Golden Care Living

Allegation investigated: Staff sexually abused a resident in care

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Rachel Lugtu, House Manager IB conducted investigation, IB investigator Laarni Santiago’s investigation consisted of following: Interviews and Record reviews. Between 08/11/22 – 11/08/22, IB investigator interviewed W#1 – W#14. LPA Cifuentes requested and received the following documents on 07/28/22: Staff roster, resident roster, and other documents pertinent to the investigation. Unsubstantiated Based on the IB’s investigation, the investigation revealed the following. For Allegation – Staff sexually abused a resident in care. Interviews were conducted with collateral agencies and pertinent parties which revealed that there is insufficient evidence indicative of the alleged sexual abuse committed by staff. Although the informant perpetuated the alleged, staff refuted the claim and there were no witnesses to corroborate the incident. The victim could not disclose sexual abuse and was unable to provide a name or description of the staff due to their medical condition. Other residents were interviewed and denied any history of sexual abuse or misconduct by staff. Administrator and other staff members did not disclose any concerns pertaining to staff toward residents. Investigation revealed that there was insufficient evidence to support the alleged sexual abuse, therefore, the alleged is found to be unsubstantiated. 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 An interview was conducted with Rachel Lugtu, House Manager and a hard copy of report was provided.the state’s words, verbatim · CDSS document, May 5, 2023 · control 11-AS-20220727140407

Type of visit: Case Management - Deficiencies

On 03/13/23, Licensing Program Analyst (LPA) Ernand Dabuet initiated a case management visit to the above facility. Today’s case management visit was conducted with Rachel Lugtu care staff and spoke with Administrator Catherine Espino via telephone, and today's visit was explained. The purpose of the visit was to follow up on a Proof of Correction in association with complaint # 11-AS-20201222113312. LPA inspected the facility. During the inspection, LPA observed room #1 for resident #1 (R1) did not have a closet space available for personal items. LPA identified a closet door with a hanging padlock utilized for staff personal clothing, hygiene supplies, and three 3) clothing items that belong to (R1). According to Lugtu, the resident was prevented from accessing (R1's) clothing items as the resident would take the items and wash them in the bathroom and they were concerned for (R1's) safety. An interview with administrator Espino expressed she was not informed by the care staff that had made these modifications in (R1's) room. A resident not having access to personal items is of Title 22 Section 87468.1 Personal Rights of Residents in All Facilities and not having a closet space and is a violation of Title 22 Section 87307 Personal Accommodations and Services. Based on the interviews and observation, the preponderance of evidence standard has been met. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099-D). An exit interview was conducted with Rachel Lugtu, copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 13, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 27, 2023

87468.1 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: Resident #1 was not accorded a comfortable accomdations and did not have access to to personal clothing items. This violation is a potential risks to resident in care.the state’s words, verbatim · CDSS document, Mar 13, 2023

Plan of correction: Licensee & Administrator shall read Title 22, Section 87468.1 and send a written statement to CCLD by the POC date that they will ensure that all residents in care are provided Personal Rights. A plan to address the behavior without violating the resident's rights. POC is due to the CCLD/El Segundo ASC Office by the POC date of 03/27/23,.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(E) · Plan of correction due date: Mar 27, 2023

87307 Personal Accommodations and Services (E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided. This requirement is not met as evidenced by: Resident #1 was not accorded a comfortable accomdations and did not have a closet space as required by Title 22 Sec 87307. This violation is a potential risks to resident in care.the state’s words, verbatim · CDSS document, Mar 13, 2023

Plan of correction: Licensee & Administrator shall read Title 22, Section 87307 and send a written statement to CCLD by the POC date that they will ensure that all residents in care are provided a comfortable enviroment. A plan to address the missing closet space. POC is due to the CCLD/El Segundo ASC Office by the POC date of 03/27/23,.

