No Ho Residential Care

Allegation investigated: Staff do not ensure residents are properly fed while in care

A subsequent complaint visit was conducted today to deliver above allegation finding. Upon arrival Licensing Program Analyst (LPA) met with staff and later with Administrator Rebeka Durgaryan. During todays visit LPA met with staff at approximately 2:20PM and conducted a physical plant tour. Facility had sufficient food supply during todays visit. At approximately 3:45PM LPA conducted interview with Administrator and explained reason for the visit. Following is a summary of the investigation: On 12/08/2021, an initial complaint inspection was conducted by LPA Saila Walker - the LPA conducted a physical plant tour at approximately 3:51PM; From 3:55PM to 4:08PM, the LPA conducted interviews with two (2) out of six (6) residents. From 4:10PM to 4:26PM, the LPA conducted an interview with administrator. From 4:29PM to 4:33PM, the LPA conducted interviews with one (1) out of two (2) staff. (LIC9099c) Unsubstantiated On 12/28/2021, a subsequent visit was conducted by LPAs Salia Walker and Elsie Campos - LPAs conducted a physical plant tour at 2:15PM. From 2:18PM to 2:22PM, the LPAs conducted an interview with one (1) out of six (6) residents. From 2:49PM to 3:04PM, the LPAs conducted an interview with the administrator. From 3:04PM to 3:35PM, LPAs reviewed and obtained copies of documents. Records reviewed by LPA Walker revealed that former resident (R1) was admitted to the facility on 11/25/2021 upon discharge from hospital. R1 started declining rapidly once at the facility and therefore was placed on comfort care (24 hours) by ABC Hospice. R1 was eventually not taking any food or liquids per hospice plan. R1 lived at the facility for only two weeks (11/25/2021 - 12/09/2021). R1 passed away at this facility with hospice present on 12/10/2021. During the initial and subsequent visit to this home three (3) out (6) residents interviewed did not have any issues with food service. During todays visit (03/28/2023) LPA observed residents eating and enjoying there meals. Based on observation, interviews conducted and records reviewed there is insufficient evidence to support the allegation "Staff do not ensure residents are properly fed while in care". Therefore the allegation is Unsubstantiated at this time. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, Mar 28, 2023 · control 29-AS-20211129153412

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required annual inspection, with emphasis on the infection control procedures and practices and was let into the home by Naira Aghajanyan, Staff. LPA Yee's temperature was taken upon entry. Rebeka Durgaryan, Administrator was contacted via telephone and she arrived at 9:36am to conduct the visit. The reason for today's visit was explained. The home is a single storey home consisting of 5 bedrooms, 3 full bathrooms, a living room, dining room, office and a kitchen. The home has a fire place and is not used. Gas is capped off and fire grates dismantled. During this inspection, a tour of the home, inside and outside was conducted beginning at 11:00am and the following was observed: Coronavirus poster on front door with safety advices and tips Coronavirus poster on wall by the front door Plenty of Personal Protective Equipment were stored in 3 outside storage cabinets Hand sanitizers were observed around the home Facility has cameras located in the dining room, living room and 4 cameras located outside. Licensee is the only one who has access to the recorded information Continued on LIC809-C Staff were observed wearing surgical mask There were sufficient perishable and non-perishable foods Medications were centrally stored in 2 locked filing cabinets Sharp knives were stored in a locked case in kitchen drawer First aid kit was reviewed and met Title 22 requirements. First aid manual was observed Per tour of the 3 resident rooms, a hospital bed, lamps, night stands, chairs and closets were observed except, bedroom #3 is missing a dresser. The front bedroom is used by staff Per tour of the 2 full bathrooms-back and front- utilized by residents, non-skid mats were observed. The front bathroom was missing grab bars. The interconnected Smoke and carbon monoxide combo detectors were tested and were operational. The facility has 2 fire extinguishers - kitchen and in the back lounge were fully charged and expires on May 5, 2023 Water was tested in the front and back bathroom and the water temperature read 140.6 and 137.4 degrees, respectively The backyard was observed to be clean and the front yard was set up with rattan chairs, a table with an umbrella for shade. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted, Appeals Rights discussed and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 24, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Rebeka Durgaryan at 12:03 p.m., and explained the reason for the visit. The LPA toured the physical plant areas inside and outside, with the Administrator at 12:06 p.m., to ensure there are no health and safety hazards. BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. From 12:15 p.m. until 12:42 p.m., hot water temperatures measured between 114.5 and 116.9 degrees Fahrenheit in the common restroom(s). KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. The facility maintains a second refrigerator that contains additional perishable food items. Hot water measured degrees Fahrenheit at 1:12 p.m. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway. Two (2) fire extinguishers were observed to be fully charged and purchased on 06/2021. BACKYARD/FRONT YARD: The front yard has a covered outdoor area equipped with furniture for resident use. The backyard has additional outdoor furnisher for resident use. There were no bodies of water noted. The facility shed is located in the backyard, and is being utilized as additional storage. Continue on LIC 809C.. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time, and the LPA reviewed facility’s policies and procedures as it pertains to infection control. No deficiencies cited at this time. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 15, 2022

