Gardena Retirement Center

Allegation investigated: Due to lack of supervision, resident got into a physical altercation with another resident

On 10/30/23 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA spoke to Administrator Susie Fuentes and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 10/30/23 LPA reviewed Resident files and interviewed both facility staff and residents. LPA reviewed and requested copies of the following records: Client Roster, Staff roster, facility files and incident report dated 10/4/23. Continued on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Due to lack of supervision, resident got into a physical altercation with another resident. On 10/30/23, LPA spoke with Administrator at 10:30am she stated on 10/4/23 at 5am there was an altercation happen between two parties and the police department was called. On 10/30/23 at 10:30 am , LPA Shirley interviewed resident 1 – resident 10 (R-1 - R-10). LPA asked, “Have you ever gotten into a physical altercation with another resident”. of those interviewed, nine out of ten residents interviewed replied in the negative. LPA asked residents had you ever had a situation/altercation and staff was not available to assist you. Of those interviewed, nine out of ten answered no, there has never been a situation/altercation that staff was not there to assist them. On 10/30/23, at 12:00pm LPA Shirley interviewed staff 1 – staff 9 (S-1 - S-9). LPA asked if there had been any physical altercations with resident against another resident. Based on interviews 3 out of 9 staff interviewed stated that yes there was an incident that occurred on 10/4/23 with two residents that was reported to the administrator. On 10/30/23, at 11:15am LPA reviewed facility files. During file review, LPA found that resident visited Gardena Memorial on 10/4/23 and 10/5/23 for upper extremity pain. LPA also observed unusual incident/injury report and SOC 341 dated the same date as the incident that was reported by resident. Based on interviews and information gathered, this incident happened on 10/4/23 at around 5am, S-5 heard the commotion and intervened in the situation between the two residents and contacted Administrator. One resident elected to be taken to the hospital, the other resident chose to be patched up by ambulance but later called 911 to be transported to Gardena Memorial Hospital. Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation: Due to lack of supervision, resident got into a physical altercation with another resident. 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 are Unsubstantiated. Exit interview was conducted and a copy of this report was provided to the Administrator Susie Fuentes.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 11-AS-20231024100408

Allegation investigated: Facility staff dispensed medications not prescribed to resident Facility staff did not allow resident to have private visits with family Facility staff did not allow resident to keep their own personal possessions

This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 9/29/23. On 9/29/23, Licensing Program Analyst, Felisa Shirley, returned to above name facility to conclude investigation into said allegations. LPA Shirley met with Business Office Manager, Christina Novoa and explained the purpose of today's visit and was granted access. The investigation consisted of the following: On 9/1123 LPA requested received and reviewed the following: Staff and Resident rosters, facility visitor list, and facility files. LPA interviewed Administrator Susie Fuentes, S-1 and S-2 through - staff S-8 (S-2 - S-8). LPA interviewed resident R-1 through R-8. The investigation revealed the following: Cont'd on 9099-C Unsubstantiated Allegation: Facility staff dispensed medications not prescribed to resident On 9/11/2023 LPA Shirley reviewed facility files. During file review, LPA reviewed resident’s medication records and actual medication and did not find any discrepancies. All required medications on the list are accounted for as given as prescribed. On 9/11/23 LPA Shirley interviewed residents 1 – resident 8 (R1-R8). LPA asked have you ever been given the wrong medication and all eight clients interviewed stated that they have not to their knowledge. On 9/11/23 LPA Shirley interviewed staff 1 - staff 8 (S1-S8). LPA asked staff if any resident reported that they received the wrong medication and all staff interviewed stated that no resident had reported to them that they received the wrong medication. Based on interviews and records review there is insufficient evidence to support the allegation: Facility staff dispensed medications not prescribed to resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. Allegation: Facility staff did not allow resident to have private visits with family On 9/11/23 LPA reviewed facility visitors list. During review, LPA noted that between the periods of 10/11/22 and 9/11/23, resident’s daughters visited over 30 times. This number does not include the number of visits from, “family” written on visitors list. On 9/4/23, Labor Day, S1 stated that the facility had an outbreak of covid-19 and visitors were given a choice to visit or not but must wear PPE. Cont'd On 9/11/23 LPA interviewed residents 1- resident 8 (R1 – R8). LPA asked residents has any of your visits been refused and all eight residents interviewed stated that their visits have not been refused. On 9/11/23 LPA Shirley interviewed staff 1 – staff 8 (S1 – S8). LPA asked staff if any one’s visits were being refused and all staff interviewed stated that no resident has had any visits denied. Based on interviews and records review there is insufficient evidence to support the allegation: Facility staff did not allow resident to have private visits with family. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. Allegation: Facility staff did not allow resident to keep their own personal possessions On 9/11/23 LPA interviewed the Director asking them if any personal possessions are being locked up in their office. The Director stated that the police called and said to take the residents personal phone because resident was making numerous calls to the police department. On 9/4/23, a family member called the police from the facility, police came out to investigate and gave the phone to the family member and verified that resident’s landline was in their room just unplugged. The Director gave the phone to the policeman. This facility has no knowledge regarding any missing items/possessions for this resident. Based on interviews and records review there is insufficient evidence to support the allegation: Facility staff did not allow resident to keep their own personal possessions. 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 exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to the Director, Susie Fuentes. Page left blank as document was amended.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 11-AS-20230905083922

Allegation investigated: Staff are not assisting resident

Document is being revised but does not change the findings. On 09/29/23, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Christina Novoa, Business Office Manager, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility. The investigation consisted of the following: On 9/11/23 LPA conducted interviews with the Administrator, Susana Fuentes (S1) and staff 2- Staff 8 (S2-S8) and resident 1 - resident 8 (R1 – R8.) LPA requested and obtained copies of the following documents: Staff and Resident rosters, facility visitor list, facility shower schedule, and facility files. The investigation revealed the following: Cont'd on 9099-C Unsubstantiated Regarding allegation: Staff is not assisting residents. It is being reported that staff is not assisting this resident. During file review, interviews and observations, resident is registered in the Assisted Living Waiver program and receives assistance with all ADL’s. Resident has excessive behaviors and there is currently no formal written plan in place. The current plan is redirecting residents behavior. There is no written assessment from treating doctor but family is aware of behaviors and have been in communication with staff from the facility. LPA spoke with family and LPA interviewed staff-1 to staff-8 (S1-S8). LPA asked, when a resident needs assistance as far as necessities, or help, what is the process? Of those interviewed, 7 out of 8 answered, to tell family if supplies are needed. If family is not involved, the administrator/facility provides supplies. All staff deny not helping residents when needed. LPA interviewed resident -1 – resident -8, (R-1 – R-8). LPA asked, when you ask staff for assistance, do you get the help that you need. Of those interviewed, 5 out of 5 answered yes. Based on interviews and file review there is insufficient evidence to support the allegation: Staff is not assisting residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. No deficiencies were cited during the visit.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 11-AS-20230905152123

Type of visit: Case Management - Other

On 9/8/23, LPA met with Administrator Susana Fuentes regarding 30 day Eviction Notice for R1. At 12:57pm LPA and Administrator Susana observed room #32, (no name plate), for resident. LPA observed that his belongings were still in his room. LPA received the following forms from Susana Fuentes: Copy of 30 Day Notice of Eviction dated 6/16/23, copy of 30 Day Notice of Eviction dated 7/31/23, copies of statements for balances due dated 3/31/23 and 4/30/23. Administrator Susie will email requested copy of email sent to LPM Eva Alvarez and copy of pay history for the account of R1. A copy of this report is being signed and provided to Administrator Susana Fuentes.the state’s words, verbatim · CDSS document, Sep 8, 2023

Allegation investigated: Staff stole residents Identification Card Staff interferes with the residents' visitation Staff threatened residents in care

*This is an amended document to clarify findings but does not change the outcome. On 08/14/23, Licensing Program Analyst (LPA) Felisa Shirley conducted a subsequent visit to the facility listed above for a 10-day complaint investigation. LPA arrived at facility and was met by Jasmine Navarro, Receptionist, and explained the purpose of the visit was to investigate the allegations listed above and was granted access to the facility. The investigation consisted of the following: On 8/4/23 LPA conducted interviews with the Administrator, Susana Fuentes, (S1)and staff 2- Staff 8 (S2-S8) and resident 1 - resident 8 (R1 – R8 LPA requested and obtained copies of the following documents: Resident & Staff roster, facility visitor sign-in sheet, Conservator Document, Community Rules, Copy of “Family Visits”, section from Admission Agreement, ID/Emergency information, physicians report, appraisals/Needs and Services Plan and any incident reports regarding ID theft. The investigation revealed the following: con'd on 9099-C Unsubstantiated Regarding allegation #1: Staff stole residents Identification Card. It was reported that the resident’s Identification Card was stolen by the staff. During file review, LPA did not observe copies of an Identification card upon admission. LPA observed that Personal Property and Valuables page is blank. There are no incident reports reporting stolen ID’s. Staff S2 stated that R1 arrived with nothing besides the clothes they were wearing. LPA interviewed staff 1 through Staff 8, (S1-S8). LPA ask, “Has any resident report their ID being stolen.” Of those interviewed, 5 out of 8 stated No. LPA interviewed resident 1 through resident 8, (R1-R8) LPA ask, “Have you ever reported a stolen ID.” Of those interviewed, 7 out of 8 answered no their Identification card was never stolen. Resident 4 (R4) is no longer at this facility. Based on interviews there is insufficient evidence to support the allegation: Staff stole residents Identification Card. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. Allegation #2: Staff interferes with residents visitation. It was reported that the staff interferes with the residents visitation. LPA interviewed staff S1-S8, and 8 out of 8 denied the allegation. All Staff stated that there have been no refusals of visitation. Per Section XV. Family Visits, in the facility’s Admission Agreement, it states that Management encourages family and friends to visit you, subject to the Community Rules and Regulations. Per S1 and S2, a reason to reject a visit would be based on a Court order or Threat to Staff or Resident safety. LPA interviewed R1 – R8. R4 was not available. LPA ask, has any of your visitors been refused entry. Of those interviewed, 4 out of 7 answered no. Con'd on 9099-C Based on interviews there is insufficient evidence to support the allegation: Staff interferes with visitation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated Allegation #3: Staff threatened residents in care It is alleged that staff threatened to take away resident’s personal phone so that the resident can’t communicate with family. Per S1 the resident always become rattled and agitated and tries to AWOL from the facility after R1 speaks with family. For the safety and well-being of the resident S1 gave the phone back to conservator. On 8/17/23 LPA spoke with the Conservator and she felt that it is better that R1 not have the cellphone at this time. Conservator stated that RP is free to call facility to speak with R1 any time. LPA interviewed all staff, staff 1 – staff 8 (S-1 – S-8). LPA asked is there any knowledge of threats to a resident or staff. Of those interviewed 8 out of 8 stated no. LPA interviewed residents 1 – resident 8 (R-1 – R-8). LPA asked residents, has anyone threatened you? Of those interviewed, 6 out of 8 answered, No. R4 was not available. Based on information gathered, the department did not find sufficient evidence to support allegations "Staff threatened residents in care.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited during the visit.the state’s words, verbatim · CDSS document, Aug 14, 2023 · control 11-AS-20230728100550

Allegation investigated: Staff not responding to residents call for assistance. Staff did not safeguard resident’s belongings. Staff not allowing resident of personal phone call. Staff refusing to allow resident to have visitor(s).