Type of visit: POC

On 03/13/23, Licensing Program Analyst (LPA) Ernand Dabuet initiated a case management visit to the above facility to clear POCs. Today’s case management visit was conducted with Rachel Lugtu care staff and spoke with Administrator Catherine Espino via telephone, and today's visit was explained. LPA and toured the entire facility to inspect if corrections were made for citations cited on 02/11/23 for complaint # 11-AS-20201222113312. Proof of corrections were sent via facsimile 02/12/23 and 02/16/23: The administrator dd clear the following citations: Administrators Qualifications and Duties - 87405 (a-C) Personnel Requirements – General - 87411(a) Allowable Health Conditions and the Use of Home Health Agencies - 87609 (c) Prohibited Health Conditions - 87615 (a)(1) Observation of the Resident - 87466 Citations that were all cleared did not incur civil penalties. An exit interview was conducted with Rachel Lugtu, copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 13, 2023

Allegation investigated: Resident sustained multiple pressure injuries while in care. Staff failed to meet the resident's needs. Staff failed to meet resident's incontinence needs.

Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent visit at this facility. LPA was greeted by care staff (S2) Rachel Lugtu. LPA conducted a risk assessment prior to entering the facility. Lugtu informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. Lugtu contacted administrator (S1) Catherine Espino by phone and LPA explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. Licensing Program Analyst (LPA) Jose Calderon conducted the 10-day tele-visit (via FaceTime) on 12/24/2020 approximately 4:45 p.m. with Administrator Angelique Gradney. LPA toured the facility (via FaceTime) with Administrator and requested copies of the following documents: facility staff and resident rosters; Admission Agreement, Appraisal/Needs and Services Plan, Physician’s Report, medical records (to include hospital records), Medication Administration Records (July 2021), and Unusual Incident/Injury Report for Resident #1. A separate investigation was conducted by the Department of Social Services, Investigator Jose Santana that included a review of hospital medical records, interview with witnesses, facility staff, and medical services staff. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Regarding Allegation #1: this investigation revealed that Resident #1 was admitted to the hospital on 08/21/20 with an open wound to the right hip – measuring: 8cm x 0.2cm. Upon discharge on 08/24/20, home health services were obtained, effective 08/25/20. Despite regular wound care by home health nurses, Resident #1’s right-hip wound worsened over time; and, the wounds increased in number to include pressure injuries on their bilateral heels. On Resident #1’s return from hospitalization on 08/25/20, there was an order for the fungal rash: cleanse with soap and water, pat dry, apply Miconazole Topical 2% and Calmoseptine, and leave open to air. Although, it is possible that Resident #1’s scratching of their wounds and fungal infection prevented the pressure injuries from resolving, it is more likely that unattended moisture and failure to reposition the resident every two (2) hours at night contributed to the progression of the pressure injuries. Witness #4 (Home Health Care Manager) believes the lack of frequent repositioning and keeping Resident #1 dry overnight was the primary reason why the right hip progressed from Stage II pressure injury at the beginning of home health services to an Unstageable pressure injury – measuring: 4.6cm x 1.8cm x 0.2cm by 09/14/20. As of 01/20/21, the right hip pressure injury remained Unstageable. The facility retained Resident #1; and, the resident’s pressure injury was over a Stage II, a prohibited health condition. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained multiple pressure injuries while in care is found to be SUBSTANTIATED. Regarding Allegation #2: this investigation revealed that the Home Health Agency skilled nurse was aware that Resident #1 was not being repositioned overnight because there was no nighttime caregiver available. Despite regular wound care by the home health nurses, Resident #1’s right-hip wound worsened over time; and, the Home Health Agency skilled nurse recommended that Resident #1 be transferred to a higher level of care. This requirement is not met as evidenced by: Lack of frequent repositioning every two (2) hours and keeping Resident #1 dry overnight was the primary reason why the right hip progressed from a Stage II pressure injury to Unstageable. Evaluation Report continues LIC-9099-C Based on the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of LEVEL OF CARE: Staff failed to meet the resident’s needs is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). Regarding Allegation #3: this investigation revealed that the facility hired live-in caregivers with no designated awake night staff. Residents who required overnight care (i.e., incontinence care and pressure injury prevention, such as, turning and repositioning every two (2) hours are not always receiving the care they need. In addition, Home Health Agency skilled nurse reiterated instructions for facility caregivers to turn and reposition Resident #1 every two (2) hours, to change diaper promptly after incontinence episodes. Based on interviews conducted, the majority staff corroborated that they are not paid to work overnight; therefore, turning and repositioning Resident #1 at 9:00 p.m., 11:00 p.m., 1:00 a.m., and 3:00 a.m. was not being done. Staff #2 (Lead Caregiver/House Manager) admitted that Resident #1 was not always turned and repositioned every two (2) hours overnight, but maybe at 9:00 p.m. and 3:00 a.m. This requirement is not met as evidenced by: There is no overnight staff to assist residents with personal hygiene (incontinence care) needs. Based on the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of LEVEL OF CARE: Staff failed to meet resident’s incontinence needs is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). ****Civil penalty is assessed.*** An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to Administrator Catherine Espino.the state’s words, verbatim · CDSS document, Feb 11, 2023 · control 11-AS-20201222113312