Allegation investigated: Resident sustained unexplained injuries while in care

Licensing Program Analyst (LPA) Salia Walker conducted a subsequent complaint visit to deliver findings for the above allegation. The initial complaint visit was conducted on 06/03/2021 by LPAs Salia Walker and Brian Balisi. During today’s visit, LPA Walker met with Administrator Rebeka Durgaryan at 9:10 a.m., and explained the reason for the visit. On 06/02/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was noted that Resident #1 (R1) was hospitalized with extensive injuries which included a humerus fracture to left shoulder due to an assault by R1’s roommate, Resident #2 (R2). R2 also assaulted additional residents causing injury which required medical attention. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Laura Garcia. Continue on LIC9099C.. Unsubstantiated On 06/02/2021, at 9:00am, LPAs Walker and Balisi conducted the initial complaint visit and met with Rebeka Durgaryan, Administrator. Between 9:00am and 11:30am, the LPAs toured the facility with the Administrator, reviewed and obtained copies of records pertinent to the investigation. The LPAs informed the Administrator that the complaint allegation required further investigation. Investigator Garcia conducted interviews with the Administrator on 07/15/2021, at approximately 10:18am and on 09/16/2021, at approximately 12:30pm; with facility staff on 07/15/2021, at approximately 11:00am, on 09/17/2021, at approximately 2:00pm, and on 09/18/2021, at approximately 1:00pm; ; with residents on 09/17/21, from approximately 1:30pm to 2:30pm; and with Resident #3 (R3) responsible party on 10/18/2021, at approximately 11:00am. Investigator Garcia was unable to interview R2 and Resident #4 (R4) due to unable to locate R2’s current placement and R4’s diagnosis of dementia. Investigator Garcia also obtained and reviewed Incident reports, facility records, Los Angeles Police Department (LAPD) Investigative Report, and Kaiser medical records. Information obtained from interviews, incident reports, police reports and medical records, revealed that on 05/30/21 at approximately 12:45am, R2 began assaulting staff and residents by breaking and throwing large blunt objects including furniture and a wheelchair. Staff attempted to intervene and called 911. R2 fled the scene and later returned to the facility. R2 stated to police that an argument had taken place with R1, which prompted R2 to throw an unknown object at R1. R2 told the officers that R2 “blacked out” and when the blackout episode was over, R2 ran out of the facility. R2 was arrested for assault with a deadly weapon and transported to the Hollywood station for processing. R1 sustained extensive injuries including a proximal humeral head fracture to the left shoulder, multiple abrasions, lacerations, traumatic head injury, and was transported to Kaiser Hospital. R3 suffered bruising and a half inch laceration above left eye which required first aid treatment. R4 sustained a nasal fracture and was transported to the hospital. Staff #1 (S1) sustained a laceration to nose and bruising to hand caused by R2 throwing a chair at S1’s head. Continue on LIC9099C.. On the allegation, Neglect/Lack of Care and Supervision - Resident #1 (R1) sustained unexplained injuries while in care: The information Investigator Garcia obtained through interviews with R1, residents at the facility, staff members, and review of the police and medical records found that there was insufficient evidence to determine neglect/lack of supervision by the staff. R1 denied any type of neglect/lack of supervision on behalf of S1 that was caring for residents at the time of the incident on 05/30/2021. R1 stated that S1 immediately intervened in order to protect the residents and attempted numerous times to stop R2 from additional attacks. S1 immediately dialed 911 and provided first aid. According to the police report, officers determined that R2 suffered from a medical emergency/black outs while R2 assaulted the residents. Additionally, upon detaining R2, R2 appeared disoriented and confused. Based on the information and documentation provided, Investigator Garcia determined there was not sufficient evidence to support the above allegation. Therefore, the allegation of neglect/lack of care and supervision is deemed Unsubstantiated at this time. Exit interview, copy of report given.the state’s words, verbatim · CDSS document, Feb 24, 2022 · control 29-AS-20210602122148