On 06/07/23, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced 10-day complaint investigation at the facility listed above. LPA arrived at facility and was met by Susana Fuentes, Administrator, and explained the purpose of the visit was to investigate the allegations listed above and was granted access to the facility. On 06/07/2023, the investigation consisted of the following: During today's visit LPA conducted a tour check of the facility. LPA conducted interviews with the Administrator, Susana Fuentes (S1) staff (S2-S6) and residents (R1-R8). LPA requested and obtained copies of the following documents: Resident & Staff roster, client/resident personal property and valuables information, ID/Emergency information, physicians report, admissions agreement, incident reports, medical administration records, and appraisals/Needs and Services Plan for R1. The investigation revealed the following: Report contiunued on LIC9099-C Unsubstantiated Regarding allegation #1: Staff not responding to residents call for assistance. It was reported that the resident called for assistance and remained on the floor for 15 minutes, but no one came to assist. LPA interviewed staff S1-S6, and 6 out of 6 denied the allegation. All staff reported that the resident has never fallen while in their care. They further add that all residents have call buttons in their rooms and they respond to the residents when it is activated. LPA interviewed R1 about the alleged fall and R1 denied that the fall ever happened and stated that the staff responds when called. R2-R8 when interviewed, also stated that whenever they need assistance it is given. Based on interviews there is insufficient evidence to support the allegation: Staff not responding to residents call for assistance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. Allegation #2: Staff did not safeguard resident’s belongings. It was reported that the residents’ belongings were stolen by the staff (a potted plant, and pajamas). LPA interviewed staff S1-S6, and 6 out of 6 denied the allegation. S1 stated that when the resident came to the facility R1 did not have any belongings other that what R1 was wearing. S2-S6 also denied that anything has been stolen and neither R1 nor other residents have reported any theft in the facility. R1-R8 also stated when interviewed that they haven’t had any issues with theft. Based on interviews there is insufficient evidence to support the allegation: Staff did not safeguard resident’s belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. Allegation #3: Staff not allowing resident of personal phone call It was reported that staff is not allowing the resident any personal phone calls. It is alleged that S1 went into R1’s belongings while R1 was sleeping and took R1’s cell phone and then told family member that they could no longer talk to R1. LPA interviewed S1 about the allegation and S1 denied the allegation. S1 stated that the facility does not prevent anyone from talking to the residents. S1 stated that R1 had a cell phone but the facility gave it back to the family member and instructed them to use the front desk telephone to communicate with R1 because when they call, the resident always become rattled and agitated and tries to AWOL from the facility. S1 stated that R1 has tried to do this several times at all hours of the night when speaking on the cell phone. For the safety and well-being of the resident they gave the phone back to the family member and stated that they could speak to the resident whenever they wanted but they needed to call the facilities phone and they would bring the resident to the front desk. Report continued on LIC9099-C LPA interviewed S2-S6 about the allegation and 5 out of 5 denied the allegation. They stated that at no time are they preventing anyone from speaking to any of the residents. LPA interviewed R1-R8, and 8 out of 8 denied that anyone was preventing them from communicating with their family or friends. Based on interviews there is insufficient evidence to support the allegation: Staff not allowing resident of personal phone call. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. Allegation #4: Staff refusing to allow resident to have visitor(s). LPA interviewed S1-S6 about the allegation that the staff were not allowing the resident to have visitors. 6 out of 6 staff denied the allegation and stated that all residents are allowed visitors between the hours of 10am-6pm every day. LPA interviewed R1-R8, and 8 out of 8 denied the allegation. They all confirmed that they did not have a problem with visiting friends and family. Based on interviews there is insufficient evidence to support the allegation: Staff refusing to allow resident to have visitor(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 allegations are Unsubstantiated. No deficiencies were cited during the visit. An exit interview was conducted with Administrator, Susana Fuentes and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 26, 2023 · control 11-AS-20230602134247

Type of visit: Case Management - Other

On 7/19/23, LPA met with Administrator Susana Fuentes regarding 30 day Eviction Notice for R1. 11:09am LPA and Administrator Susana observed room #32, (no name plate), for resident. LPA observed that his belongings were still in his room. LPA received the following forms from Susana Fuentes: Copy of Email dated 6/29/23 at 5:07pm re Revised Eviction notice, Copy of Email dated 6/16/23 re 30 Day Notice of Eviction, Copy of 30 Notice of Eviction, and Resident Appraisal. A copy of this report is being signed and provided to Administrator Susana Fuentes.the state’s words, verbatim · CDSS document, Jul 19, 2023

Allegation investigated: Illegal Eviction

On 06/16/2023 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced visit to deliver the findings of the complaint with the above allegation Unlawful Eviction. LPA identified himself and discussed the purpose of the visit and the elements of the allegation with Administrator Susana Fuentes. The investigation consisted of the following: LPA conducted observation of physical plant, Staff Interviews (S1), and review of R1’s Facility File, LPA requested and obtained copies of Pertinent documents pertaining to the allegation. LPA requested from the facility (Admissions Agreement, House Rules, Client Roster, Staff Roster) R1's Needs and Services, Functional Capability Assessment.There were no Eviction Notices in R1's file. Unsubstantiated Investigation Revealed the following. Regarding Allegation: Unlawful Eviction. It was alleged by R1 resident's Facility Unlawfully Evicted R1. LPA Jeremiah Randle conducted an interview with (R1), R1 stated had been evicted from Gardena Retirement Center via telephone. R1 stated to LPA during telephone interview that R1 is currently in nursing home since 12/30/2022 to current. R1 stated he was on the Waiver Program. R1 stated R1 has been in a nursing home since 12/30/2022 to current, but R1 continues to pay his share of his rent. R1 stated in March 2023, R1 lost his Waiver, LPA Jeremiah Randle conducted an interview with facility administrator Susana Fuentes (S1). Susana Fuentes denied that R1 had been evicted and stated, “the resident has not been evicted or served any eviction notices”, S1 confirmed to LPA Randle, R1 was in the hospital receiving care. S1 stated " I never told the resident R1, R1 was evicted". LPA requested to view R1’s room LPA observed R1’s name plate on the door, R1’s personal affects situated in the room, as well as R1’s mail on the dresser. R1 was not present in room as observed by LPA Randle. S1 provided LPA with a copy of the resident roster and R1’s name was still listed as a resident. Findings Based on LPA’s observations and interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation 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. Exit interview was conducted with the and a copy of this report was provided to Administrator Susana Fuentesthe state’s words, verbatim · CDSS document, Jun 16, 2023 · control 11-AS-20230609090233

Type of visit: Required - 1 Year

On 4/14/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Susana Fuentes/Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (108) non-ambulatory elderly adults ages 60 and above. The facility is approved for dementia. Currently they are (80) residents living in the facility. The facility is a two-story structure located in a commercial neighborhood. It consists of the following:(54) resident bedrooms. Each room has a bathroom in the unit. The facility houses an activity room, dining area, kitchen, administrative offices, outside patio with shaded area and TV room on second floor. LPA Iniguez toured the physical plant with director. There were no bodies of water or obstructions on the premises. A total of (10) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1; #2; #19; #4; #18; #46; #40; #49; #51 and #33 and call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 110.5F° – 114.2F°. The room temperature ranged from 76F° – 78F°. Evaluation Report continues on LIC 809-C LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 01/30/23. Annual fire clearance performed on 2/1/2023 and Fire Kitchen inspection conducted on 3/1/2023. Working landline phones are available on-site. A review of (5) residents' service files (R1-R5) and (5) staff personnel files (S1-S5) and Medication Administration Records (MAR) were maintained in order. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings. All mandated inspection control posters were posted throughout the facility. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted and a copy of the Facility Evaluation Report was provided to the Director Susana Fuentes) .the state’s words, verbatim · CDSS document, Apr 14, 2023

Allegation investigated: Facility not providing a safe environment for resident.

The purpose of this report is to clarify the allegation findings narrative documented in the report created on 10/6/2022. The “Substantiated finding remain unchanged; however, this report created on 3/30/2023 supersedes the complaint investigation report created on 10/6/2022. On 3/30/32 LPA met with Christina Nova-Office Manager. On 10/6/22, Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced subsequent complaint investigation at the facility listed above. LPA Conducted risk assessment before entering the building. LPA was greeted by Office Manager/ Christina Novoa and later by the Administrator/ Susan Fuentes. LPA explained the purposed of the visit is to deliver findings. The investigation consisted of the following: On 5/23/2022, LPA Brown toured the facility and obtained Staff and Residents roster. LPA interviewed (8) residents (R1-R8) and the administrator. On 10/6/22, LPA conducted interviews with Administrator and (4) staff (S1-S4). LPA reviewed and obtained copies of residents R1’s admission agreement, physicians’ reports, appraisal and needs/services and activity calendars. LIC 9099-C is on the next page Substantiated The investigation revealed the following: Facility not providing a safe environment for resident. The complainant alleges that a resident repeatedly was walking from one end to the driveway back and forth, while the delivery truck was backing into the driveway and resident might get harm. On 5/23/22, during the interview 4 out of 8 residents, stated they saw (R1) pacing back and forth in the driveway. Interview conducted with Resident (R1) indicated they like to walk/exercise in the driveway. During interview with the Administrator Fuentes, stated the day of the incident with R1 was leaving the facility and waiting for a ride. On 10/6/22, LPA interviewed staff members (1-4) All staff stated the facility is providing a safe environment. Staff members also stated residents are observed by video camera. Some of the residents like to walk around the building. Another resident would like to walk back and forth on the driveway and smoke cigarettes. LPA observed the driveway and cars are leaving in and out to park frequently. LPA reviewed R1’s physicians report and resident is not able to leave facility unassisted. LPA found enough evidence to support that above mentioned allegation. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was provided and a copy of the report was given to Christina Nova.the state’s words, verbatim · CDSS document, Mar 30, 2023 · control 11-AS-20220519161012

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 14, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on interviews conducted and records reviewed, showed that Resident (R1) physicians report physicians assessment indicates that R1 was not able to leave the premises unassisted. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 30, 2023

Plan of correction: Administrator will submit a plan on how she will ensure that residents that are not able to leave on their own are not walking back and forth in the driveway. Administrator will submit to LPA Brown by POC due date 10/14/22.

Allegation investigated: Illegal eviction

On 3/15/23 at 9:36 am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-Day complaint visit to the above facility. LPA was met by Susana Fuentes, administrator, and the purpose of the visit was explained. LPA toured the physical plant prior to the investigation. The investigation consisted of the following: On 3/15/23 at 10:30am, LPA interviewed the administrator (S1) and attempted to interview resident (R1). LPA obtained copies of resident/staff rosters, a copy of R1s file which included (admission agreement, eviction notice, needs and service plan, physicians report, and other supporting documents). The investigation revealed the following: Report continued on LIC-9099-C Substantiated The investigation revealed the following: Allegation: Illegal Eviction LPA interviewed administrator, (S1) about the allegation. S1 stated that S1 issued an eviction notice to R1 for nonpayment of rent. R1 was given a written 30-day eviction notice on 3/02/23, and that R1s family was notified as well. S1 stated that R1 has a history of being late on the rent, and that the family has stepped in on several occasions to get R1 out of the arrears; but that it keeps happening and the facility had no other alternative but to evict R1 on the basis of non-payment of rent. On 3/15/23, LPA attempted to interview R1. R1 was not at the facility, at the time of the visit; nor did R1 respond to several voice mail messages left by LPA Scott calling to address the allegation and to confirm that R1 was issued an eviction notice. Based on the interview and record review, the administrator failed to serve R1 with an eviction notice in accordance with tittle 22 regulations. A review of the eviction notice dated 03/02/23, revealed that all components of the eviction letter were included per title 22 regulations; However, a written copy of the eviction notice was not issued to Community Care Licensing within 5-days. Therefore, the allegation of an illegal eviction is substantiated. Deficiencies cited under California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the report was given to the administrator, Susana Fuentes.the state’s words, verbatim · CDSS document, Mar 15, 2023 · control 11-AS-20230309161825

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(f) · Plan of correction due date: Mar 16, 2023

A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on the interview and record review, the licensee failed to provide a copy of the eviction notice for the resident to Community Care Licensing Department within 5 days. This poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 15, 2023

Plan of correction: The licensee shall review title 22 regulations for evictions and dismiss the eviction notice to the resident in writing and submit a copy of the dismissal letter and acknowledgement of the regulations by the POC due date of 03/16/23.

Allegation investigated: Unlawful Eviction

On 11/27/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit, to the facility listed above, to amend past complaint report from 02/24/23. LPA met with Administrator (A1), Susana Fuentes, and explained the purpose of today’s visit. On 02/24/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced 10-day complaint visit to Gardena Retirement Center. LPA met with Administrator, Susana Fuentes, and explained the purpose of this visit, regarding the complaint allegation listed above. According to Administrator there are currently 78 residents residing in the facility. LPA is conducting a complaint visit regarding an unlawful eviction of R1. LPA and Administrator toured the facility. LPA observed all walkways to be clean, clear, and free of obstructions or hazards. There are no bodies of water present on the premises. A comfortable temperature was maintained throughout the facility. LPA observed Resident’s morning exercise and activities. Continued on LIC9099-C Unsubstantiated LPA requested documents pertaining to the investigation. The following documents were received and reviewed: Admission Agreement, Physicians Report, Needs & services Assessment, and nurse and physician’s notes pertaining to R1. The investigation revealed the following: Allegation: Unlawful Eviction The allegation alleges the Administrator (A1) refused to accept R1 back into the facility. During the tour LPA and Administrator inspected R1’s room. LPA observed R1’s belongings are in their room, and R1’s name is still on the placard outside the door. During the interview with Administrator (A1), stated R1 was not issued an eviction notice. A1 stated that at this time the facility is unable to provide proper care and services for R1. Administrator informed LPA, that R1 can return to facility when medically cleared. Upon file review, LPA reviewed medical documents from R1’s physician stating a higher level of care is recommended, due to the need of daily wound care and R1 needing a wound vac. The facility is unable to meet the care needs for R1. Based on LPA’s observations, record review and interviews that were conducted, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. No deficiencies were observed or cited. An exit interview was conducted Administrator, Susana Fuentes and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 24, 2023 · control 11-AS-20230217105407

Allegation investigated: Resident sustained an unexplained injury while in care. Staff did not seek medical care for resident in a timely manner.

