Chateau Magnolia

Allegation investigated: Staff hit resident Staff covered resident's face Staff threatened resident with harm

The purpose of this report is to provide additional infomation regarding Staff S1's date of termination. Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Karine Filikyan. The purpose of the visit is a subsequent complaint visit and to deliver findings from the original complaint dated 06/07/2022. The initial visit was conducted on 06/14/2022 and the following was done: Facility tour was conducted at 10:00 AM which included 6 client bedrooms, 2 client bathrooms, living room, dining room, kitchen, front and backyard area. Interviews were conducted at 10:15 AM to 11:00 AM with S 1 and Administrator. A subsequent visit was conducted on 10/05/2022 and included the following: Interviews were conducted at 10:50 AM to 11:05 AM with Administrator. Interview was conducted telephonically with former Staff S 1 from 11:05 to 11:20 AM. The termination date from the facility for Staff S 1 was 06/01/2022. Substantiated At today's visit interviews were conducted with Staff S2 and Resident's # R 2- R 4 from 930AM to 10:10 AM. Interviews with Staff S 2 and Resident's 2-4 were done telephonically with Licensing Program Analyst (LPA) Nune Margaryan acting as translator in the Armenian language with R2-R 4 who were Armenian speaking. Investigation included the following: Interviews with staff, residents, family member of Resident R 1 and video of the incident inside Resident R1's room. In regards to the allegation Staff hit resident, video footage was obtained that shows Staff S 1 hitting R1 with a pillow and placing the pillow over the resident's head, calling the client an "asshole" and threatening the resident with physical restraints. Video obtained by family member of R 1 who stated that the incidents occurred between May 3 and June 1, 2022. Based on LPA's interviews and record review, the investigation revealed 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 1 are being cited on the attached LIC 9099D. In regards to the allegation Staff covered resident's face, video footage was obtained that shows Staff S 1 hitting R1 with a pillow and placing the pillow over the resident's head, calling the client an "asshole" and threatening the resident with physical restraints. Video obtained by family member of R 1 who stated that the incidents occurred between May 3 and June 1, 2022. Based on LPA's interviews and record review, the investigation revealed 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 1 are being cited on the attached LIC 9099D. In regards to the allegation Staff threatened resident with harm, video footage was obtained that shows Staff S 1 hitting R1 with a pillow and placing the pillow over the resident's head, calling the client an "asshole" and threatening the resident with physical restraints. Video obtained by family member of R 1 who stated that the incidents occurred between May 3 and June 1, 2022. Based on LPA's interviews and record review, the investigation revealed 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 1 are being cited on the attached LIC 9099D. the alleged violation did or did not occur, therefore the allegation is unsubstantiated. In regards to the allegation Staff does not ensure that COVID masking protocols are followed, LPA on facility visits 06/14/2022,10/05/2022 and today's visit 06/22/2023 observed staff wearing masks and the facility being equipped with a 90 day supply of PPE. 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. In regards to the allegation Staff had inappropriate interaction with a resident, interviews with staff who stated that there has not been inappropriate interactions such as massages being done by staff to residents and nothing inappropriate. Resident's R2- R 4 stated that there has not been any massages or any inappropriate interactions with staff and resident's. 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. In regards to the allegation Facility smells like cigarette smoke, LPA on facility visits 06/14/2022,10/05/2022 and today's visit 06/22/2023 did not smell any cigarette smoke and did not see any cigarette buds or ashtrays at the facility. Interview with Resident's R2-R4 who all stated that no resident or staff are smoking at the facility and there has never been a smell of smoke at the facility. 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.the state’s words, verbatim · CDSS document, Jul 24, 2023 · control 28-AS-20220607104211

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jun 23, 2023

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on video observation and interview the licensee failed to have client free from punishment, infliction of pain and humiliation by Staff S 1 calling the client an "asshole" and threatening the resident with physical restraints, and by Staff S 1 hitting R1 with a pillow and placing the pillow over R1's face which posed an Immediate Health and Safety Risk to resident's in care.the state’s words, verbatim · CDSS document, Jul 24, 2023

Plan of correction: Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date. Administrator to review Title 22 Regulations, Section 87468.1 on Personal Rights, and conduct an in-service staff training on Personal Rights and Mandated Reporting. Submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training.