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Feb 12, 2023

Section 87615(a)(1) Prohibited Health Conditions: Persons who require health services or have a health condition including... shall not be... retained in a... care facililty sores (dermal ulcers). This requirement is not met as evidenced by: Resident #1 was diagnosed with Unstageable and Stage 3 dermal ulcers on 08/21/22 and Administrator retained Resident #1 at the facility following Resident #1’s discharge from the hospital on 08/24/22 with “Unstageable” and “Stage III” wounds. This violation poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2023

Plan of correction: Licensee/Administrator shall read Title 22, Section "Prohibited Health Conditions"...send a written statement to CCLD that they will ensure to stay in constant communication with medical professional(s) and if the resident's medical condition elevates; meaning they require a higher level of care, they will ensure the resident is relocated to a skilled-nursing facility (SNF) or hospital... Civil penalties are assessed in the amount of Five-hundred Dollars ($500) for retaining Resident #1 with a prohibited health condition. This plan is due to CCLD/El Segundo ASC Office by POC date of 02/12/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 12, 2023

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement is not met as evidenced by: Home Health Agency skilled nurse was aware that Resident #1 was not being repositioned overnight because there was no nighttime caregiver available to do so and recommended Resident #1 to a higher level of care. This violation poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2023

Plan of correction: Licensee/Administrator shall read Title 22, Section 87466 “Observation of the Resident” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 02/12/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a)-(C) · Plan of correction due date: Feb 27, 2023

Section 87405(a)–(c) Administrator - Qualifications and Duties:(a) All Facilities shall have a qualified and currently certified administrator...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours... to permit adequate attention to the management and administration of the facility as specified in this...have qualifications adequate to be responsible and accountable for management and administration... (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (c) Failure to comply with all licensing requirements... may constitute cause for revocation of the license of the facility. This requirement is not met as evidenced by: Resident #1 was transported to the hospital on 08/21/21 and hospital staff noted Stage II pressure injury to their right hip. By November 2020, Resident #1’s right hip developed from a Stage II to Unstageable/Stage III. This violation poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2023

Plan of correction: Licensee/Administrator shall read Title 22, Section 87405(a)–(c) “Administrator - Qualifications and Duties” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 02/27/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87609(C) · Plan of correction due date: Feb 12, 2023

87609(c) Allowable Health Conditions and the Use of Home Health Agencies: (c) The use of home health agencies to care for a resident’s medical condition(s) does not expand the scope of care and supervision that the licensee is required to provide. This requirement is not met as evidenced by: Home Health Agency skilled nurse provided training to facility staff on how to turn and reposition resident every two (2) hours; of which, facility staff failed to turn and reposition Resident #1 every two (2) hours over night. This violation poses an immediatel health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2023

Plan of correction: Licensee/Administrator shall read Title 22, Section 87609(c) "Allowable Health Conditions" and send a written statement to CCLD that licensee and home health agency agree (in writing) on the responsibilities of the home health agency and those of the licensee in caring for the resident’s medical condition. This plan due to CCLD/El Segundo ASC Office by POC date of 02/12/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 27, 2023