On 12/19/2022 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Susana Fuentes. The purpose of the visit was to deliver findings on the allegations listed above. The investigation consisted of the following: On 10/11/2022 Licensing Program Analyst (LPA) Don Senaha initiated and interviewed residents (R1-R10), Administrator and staff (S1-S6). LPA requested and obtained resident, facility and medical records. Investigation revealed: Allegation: Resident sustained an unexplained injury while in care. During the course of the investigation, LPA was able to find evidence supporting the allegation. Record reviews indicate the following: on 09/29/22 at 05:00am, Administrator told staff to call 911. R1 was sent to the hospital due to a bleeding wound. Substantiated Hospital records show R1’s wound on the right lower leg was a “gaping and deep” 6cm x 3cm. Per the paramedics, care home staff did not know when or how R1 received this wound. Interviews indicate the following: Per interview with S5, on 9/28/22 at 03:20pm S5 noticed blood coming out on R1’s right leg, S5 notified S6 that R1 had a blister that had popped. S6 provided S5 a band aid for R1's wound, S6 did not assess R1’s wound. Per interview with S4, on 09/29/22 at 05:15am S4 noticed blood on R1's leg. Administrator was notified via facetime. Administrator immediately told staff to call 911. Per interview with S6, On 10/2/22 when S6 cleaned the stitches and saw it, “it was bigger than I thought”. S6 stated, “I did not check it, that was my mistake”. Administrator stated, "Staff should have reported the wound to me right away.". S5 was given counseling and was told the protocols for incidents.Based on the Department’s interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “resident sustained an unexplained injury while in care” is found to be “Substantiated” California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Allegation: Staff did not seek medical care for resident in a timely manner. During the course of the investigation, LPA was able to find evidence supporting the allegation. It is being alleged that R1’s wound was discovered by staff sometime on the night of 9/28/22 and R1 was not brought into ER until the morning on 9/29/22. Record reviews indicate the following: On 09/29/22 at 05:00am, Administrator told staff to call 911. R1 was sent to the hospital due to a bleeding wound. Hospital records show R1’s wound on the right lower leg was a “gaping and deep” 6cm x 3cm. Interviews indicate the following: Per S5, on 9/28/22 at 03:20pm S5 noticed blood coming out on R1’s right leg. S5 notified S6 that R1 had a blister that had popped. S6 provided S5 a band aid for R1s wound, S6 did not conduct assessment of R1’s wound. Per interview with S4, on 09/29/22 at 05:15am S4 noticed blood on R1's leg. S4 called S3 and S7 to witness the wound bleeding and S7 called Administrator via facetime. Administrator told staff to call 911. On 10/2/22 when S6 cleaned R1's stitches and stated, “it was bigger than I thought”. S6 stated, “I did not check it, that was my mistake”. Administrator stated, "Staff should have reported the wound to me right away.". Based on record reviews and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “resident sustained an unexplained injury while in care” through neglect and lack of care and supervision is found to be “Substantiated” California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. A copy of this report and appeals rights were provided during the visit.the state’s words, verbatim · CDSS document, Dec 19, 2022 · control 11-AS-20221003130042

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jan 3, 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 not met as evidenced by: Based on record reviews and interviews, resident (R1) was injured due to neglect/lack of care and supervision and suffered an injury to the leg which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2022

Plan of correction: The licensee agreed to read, understand, Title 22 Regulation 87466 Observation of the Resident regulations. Licensee to do in-service training with staff on observation of resident and send proof of the in-service with signatures of staff. Proof of correction to CCLD by POC due date of 01/03/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Jan 3, 2023

87411 Personnel Requirements-General(d)(5) All personnel shall be given on the job training or have related experience assigned to them. This training and/or related experience…(5) Knowledge necessary in order to recognize early signs of illness and the need for professional help… This requirement not met as evidenced by: Based on record reviews and interviews, resident (R1) was injured due to neglect/lack of care and supervision and suffered an injury to the leg which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2022

Plan of correction: The licensee agreed to read, understand, sign and date Title 22 Regulation 87411(d)(5) Personnel Requirements-General. Licensee to do in-service training with staff on seeking medical attention and send proof of the in-service with signatures of staff. Proof of correction to CCLD by POC due date of 01/03/2023.

Allegation investigated: Unlawful Eviction.

On 12/13/2022 at 10:00 a.m. Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced visit to deliver the findings of the complaint with the above allegation Unlawful Eviction. LPA identified himself and discussed the purpose of the visit and the elements of the allegation with Administrator Susana Fuentes/designee Office Manager Christina Novoa . The investigation consisted of the following: LPA conducted observation of physical plant, Staff Interviews (S1), and R1’s Facility File, LPA requested and obtained copies of Pertinent documents pertaining to the allegation. LPA requested from the facility (Admissions Agreement, House Rules, Physicians Report /Medical Records, Client Roster, Staff Roster) Needs and Services, Functional Capability Assessment, SIR’s/SOC 341, staff / nursing notes. There were no Eviction Notices in the file. Unsubstantiated Investigation Revealed the following. Regarding Allegation: Unlawful Eviction. It was alleged by CW1 resident's Facility Unlawfully Evicted R1. CW1 stated to LPA that it was difficult to reach the facility administrator after R1's hospitalization. LPA Jeremiah Randle conducted an interview with facility administrator Susana Fuentes (S1). Susana Fuentes denied that R1 had been evicted and stated, “the resident has not been evicted or served any eviction notices”, S1 confirmed to LPA R1 was in the hospital however R1 was returned to the facility via hospital transportation. S1 stated " I never told anyone from the hospital the resident could not return to the facility". S1 requested LPA to view R1’s room LPA observed R1’s name plate on the door, R1’s personal affects situated in the room, and R1 was present in room as observed by LPA Randle. Findings Based on LPA’s observations and interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation 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. Exit interview was conducted with the and a copy of this report was provided to Christina Novoa.the state’s words, verbatim · CDSS document, Dec 13, 2022 · control 11-AS-20221208122033

Allegation investigated: Staff are retaining a resident that requires a higher level of care

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, November 09, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker met with Administrator Susana Fuentes. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: LPA Bunker interviewed staff 1-3 (S1-S3) and residents 1-7 (R1-R7). S1-S3 stated staff is not retaining a resident that requires a higher level of care. The resident was placed at the facility by her doctor. R1 is on hospice and her nurse and doctor visit her at the facility once a week. The administrator stated the hospital could not provide one on one. The facility staff is providing R1 with the necessary care and supervision according to her doctor's order. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Allegation: Staff are retaining a resident that requires a higher level of care Staff 1-3 (S1-S3) stated residents are provided with a comfortable environment. Residents 1-7 (R1-R7) state staff is providing residents with a comfortable environment. R1-R7 stated that they do not have any issues, problems, or concerns regarding the care and supervision being provided to them by the staff. S1-S3 stated the facility staff does not retain a resident that requires a higher level of care. Investigation revealed the following: Interviews were conducted with staff 1-3 (S1-S3), and residents 1-7 (R1-R7), stated residents are provided residents with a safe, healthful, and comfortable environment. S1-S3 stated staff is trained and competent to do their jobs. S1-S3 stated R1 doctor placed R1 at this facility. R1 is on hospice. R1's doctor and nurse come to the facility once a week or as often as needed to assist R1. S1-S3 stated R1 has a history of falls and is a fall risk before she came to Gardena Retirement Center and it is documented. S1-S3 stated R1 had one fall since she was admitted. R1 slipped off her wheelchair, and the facility staff could not have prevented R1 from falling. S1-S3 stated the facility reported a special incident report to Community Care Licensing and all the appropriate agencies in a timely manner regarding the fall prior to the complaint allegation. S1-S3 stated none of the residents living here requires a higher level of care. S1-S3 stated residents in placement are compatible. R1-R7 states they are happy at the facility, and the staff is providing the necessary care and supervision needed to meet resident care needs. S1-S3 stated the allegation is false. S1-S3 and R1-R7 all denied the allegation. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, LIC9099-C, and Confidential Names LIC811 was provided to the facility Administrator Susan Fuentes. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Nov 9, 2022 · control 11-AS-20221020162056

Allegation investigated: Facility not providing a safe environment for resident.

On 10/6/22 2022 Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced subsequent complaint investigation at the facility listed above. LPA Conducted risk assessment before entering the building. LPA met was arrived was greeted by Office Manager Christina Novoa and later by administrator. LPA explained the purposed of the visit is to deliver findings on the allegation listed. The investigation consisted of the following: On 5/23/2022 LPA Brown toured the facility and obtained Staff and residents roster. LPA interviewed 8 residents (R1-R8) and the administrator. On 10/6/22 LPA conducted interviews with 5 staff(S1-S5). LPA reviewed and obtained copies of residents R2 and R9 admission agreement, physicians’ reports, appraisal and needs and activity calendars. The investigation revealed the following.: Substantiated The complainant alleges that a resident was walking with a walker repeatedly from one end to the driveway and back. Complainant in stated there was a truck backing in the driveway and feared the resident may get hurt. On 5/23/22, LPA interviewed Residents (R1-R8), and out of those that interview 4 stated they had saw residents pacing in the driveway and another on the side of the building and the 5th stated that they like to exercise and had walk in the driveway. LPA conducted interview with the administrator, she stated the day of the incident that particular resident was waiting for a family member and another resident like to smoke and would pace the driveway. On 10/6/22, interviewed staff members (1-5) All staff members stated the facility is a safe environment and the residents that smoke will exit the backdoor but will have to walk the driveway to enter the front of the building. Staff also mentioned residents safety are seen on video camera while outside. 2 out of 5 staff stated one residents likes to walk around the building and another resident would like to walk back and forth on the driveway and smoke cigarettes. LPA reviewed files pertaining to the allegation and both residents that were mentioned has health condition indicated they have confusion and disoriented. Based on interviews and records the above allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Oct 6, 2022 · control 11-AS-20220519161012

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 14, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on interviews conducted and records reviewed, showed that residents were not able to leave the premises on their own were walk up and down the driveway. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Administrator will submit a plan on how she will ensure that residents that are not able to leave on their own are not walking back and forth in the driveway. Administrator will submit to LPA Brown by POC due date 10/14/22.

Allegation investigated: Staff leaves resident in soiled diapers Staff do not answer call bells timely Staff did not meet residents hygiene needs Staff left resident in bed Staff did not provide lunch to resident Staff is rough with resident Staff do not assist resident Facility does not have sufficient staff to meet residents needs

On 8/8/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Office Manager Christina Novoa. LPA explained the purposed of the visit is to deliver findings on the allegations listed above and was grated entry. The investigation consisted of the following: On 2/24/2022 LPA Cifuentes toured facility grounds, reviewed facility files and interviewed staff 1-staff 4 (S1-S4) and resident 1(R1). On 8/8/2022 LPA Cifuentes spoke with staff 5-staff 7(S5-S7) and residents 2-resident 7 (R2-R7). LPA requested and received the following files: Staff roster, resident roster and other documents relevant to the investigation. Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff leaves resident in soiled diapers The complainant alleges that facility residents are often left in soiled diapers. LPA spoke to facility administrator who stated caregivers have a list of the residents that need changes and as the changes are completed they ae marked off on list. No one has missed changes but there are times that residents refuse and ask staff to come by later. LPA spoke with residents (R1-R7) regarding the allegations. Of those interviewed 5 out of 7 stated staff did not leave them in soiled diapers. LPA spoke with staff (S1-S7) regarding allegations. Of the staff questioned, 7 out of 7 stated residents are not left in soiled diapers. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff leaves resident in soiled diapers” Allegation: Staff do not answer call bells timely The complainant alleges that when staff are called for assistance they take a long time to answer. LPA spoke to facility staff, who stated call system is answered by office manager, who then directs caregivers to assist residents as needed. If caregivers are busy with other residents, residents are asked to standby and that staff will be with them shortly. LPA interviewed residents (R1-R7) regarding allegation. Of the residents interviewed 5 out of 7 stated call button was answered promptly. Some residents added that the time it took caregivers to get to room varied, sometimes it was immediate, sometimes it took longer. Of the staff interviewed, 7 out of 7 stated the facility staff answered call button timely, but caregiver response to room varied depending on tasks already being completed. Based on information gathered, the department did not find sufficient evidence to support allegation “Staff do not answer call bells timely Allegation: Staff did not meet resident’s hygiene needs The complainant alleges that staff do not assist residents with changing and grooming. LPA spoke to administrator who stated residents are assisted with changing and grooming daily unless they request to stay in bed. LPA spoke with residents (R1-R7) regarding the allegations. Of those interviewed 6 out of 7 stated staff were assisting with bathing and grooming if they needed assistance. LPA interviewed staff (S1-S7) regarding allegation. 7 out of 7 staff stated that residents are assisted with changing and grooming with some staff adding that some residents may request to be left in bed if they are tired. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff did not meet residents hygiene needs.” Allegation: Staff left resident in bed The complainant alleges staff leave residents in bed all day instead of putting them in wheelchair. LPA spoke to administrator Susana Fuentes who stated residents are not left in bed by staff unless they request to be left in bed. Administrator added that some residents will request to be moved from bed later and staff will assist. There is an occasional delay if the resident requires a two person assist or staff are occupied with other residents. LPA spoke with residents (R1-R7) regarding the allegations. Of those interviewed 5 out of 7 stated they were not left in bed by staff. LPA interviewed staff (S1-S7) regarding allegation. 7 out of 7 staff stated that residents are not left in bed all day. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff left resident in bed.” Allegation: Staff did not provide lunch to resident. The complainant alleges residents are not provided lunch by staff. LPA spoke with administrator, who stated residents are provided 3 meals and snacks. If a resident is not in dining room, they will be called by staff. Residents will at times go out to eat and let staff know they will not be attending meals LPA spoke with residents (R1-R7) regarding the allegations. Of those interviewed 6 out of 7 stated facility did not miss any of their meals with some adding that they sometimes notified facility staff if they wanted to skip a meal. LPA interviewed staff (S1-S7) regarding allegation. 7 out of 7 staff stated residents are provided all meals. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff did not provide lunch to resident.” Allegation: Staff is rough with resident. The complainant alleges staff handle residents roughly when changing them. LPA spoke with staff who stated they are not rough with residents, but that some residents can be rough with staff members. LPA spoke with residents (R1-R7) regarding the allegations. Of those interviewed 6 out of 7 stated staff were not rough with them. LPA interviewed staff S1-S7 regarding allegation. 7 out of 7 staff stated that staff are not rough with residents when assisting them. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff is rough with resident.” Allegation: Staff do not assist resident The complainant alleges staff do not help residents. Per interview with administrator, all residents receive assistance from staff. Administrator added that sometimes residents will be agitated and, in those cases, staff will let them know they will give them time and will come back after a few minutes. Facility will change staff when this happens, as a different face can assist the resident in becoming calmer. LPA spoke with residents (R1-R7) regarding the allegation. Of those interviewed 6 out of 7 staff assisted them when they requested assistance. LPA interviewed staff (S1-S7) regarding allegation. 7 out of 7 staff stated they assisted residents. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff do not assist resident Allegation: Facility does not have sufficient staff to meet residents needs The complainant alleges facility has a staffing shortage. LPA spoke with facility administrator, who stated they had enough staff on all shifts. LPA reviewed staff schedule LPA spoke with residents (R1-R7) regarding the allegations. Of those interviewed 5 out of 7 stated they believed facility needed more staff. LPA interviewed staff (S1-S7) regarding allegation. Of those interviewed, 4 out of 7 believe facility has enough staff. Based on information gathered, the department did not find sufficient evidence to support allegation " Facility does not have sufficient staff to meet residents needs” The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegations: " Staff leaves resident in soiled diapers, “Staff do not answer call bells timely,” “Staff did not meet residents hygiene needs,” “Staff left resident in bed,” “Staff did not provide lunch to resident,” “Staff is rough with resident,” “Staff do not assist resident,” “Facility does not have sufficient staff to meet residents needs.” Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Susie Fuentes and a hard copy was provided.the state’s words, verbatim · CDSS document, Aug 8, 2022 · control 11-AS-20220223123952