Allegation investigated: Staff hit resident Staff covered resident's face Staff threatened resident with harm

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Karine Filikyan. The purpose of the visit is a subsequent complaint visit and to deliver findings from the original complaint dated 06/07/2022. The initial visit was conducted on 06/14/2022 and the following was done: Facility tour was conducted at 10:00 AM which included 6 client bedrooms, 2 client bathrooms, living room, dining room, kitchen, front and backyard area. Interviews were conducted at 10:15 AM to 11:00 AM with S 1 and Administrator. A subsequent visit was conducted on 10/05/2022 and included the following: Interviews were conducted at 10:50 AM to 11:05 AM with Administrator. Interview was conducted telephonically with former Staff S 1 from 11:05 to 11:20 AM. At today's visit interviews were conducted with Staff S2 and Resident's # R 2- R 4 from 930AM to 10:10 AM. Interviews with Staff S 2 and Resident's 2-4 were done telephonically with Licensing Program Analyst (LPA) Substantiated Nune Margaryan acting as translator in the Armenian language with R2-R 4 who were Armenian speaking. Investigation included the following: Interviews with staff, residents, family member of Resident R 1 and video of the incident inside Resident R1's room. In regards to the allegation Staff hit resident, video footage was obtained that shows Staff S 1 hitting R1 with a pillow and placing the pillow over the resident's head, calling the client an "asshole" and threatening the resident with physical restraints. Video obtained by family member of R 1 who stated that the incidents occurred between May 3 and June 1, 2022. Based on LPA's interviews and record review, the investigation revealed 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 1 are being cited on the attached LIC 9099D. In regards to the allegation Staff covered resident's face, video footage was obtained that shows Staff S 1 hitting R1 with a pillow and placing the pillow over the resident's head, calling the client an "asshole" and threatening the resident with physical restraints. Video obtained by family member of R 1 who stated that the incidents occurred between May 3 and June 1, 2022. Based on LPA's interviews and record review, the investigation revealed 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 1 are being cited on the attached LIC 9099D. In regards to the allegation Staff threatened resident with harm, video footage was obtained that shows Staff S 1 hitting R1 with a pillow and placing the pillow over the resident's head, calling the client an "asshole" and threatening the resident with physical restraints. Video obtained by family member of R 1 who stated that the incidents occurred between May 3 and June 1, 2022. Based on LPA's interviews and record review, the investigation revealed 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 1 are being cited on the attached LIC 9099D. the alleged violation did or did not occur, therefore the allegation is unsubstantiated. In regards to the allegation Staff does not ensure that COVID masking protocols are followed, LPA on facility visits 06/14/2022,10/05/2022 and today's visit 06/22/2023 observed staff wearing masks and the facility being equipped with a 90 day supply of PPE. 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. In regards to the allegation Staff had inappropriate interaction with a resident, interviews with staff who stated that there has not been inappropriate interactions such as massages being done by staff to residents and nothing inappropriate. Resident's R2- R 4 stated that there has not been any massages or any inappropriate interactions with staff and resident's. 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. In regards to the allegation Facility smells like cigarette smoke, LPA on facility visits 06/14/2022,10/05/2022 and today's visit 06/22/2023 did not smell any cigarette smoke and did not see any cigarette buds or ashtrays at the facility. Interview with Resident's R2-R4 who all stated that no resident or staff are smoking at the facility and there has never been a smell of smoke at the facility. 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.the state’s words, verbatim · CDSS document, Jun 22, 2023 · control 28-AS-20220607104211

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jun 23, 2023

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on video observation and interview the licensee failed to have client free from punishment, infliction of pain and humiliation by Staff S 1 calling the client an "asshole" and threatening the resident with physical restraints, and by Staff S 1 hitting R1 with a pillow and placing the pillow over R1's face which posed an Immediate Health and Safety Risk to resident's in care.the state’s words, verbatim · CDSS document, Jun 22, 2023

Plan of correction: Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date. Administrator to review Title 22 Regulations, Section 87468.1 on Personal Rights, and conduct an in-service staff training on Personal Rights and Mandated Reporting. Submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training.

