Sunrise of Westlake Village

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Teresa Camara and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:10 a.m. Upon arrival LPAs met with Executive Director Zak Howell and explained the reason for the visit. Entrance interview conducted. At 10:15 a.m., the LPAs along with the Executive Director, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. DINING ROOM / KITCHEN: The LPAs toured the kitchen / food service area at 12:20 p.m., The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperature. There was a sufficient amount of perishable and non-perishable food in the kitchen properly stored. Food labels were inspected and checked for dates and expiration dates. At 12:25 p.m., the LPA observed perishable items in poor condition as they had passed their expiration dates. These items included: three (3) containers of yogurt and one (1) container of egg whites. Items were discarded at the time of the visit. Residents do not have access to the kitchen, dangerous items are stored inaccessible to residents. The facility menu appears to meet the daily dietary needs of residents. There were no pesticides or poisons observed near any food areas. COMMON AREAS: LPAs inspected the common areas throughout the building. The common areas were observed to be properly furnished and relatively clean at the time of the visit. Fireplaces were observed to have adequate screens at the time of the visit. LPAs observed sanitizer readily available in areas with high touch surfaces. Furniture was observed to be in good condition in each common area. The facility maintained a comfortable temperature. Carbon monoxide detectors were operational at the time of the visit. The smoke (continued on 809C; page 2) (continued from 809; page 1) detectors and fire suppression system was last serviced on 8/4/2023. Fire extinguishers were observed throughout the facility, fully charged, and last serviced on 10/03/2023. An adequate supply of emergency food and water was observed. The LPAs observed required postings throughout the common spaces. Entry/exits were free of obstruction. The outdoor areas were clean and free of hazards. The patios and balconies have proper furnishings. BEDROOMS / BATHROOMS: The LPAs inspected ten (10) randomly selected bedrooms throughout the three (3) floors. The resident bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPAs observed all bathrooms in each resident bedroom were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. RECORDS: Records review began at 12:45 p.m., five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time. Five (5) Personnel records and current Executive Director files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Fire and earthquake drills were conducted within the last 6 months as per regulation; the last one conducted 10/03/2023. MEDICATIONS: Medications review began at approximately 1:30pm. The medications are centrally stored and inaccessible to residents in care. Medication carts were observed on each floor locked and inaccessible at the time of the visit. No medication errors observed at this time. (continued on 809C; page 3) (continued from 809C; page 2) INFECTION CONTROL: Upon entry, there is a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promote good hand hygiene and symptoms of communicable diseases. The facility has 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 a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Between 10:50 a.m. and 2:20 p.m., the LPAs interviewed five (5) residents and five (5) staff members. During today’s visit, the LPAs obtained copies of the following: staff schedule, resident roster, Emergency Disaster Plan, and current liability insurance. Exit interview conducted. No deficiencies issued at this time. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 13, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. This visit was conducted in conjunction with the local and state health department. In attendance included Deborah Leonard from Ventura County Public Health, and Cherish Mendoza and Shantala Ahanya from the California Department of Public Health. All parties met with Executive Director Zak Howell and explained the reason for the visit. All parties toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Common Areas: Common areas were observed to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. Exits with doors were inspected. The facility maintains a comfortable temperature at 75 degrees Fahrenheit. Planned activities are offered, but at this time there are no group activities. Activity schedule is posted throughout the community. There are fire extinguishers throughout the community, which were charged and last serviced October 2021. The smoke detectors are hard-wired in the common areas and were last tested December 2021. The sprinkler system is tested quarterly. Kitchen: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. The facility uses Sysco Foods for food delivery. The menu was posted, and the facility offers an alternate menu. Due to a current COVID-19 positives within the facility, dining is suspended. Staff are delivering meals to the resident’s rooms, and regularly providing snacks and hydration to the residents. Restrooms: Common restrooms were observed, and the LPA observed signs in the restrooms that promoted good hand hygiene. Restrooms were fully stocked with paper towels and soap. Exterior Grounds: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors. Infection Control: Throughout the visit, the LPA observed signs in common areas that promoted guidance around COVID-19, appropriate masking, physical distancing, and the disinfection protocol. In addition, the LPA observed hand sanitizer interspersed throughout the common grounds. The community continues to monitor the vitals, symptomatic screening, and temperatures of the staff and visitors that come into the community. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. During today's visit, discussion was had regarding testing, symptom screening, and adjusted procedures around visitation. The cleaning and disinfectant protocol is adequate; however, staff were reminded to observe the contact time needed for surfaces to be properly disinfected. The community is not experiencing any issues with staffing or obtaining Personal Protection Equipment (PPE) at this time. Isolation carts were observed outside the rooms in which there is a confirmed positive case. It was recommended to provide additional staff training pertaining to donning, doffing, and appropriate disinfecting practices. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The Infection Control plan and required updates were submitted timely. The community's policies and procedures as it pertains to infection control are adequate. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 25, 2022