Allegation investigated: Staff do not administer resident's medication as prescribed by physician Staff do not assist resident with incontinence care Staff do not allow resident to keep personal care item in room *Staff and residents are not provided adequate masks. *Facility is not following universal precautions. *Facility limits residents use of toilet paper.

On 6/27/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Office Manager Christina Novoa. LPA explained the purposed of the visit was to investigate the allegations listed above and was grated entry. The investigation consisted of the following: On 10/19/2021 LPA Cifuentes toured facility grounds, reviewed facility files and interviewed staff 1-staff 6 (S1-S6). On 6/27/2022 LPA Cifuentes interviewed residents 2-resident 7 (R2-R7) and staff 7(S7) LPA requested and received the following documents: staff and client rosters, needs and services plans and physician’s assessment for clients R1, R7, R8. Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff do not administer resident's medication as prescribed by physician The complainant alleges administrator forgot to give resident their medication. LPA toured facility grounds and reviewed files. LPA noted that facility has three medtechs, one per shift, to hand out resident medications. Per administrator Susie Fuentes, only if the medtechs are out will the administrator give out medications. LPA reviewed Medication administration record and noted that no medications were missed on 10/9/2021 or 10/10/2022 for R1. LPA spoke with residents (R2-R7) regarding the allegations. Six out of six residents interviewed stated they are taking medications and they are given to them daily by staff and at the correct times. LPA spoke with staff (S1-S6) regarding allegations. Of the staff questioned, 4 out 7 stated the residents received medications timely, with the other three stating they did not know. Based on information gathered, the department did not find sufficient evidence to support allegation "Staff do not administer resident's medication as prescribed by physician” Allegation: Staff do not assist resident with incontinence care. The complainant alleges that residents are not being assisted with their incontinence needs. LPA reviewed facility documents and noted that facility has a list of all residents with incontinence care needs, the list outlines which staff will be changing the residents. LPA interviewed residents regarding allegation and 2 out of 6 residents stated they received assistance with incontinence care, 3 of those interviewed stated they assisted themselves and 1 did not answer. Of the staff interviewed, 5 out of 7 stated the facility staff assist residents with incontinence care with the remaining two staff stating it was not part of their job duties. Based on information gathered, the department did not find sufficient evidence to support allegation “Staff do not assist resident with incontinence care.” Continued on 9099-C Allegation: Staff do not allow resident to keep personal care item in room The complainant alleges that staff are not allowing residents to keep personal care items in rooms. LPA Cifuentes toured the facility and noted adult incontinence briefs in several of the rooms, reusable bed pads, lotions, and bathing supplies. LPA Cifuentes spoke to Administrator who stated residents can keep personal care items in their rooms, but their were issues with residents taking incontinence supplies from other residents who were not as alert or ambulatory, so some of those supplies were being kept in storage. LPA spoke with residents (R2-R7) regarding the allegations. Of those interviewed 6 out of 7 stated they were allowed to keep personal care items in their rooms. One of those interviewed did not answer the question. LPA interviewed S1-S6 regarding allegation. Out of those interviewed 7 out of 7 staff stated that residents are allowed to keep personal care items in their rooms, with some staff adding that it depended on the cognitive level of the resident.. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff do not allow resident to keep personal care item in room Allegation: *Staff and residents are not provided adequate masks. The complainant alleges that residents are not being provided masks by facility. LPA toured facility and noted that receptionist gave resident a mask when they requested one. LPA spoke to facility administrator, who stated facility staff has sufficient PPE for their needs and residents are provided masks when they request them. LPA spoke with residents (R2-R7) regarding the allegations. Of those interviewed, 6 out of 7 stated masks were provided upon request, with on resident not answering question. LPA spoke with staff (S1-S6) regarding allegations. Of the staff questioned, 7 out of 7 stated that facility proved both staff and residents with masks when needed, several staff adding that there is a supply of masks in front office for that purpose. Based on information gathered, the department did not find sufficient evidence to support allegation " *Staff and residents are not provided adequate masks.” Continued on 9099-C Allegation: *Facility is not following universal precautions. The complainant alleges that staff are not provide with gloves or trash bags to dispose of waste. LAP interviewed administrator Fuentes, who states that gloves supplies are checked by maintenance supervisor and extra quantities are supplied at the end of their shift as needed for the upcoming shifts. Administrator also stated that staff are provided with black trash bags for incontinence waste, which they then throw away outside. LPA interviewed residents R2-R7 regarding allegation and of those interviewed 1 out of 7 stated that staff take incontinence waste with them when they leave their room. The other 6 interviewed did not know what happened to incontinence waste or declined to answer. LPA spoke to staff S1 – S6 regarding the allegations, and 7 out of 7 staff stated they used gloves to change residents, with 2 of the 7 stating it was not part of their job duties. Of the staff interviewed, 5 out of 7 staff stated incontinence waste is put in a bag and disposed of outside of resident rooms, with 2 of the 7 stating it was not part of their job duties. Based on information gathered, the department did not find sufficient evidence to support allegation “*Facility is not following universal precautions. Allegation: Facility limits residents use of toilet paper The complainant alleges that the facility only gives residents one roll of toilet paper a week. Per administrator Susan Fuentes, residents receive toilet paper daily. LPA spoke with residents (R2-R7) regarding the allegations. Of those interviewed 3 out of 6 stated they had toilet paper in their rooms while the other 3 did not know. LPA interviewed staff S1-S6 regarding allegation. 6 out of 6 staff stated that residents have toilet paper in their rooms, and that there was extra available if any of the residents requested the item. Based on information gathered, the department did not find sufficient evidence to support allegation " Facility limits residents use of toilet paper” The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegations: " Staff do not administer resident's medication as prescribed by physician,” “Staff do not assist resident with incontinence care,” “Staff do not allow resident to keep personal care item in room.” “Staff and residents are not provided adequate masks,” “Facility is not following universal precautions,” “Facility limits residents use of toilet paper.” Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Susana Fuentes and a hard copy was provided.the state’s words, verbatim · CDSS document, Jun 27, 2022 · control 11-AS-20211011093016

Allegation investigated: Facility is not following COVID-19 protocols.

On 6/16/22 at 12:19 pm, Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegation listed above. LPA was allowed entry into the facility by Administrator Susana Fuentes. LPA explained to Ms. Fuentes the purpose of the visit. The investigation consisted of the following: LPA conducted interviews on 6/16/22 with (4) staff members, and (6) facility residents. In addition, on 6/16/22, the LPA and Ms. Fuentes conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. The LPA also reviewed the following documents provided by Administrator Susana Fuentes from the Gardena Retirement Center: LIC 500-Staff Roster, Client Roster, Facility Mitigation Plan, and House Rules. Report continued on LIC 9099C Unsubstantiated Investigation Allegation: Facility is not following COVID-19 protocols. The investigation revealed, per LPA interviews, with (4) staff members, (6) residents from the Gardena Residential Center facility, and also review of facility documents, that the facility follows COVID-19 protocols. S1 informed the LPA, that the facility follows COVID-19 protocols, and specifically follows the facility mitigation plan. S1 also informed the LPA, that there is COVID testing weekly for staff and residents. In addition, S1 stated that the facility staff encourage the residents to use face masks inside and outside the facility. LPA conducted an inspection and observed that the facility is following its mitigation plan measures. The LPA also interviewed (4) facility staff personnel, and 4 of the 4 staff personnel interviewed, informed the LPA that they have been trained in COVID protocol procedures, and also, that the staff encourage residents to wear face masks in the facility, and to wear face masks outside the facility. In addition, the LPA interviewed (6) residents, and 6 of 6 residents interviewed, informed the LPA, that the facility staff follow COVID-19 procedures when there are positive cases in the facility. Also, the LPA interviewed (6) residents, and 6 of 6 residents interviewed, informed the LPA, that the facility staff provide them with face masks, to use inside and outside the facility. Furthermore, during the LPA interviews, 6 residents, informed the LPA that the facility staff assist them with their care needs, and also, 6 of 6 residents interviewed, informed the LPA, that staff are available to them when needed. Based on information gathered, the LPA did not find sufficient evidence to support allegation " Facility is not following COVID-19 protocols. ” Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Susana Fuentes, Administrator, and a hard copy of a LIC 9099 was provided.the state’s words, verbatim · CDSS document, Jun 16, 2022 · control 11-AS-20220608152646

Allegation investigated: Facility is not providing a comfortable environment for resident in care.