Section 87411(a) Personnel Requirements – General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff... ensure provision of ...care as required in Section 87608, Postural Supports. This requirement is not met as evidenced by: There is no overnight staff to assist residents with personal hygiene (incontinence care) needs. This violation poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2023

Plan of correction: Licensee/Administrator shall read Title 22, Section 87411(a) “Personnel Requirements – General” and send a written statement to CCLD that licensee has read and understands that facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident’s needs. This plan due to CCLD/El Segundo ASC Office by POC date of 02/27/23.

Type of visit: Required - 1 Year

On 2/9/2023 LPA Alfonso Iniguez conducted an unannounced annual visit. LPA met with Administrator/Cathy Espino and Caregiver/Rachel Lugtu. There are currently (4) residents residing in the facility. The facility is licensed to serve (6) elderly residents 60 and over. The facility is approved to support (1) hospice, (1) bedridden resident and (4) non-ambulatory residents. At this time, there is (3) non-ambulatory, and (1) bedridden hospice resident living at this facility. The facility is a single-story structure located in a residential neighborhood. It consists (5) resident bedrooms, (3) full bathrooms, kitchen, dining area, living room, and patio area with shade located in backyard. The facility entrance and exits are wheelchair accessible. The facility has (1) garage that is utilized for supplies. LPA observed required posting at the entrance and throughout the facility. The facility smoke detectors and carbon monoxide detectors were tested are operational. The light switches contain night-light in hallways . Restroom #1, #2 and #3 has non-skid mats and grab bars. Fire extinguisher is up to code. LPA observed a sign-in/sanitation station at the facility entry. Facility has screening process for visitors, sanitizer/soap, paper towels, and additional PPE supplies are stored in the garage. The facility is prepared to provide a private room for isolation if needed. The facility mitigation plan was approved by CCL on 4/11/2021. No citations were issued during this visit. An exit interview was conducted with Cathy Espino and copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced case management visit for deficiencies observed during investigation of complaint 11-AS-20220727140407 on 7/28/2022. LPA met with assistant administrator Catherine Espino and explained the purpose of today’s visit is to issue citations and was granted permission to enter the premises. During tour of facility grounds LPA Cifuentes noted the following deficiencies: 1. At 10:20am LPA Cifuentes noted that Physician's Report for Resident 1(R1) is not signed by a physician. 2. At 10:18am LPA Cifuentes observed that R1 and R2 do not have TB tests. 3. At 11:18am LPA Cifuentes noted an assortment of empty boxes, boards and electrical parts around perimeter of facility. At 11:26am LPA noted that light in bathroom 2 is in disrepair and at 11:30am LPA observed pests in facility kitchen. 4. 11:33 LPA observed unlocked drawer in the kitchen were knives were stored and at 12:02pm LPA observed lock to closet were toxins are stored was not locked. 5. At 11:33am LPA Cifuentes observed knife in container on kitchen counter and at 11:38am, 11:46am, 11:50am and LPA Cifuentes observed toxins in both bathrooms and R1's room that were not in a locked area. 6. At 11:42 am and 11:44am LPA Cifuentes observed half-bed rails in bedrooms of R1, resident 2 (R2) and resident 3 (R3) and no physicians order was found in residents files. 7. At 11:56am LPA Cifuentes noted medication administration record was not marked for resident R3 from dates of 7/22/2022 until 7/28/2022. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citations issued (809-D) An exit interview was conducted, and a copy of the report and Appeal Rights were provided to Staff Catherine Espino.the state’s words, verbatim · CDSS document, Jul 28, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 29, 2022

Storage Space Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: Based on observation, at 11:33am LPA Cifuentes observed kinfe in container on kitchen counter and at 11:38am, 11:46am and 11:50am LPA Cifuentes observed toxins in two of the bathrooms and R1's room. This is an immediate health and safety hazard for residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Administrator will store toxins an knives in a locked area inaccesible to clients and will review regulation 87309 with staff. POC will be submitted to CCLD via fax by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a)(1) · Plan of correction due date: Jul 29, 2022