Allegation investigated: Staff are prohibiting resident to move from the facility

Licensing Program Analyst (LPA) Salia Walker arrived unannounced for an initial complaint inspection for the above allegation. The LPA met with Naira Aghajanyan at 9:56 a.m., and explained the reason for the visit. During today’s visit, the LPA conducted a physical plant tour at 11:18 a.m., to ensure there are no health and safety hazards. From 10:01 a.m. until 10:20 a.m., the LPA conducted interviews with one (1) staff. From 10:20 a.m. until 10:38 a.m., the LPA conducted an interview with the administrator. From 10:39 a.m. until 11:18 a.m., the LPA conducted interviews with facility residents. From 11:28 a.m. until 11:49 a.m., the LPA conducted a record reviewed and obtained copies of documents pertinent to the investigation. From 12:21 p.m. until 1:11 p.m., the LPA conducted an interview with resident family member(s). Regarding the allegation, ‘Staff are prohibiting resident to move from the facility,’ the complainant’s concern is that the facility is prohibiting resident #1 (R1) from moving out of the facility, and is keeping R1 against R1’s will. Continue on LIC9099C.. Unsubstantiated During the investigation, the LPA conducted interviews with facility staff, the administrator, facility residents, and resident family member(s) which revealed that they believe that there is a language barrier which prohibits staff from communicating effectively with the residents. LPA Walker asked staff #1 (S1) multiple questions regarding care and supervision such as, ‘What would you do if you observed a resident having a heart attack’; ‘Do you know how to call the paramedics’; and ‘What would you do if you observed a resident having a seizure.’ S1’s responses were not consistent with the LPAs questions. When the LPA interviewed the administrator, the administrator denied the allegation. The Administrator stated that staff are able to communicate effectively with all of the residents. The Administrator also stated that staff are utilizing Apps, and books to learn Basic English. When the LPA asked the administrator to instruct S1 to show the App that staff is using to learn English, the administrator stated that S1 did not have it on this phone due to recently switching phones. Interviews with facility residents, and resident family members revealed that they believe ‘It would be good to have a caregiver there that is fluent in English.’ Interviews also revealed that ‘sometimes [staff] don’t understand well’ when residents are asking questions they ‘give [a] blank stare.’ Based on interviews with staff, the administrator, facility residents, and resident family member(s), there is sufficient evidence to support the allegation ‘Staff is unable to communicate effectively with the residents while in care.’ Therefore, the above allegation is found to be Substantiated. The facility was previously cited for the same allegation on 09/14/2021 under section 87411(a). Additionally, civil penalties are being assessed for a repeat violation. Pursuant to Title 22 Division 6 Chapter 8 of the California Code of Regulations, the following deficiency was cited (refer to LIC 9099D). Civil Penalties assessed for Repeat Violation. Exit interview conducted, and appeal rights discussed. A copy of the report, and appeal rights were issued. During the investigation, LPA Walker conducted a record review, interviews with staff, the administrator, facility residents, and resident family member(s). Interviews revealed that It has been proven that R1 not able to care for themselves in their own home. It was reported that upon entry of R1’s home the refrigerator was full of rotten food, overflowing sink with dirty dishes, and the house was unkept. Interviews also revealed that R1 has gone on outing with family, and is not being locked in the facility by any means. Record review revealed that R1 requires supervision, and is not able to leave the facility unassisted due to history of altered mental status. Based on LPAs observation, record review, and interviews conducted. Although, R1 is requesting to move from the facility, given the circumstances R1’s family and medical professionals have highly recommended that R1 remains in a facility providing care and supervision. Based on LPAs observation, R1 is able to go outside to the facility’s front porch, and backyard at any time. Therefore, there is insufficient evidence to support the allegation ‘Staff are prohibiting resident to move from the facility.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 3, 2022 · control 29-AS-20211231141147