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, June 07, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker met with Administrator Susana Fuentes. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: LPA Bunker interviewed staff 1-4 (S1-S4) and residents 2-6 (R2-R6). LPA Bunker asked questions relevant to the nature of the complaint. The Administrator and staff stated the facility is providing a comfortable environment for residents in care. S1-S4 stated none of the residents is playing loud music. S1-S4 stated residents have personal rights and can listen to music on their cellphones. S1-S4 and R2-R6 stated that residents listening to music from their cellphones is not disturbing other residents. R2-R6 stated the facility staff is providing residents with a comfortable environment. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Allegation: The facility is not providing a comfortable environment for residents in care. Staff 1-2 (S1-S4) stated residents are provided with a comfortable environment. Residents 2-6 (R2-R6) state staff is providing them with a comfortable environment. R2-R6 stated that they do not have any issues, problems, or concerns regarding the care and supervision being provided to them by the staff. R2-R6 stated they did not have any concerns regarding residents playing music on their cellphones, and the music is not loud, nor is the volume up too loud. S1-S4 stated the residents in placement have personal rights and are allowed to listen to music on their cellphone. The residents that listen to music are not disturbing other residents. Investigation revealed the following: Interviews were conducted with staff 1-4 (S1-S4), and residents 2-6 (R2-R6), who stated residents are provided a comfortable environment. S1-S4 and R2-R6 stated the allegation is false. S1-S4 and R2-R6 stated no one is harassing any residents. S1-S4 and R2-R6 stated residents never yelled at another resident stating that they would not turn off the music. S1-S4 stated the facility is meeting the age requirement. Residents in placement are compatible. S1-S4 states they were aware of who reported this complaint. The resident will tell them he is going to file a complaint. Staff stated the resident that reported the complaint moved out on June 01, 2022, and is still filing complaints against the facility that is not true. S1-S4 and R2-R6 all stated residents are not playing their music too loud on their cellphone and they are not turning up the volume. R2-R6 states they are happy at the facility, and the staff is providing the necessary care and supervision needed to meet resident care needs. S1-S4 stated residents are treated with dignity and respect. S1-S4 and R2-R6 all denied the allegation. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, LIC9099-C, and Confidential Names LIC811 was provided to the facility Administrator Susan Fuentes. There were no deficiencies cited. An exit interview conducted.the state’s words, verbatim · CDSS document, Jun 7, 2022 · control 11-AS-20220531131957

Allegation investigated: Facility illegally evicted resident. Facility retaliated against resident.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility on 06/07/2022 at around 09:00 AM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10 day visit on 06/07/2022 approximately around 09:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 06/03/2022 LPA Calderon interviewed W1 for complaint. On 06/07/2022 LPA Calderon requested copies of the following: Staff and Resident rosters, admission agreement for W1, last filed 30-day eviction notice, court eviction paperwork for W1. On 06/07/2022 LPA Calderon interviewed S2 – S3 for complaint. Unsubstantiated Regarding Allegation #1: Facility illegally evicted resident. On 06/03/2022 LPA Calderon interviewed W1 for complaint. W1 states that W1 was served 30-day notice of eviction which W1 ignored. W1 states W1 was served court paperwork for W1 eviction and W1 went to court. W1 states that 3 staff members testified against W1 claiming W1 violated house rules and failed to pay W1 rent and this was the reason why W1 was being evicted. W1 states that there was no way to fight the court and W1 settled with the facility. W1 states that the judge ordered a 30-day eviction process and that W1 had to be out of the facility by 06/02/2022. W1 states that W1 moved out as the court ordered. On 06/07/2022 LPA Calderon interviewed S1 – S3 regarding the complaint all state that they were asked to testify in court regarding the eviction of W1 and the judge ordered W1 to leave the facility no later than 06/02/2022 or be arrested. Per S1 -S3 information there was no mention of the facility staff retaliating towards W1 in court and W1 never brought up any issues with staff or the facility. On 06/07/2022 LPA Calderon received and reviewed superior court paperwork for eviction of W1. Date court paperwork was served 03/09/2022. Court judgement was found against W1 and W1 was given 30 days to leave the facility as of 06/01/2022. W1 did not testify or present any proof of a in proper eviction or any proof of retaliation by staff or the facility due to W1 making complaints. Regarding Allegation #2: Facility retaliated against resident. On 06/03/2022 LPA Calderon interviewed W1 for complaint. W1 states that W1 was served 30-day notice of eviction which W1 ignored. W1 states W1 was served court paperwork for W1 eviction and W1 went to court. W1 states that 3 staff members testified against W1 claiming W1 violated house rules and failed to pay W1 rent and this was the reason why W1 was being evicted. W1 states that there was no way to fight the court and W1 settled with the facility. W1 states that the judge ordered a 30-day eviction process and that W1 had to be out of the facility by 06/02/2022. W1 states that W1 moved out as the court ordered. W1 states that W1 has filed many complaints since the facility is making decisions that is against the rights of the residents, but no one will call the administrator out and W1 states that W1 must call out the facility and therefore the facility evicted W1 from the facility. On 06/07/2022 LPA Calderon interviewed S1 – S3 regarding the complaint all state that they were asked to testify in court regarding the eviction of W1 and the judge ordered W1 to leave the facility no later than 06/02/2022 or be arrested. Per S1 -S3 information there was no mention of the facility staff retaliating towards W1 in court and W1 never brought up any issues with staff or the facility. On 06/07/2022 LPA Calderon received and reviewed superior court paperwork for eviction of W1. Date court paperwork was served 03/09/2022. Court judgement was found against W1 and W1 was given 30 days to leave the facility as of 06/01/2022. W1 did not testify or present any proof of a in proper eviction or any proof of retaliation by staff or the facility due to W1 making complaints. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of Facility illegally evicted resident., Facility retaliated against resident. is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator Susana Fuentesthe state’s words, verbatim · CDSS document, Jun 7, 2022 · control 11-AS-20220601141229

Allegation investigated: Staff administered unprescribed medication to resident. Facility has pests.

On 5/31/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA called and spoke to administrator Susana Fuentes and was told the facility has no current COVID-19 cases nor do any of the staff or residents show any signs or symptoms. LPA arrived at facility and was greeted by Office Manager Christina Novoa. LPA explained the purposed of the visit was to investigate the allegations listed above and was granted entry. The investigation consisted of the following: On 1/5/2022 LPA Cifuentes spoke to facility administrator and reviewed facility records. LPA reviewed, requested and received the following documents: staff and client rosters, copies of MAR and pest control records. On 5/31/2022 LPA Cifuentes interviewed staff 1-staff 6 (S1-S6) and residents 1-resident 6 (R1-R6). Continued on 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff administered unprescribed medication to resident. It is alleged that facility staff gave resident a medication which was not prescribed by doctor. LPA reviewed MAR and medications and found no medications without prescription by doctor. LPA spoke with residents (R1-R6) regarding the allegation. LPA asked residents if they had ever received an unprescribed medication. Of those interviewed, 5 out of 6 stated that they had not been given a medication that was not prescribed to them, with a few adding that all their medications were prescribed by the doctor. LPA spoke with staff (S1-S6) regarding allegation. 6 out of 6 answered that residents are not given medications that are not prescribed. Based on information gathered, the department did not find sufficient evidence to support allegation "Staff administered unprescribed medication to resident.” Allegation: Facility has pests. It is alleged that facility has bed bugs. On 1/3/2022 LPA Cifuentes inspected facility grounds and found no traces of bed bugs. LPA was given exterminator reports from Orkin dating from January 2022 to May 2022, as well as a few from late 2021 from both Orkin and Western Exterminators. No bedbugs were found in any of the reports. LPA interviewed residents regarding allegation and of the residents interviewed 6 out of 6 stated facility does not have bed bugs. LPA Cifuentes interviewed staff regarding allegation. Of the staff interviewed, 6 out of 6 stated facility does not have bed bugs. Based on information gathered, the department did not find sufficient evidence to support allegation “Facility has pests.” The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegations: “Staff administered unprescribed medication to resident, ” and “Facility has pests.” Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Susie Fuentes and a hard copy was provided.the state’s words, verbatim · CDSS document, May 31, 2022 · control 11-AS-20220103154748

Allegation investigated: Facility is not preventing the spread of COVID-19. Resident's are confined to their bedrooms.

On 5/31/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA called and spoke to administrator Susana Fuentes and was told the facility has no current COVID-19 cases nor do any of the staff or residents show any signs or symptoms. LPA arrived at facility and was greeted by Office Manager Christina Novoa. LPA explained the purposed of the visit was to investigate the allegations listed above and was granted entry. The investigation consisted of the following: On 2/17/2022 LPA Cifuentes toured facility grounds, reviewed facility files and interviewed staff 1-staff 6 (S1-S6) and residents 1-resident 6 (R1-R6). LPA requested and received the following: Staff roster, resident roster and other documents in association with the alelgations. Continued on 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility is not preventing the spread of COVID-19. It is alleged that facility staff were not following covid-19 protocols during recent outbreak. LPA Cifuentes toured facility on 2/17/2022 and noted the following: Facility has one main entry. Upon entry to the facility LPA’s temperature was checked, they were asked to use hand sanitizer and fill out a sign in sheet which asked temperature and screened LPA for covid-19 symptoms. LPA noted sanitizer stations and hot water and paper towels were located in public bathrooms. LPA Cifuentes was shown to room 22, which had PPE supplies and had donning and doffing posting in both English and Spanish posted. Per Administrator Fuentes, facility was conducting weekly testing, cleaning high touch surfaces every 30 minutes and cleaning rooms of positive residents daily. Residents in red and yellow zone were kept in isolation with meal and medication delivery to rooms. There was a specific designated staff person who entered the isolated residents’ rooms, they took their breaks outside and had a designated bathroom. Residents were asked to maintain social distancing at the time and wear face masks when exiting rooms. Facility also suspended eating in dining room after the New Year and had tray service for the residents until outbreak numbers dropped. LPA spoke with residents (R1-R6) regarding the allegations. LPA asked residents if staff wore PPE while in the red zone, or those interviewed, 1 refused to answer, 2 stated they did not know, 2 said yes, and 1 answered no. LPA spoke with staff (S1-S6) regarding allegations. LPA Cifuentes asked staff if they had received PPE training, if they or those assigned to isolation area were properly donning and doffing PPE when entering isolation rooms and if isolation rooms in the red zone remained closed. Of the staff questioned, 6 out of 6 answered yes to all questions. Based on information gathered, the department did not find sufficient evidence to support allegation " Facility is not preventing the spread of COVID-19.” Continued on 9099-C Allegation: Residents are confined to their bedrooms. It is alleged that facility staff is confining residents to their bedrooms. On 1/21/2022 LPA Cifuentes was contacted by Administrator Susana Fuentes who informed LPA that facility was conducting weekly Covid-19 tests as a preventive measure and that the latest test results showed facility had several residents test positive for Covid-19. Public health was also contacted. LPA checked in with Administrator Fuentes during outbreak and was told that despite contacting the local Public Health department, they had not received any contact in return. To prevent the further spread of Covid-19 in the facility and due to the length of time it was taking to get test results back from laboratories, Administrator Fuentes ceased communal dining and group activities until the transmission could be contained or other direction was received from Public Health but stared that some residents still chose to leave their rooms and although staff offered redirection, they could not prevent them from going out. Per PIN 21-49-ASC, which was released on 11/17/2022, Residents not in isolation or quarantine maintained the right to participate in communal dining and group activities, but during an outbreak at the facility, the local department of public health could require a cessation of all communal activities until transmission could be contained. LPA interviewed residents regarding allegation and of the residents interviewed 5 out of 6 stated they wore masks out of the rooms during the quarantine. Of the staff interviewed, 5 out of 6 said yes when asked if the residents wore masks outside of their rooms during the quarantine. Based on information gathered, the department did not find sufficient evidence to support allegation “Resident's are confined to their bedrooms.” The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegations: " “Facility is not preventing the spread of COVID-19,” “Resident's are confined to their bedrooms.”. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiatedthe state’s words, verbatim · CDSS document, May 31, 2022 · control 11-AS-20220209154559

Allegation investigated: Staff did not seek timely medical attention for resident in care Staff refused to let resident back in the facility

On 5/31/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA called and spoke to administrator Susana Fuentes and was told the facility has no current COVID-19 cases nor do any of the staff or residents show any signs or symptoms. LPA arrived at facility and was greeted by Office Manager Christina Novoa. LPA explained the purposed of the visit was to investigate the allegations listed above and was granted entry. The investigation consisted of the following: On 2/17/2022 LPA Cifuentes toured facility grounds and viewed facility files. LPA interviewed staff 1-staff 6 (S1-S6) and residents 1-resident 6 (R1-R6). LPA Cifuentes requested and received a staff roster, resident roster and other documents relevant to the allegations. Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not seek timely medical attention for resident in care It is alleged that facility staff denied resident medical attention and they had to call 911 themselves. LPA Cifuentes spoke with administrator and several staff regarding incident. Per staff R1 arrived at facility very agitated and was screaming threats against residents and then stating they had been poisoned. Staff asked them to calm down and called 911, the police arrived within five minutes and called ambulance to have resident taken to hospital. LPA spoke with residents (R1-R6) regarding the allegation. LPA asked residents if they had ever been denied medical attention by staff. Of those interviewed, 3 answered no, 1 said yes, 1 did not answer and 1 was unsure. LPA spoke with staff (S1-S6) regarding allegation. LPA Cifuentes asked staff if they had ever denied a resident medical attention. Of the staff questioned, 5 out of 6 answered that medical attention was not denied to residents. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff did not seek timely medical attention for resident in care Allegation: Staff refused to let resident back in the facility. It is alleged that facility staff refused to let resident back into facility. LPA interviewed administrator Susie Fuentes who stated residents had not been denied reentry to facility. There was an incident with a resident returning, who was very agitated, screaming and yelling threats as well as saying they were poisoned. As there was a safety concern, staff called 911 and tried to calm the resident. LPA interviewed residents regarding allegation and of the residents interviewed 4 out of 6 stated they had not been denied entry to the facility. Of the staff interviewed, 5 out of 6 said residents had not been denied entry to the facility with 1 being unsure. Based on information gathered, the department did not find sufficient evidence to support allegation “Staff refused to let resident back in the facility.” The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegations: " Staff did not seek timely medical attention for resident in care “Staff refused to let resident back in the facility Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Susie Fuentes and a hard copy was provided.the state’s words, verbatim · CDSS document, May 31, 2022 · control 11-AS-20220209113243

Allegation investigated: Resident sustained burns while in care

On 5/27/2022 at 12:52pm., Licensing Program Analyst (LPA)/Susan Campos, initiated a complaint investigation visit to deliver findings for the allegation listed above. LPA was allowed entry into the facility by Susana Fuentes, Administrator. LPA explained to Ms. Fuentes the purpose of the visit. On 3/4/22, the Department of Social Services Investigative Bureau, initiated a complaint investigation regarding “ Resident sustained burns while in care”. On 3/4/22, LPA and Ms. Fuentes conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. Report continued LIC 9099C Unsubstantiated Investigation Revealed Allegation: Resident sustained burns while in care The Department of Social Service Investigative Bureau, Investigator Edward Hector, conducted interviews with R1, facility staff members, and also reviewed R1’s facility and medical documents. On 2/26/22, R1, Gardena Residential Center facility resident, suffered severe accidental burns, as a result of getting into a bathtub, with hot water temperature. R1, informed Investigator Hector, that R1 did not feel the temperature of the hot water due to R1’s medical condition. Also, Investigator Hector interviewed Gardena Residential Center facility staff, and they confirmed that R1 is independent, and does not use assistance to bathe self. In addition, Investigator Hector interviews, and record review confirmed that R1 does not use facility staff assistance to bathe self, and does not request staff services for assistance. R1 informed Investigator Hector that takes full responsibility for self-injury. Based on interviews and facility documents, R1 is independent and does not request services for bathing. Per Title 22, Division 6, Chapter 8, Article 8 CCR 87468.1(a)(16) Personal Rights of Residents in All Facilities, states: “Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services .“ Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Susana Fuentes, Administrator, and a hard copy of a LIC 9099 was provided.the state’s words, verbatim · CDSS document, May 27, 2022 · control 11-AS-20220303162611

Allegation investigated: Staff are not providing adequate activities to residents.