Type of visit: Case Management - Deficiencies

During the course of complaint investigation # 28-AS-20220607104211 issued on 06/07/2022 the following deficiency was observed: 87405(d)(5)- the administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. Good character and a continuing reputation of personal integrity. 87405 (d)(5) Administrator was not forthright with the Department by denying knowledge of the incident and saying client left because of constipation issues and did not disclose the incident.the state’s words, verbatim · CDSS document, Jun 22, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(5) · Plan of correction due date: Jun 26, 2023

Administrator - Qualifications and Duties The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by: Administrator was not forthright with the Department by denying knowledge of the incident and saying client left because of constipation issues and did not disclose the incident which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 22, 2023

Plan of correction: Administrator to review Title 22 Regulations and submit self certification by POC due date that she will show good character and integrity at all times.

Allegation investigated: Staff are unable to communicate due to language barrier Medications were left accessible to residents Staff do not follow protocals to prevent the spread of COVID-19

Subsequent visit made 10/17/2022 to correct the sections cited on 809D only. Findings remain the same. Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to the facility. LPA was greeted by caregiver who was not wearing a mask and did not screen LPA as required. Administrator arrived a little later. Facility tour was conducted at 9:47am which included 6 client bedrooms, 2 client bathrooms, living room, dining room and kitchen. Interviews were conducted with Administrator, House manager and staff #1 and #2. Interviews were conducted with R1 and R2 Regarding allegation: Staff do not follow protocols to prevent the spread of COVID-19 LPA was greeted by S1 and S1 was not wearing a mask and did not screen LPA at entrance. A tray was set up at entrance to screen, but screening was not done. LPA observed Administrator and house manager wearing mask most of the time of visit, Administrator would pull mask down under her chin and house manager wore mask under her nose. Substantiated Regarding the allegation: Staff are unable to communicate due to language barrier with residents, on visit conducted 04/26/22 and based on LPA's observation and interviews staff member who greeted LPA had difficulty communicating because of the language barrier. S1 stated did not understand English very well. R1 stated that the language barrier is the barrier that most affects care and needs. Regarding allegation: Medications were left accessible to residents, LPA, administrator and S1 observed medication and PRN (vitamins) accessible to clients. LPA observed the cabinet with key hanging from the lock and drawer of medications under kitchen cabinet unlocked. During visit LPA observed S2 working and not being associated with facility. S2 stated today was her first day. S2 was sent home during visit. Civil penalties issues. Based on LPA's observations and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Oct 17, 2022 · control 28-AS-20220418123049

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 24, 2022

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: LPA observed PRN and tylenol in 3 of 4 rooms.the state’s words, verbatim · CDSS document, Oct 17, 2022

Plan of correction: Administrator locked and removed all PRN and medication at time of visit. ***No further Action required***

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(c)(1)(f) · Plan of correction due date: Oct 24, 2022

87470 (c) (1) (f) 87470 - Infection Control Requirements..An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. The requirement is not met as evidenced by: On 4/26/22 1 staff was observed not wearing a mask.the state’s words, verbatim · CDSS document, Oct 17, 2022

Plan of correction: The administrator will ensure the facility is following infection control plan and the administrator will retrain the staff about the infection control and send the staff training log to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Oct 24, 2022

87411 Personnel requirements: (d)(3) Skill and knowledge required to provide necessary resident care and supervision. This requirement is not met as evidenced by: Based on observation and interviews conducted with staff and residents, One staff is unable to communicate with english speaking residents.the state’s words, verbatim · CDSS document, Oct 17, 2022

Plan of correction: Licensee will review Title 22 Regulations, Section 87411 and submit a written plan detailing on how licensee will ensure that staff are receiving the required in-service trainings according to the Regulation and send proof of training by the POC due date.