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 7, 2022

87411(a) Personnel Requirements – General: Facility personnel shall at all times be.. competent to provide the services necessary to meet resident needs.. facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews and documents reviewed, the Licensee did not comply with the section cited above, as the Licensee failed to ensure that staff are able to communicate effectively with the residents while in care, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 3, 2022

Plan of correction: The Licensee has agreed to do the following: 1.Submit proof of staff training to communicate with residents through the use of communication boards. 2.Submit proof of staff’s translating devices and apps, for basic English.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Salia Walker and Elsie Campos conducted an unannounced Case Management- Deficiencies inspection visit at the facility today due to deficiencies observed during the subsequent visit of complaint control #29-AS-20211129153412. At 2:11 p.m., the LPAs observed a key inserted on the facility’s front entrance doorknob on the outside. At 2:13 p.m., the LPAs advised staff #1 (S1) the facility entrance key is not to be on the front doorknob for the safety of the residents and staff. S1 immediately removed the facility entrance and acknowledged understanding. At 2:49 p.m., the LPAs advised Administrator Rebeka Durgaryan of the facility key being inserted in the front entrance doorknob. The Administrator acknowledged, and explained the reason for the key being placed on the doorknob is per resident request. The LPAs explained to the Administrator and residents the severity of leaving the facility key on the outside front entrance doorknob, as any one can enter the facility, which poses immediate risk to the residents in care. At 2:13 p.m., Resident #1 (R1) opened the front door providing access for the LPAs to enter. At 2:13 p.m., S1 rushed to the LPAs stating that S1 was in the middle of changing another resident. During the physical plant tour at 2:15 p.m., the LPAs also observed a mop bucket with water in the common bathroom. S1 stated she was also in the middle of mopping the common bathroom floor, but stepped away to tend to other resident needs. At 2:49 p.m., the Administrator confirmed R1 has Dementia. The LPAs advised the Administrator that upon arrival R1 opened the door for the LPAs as S1 was unable to open the door timely due to being occupied assisting another resident. The administrator acknowledged understanding. Civil Penalties are being assessed today for a Repeat Violation on section 87411(a), as the facility had been cited for the same citation section 87411(a) on 09/14/2021. Continue on LIC809C.. At 2:26 p.m., the LPAs observed two (2) cabinet doors unlocked containing accessible medications such as over the counter ointments ‘Calmoseptine’, and ‘Triple Antibiotic Ointment.’ At 2:30 p.m., the LPAs observed accessible medication in two (2) out two (2) facility refrigerators that were not properly stored inside a medication lock box. Medications accessible included; ‘risperidone,’ ‘Dulcolax,’ ‘Lorazepam,’ and ‘Sodium Chloride Inhalation Solution.’ The LPAs advised S1 and the Administrator all medications shall be stored inaccessible to residents with Dementia. The administrator stated the facility only has one medication lock box, but would immediately obtain a second medication lock box to secure the remaining resident medications that did not fit in the first lock box. At 2:27 p.m., the LPAs observed the facility’s sharp items lock box was unlocked and accessible to residents in care. The LPAs advised S1 that knives, and sharps shall be locked and secured at all time inaccessible to residents in care. At 2:49 p.m., the LPAs advised the Administrator that the LPAs observed culinary knives, and other sharps were accessible in the kitchen, which poses an immediate health and safety risk to residents in care. The LPA advised the Administrator that all sharps including knives must remain locked and secured at all times while caring for persons with dementia. The Administrator acknowledged understanding. At 2:31 p.m., During the physical plant tour the LPAs observed one (1) out of two (2) facility kitchen refrigerators contained expired condiments. S1 removed the expired condiments and discarded them into the trash bin. At 3:04 p.m., the LPAs conducted a record review. Record review revealed, Resident #1 (R1) did not have a completed facility file, including a completed medical assessment, emergency identification, signed personal rights, resident appraisal, Appraisal needs and Services plan, centrally stored medication and destruction record, Consent to Medical Examination. The only records R1 had in file was hospital records. Record review also revealed the following, Resident #2 (R2) did not have a completed facility file, including a medical assessment, emergency identification, signed personal rights, resident appraisal, Appraisal needs and Services plan, centrally stored medication and destruction record. Record review revealed that Resident #3 (R3) did not have a completed facility file, including an admissions agreement, a completed medical assessment, emergency identification, signed personal rights, resident appraisal, Appraisal needs and Services plan, centrally stored medication and destruction record, Consent to Medical Examination. At 2:49 p.m., the LPAs advised the Administrator that all resident file shall be completed and contain the required forms filled out completely. The Administrator stated that she mailed the form for the residents to the responsible parties, but the responsible parties did not return the completed forms. Continue on LIC809C.. At 3:20 p.m., during the record review the LPAs inquired about the Hospice Care Plans for R2, and R3. The Administrator stated that the ‘ABC Hospice’ did not provide the Care plan for R2. The Administrator also stated that ‘ABC Hospice’ retrieved the Hospice Care plan for R3. The LPAs advised the Administrator the required documentation for two (2) out of five (5) resident files did not contain the Hospice care plan. The LPAs advised the administrator that all records shall be maintained in the facility for the duration of three years. Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties issued.the state’s words, verbatim · CDSS document, Dec 28, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Dec 31, 2021

87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as... cleaning supplies ... This requirement is not met as evidenced by: Based on LPAs observation, the licensee did not comply with the section cited above, as ointments, and multiple medications were accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 28, 2021

Plan of correction: Staff locked and secured items during visit. The Licensee has agreed to do the following: 1. Submit staff training log of section 87705(f)(2) to CCL by 12/31/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Dec 31, 2021

87555(b)(8) General Food Service Requirements(b)The following food service requirements shall apply:(8)All food shall be of good quality.. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as expired food was observed in one (1) out of two (2) facility kitchen refrigerators, which poses a potential health, and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 28, 2021

Plan of correction: The Licensee agreed to do the following: 1. Audit all food, and submit proof of completion to CCLD by 12/31/2021.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 29, 2021

87411(a) Personnel Requirements – General: Facility personnel shall at all times be.. competent to provide the services necessary to meet resident needs.. facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on LPAs observations, the Licensee did not comply with the section cited above, as the Licensee failed to ensure Facility personnel is competent to provide the services necessary to meet resident needs, as the front door had the facility key in the doorknob and a resident had to open the door for the LPAs due to staff being occupied with another resident, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 28, 2021

Plan of correction: The Licensee has agreed to do the following: 1. Submit proof of staff retraining on section 87411(a) to CCLD by 12/29/2021.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(1) · Plan of correction due date: Dec 29, 2021