On 05/26/2022 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Administrator Susana Fuentes. The investigation consisted of the following: LPA requested and received resident roster, staff roster and other service documents on 05/26/2022. LPA interviewed staff (S1-S5) and Residents (R1-R9). A plant inspection of the facility was conducted on 05/26/2022. Investigation revealed: See LIC 9099-C Unsubstantiated Allegation: Staff are not providing adequate activities to residents. It is alleged the staff are not providing adequate activities to residents. Seven of nine residents stated they are encouraged to participate in activities. Resident (R7) stated (R7) chooses not to participate in activities. Seven of nine residents stated facility does provide an activities calendar in hallway. Resident (R4, R6, R8) all participated in a session on “Aroma therapy” this past Monday. Resident (R3, R6, R8, R9) stated the facility does offer “word puzzles” as an activity to residents. Staff (S1-S5) stated they encourage all residents to participate in activities. Staff (S1-S5) stated the facility offers various types of activities each day and should the residents want to do another activity in the activity room, the resident is not denied and the resident is given their choice activity. Four of five staff stated the facility does offer “Aroma therapy” to residents. Staff (S4) stated (S4) did aroma therapy this past Monday. Staff (S1-S5) stated word puzzles are offered as an activity. Staff (S2) stated word puzzles were offered on the schedule prior but it was not a popular choice any longer so it was taken off; however, residents still do ask for word puzzles and we provide them printouts. Staff (S1-S5) stated the activities calendar is on the wall in the hallway. LPA observed activity taking place as LPA entered the facility at 09:25 am in the activity room according to the activity calendar – chair exercises with ball toss. LPA observed activity calendar in hallway up to date with various activities listed. LPA observed activity calendar for each day of the month including morning and afternoon activities each day. LPA observed various completed decorations completed by different residents including wreaths, plant pots, door decorations during facility tour on resident’s doors. LPA heard over the loud speaker at 12:49 pm announcing the 1pm activity is “Bingo” while at the facility. LPA obtained activity “outings” log in sheet. LPA obtained copy of the current activity calendar. Based on LPA’s interviews conducted, observation and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, May 26, 2022 · control 11-AS-20220519131723

Allegation investigated: Staff did not prevent a resident from disturbing another resident in care.

On 5/23/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint visit at this facility. LPA spoke with Administrator Susie Fuentes via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to investigate the allegation listed above. The investigation consisted of the following: On 2/4/2022 LPA Cifuentes conducted a tour of facility grounds and reviewed records for staff and residents. On 2/4/2022 and 5/23/2022 LPA conducted interviews with staff (S1-S8), and residents (R1-R6). LPA Cifuentes requested and received the following documents: Client roster, staff roster and other documentation relevant to the investigation. Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not prevent a resident from disturbing another resident in care. The complainant alleges that facility residents are yelling and playing loud music and when it is reported to staff, nothing is done about it. LPA Cifuentes interviewed residents (R1-R6) and of those interviewed, 4 out of 6 stated the facility residents are not loud so they have had no need to report anyone to staff. LPA interviewed staff (S1-S8) regarding the allegation. Of those interviewed 7 out of 8 stated facility residents don’t normally play loud music or speak loudly. One staff further added that the times it has occurred, the resident was asked to turn down the music and self corrected after.. Based on information gathered, the department did not find sufficient evidence to support allegations " Staff did not prevent a resident from disturbing another resident in care.” Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Administrator Susie Fuentes.the state’s words, verbatim · CDSS document, May 23, 2022 · control 11-AS-20220131163749

Allegation investigated: Facility allowing residents to work at facility.

On 5/23/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint visit at this facility. LPA spoke with Administrator Susie Fuentes via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to investigate the allegation listed above. The investigation consisted of the following: On 5/23/2022 LPA conducted a tour of facility grounds and reviewed records for staff and residents. LPA conducted interviews with staff (S1-S7), and residents (R1-R6). LPA Cifuentes requested and received the following documents: Client roster, staff roster and other documentation relevant to the investigation. Continued on 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility allowing residents to work at facility. The complainant alleges that some residents are assisting staff with their duties and they are not fingerprint cleared. LPA reviewed facility files and spoke with administrator. Per administrator Susie Fuentes, none of the residents at the facility have been asked to complete staff jobs nor are they being paid by the facility, but two residents do shadow staff in their tasks or assist with simple things like folding linens in the laundry room. The residents see it as an activity. LPA Cifuentes interviewed residents (R1-R6) and of those interviewed, 6 out of 6 stated they had seen residents completing some tasks around the facility or following a staff member as they completed their duties, but where unaware if they were paid to do so. One resident added that they had assisted staff with activities in the past. LPA interviewed staff (S1-S7) regarding the allegation. Of those interviewed 4 out 7 stated they had seen a resident shadowing staff or assisting with simple tasks. Those who answered stated that is was not a paid position, but more of an activity for the residents. Based on information gathered, the department did not find sufficient evidence to support allegations " Facility allowing residents to work at facility.” Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Administrator Susie Fuentes.the state’s words, verbatim · CDSS document, May 23, 2022 · control 11-AS-20220516090018

Allegation investigated: Resident is being financially abused while in care.

This report serves as an ammendment to correct the report creation date and the date of visit. It does not supersede the complaint investigation finding reflected on the report created on 05/19/22. On 05/19/22, Licensing Program Analyst (LPA) Gail Johnson and Licensing Program Manager (LPM) Eva Alvarez conducted a subsequent complaint visit. LPA Johnson and LPM Alvarez met with Administrator Susana Fuentes and explained the purpose of today's visit. Investigation consisted of: LPA Johnson conducted interviews with Administrator Fuentes, Staff (S1) – (S3) and Residents (R1) - (R7). LPA Johnson obtained copies of (R1)’s Physician’s Report, (R1)’s Appraisal/Needs and Services Plan, (R1)’s Trust Transaction History (dated January 1, 2018 – January 12, 2022), written correspondence (dated 01/12/2022) to (R1) from facility communicating discontinuing management of (R1)’s account, facility issued reimbursement check for the balance of R1’s Trust Account (dated January 12, 2022), facility Trust Fund Agreement terms, as well as current rosters for Staff and Residents. Continued on 9099-C Unsubstantiated Investigation revealed: Allegation - Resident is being financially abused while in care. During interviews conducted, Resident (R1) stated the facility did not clearly explain the history of R1’s Trust Fund account transactions and this caused confusion. R1 stated the facility did not explain transaction history and R1 believed there were account balance discrepancies. R1 stated he found no discrepancies after reviewing his account statements recently. R1 stated when his Trust Fund account was active, he received his check, signed the check, and endorsed it to the facility for deposit. R1 would then withdraw funds from this account. LPA Johnson and LPM Alvarez conducted an interview with Administrator Fuentes, who stated R1 has made multiple accusations of the facility mismanaging R1’s account. The facility made a decision to no longer manage R1’s Trust Fund as of 1/12/2022. R1 was issued a check for the Trust Fund account remaining balance. Administrator Fuentes notified R1 of discontinuing management of R1’s Trust Fund in writing and verbally on 1/12/2022. As of 5/17/2022, R1 has not agreed to receive the check issued from the facility for the Trust Fund account balance. Administrator Fuentes stated all Residents with Trust Funds sign out funds and receive receipts when funds are dispersed. Administrator Fuentes states the facility maintains copies of receipts on record. LPA Johnson and LPM Alvarez conducted an interview with Office Manager Christina Nova, who stated she is present when Residents withdraw funds as a witness to transactions as well as a Social Worker at times. Administrator Fuentes stated Resident statements are accessible. LPA Johnson and LPM Alvarez conducted a review if R1’s Physician Report (dated 2/10/2021) indicating R1 is able to manage own cash resources. Two (2) out of seven (7) Residents interviewed, stated that they have Trust Fund accounts. Two (2) of the (2) two Residents with Trust Fund accounts, reported not having any concerns regarding their own Trust Fund Account or knowing of Residents that have Trust Fund account management concerns. Four (4) out of seven (7) Residents interviewed stated they do not have Trust Fund accounts and do not have knowledge of Residents with concerns regarding Trust Fund account management. Staff (S1) and (S3) stated they have not received reports from Residents regarding Trust Funds account management concerns. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted. A copy of this report was given to Administrator Susana Fuentes.the state’s words, verbatim · CDSS document, May 19, 2022 · control 11-AS-20220504104523

Allegation investigated: Staff did not respond to resident's call button in a timely manner.

On 05/12/22, Licensing Program Analyst (LPA) Gail Johnson and Licensing Program Manager (LPM) Eva Alvarez conducted a subsequent unannounced complaint visit. LPA Johnson and LPM Alvarez met with Administrator Susana Fuentes and explained the purpose of today's visit. Investigation consisted of: LPA Johnson conducted interviews with Administrator Fuentes, Staff (S1) – (S3) and Residents (R1), (R3), (R4), (R5), (R6), and (R7). LPA Johnson obtained copies of the staff training on 03/10/22 in Recognizing Residents’ Needs and Communication Expectations, Staff roster, and Resident Roster, (R1)’s Admission Agreement, (R1’s) Appraisal/ Needs and Services Plan, and (R1’s) Physician’s Report. Continued on 9099-C Unsubstantiated Investigation revealed: Allegation - Staff did not respond to resident's call button in a timely manner. Based on the review of records and interviews conducted, LPA found that the call button is used for all types of needs. The facility call button and alert system is used for emergencies and non-emergencies. When a resident uses the call button, the front desk receives an alert and responds to the resident through their room intercom immediately. Once the alert is received at the front desk, a caregiver is called on a transceiver (two-way radio). The caregiver notifies the front desk of the time frame that they will arrive at the resident’s room. The front desk then calls the resident on the intercom system and communicates the wait time to the Resident. If the Resident reports an urgent (Emergency) need by call button, a Staff member reports to the Resident room without delay. Based on interviews conducted, six (6) of six (6) Residents stated not having any call button response concerns or knowing of any Residents speaking of call button response concerns. LPA conducted interview with (R1), who stated not having used the call button since moving into the facility and commented, “I need assistance but not like that.” LPA conducted interviews with Administrator Fuentes and Staff (S1) – (S3), who stated that staff respond immediately when a call from the resident is placed, and the residents are informed of approximate wait time if Caregivers are providing assistance to other Residents. Staff state an average wait time is 5 - 15 minutes. The front desk notifies the resident on the intercom If the wait will take more than 15 minutes. Staff (S1) – (S3) stated, the front desk always remains consistently staffed to attend the call alert system and supervise the lobby area for safety purposes. When Staff need to leave the front desk, they wait for another Staff member to arrive before leaving. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of this report was given to Administrator Susana Fuentes.the state’s words, verbatim · CDSS document, May 19, 2022 · control 11-AS-20220217133251

Type of visit: Required - 1 Year

On 05/19/22, Licensing Program Analysts (LPA) Gail Johnson conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Johnson met with the Administrator Susana Fuentes. LPA Johnson explained the purpose of today’s visit. The facility is licensed to operate 108 non-ambulatory residents 60 years and above. Facility Structure The facility is a two-story building located in a residential neighborhood. It consists of the following: Administrator’s office, front office, medication room, dining room, two activity rooms, kitchen, laundry room, patio, shaded area, indoor and outdoor activity areas, and storage room. Physical Plant LPA Johnson toured the physical plant. There were no bodies of water or obstructions on the premises. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.8 degrees F. Storage & Inaccessible Items Storage areas for cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and found as clean and in adequate condition. Nine (9) fire extinguishers were fully charged. Smoke detectors and carbon monoxide detectors were operable. Continued on LIC 809-C Activities Calendar: LPA Johnson observed a bulletin board in the hallway that displayed various activities. The activities listed on the bulletin board included: movies, arts and crafts, outdoor outings, games and exercising. Pool/Jacuzzi & Pets: LPA's did not observe any pet or bodies of water at the facility. Fire Inspection was approved on 02/08/2022. Infection Control During the visit, LPA Johnson observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. Sanitizing stations in common areas and restrooms. LPA Johnson observed staff was wearing face coverings. LPA observed the facility has a 60-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file. Deficiencies were not identified during this annual inspection visit. An exit interview was conducted with Susana Fuentes. A copy of this report was printed and provided to Susana Fuentes.the state’s words, verbatim · CDSS document, May 19, 2022

Allegation investigated: Staff speaks inappropriately of residents.