Storage Space Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by: Based on observation, 11:33 LPA observed unlocked drawer in the kitchen where knives are stored. At 12:02pm LPA observed lock to closet were toxins are stored was not locked. This is an immediate health and safety hazard for residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Adminstrator will lock all storage areas containing knives, toxins/poisons. POC will be submitted to CCLD via fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Aug 18, 2022

Medical Assessment Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year... This requirement is not met as evidenced by: Based on observation, At 10:20am LPA Cifuentes noted that Physician's Report for Resident 1 (R1) is not signed by a physician. This is a potentail health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Adminsitrator will obtain a Physician's report for R1 and review with staff regulaition section 87458 and write a statement confirming they have read and understood regulation. Facility will submit POC to CCLD via fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(b)(1) · Plan of correction due date: Aug 18, 2022

Medical Assessment A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis...which would preclude care of the person by the facility. This requirement is not met as evidenced by: Based on observation, At 10:18am LPA Cifuentes observed that R1and R2 do not have a TB test. This is a potential heath and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Adminsitrator will obtain TB tests for R1 and R2 and send POC to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 18, 2022

Maintenance and Operation 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 observation, at 11:18am LPA Cifuentes noted an assortment of empty boxes, boards and electrical parts around perimeter of facility. At 11:26am and 11:58am LPA noted that lights in bathroom 1 and 2 are in disrepair. At 11:30am LPA Cifuentes observed pests in facility kitchen. This is a potential health and safety risk for the clients in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Administrator will fix lights and make and implement a plan for pest control involving a pest control companh and send proof of correction to CCLD via fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)3 · Plan of correction due date: Aug 18, 2022

Postural Supports A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Based on observation, At 11:42 am and 11:44am LPA Cifuentes observed half-bed rails in bedrooms of R1, resident 2(R2) and resident 3 (R3) and a lap belt on R3 and no physicians order was found in residents files.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Administrator will remove rails from beds and lap belt from resident until a physicians order is obtained and plan of correction is submitted to CCLD via fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a) · Plan of correction due date: Aug 18, 2022

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on observation, at 11:56am LPA Cifuentes noted medication administration record was not marked for resident R3 from dates of 7/22/2022 until 7/28/2022.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Administrator will review medication adminstration practices with staff and submit a sign in sheet and summary of topics covered to CCLD via fax by POC due date.

Type of visit: Required - 1 Year

On 03/24/2022 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Calderon was met by caregiver Rachael Augto and the purpose of today’s visit was explained. The facility is licensed to serve 6 elderly 59 years or older. There are currently 3 residents in care. There are 3 non-ambulatory clients. The facility is a one-story structure with 5 bedrooms and 3 bathrooms, living room, dining room, kitchen and patio. LPA Calderon and Administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA Calderon observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were accessible to clients. The kitchen was inspected and there is an enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. During today’s visit there were no deficiencies observed under California code of regulation title 22, division 6, chapter 8. Exit interview held. A copy of the report was provided to Administrator Rachael Augto.the state’s words, verbatim · CDSS document, Mar 24, 2022

Allegation investigated: Staff failed to seek timely medical attention for resident. Resident's toileting needs are not being met. Resident's hygiene needs are not being met.' Facility staff left resident in soiled bedding Facility staff left resident in a soiled diaper. Facility staff do not keep accurate records about resident in care.