87705(f)(1) Care of Persons with Dementia: (f)The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on LPAs observation, the licensee did not comply with the section cited, as culinary knives and additional sharp items were accessible during physical plant tour to residents with Dementia, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 28, 2021

Plan of correction: S1 secured the culinary knives and sharp items upon observation. Plan of correction met.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(b) · Plan of correction due date: Dec 31, 2021

87633(b) Hospice Care of Terminally Ill Residents: (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as two (2) out of five (5) resident files did not contain the resident Hospice care plan, which poses a potential health, and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 28, 2021

Plan of correction: The administrator provided a copy of R3's Hospice Care plabn during the visit. The Licensee agreed to do the following: 1. Submit required Hospice records for R2 to CCLD by 12/31/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(a)(g)(A) · Plan of correction due date: Dec 31, 2021

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement,...(g) Admission agreements shall specify the following:(A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. This requirement is not met as evidenced by: Based on record review, the licensee failed to comply with the section cited above, as three (3) out of five (5) residents files were incomplete, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 28, 2021

Plan of correction: The Licensee agreed to the following: 1. Submit proof R1, R2, and R3 completed and signed forms identified in the report to CCLD by 12/31/2021.

Allegation investigated: Staff is unable to communicate effectively with the residents while in care

Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit to deliver the investigation finding for the above allegation. The LPA met with Administrator Rebeka Durgaryan at 08:34 a.m. and explained the reason for the visit. During today’s visit, the LPA conducted a physical plant tour at 08:29 a.m., and conducted an interview with staff #1 (S1). On 07/02/21, LPAs Walker and Balisi conducted an initial complaint visit. Between 9:00 a.m. and 12:00 p.m., the LPAs conducted a physical plant tour, interviewed residents, administrator, as well as reviewed and obtained copies of documents pertinent to the investigation. The LPAs determined, at that time, that further investigation was required. Continued on LIC 9099C.. Substantiated Regarding the allegation, ‘Staff is unable to communicate effectively with the residents while in care’, the complainant’s concern is that the two (2) facility staff are unable to effectively communicate with the residents and/or visitors in English. As a result, there is concern that resident needs are not being met. During the investigation, the LPAs conducted interviews with the facility residents which revealed that they believe that there is a language barrier which prohibits staff from communicating effectively with the residents. It was stated that staff only understand basic needs in English. When the LPAs interviewed the administrator, the administrator denied the allegation. The Administrator stated that staff are able to communicate effectively with all of the residents. The LPAs asked the administrator if staff have ever called the administrator to translate for them. The Administrator stated that this has never happened. The Administrator also stated that staff and residents are always able to communicate with one another. On 06/30/21, a record review revealed that outside agency credible witness have visited the facility and during these visits, the collateral agencies also had difficulty communicating with staff. The records review revealed that they believe that there is a language barrier which prohibits staff from communicating effectively with the residents and outside agencies. It was stated that at times, the staff have to contact the administrator for translation. On 07/15/21, LPA Walker received additional information, which references caregivers whom were unable to speak English. A record review of this additional information revealed that the facility has not maintained consistent English-speaking staff. The LPAs conducted visits on June 3, 2021, July 2, 2021 and on July 16, 2021. During those visits, the LPAs have only observed staff #1 to be working at the facility. The LPAs have never witnessed staff #2 present in the facility. Staff #1 was unable to effectively communicate with residents, outside agencies and the LPAs. During today’s interview, LPA Walker asked staff #1 several questions such as, ‘Does any resident have dietary needs’; ‘How often are residents checked’; ‘In case of an emergency, who would you contact’; ‘What would you do if you observed a resident having a heart attack’; ‘What would you do if you observed a resident fall’; ‘Do you know how to call the paramedics’; and ‘What would you do if you observed a resident having a seizure’. Staff #1 did not appear to understand any of the LPA’s questions and stated ‘no understand, and I don’t know’. Continued on LIC 9099C.. Based on the record review, outside agency creditable witness, interviews with staff, residents, and the administrator, there is sufficient evidence to support the allegation ‘Staff is unable to communicate effectively with the residents while in care.’ Therefore, the allegation, ‘staff is unable to communicate effectively with the residents while in care’ is deemed Substantiated at this time. Deficiencies cited on 9099-D Exit interview conducted, a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 14, 2021 · control 29-AS-20210628101044