Type of visit: Case Management - Deficiencies

This report is being written separately as it is not part of the complaint dated 4/18/2022 During the course of the complaint investigation on 4/26/2022 and while interviewing staff, It was discovered that S2 did not have background Clearance nor associated with facility. Licensee has been cited and civil penalties issued, please 809D for details. Exit interview conducted and copy of report will be emailed to Licensee due to printer issuesthe state’s words, verbatim · CDSS document, Oct 17, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87219(e) · Plan of correction due date: Oct 24, 2022

Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement was not met as evidenced by: Based on interview, record review and observation, 1 sttaff S2, did not have background clerance or assosicated with facility.the state’s words, verbatim · CDSS document, Oct 17, 2022

Plan of correction: Administrator will obtain background clerance associated S2 prior to working at facility. S2 was sent home during visit. Civil penanty assesesd $100

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff Gohar Retzosyan. Administrator Karine Filikyan arrived shortly thereafter. The purpose of this report is regarding Complaint # 28-AS-20220607104211 dated 06/07/2022. During the course of the complaint investigation the following deficiencies were observed: 87412(a)(9)(10)- Personnel Records The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: Termination date if no longer employed by the facility. Reasons for leaving. Deficiency cited on the 809 D.the state’s words, verbatim · CDSS document, Oct 5, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)(9)(10) · Plan of correction due date: Oct 5, 2022

Personnel Records The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: Termination date if no longer employed by the facility. Reasons for leaving. This requirement is not met as evidenced by: Based on interviews and file review licensee failed to maintain personnel records for former Staff S1 regarding termination date and reason for leaving which posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 5, 2022

Plan of correction: Facility to submit by POC due date personnel records for Staff S1 regarding termination date and reason for leaving. At today's visit facility submitted S1's personnel records. Deficiency cleared.

Allegation investigated: Staff are unable to communicate due to language barrier Medications were left accessible to residents Staff do not follow protocals to prevent the spread of COVID-19

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to the facility. LPA was greeted by caregiver who was not wearing a mask and did not screen LPA as required. Administrator arrived a little later. Facility tour was conducted at 9:47am which included 6 client bedrooms, 2 client bathrooms, living room, dining room and kitchen. Interviews were conducted with Administrator, House manager and staff #1 and #2. Interviews were conducted with R1 and R2 Regarding allegation: Staff do not follow protocols to prevent the spread of COVID-19 LPA was greeted by S1 and S1 was not wearing a mask and did not screen LPA at entrance. A tray was set up at entrance to screen, but screening was not done. LPA observed Administrator and house manager wearing mask most of the time of visit, Administrator would pull mask down under her chin and house manager wore mask under her nose. Substantiated Regarding the allegation: Staff are unable to communicate due to language barrier with residents, on visit conducted 04/26/22 and based on LPA's observation and interviews staff member who greeted LPA had difficulty communicating because of the language barrier. S1 stated did not understand English very well. R1 stated that the language barrier is the barrier that most affects care and needs. Regarding allegation: Medications were left accessible to residents, LPA, administrator and S1 observed medication and PRN (vitamins) accessible to clients. LPA observed the cabinet with key hanging from the lock and drawer of medications under kitchen cabinet unlocked. During visit LPA observed S2 working and not being associated with facility. S2 stated today was her first day. S2 was sent home during visit. Civil penalties issues. Based on LPA's observations and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 28-AS-20220418123049

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: May 3, 2022

The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement was not met by evidence of On January 26, 2022 2 staff were observed not wearing face coverings. On 4/2622 1 staff was observed not wearing a mask. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee shall ensure that facility is following California Dept of Public Health and CCLD requirements. Provide a written statement stating that facility staff were re-trained and will comply with CDSS requirements and regulations, and will maintain a safe and healthful environment for residents and staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 3, 2022

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met by evidence of: Based on observation licensee failed to have personnel competent to provide services necessary with LPA observing staff member unable to answer questions and stated she did not understand English very well. This poses an immediate health and safety risk to residents in care. Prior violation within 12 months.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Facility to submit a plan by POC due date addressing staff's competency to provide services necessary to meet resident's needs in the future.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 97465(h)(2) · Plan of correction due date: Apr 26, 2022

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met by evidence of: LPA observed PRN and tylenol in 3 of 4 rooms.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Administrator locked and removed all PRN and medication at time of visit.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87219(e) · Plan of correction due date: Apr 26, 2022

Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption This requirement was not met as evidenced by LPA Observed S2 working at facilty and not associated to facility.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Administrator will associated S2 prior to working at facility. S2 was sent home during visit. Civil penanty assesesd $100

Type of visit: Required - 1 Year

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, food and medication review. LPA Flores met with Susanna Babayan Caregiver and explained the reason for the visit. Administrator arrived 10 minutes after. Facility is licensed for six (6) non-ambulatory clients age 60 and above, of which six (6) may be bedridden in rooms #1, #2, and #3. Facility is approved for one (1) hospice waiver. Facility is a single home located in a residential area, has a kitchen, dining room, living room, 5 resident bedrooms, 2 bathrooms, a front and back yard, and a detached garage. No large bodies of water were observed. LPA Flores conducted a tour of the facility with Karine Filikyan administrator and observed the following: Kitchen area - facility has sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Medication was observed in drawer across from the stove, cleaning supplies under sink, and cooking knives in drawers to the left of the sink unlocked at the time of the visit. Fire extinguisher was observed on the wall in the kitchen doorway. Living room was observed to have a cover fireplace. All bedrooms have sufficient lighting, all bedding and furniture required. Bathroom #1(B1) and #2(B2) was observed with grab bars and skid mats, water was tested in B1 at 124.9 degrees F., and B2 at 124.4 degrees F., which is not within the required 105-120 degrees F. LPA reviewed medication and files for 5 residents and flies for staff #1,#2,#3. Exit door to street, exit doors in living room and residents room with access to backyard were observed and no auditory device was heard or observed. Administrator certificate was observed for Karine Filikyan #6024067740 expiration date 1/21/21, per administrator renewal documents have been submitted and is waiting for certificate. LPA has noted technical assistance regarding infection control recommendations. Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted with Karine Filikyan administrator and a copy of this report, LIC 809D and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 20, 2022

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are unable to communicate with residents due to language barrier. Staff not wearing masks.

This report is amended to remove staff names. Previously issued LIC 9099s are rescinded. The amendment does not change the findings. LPA Nune Margaryan redelivered report on 04/14/2022 to obtain signatures. Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff 1. Initial visit was conducted on 1/26/22 and the following was done: Facility tour was conducted at 10:AM which included 6 client bedrooms, 2 client bathrooms, living room, dining room and kitchen. Interviews were conducted at 10:15 AM with Client 1 and 11:30 AM with Client 2. Interviews were conducted from 10:30 AM to 11:30 AM with Staff 1 -3. In regards to the allegation Staff are unable to communicate with residents due to language barrier, on initial visit conducted 1/26/22 based on LPA's observation staff member who greeted LPA had difficulty communicating because of the language barrier. LPA asked questions of where could the computer be set up and is the administrator present. Staff member did not understand questioning and requested to use a mechanical translator to help translate what was communicated. The staff member was the only staff on duty at that time. Staff member also asked for a resident's assistance to help in understanding LPA's questions. Substantiated Based on LPA's observations and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. In regards to the allegation Staff not wearing masks, based on LPA's observation on initial visit conducted 1/26/22 the staff member who greeted LPA at the door did not have a mask on and was providing care to residents at that time. Shortly thereafter Staff 2 arrived to greet the LPA and was not wearing a mask. At today's visit 03/02/22 Staff 1 who greeted LPA was observed without a mask on and was providing care to residents at that time. Based on LPA's observations and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Mar 2, 2022 · control 28-AS-20220118125103

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: Mar 3, 2022

The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement was not met by evidence of: On January 26, 2022 2 staff were observed not wearing face coverings. On 3/2/22 1 staff was observed not wearing a mask. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2022

Plan of correction: Licensee shall ensure that facility is following California Dept of Public Health and CCLD requirements. Provide a written statement stating that facility staff were re-trained and will comply with CDSS requirements and regulations, and will maintain a safe and healthful environment for residents and staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 9, 2022

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on observation licensee failed to have personnel competent to provide services necessary with LPA observing staff member unable to answer questions without use of a mechanical translator This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2022

Plan of correction: Facility to submit a plan by POC due date addressing staff's competency to provide services necessary to meet resident's needs in the future.