On 05/11/22, Licensing Program Analyst (LPA) Gail Johnson and Licensing Program Manager (LPM) Eva Alvarez conducted an unnanounced complaint investigation. LPA Johnson and LPM Alvarez met with Administrator Susana Fuentes and explained the purpose of today's visit. Investigation consisted of: LPA Johnson conducted interviews with Administrator Fuentes, Staff (S1) – (S3) and Residents (R1) - (R7). LPA Johnson obtained copies of the staff training on 03/10/22 in recognizing residents’ needs and communication and expectations, and Personal Resident Rights training dated 04/14/22, Staff roster, and client roster. Continued on 9099-C Unsubstantiated Investigation revealed: Allegation- Staff speak inappropriately to residents. On 05/11/22 and 05/12/22, LPA Johnson obtained relevant documents, interviewed Administrator, Staff (S1)-(S3) and Residents (R1)-(R7). LPA was unable to verify that “Staff speak inappropriately to or about residents.” LPA conducted interviews with (S1)-(S2) and stated that, they have not spoken inappropriately to or about residents. LPA conducted interviews with (R1) ,who stated that Staff communication is “friendly and helpful.” LPA did not find sufficient evidence to support allegation above. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of this report was given to Administrator Susana Fuentes.the state’s words, verbatim · CDSS document, May 12, 2022 · control 11-AS-20220504155701

Allegation investigated: Resident wandered from the facility. Facility is not properly secured.

Licensing Program Analyst (LPA) Jey Cardenas conducted a subsequent complaint visit to Gardena Retirement Center and continued investigation into the allegations listed above. Upon arrival at the facility LPA meet with Staff#1 (S1); LPA explained the reason for today’s visit and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. The investigation consisted of the following: Initial 10-day complaint visit was conducted on 3/22/22, LPA obtained a copy of resident and staff roster, interviewed Staff#1-Staff#7 (S1-S7) and Resident#1 -Resident#7 (R1-R7), Reviewed resident files, obtained copies of records relevant to the investigation, and tour the physical plant. On 5/4/22 LPA Cardenas conducted a tour of the physical plant. It is alleged that on 3/17/22 the front desk was unmanned, consequently at approximately 9:00AM, R2 who has dementia left the facility unattended. Substantiated (continued pg2) -Regarding allegation: Facility is not properly secured. On 3/22/22 LPA reviewed the camera footage and observed that on 3/17/22 approximately 8:35am there wasn’t a staff at the front desk, nor was there staff around the area to supervise that dementia residents do not wander outside unsupervised. On 3/22/22 LPA interviewed administrator, Susana Fuentes and asked if there are auditory devices to notify staff when someone walks through the backdoor. Susana states that the facility is not a locked facility, and there are no alarms, however facility has an auditory device on exits. There’s a box located at the front desk, and when the backdoor is opened it will make a sound to notify staff. Staff will then review the camera to ensure its not a resident with dementia attempting to exit unassisted. On 3/22/22 at approximately 1:06pm LPA asked Susana to test the backdoor auditory devices, S1 opened the backdoor, however there was no alarm heard at the front desk. On 5/4/22 at approximately 9:31am LPA observed resident walk out the backdoor and LPA didn’t hear an auditory alarm go off to notify backdoor was opened. LPA asked S1 about the auditory device, in which she replied; the backdoor was replaced recently and the alarm was disabled. Facility is working to get the auditory device to work. Based on LPA’s interviews, and record review(s), the preponderance of evidence standard has been met, therefore the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. Exit interview conducted and a copy of this report and appeal rights provided to facility representative. -Regarding allegation: Resident wandered from the facility. Per Unusual incident report (UIR) dated 3/17/22; on 3/17/22 an outside pedestrian came to notify facility that resident was walking outside and was requesting to go to Torrance. S2 went out to check and determined that it was R2. Per Physician report R2 is diagnosed with Dementia and requires supervision to leave facility. Per Preplacement Appraisal dated 3/4/13 R1 has no sundowning, aggression, nor wandering behaviors. A reappraisal was not available at time of visit. On 3/22/22 LPA Cardenas reviewed the camera footage and observed that on 3/17/22 R2 walked out of the facility front entrance unassisted by a staff at approximately 8:35AM and was assisted back to the facility by staff at 9:03AM. told that the maintenance man would be notified, however the heater was not adjusted and the bedroom was 68 degrees. In addition, during a conversation with R3 it was brought up that administrator Susana didn’t allow R3 to install a television in the bedroom because a tv was already in that bedroom. -Regarding allegation: Resident was spoken to in an inappropriate manner. On 3/22/22 LPA Cardenas interviewed R1-R7, of those interviewed five (5) indicated that staff do not speak to them in an inappropriate manner. R7 indicates facility is fine and refused to continue the interview. On On 3/22/22 LPA interviewed S1 who indicates that none of the residents have complained that staff are speaking to them inappropriately. Nor that none of the staff have reported witnessing other staff speak inappropriately to resident. S1 denies speaking inappropriately to a resident. -Regarding allegation: Resident's request for heat in their room was denied. On 3/22/22 LPA interviewed S1 who indicates that thermometer temperature is automatically regulated. There are residents that feel facility is too cold, others feel its too hot, therefore temperature is kept in between to accommodate everyone. Temperature varies throughout the facility. S1 states that two weeks ago, a resident complained that their bedroom was too cold so S4 was asked to adjust temperature. On 3/22/22 LPA Cardenas interviewed S4 who indicates that one resident prefers room to be on the warmer side. A few days ago the thermometer read 78 degrees F and the resident complained that it was cold. Temperature is usually adjusted as needed per request; however other residents need to also be taken into consideration. On 3/22/22 LPA interviewed R1-R7, four (4) resident indicated that room is comfortable temperature and requests are responded appropriately. R2 states it was cold in the room once because a window was left open. R7 indicates facility is fine and refused to continue the interview. On 3/22/22 LPA Cardenas toured the facility in the AM and PM and noted temperature on the first and second floor (mid-points). LPA observed temperature was within title 22 regulations. On 5/4/22 LPA toured the facility in the AM and observed temperature was within title 22 regulations. -Regarding allegation: Resident was not allowed to install a television in their room. On 3/22/22 LPA interviewed R1-R7. R3-R6 indicates that they are allowed to bring furnishings of their choice to their bedroom. R3 also confirmed being allowed to install a television in the bedroom. However, it took a few days because the wifi needed to be hooked up. R7 indicates facility is fine and refused to continue the interview. On 3/22/22 LPA Cardenas interviewed administrator, Susana who indicates that resident bedrooms are furnished upon mo “Although the allegation may have happened or is valid, there is ving in. However, residents are allowed to bring in any furnishing of their choice. They can decorate the walls with pictures to their liking. Facility generally won’t provide a tv, but if residents need a tv facility has donations that residents can have. not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.” Exit interview conducted and a copy of this report was provided to facility representative.the state’s words, verbatim · CDSS document, May 4, 2022 · control 11-AS-20220317152343

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: May 5, 2022

The licensee shall have an auditory device or other staff alert feature to monitor exits... This requirement not met as evidenced by: On 3/22/22 and 5/4/22 LPA observed backdoor was opened and auditory device was inoperable. This poses immediate risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2022

Plan of correction: Facility will submit in writing plan with timelines to ensure that exits have auditory devices.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: May 6, 2022

The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes...This requirement not met as evidenced by: On 3/22/22 LPA didn't observe a reappraisal for R2 after wandering behavior. This poses a potential health and safety risk to resident.the state’s words, verbatim · CDSS document, May 4, 2022

Plan of correction: Facility will ensure that R2 has a reappraisal on file and will submit document to LPA via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(2) · Plan of correction due date: May 6, 2022

Safety measures to address behaviors such as wandering, aggressive behavior...This requirement not met as evidence by: On 3/22/22 LPA observed that R2 exited the facility unassited by staff, there was no staff monitoring exits. This poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, May 4, 2022

Plan of correction: Facility will outline plan with safety measures to address wandering behavior. Ensure all staff receive and understand plan. Submit plan to LPA by email.

Allegation investigated: Resident is not afforded a comfortable accommodation while in care. Staff do not ensure the residents are taking universal precautions.

On 04/13/2022 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Administrator Susana Fuentes. The investigation consisted of the following: LPA requested and received resident roster, staff roster and other service documents on 04/13/2022. LPA interviewed staff (S1-S5) and Residents (R1-R8). A plant inspection of the facility was conducted on 04/13/2022. Investigation revealed: See LIC-9099C Unsubstantiated Allegation: Resident is not afforded a comfortable accommodation while in care. It is alleged the resident is not afforded a comfortable accommodation while in care. Resident (R2-R8) stated they are given comfortable accommodations while in care here. Resident (R2-R8) stated they like it here and staff treats them good. Resident (R2-R8) stated their care needs are being met daily. Resident (R2-R8) stated they have not had any issues with loud music being played. Staff (S1-S5) stated they feel the residents are given comfortable accommodations while in care at the facility. Staff (S1-S5) stated there is not an issue with loud music. 4 out of the 5 staff stated the only music residents listen to is on their cell phones and no residents have a boom box or blue tooth speaker to play music. Staff (S1) stated there is a house rule #15 that states “Radio or televisions may not be played too loudly. QUIET TIME 8:00pm. Please be courteous. LPA obtained copies of the house rules. LPA did not observe any music playing while at the facility during the visit. Based on LPA’s interviews conducted, observation and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated Allegation: Staff do not ensure the residents are taking universal precautions. It is alleged that staff do not ensure the residents are taking universal precautions. Resident (R2-R8) stated they are given comfortable accommodations while in care here. Resident (R2-R8) stated they like it here and staff treats them good. Resident (R2-R8) stated their care needs are being met daily. Resident (R2-R8) stated they have not had any situations that has made them feel uncomfortable for any reason. Staff (S1-S5) stated they feel the residents are given comfortable accommodations while in care at the facility. Staff (S1-S5) stated there are two (2) residents who use a catheter in care. Staff (S1-S5) stated the catheter is secured to the residents. Staff (S1-S2) stated resident (R9) did have his catheter leak by the activity room but they immediately notified maintenance who deep cleaned the furniture. Staff (S1-S5) stated if there is spillage from the catheter maintenance is notified and it is cleaned immediately. Staff (S5) stated staff (S5) continuously looks to check the catheter and if staff (S5) feels it needs a change then staff (S5) sends the resident out to the hospital to change it. Based on LPA’s interviews conducted, observation and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 13, 2022 · control 11-AS-20220406152221

Allegation investigated: Facility staff is not adequately supervising residents in care.

On 04/12/22 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility. LPA met with administrator Susana Fuentes and explained the purpose of today's visit is to gather information for the allegation mentioned above. The investigation consisted of the following: LPA inquired about questions relevant to the nature of the complaint. Interviews with staff #1- #5 (S1-S5), residents #1-#4 (R1-R4), and witness #1 (W1). A copy of resident #1 (R1) physician report and medication administration record, and other pertinent documents related to the allegation. An observation assessment video surveillance footage from 04/10/22. An inspection of the facility was conducted. Evaluation Report continues on LIC 9099 Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility staff is not adequately supervising residents in care. The details of the complaint state the facility failed to adequately supervise resident #1 (R1) in care. The complainant claims a staff member's four-year-old child was allowed in the facility on 04/10/22 unsupervised. The complainant claims the child was allowed to push (R1) around in his wheelchair unattended and that staff member (S2) was aware and did nothing to control the situation. An observation assessment of the facilities’ video surveillance footage from 04/10/22, verified the child was allowed to run around the hallways and common areas unaccompanied. The video footage also uncovered the child was in motion pushing (R1’s) wheelchair in the lobby and playing around and handling the medication cart. Several residents were featured in the video footage resident #1-#3 (R1-R3) confirmed a child was present at the facility on 04/10/22 and had seen the child hold (R1’s) wheelchair unattended by staff. (R4) who was also featured in the video declined to be interviewed. Interview with (R1) acknowledged the child had wheeled him around in his wheelchair about 50 feet from the dining room to the lobby unsupervised and unaccompanied. (R1) claims he could control his directions from his sides, however, did not have control from the rear when being pulled back and forth as he was unable to see from behind. Witness #1 (W1) confirmed a child was pushing (R1) around, and that no staff managed to supervise. Interviews with staff #1-#2 (S1-S2) admitted the child was present and had contact with (R1) while he was in his wheelchair. (S1) claims due to unforeseen family circumstances the child was at the facility for a longer stay than she had anticipated and takes full accountability for her actions. (S5) was made aware of the incident and reviewed the video surveillance footage with the Department where it displayed the child was allowed to have access to the common areas unaccompanied or unsupervised by staff. Based on information gathered, interviews, service records, and surveillance video footage reviewed, there is sufficient evidence to corroborate the allegation mentioned above. Based on the Department's observation, interviews, records, and video footage reviewed, the preponderance of evidence standard has been met, therefore the allegation of " Facility staff is not adequately supervising residents in care" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.the state’s words, verbatim · CDSS document, Apr 12, 2022 · control 11-AS-20220411152451

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 26, 2022

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 was not met as evidence by: Based on observation, interviews, and record reviews (R1) was not accorded a safe environment when staff allowed a child to roam unattended/unsupervised. This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Licensee will review Title 22 Section 87468.1 and shall provide staff with training on supervision observation of the residents. Licensee will provide copies of training materials and sign-in sheet to CCL by POC 04/26/22 due date.