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 14, 2021

87411(a) Personnel Requirements – General: Facility personnel shall at all times be.. competent to provide the services necessary to meet resident needs.. facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews and documents reviewed, the Licensee did not comply with the section cited above, as the Licensee failed to ensure that staff are able to communicate effectively with the residents while in care, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2021

Plan of correction: The Licensee has agreed to do the following: 1.The Licensee will document a plan of action, ensuring that the staff can communicate effectively and thus meeting the needs of the residents. This plan of action will be submitted to the LPA by 09/21/21.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the subsequent visit of complaint control # 29-AS- 20210628101044. At 08:39 a.m., the LPA identified there were two (2) staff to 5 residents. The staff #1 (S1) claimed that they have been working at the facility for ‘one month’. The LPA confirmed that this individual was not associated to this facility. At 9:00 a.m., it was revealed through interview with Administrator and identification verification that staff #2 (S2) was also not associated to this facility. Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties issued.the state’s words, verbatim · CDSS document, Sep 14, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 14, 2021

87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance… This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above, as two individuals (S1, S2) have been working at the facility without a background clearance, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2021

Plan of correction: The Administrator has agreed to do the following: 1. Submit documentation for S1, and S2 to be associated with the facility with background clearance by 09/17/21. Zero tolerance violation; immediate civil penalty assessed of $1000

Allegation investigated: Facility does not provide a safe environment for residents in care.

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced at 9:10 a.m. to conduct an initial complaint visit. The LPA met with Administrator Rebeka Durgaryan and explained the reason for the visit. During today's visit, the LPA conducted a tour, reviewed files at 9:30 a.m., interviewed staff at 9:49 a.m., interviewed residents from 9:59 a.m. - 10:10.am, and, interviewed a family member of a resident at 10:15a.m. Regarding the allegation, it was alleged that the facility was creating an unsafe environment, as residents were allegedly given access to lighters to smoke cigarettes. There was a concern that allowing a resident access to a lighter could create an unsafe environment, especially for residents whom use oxygen. During today's visit, the LPA observed a designated smoking area in the front and the back of the house. Observations confirmed that the designated smoking area(s) are over fifteen (15) feet from any window or entryway into the home. Unsubstantiated The LPA reviewed files at 9:30 a.m., and confirmed that facility house rules state that smoking may only take place in designated areas. At the time of the visit, there was only one resident (R1) identified as someone who smokes. At 9:55 a.m, the LPA observed that lighters were kept locked in a locked box in the kitchen drawer. The LPA interviewed R1, who confirmed that they only smoke in designated areas in the facility, and denied ever smoking inside the facility. R1 claims to not have smoked in the presence of any resident whom was on oxygen. R1 did not have their lighter and noted that it was locked up. In addition, the LPA interviewed a family member of another resident who was present during today's visit, and they confirmed that they have not observed anyone smoking either inside or outside of the facility. This particular family member visits this facility at least twice a day. During today's visit, the LPA observed appropriate 'No Smoking - Oxygen in Use' signs for those residents whom use oxygen. The Administrator confirmed that R1 occasionally smokes, and confirmed that they only allow R1 to smoke in designated areas. Based on the information obtained, there is insufficient evidence to support the claim that the facility does not provide a safe environment for residents in care. The facility has a house rule that addresses a policy around smoking in designated outdoor areas and lighters are locked up for the safety of all residents. The designated smoking areas are an appropriate distance from the facility. This allegation is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 16, 2021 · control 29-AS-20210712112759