Allegation investigated: Staff are restraining resident in care

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct an initial 10-day visit. The LPA met with Executive Director Zak Howell and explained the reason for the visit. During today’s visit, the LPA conducted a tour at 11:40 a.m., interviewed staff at 9:52 a.m., 10:05 a.m., 10:22 a.m., and 10:45 a.m., and interviewed a hospice nurse at 11:01 a.m. In addition, the LPA conducted a file review and collected documents. Regarding the allegation, it was alleged that on several occasions, staff have restrained Resident #1 (R1). It was alleged that staff have placed R1 in bed facing the wall, pulled R1’s pants to their ankles, and placed a pillow in between R1’s knees. There was a concern that with these measures in place, R1 is rendered immobile and cannot reposition on their own. Substantiated Interviews and record review revealed that R1 is currently on hospice, and because R1 has skin integrity challenges, R1 has an order on file for heel protectors. A file review confirmed the order for the heel protectors, and an interview with a hospice nurse confirmed that upon visiting R1, R1 is always observed wearing the heel protectors. Staff confirmed that R1 is repositioned every two hours, as R1’s skin is susceptible to redness. As such, staff claimed that if R1 is observed facing the wall, staff believe R1 is facing the wall for a short period of time as R1 is repositioned every two hours. During today’s visit, the LPA observed R1, and observed that R1 was wearing their prescribed heel protectors. R1 was observed lying on their back and did not appear to be in distress. However, interviews and a review of the facility’s progress notes confirmed that at least on one occasion - on 06/05/2022 - R1 was found in bed with their pants around their ankle, and a pillow was observed between their legs. Whereas the pillow was used to prevent further skin integrity challenges, staff agreed that R1’s pants should have either stayed on or been completely removed. The presence of R1’s pants around their ankles restricts R1’s movement, thus unintentionally restraining R1. As a result of this incident, Reminiscence staff will receive an in-service training regarding the proper use of postural supports and maintaining a restraint-free environment. Based on the investigation, there is sufficient evidence to support the claim that staff are restraining resident in care. This allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Jun 28, 2022 · control 29-AS-20220621092445

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 30, 2022

87468.1(a)(2) Personal Rights of Residents in All Facilities. (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. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as R1 was not afforded safe and comfortable accommodations as they were restrained on at least one occasion, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 28, 2022

Plan of correction: The Administrator has agreed to do the following: 1. An internal investigation will begin to identify the staff person(s) involved. Staff will receive a write-up and additional training. CCL to be notified of this action no later than 6/30/2022 2. All staff in the Reminiscence Unit will complete additional training pertaining to the proper use of postural supports and alternatives to restraints. Training to be completed no later than 7/5/2022.

Allegation investigated: Staff are not providing a comfortable enviornment for residents

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial complaint visit. The LPA met with Executive Director Zak Howell and explained the reason for the visit. During today’s visit, the LPA toured the surrounding perimeters at 9:35 a.m., interviewed staff at 9:57 a.m., 10:00 a.m., 10:05 a.m., 11:04 a.m., and interviewed eleven residents between 9:45 a.m. – 11:45 a.m. Regarding the allegation, it is alleged that residents are smoking on their balconies and on the outside patio, which is causing secondhand smoke to get into the facility. Interviews conducted with the Executive Director confirmed that the facility recently created a secondary designated smoking area for residents that are unable to leave the facility unassisted. The secondary smoking area is located outside of the facility ‘Lounge’ area, yet upon observation, the LPA observed that it is twenty feet away from any entrances to the facility. The LPA also observed the original smoking area, which is further from the facility, more than twenty feet from the building, and designated for both staff and residents that are able to leave the grounds unassisted. Unsubstantiated Interviews confirmed that previously, concerns were raised regarding residents not utilizing the designated smoking area. In response, the Executive Director provided documentation demonstrating that the facility has addressed all staff, residents, and responsible parties of the smoking policy. Furthermore, the facility has reminded said individuals of the smoking policy and that it is allowed only in the designated smoking area. Interviews with residents could not corroborate the claim that smoke was getting into the facility. Most interviews supported the claim that residents nor staff have smelled smoke in the facility, and all understood that residents were not allowed to smoke in the facility and could only do so in the designated smoking areas. Interviews with residents whom smoke stated that they understood the facility policy and have complied. Based on the information obtained, there is insufficient evidence to support the claim that the staff are not providing a comfortable environment for residents. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 23, 2021 · control 29-AS-20210817151106

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ashley Smith arrived at 10:30 a.m. for an unannounced Case Management visit to the facility today in response to an incident communicated to the Department on July 8, 2021. The LPA met with Becky Buck and Zak Howell and explained the reason for the visit. On July 8, 2021, the LPA received a call from Executive Director Zak Howell regarding an incident involving Resident #1 (R1). At that time, the LPA requested and received pertinent documents from the Executive Director. During today's visit, the LPA interviewed staff at 10:37 a.m. and 11:41 a.m., and spoke with Resident #1 (R1) at 11:10 a.m. Further investigation is required at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 13, 2021