigation consisted of the following: LPA requested staff and resident roster, and collected Pest Control records. LPA conducted interviews with Cartera, Tecson, Staff #1 and Residents # 1-10. The investigation revealed the following: Interviews conducted with residents revealed the facility has a on going issue with cockroaches at the facility. Eight (8) out of Ten (10) residents stated they have seen roaches in their rooms and in their drawers. Interviews with staff revealed although the facility has cockroaches they have been receiving treatments from the pest control company. Records reviewed revealed the facility has had a cockroach issue since last year. (Continued on an LIC 9099C) Substantiated Pest control records indicated the facility was on a monthly treatment last year and started doing every other week treatments for cockroaches for the past 2 months. Invoice records indicated the resident rooms are not being treated for cockroaches and only common areas are being treated. During the facility walk-through, LPA's saw a live cockroach in pantry #2 and seen several dead roaches in residents rooms and kitchen. Based on interviews conducted, observation and records review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. This is a repeated citation from 3/29/2021. Civil Penalties assessed. An exit Interview was conducted with the Assistant Administrator and a hardcopy was provided. Appeal Rights was also provided.the state’s words, verbatim · CDSS document, Aug 20, 2021 · control 28-AS-20210816084316

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 3, 2021

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews and documents reviewed, the facility continues to have issues with cockroaches at the facility despite receiving treatments every other week which poses a potential health and safety risk to residents incare.the state’s words, verbatim · CDSS document, Aug 20, 2021

Plan of correction: Administrator will increase the frequency of treatments to weekly and will treat the whole facility, including resident rooms, for cockroaches to eradicate the issue. Administrator is cleaning the facility next week and will be using a large bin to discard all unnecessary trash and infested furniture. Administrator will email new contract with pest control company by POC due date.