On 02/04/2022 around 01:00pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Angelique Gradney. The Investigation consisted of the following: On 01/19/2021 LPA Calderon interviewed Administrator Angelique Gradney (S1) and conducted a tour of the physical plant. On 2/01/2021 LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), medical records, Physicians Report and Medication list), ER medical reports Fire report. On 1/29/2021 LPA Calderon interviewed reporting party. On 2/01/2021 LPA Calderon interviewed S2-S5 and on 03/19/2021 LPA Calderon interviewed R1–R3. On 05/06/2021 LPA Calderon interviewed S2 regarding night crew. On 07/05/2022 LPA Calderon interviewed S1 for second time. The investigation revealed the following: Allegation: Staff failed to seek timely medical attention for resident. It is alleged on Staff failed to seek timely medical attention for resident. On 01/12/2021 witness 1 stated that 911 was called and his unit of the Los Angeles Fire Department arrived around 8 am and entered the facility. W1 Fire captain noted that R1 urine and catheter had dislocated and therefore 911 was called. W1 states that he does not think this is elder abuse as R1 had just soiled himself and the night staff did not know how to change the catheter for R1. On 01/19/2021 LPA Calderon interviewed administrator S1 who stated her night staff did not have a chance to clean the resident or change R1 catheter and additional training was needed. On 03/19/2021 LPA Calderon interviewed R1-R3 could not answer questions due to dementia. On 02/01/2021 LPA Calderon interviewed S2-S5 who all stated that they also work the night shift and always take care of all resident’s medical needs. On 05/06/2021 LPA Calderon interviewed S2 who stated he worked the night shift and that R1 catheter dislodged around 5pm and he believes R1 had issues some time between the day and night shift. S2 stated additional training was done with all staff regarding catheter issues. On 02/01/2021 LPA Calderon reviewed Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months, medical records, Physicians Report and Medication list, ER medical reports an1d Fire report. The reports state that staff does take care of resident’s medical needs and keeps records for review. Unsubstantiated Allegation: Resident's toileting needs are not being met. It is alleged on Resident's toileting needs are not being met. On 01/29/2021 Witness 1 stated that W` entered the facility and noted R1 had a soiled diaper and the bed was soiled. W1 states that W1 does not think this is elder abuse as R1 had just soiled himself and the night crew had not had a chance to clean R1 and R1 bed. On 01/19/2021 LPA Calderon interviewed administrator S1 who state S1 night staff did not have a chance to clean the resident or R1 bed and that W1 received paperwork stating the resident had been cleaned and R1 bed was changed. On 03/19/2021 LPA Calderon interviewed R1-R3 who stated that staff does take care of their hygiene needs and cleans their room daily. On 02/01/2021 LPA Calderon interviewed S2-S5 who all stated that they always take care of all residents needs to include soiled bedding, hygiene needs, medical attention, and keep records of what they do for residents every day. On 02/01/2021 LPA Calderon reviewed Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months, medical records, Physicians Report and Medication list, ER medical reports and Fire report. The reports state that staff does take care of residents needs and keeps records for review. On 04/28/2022 LPA Calderon interviewed administrator who stated that staff are not trained regarding Catheter replacement and that they call 911 or the hospice staff takes care of the resident’s needs. Administrator states that resident did not have a restrictive care plan as the hospice staff took care of resident’s medical needs or they called 911 Allegation: Resident's hygiene needs are not being met. It is alleged on Resident's hygiene needs are not being met. On 01/29/2021 Witness 1 stated that W1 entered the facility and noted R1 had a soiled diaper and the bed was soiled. W1 states that he does not think this is elder abuse as R1 had just soiled R1 self and the night crew had not had a chance to clean R1 and R1 bed. On 01/19/2021 LPA Calderon interviewed administrator S1 who stated that S1 night staff did not have a chance to clean the resident or his bed prior to LAFD coming to the facility and that W1 received paperwork stating the resident had been cleaned and R1 bed was changed. On 03/19/2021 LPA Calderon interviewed R1-R3 who stated staff does take care of their hygiene needs and cleans their room daily. On 02/01/2021 LPA Calderon interviewed S2-S5 who all state that they always take care of all residents needs to include soiled bedding, hygiene needs, medical attention, and keep records of what they do for residents every day. On 02/01/2021 LPA Calderon reviewed Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months, medical records, Physicians Report and Medication list, ER medical reports and Fire report. The reports state that staff does take care of residents needs and keeps records for review. On 04/28/2022 LPA Calderon interviewed administrator who stated that staff are not trained regarding Catheter replacement and that they call 911 or the hospice staff takes care of the resident’s needs. Administrator states that resident did not have a restrictive care plan as the hospice staff took care of resident’s medical needs or they called 911 Allegation: Facility staff left resident in soiled bedding. It is alleged on Facility staff left resident in soiled bedding. On 01/29/2021 Witness 1 stated that W1 entered the facility and noted R1 had a soiled diaper and the bed was soiled. W1 states that W1 does not think this is elder abuse as R1 had just soiled R1 self and the night crew had not had a chance to clean R1 and R1 bed. On 01/19/2021 LPA Calderon interviewed administrator S1 who stated that S1 night staff did not have a chance to clean the resident or his bed prior to LAFD coming to the facility and that W1 received paperwork stating the resident had been cleaned and R1 bed was changed. On 03/19/2021 LPA Calderon interviewed R1-R3 who stated staff does take care of their hygiene needs and cleans their room daily. On 02/01/2021 LPA Calderon interviewed S2-S5 who all state that they always take care of all residents needs to include soiled bedding, hygiene needs, medical attention, and keep records of what they do for residents every day. On 02/01/2021 LPA Calderon reviewed Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months, medical records, Physicians Report and Medication list, ER medical reports and Fire report. The reports state that staff does take care of residents needs and keeps records for review. 04/28/2022 LPA Calderon interviewed administrator who stated that staff are not trained regarding Catheter replacement and that they call 911 or the hospice staff takes care of the resident’s needs. Administrator states that resident did not have a restrictive care plan as the hospice staff took care of resident’s medical needs or they called 911 Allegation: Facility staff left resident in a soiled diaper. It is alleged on Facility staff left resident in a soiled diaper. On 01/29/2021 Witness 1 stated that W1 entered the facility and noted R1 had a soiled diaper and the bed was soiled. W1 states that W1 does not think this is elder abuse as R1 had just soiled R1 self and the night crew had not had a chance to clean R1 and R1 bed. On 01/19/2021 LPA Calderon interviewed administrator S1 who stated that S1 night staff did not have a chance to clean the resident or R1 bed prior to LAFD coming to the facility and that W1 received paperwork stating the resident had been cleaned and R1 bed was changed. On 03/19/2021 LPA Calderon interviewed R1-R3 who stated staff does take care of their hygiene needs and cleans their room daily. On 02/01/2021 LPA Calderon interviewed S2-S5 who all state that they always take care of all residents needs to include soiled bedding, hygiene needs, medical attention, and keep records of what they do for residents every day. On 02/01/2021 LPA Calderon reviewed Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months, medical records, Physicians Report and Medication list, ER medical reports and Fire report. The reports state that staff does take care of residents needs and keeps records for review. Facility staff do not keep accurate records about resident in care: On 01/29/2021 Witness 1 stated that he entered the facility and noted R1 had a soiled diaper and the bed was soiled. W1 states that W1 does not think this is elder abuse as R1 had just soiled R1 and the night crew had not had a chance to clean R1 and R1 bed. On 01/19/2021 LPA Calderon interviewed administrator S1 who stated that S1 night staff did not have a chance to clean the resident or R1 bed prior to LAFD coming to the facility and that W1 received paperwork stating the resident had been cleaned and R1 bed was changed. On 03/19/2021 LPA Calderon interviewed R1-R3 who stated staff does take care of their hygiene needs and cleans their room daily. On 02/01/2021 LPA Calderon interviewed S2-S5 who all state that they always take care of all residents needs to include soiled bedding, hygiene needs, medical attention, and keep records of what they do for residents every day. On 02/01/2021 LPA Calderon reviewed Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months, medical records, Physicians Report and Medication list, ER medical reports and Fire report. The reports state that staff does take care of residents needs and keeps records for review. 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. A telephonic exit interview was conducted with Administrator Angelique Gradney, and a hard copy was provided via email for recordsthe state’s words, verbatim · CDSS document, Feb 4, 2022 · control 11-AS-20210113083145