Allegation investigated: Resident not provided appointment to see onsite nurse.

On 04/11/2022 around 09:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted at the facility with Administrator Susan Fuentes. The Investigation consisted of the following: On 04/11/2022 LPA Calderon interviewed (R1) for complaint. On 04/11/2022 LPA Calderon received and reviewed needs and services plan, physician report, nurse notes and doctors name for (R1), staff and resident rosters for facility. On 04/11/2022 LPA Calderon interviewed S1-S5 for complaint and on 04/11/2022 LPA Calderon interviewed R1-R8 for complaint. LPA Calderon and Administrator (S1) conducted a tour of the physical plant, no issues were found. The investigation revealed the following: Unsubstantiated Allegation: Resident not provided appointment to see onsite nurse. It is alleged “Resident not provided appointment to see onsite nurse.”. On 04/11/2022 LPA Calderon interviewed resident 1 for complaint who states R1 has not been able to see R1 nurse for R1 diabetes or heart failure in 2022 and that R1 has called R1 doctor’s office and was told to call the facility med tech for more information. R1 states that R1 has not been told or given any information as to when the nurse will be coming or when R1 can see the nurse. On 04/11/2022 LPA Calderon received and reviewed needs and service plan and physician report for R1 the medical records state that R1 has mild cognitive impairment, heart failure, and is diabetic. Administrator states that there are four doctors that visit the facility and the clients that they served and reviewed medical records that state that the doctors nurse W1 has seen R1 every month in 2021 and 2022. On 04/11/2022 LPA Calderon interviewed S1 who stated that the facility has given R1 a 30 day notice to evict and that at no time has R1 ever been denied doctor or nurse services when R1 has requested. S1 states that resident is allowed in the med tech room due to need. On 04/11/2022 LPA Calderon interviewed S2-S5 who all state that no resident is denied access to a doctor or nurse when requested and that all resident is allowed in the med tech room with a medical need. On 04/11/2021 LPA Calderon interviewed R2-R8 for complaint all state that they are allowed access to the doctor or nurse when requested and that their medications are given in their room and they understand that no resident is allowed in the med tech room. Residents states that there is a sign on the med tech door stating no resident is allowed and only staff can enter the room. LPA Calderon spoke to Nurse (W1) who states that the medical records for R1 are correct and W1 did see R1 every month in 2021 and 2022. 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 Susan Fuentes, and a hard copy was provided for records.the state’s words, verbatim · CDSS document, Apr 11, 2022 · control 11-AS-20220408111359

Allegation investigated: Mat/rug is in disrepair.

On 3/25/2022 Licensing Program Analyst (LPA) Ngozi Nwaokoro initiated a subsequent complaint investigation visit for the allegations listed above. LPA spoke with Administrator Susana Fuentes via telephone prior to entering the facility to conduct a risk assessment and was informed that facility has no COVID-19 cases nor do any of the residents have symptoms. LPA arrived at facility and explained the purposed of the visit is to deliver findings on the allegations listed above. Investigation consisted of the following: On 3/22/2022 LPA Jey Cardenas and LPA Ngozi Nwaokoro conducted an initial 10-day visit to gather information for the allegations listed above. LPAs met with administrator Susana Fuentes. LPAs obtained a copy of the current resident and staff roster, interviewed Staff#1-Staff#7 and Resident#1 -Resident#7, reviewed resident files and obtained copies of records relevant to the investigation. LPAs toured the physical plant. Continued on 9099-C Substantiated Investigation revealed the following: The complaint alleges that a mat/rug was in disrepair. According to the complainant, there is a rubber floor mat with curled up edges located in front of the glass doors that exit to the garden. It is next to the vending machine. During the physical plant walkthrough, LPA Nwaokoro observed the mat that was in disrepair. The mat had curled up edges that could possibly be a tripping hazard. LPA Nwaokoro took a picture of the mat. During the investigation with maintenance manager, he informs LPA that he overhead our discussion with the administrator and had to remove the mat from in front of the glass doors that exit to the garden. Before existing the facility, LPA observed the mat was removed. Staff 1 -7 (S1 – S7) were interviewed and revealed the following: S1 stated that when S1 is notified about a maintenance need S1 logs it in the book and notifies maintenance. S1 stated they were notified by R1 of the mat. S1, S2, S5, and S7 stated they were not aware of any falls regarding a mat. S2 – S7 stated that maintenance is responsive to the needs of the facility. S3 was not aware of the disrepair mat but when S3 saw the LPAs in the facility they inquired about the purpose of their visit and was informed it was about a mat; S3 removed the mat. S5 stated that they have seen the mat used as a doorstopper. S4, S5, and S7 did not see the disrepair mat. S6 stated that the med cart got caught on it once but did not report it to management. Residents 1 – 7 (R1 – R7) were interviewed and revealed the following: R1 stated that the facility is not responsive to maintenance. R1 reported the disrepair mat to S1 in February 2022. S1 stated they will tell maintenance. When R1 noticed nothing was done R1 reported it to Licensing. However, on 3/22/2022 R1 realized the mat was removed. R5 thinks the facility is responsive. R6 stated that they do not pay attention the things going on in the facility. When asked if they noticed the mat in disrepair R2 was not able to answer, and R4 stated they mind their own business. R7 did not see a disrepair mat. When asked if they like the facility R3 said they like the facility and wanted to leave and play a game. R6 does not like the facility, and R7 is not satisfied with the facility. R7 stated that the staff talk about residents in the hallway. The administrator prefers some residents over others. Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Susana Fuentes, Administrator and a hard copy of a LIC 9099 and LIC 9099D was providedthe state’s words, verbatim · CDSS document, Mar 25, 2022 · control 11-AS-20220315164036

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087 · Plan of correction due date: Mar 25, 2022

Building and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidence by: LPA observed a mat in disrepair in front of the glass doors that lead out to the garden.the state’s words, verbatim · CDSS document, Mar 25, 2022

Plan of correction: Administrator will remove the disrepair mat/rug and replace it with one that do not pose hazards or led to residents fall.

Allegation investigated: Facility has inadequate staffing. Facility does not provide activites for residents.

On 03/21/22, Licensing Program Analyst (LPA/RA) Elizabeth Ceniceros conducted an unannounced subsequent visit to the facility at 8:00 a.m. LPA/RA spoke to Staff #1 (S1: Elizabeth Chavez, Med Tech-AM) prior to entering the facility to conduct a risk assessment. Staff #1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA/RA was later met by Administrator (A1) Susana Fuentes at 9:30 a.m. and explained the purpose of today’s visit was to investigate the above-mentioned allegations. The investigation consisted of the following: Licensing Program Analyst (LPA) Stephanie Cifuentes conducted the unannounced initial 10-Day complaint investigation on 12/29/21. LPA/RA Ceniceros interviewed Administrator, seven (7) staff members (S1-S7), and eight (8) residents (R1-R8). During the course of this investigation, LPA/RA toured the facility grounds and interviewed facility staff members and residents; reviewed facility records (residents roster, facility staff roster and staff work schedules). (Continued on 9099-C) Unsubstantiated Allegation: Facility has inadequate staffing: The complainant reported that facility is not providing enough care for dementia residents as well as other residents. Facility is admitting more dementia residents and the problems increase because they are using the Activity Room (1st floor) as a day care center; and, there’s an average of 10 – 14 residents and one (1) staff member watching them. LPA/RA Ceniceros spoke to Administrator Fuentes who replied, in the past, whenever the facility was going to be short staff, they would contract with a health care staffing agency to fill the vacancy on a temporary basis - until a new staff member is hired on board. Recently, the facility hired three (3) additional staff members: caregiver, housekeeper, and an activities coordinator. LPA/RA interviewed seven (7) residents; and, the majority agreed that the facility has adequate staffing to meet his/her needs. LPA/RA interviewed six (6) staff members (S1-S6); and, the majority agreed that the facility has sufficient staffing to meet the needs of the residents. LPA/RA reviewed the facility’s residents’ roster, facility staff roster and staff work schedules (week of 11/28/21 thru 12/25/21 and current); and, the facility has sufficient staffing. Based on information gathered through interviews and observations and records review, the Department did not find sufficient evidence to support the allegation mentioned above. 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 investigation consisted of the following: LPA/RA Ceniceros interviewed Administrator, six (6) staff members (S1-S6) and seven (7) residents (R1-R7). During the course of this investigation, LPA/RA toured the facility’s activity rooms (located on the 1st and 2nd floors); reviewed facility records: staff roster, residents roster, activities calendars (December 2021 – March 2022); observed current posted monthly activity calendar (posted on the board by the main entrance) and residents participating in the A.M. and P.M. activities. Allegation: Facility does not provide activities for residents: The complaint alleges that the facility does not provide activities for residents. LPA/RA Ceniceros toured the activity room and observed (approx) 16 residents participating in the morning activity (exercise) at 10:35 a.m. and approximately 12 residents participating in the afternoon activity (music choice) at 1:20 p.m. (Report continued on LIC 9099C) LPA/RA Ceniceros observed the posted March 2022 Activity Calendar (photo) and reviewed past monthly activity calendars (December 2021 – March 2022). LPA/RA interviewed residents (R1-R7) regarding activities provided at the facility; and, the majority indicated that because of COVID some of their activities where stopped; however, now that COVID has been lifted, the facility is providing in-person activities; such as: arts & crafts, movie, bingo, board games, music choice, kareoke, and exercise; but, soon they’ll be doing outings into the community (i.e., park, shopping, theatre and/or restaurant). Based on information gathered through interviews and observations and records review, the Department did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided to Administrator Susana Fuentes.the state’s words, verbatim · CDSS document, Mar 21, 2022 · control 11-AS-20211223090835

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Stephanie Cifuentes initiated a Case Management - Deficiencies visit to document deficiencies observed during the investigation of a complaint with complaint control number 11-AS-20220228091331. Today’s visit was conducted with Susana Fuentes, the facility administrator and the purpose of the visit was explained. LPA noted on 3/8/2022 that water temperature was 144.5F. During today's visit, LPA check the water temperature in 4 rooms, and noted the water temperature is between 130.2 and 135.9. Administrator immediately turned both of the facilities water heaters lower, called maintenance and the plumber. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC809D. An exit interview was conducted and plans of Corrections were developed. A copy of this report and appeals rights were provided.the state’s words, verbatim · CDSS document, Mar 11, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Mar 11, 2022

Maintenance and operation Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate...not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidence by On 3/8/2022 LPA CIfuentes noted hot water temperature to be 144F. On 3/11/2022, water in four rooms was 130.2F and 135.9F. This is an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2022

Plan of correction: Adminstrator turned down water temperature during visit and will monitor water temperature for the next 24 hours.

Allegation investigated: Smoke alarms are in disrepair.

On 03/10/22 at 3:00 p.m. Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros, conducted a subsequent complaint investigation visit regarding the above-mentioned allegation. LPA Stephanie Cifuentes conducted the initial 10-Day visit on 12/21/21. LPA/RA Ceniceros was already present conducting another subsequent visit (Complaint Control #11-AS-20211216155411). LPA/RA Ceniceros spoke with Administrator Susana Fuentes at 3:00 p.m. and explained the purpose of today's visit. The investigation consisted of the following: LPA/RA conducted interviews with (9) facility staff and (7) residents and attempted (1) resident. LPA/RA Ceniceros and Administrator Fuentes conducted an inspection of the facility’s physical plant for health and safety measures; observed the facility's wired smoke detectors & fire alarms, fire extinguishers meets regulations, posted "Exit" signs throughout the facility and Emergency Evacuation Routes for the 1st and 2nd floors; records review: fire alarm system inspection & test report (Report continued on LIC 9099C) Unsubstantiated (dated 02/08/22), cosco wet pipe fire sprinkler inspection, testing, and maintenance report (dated 02/08/22), emergency light & exit sign inspection & test report (dated 02/08/22). Allegation: Smoke alarms are in disrepair. The complaint alleges that two (2) smoke detectors situated in the hallway (over the fire doors) have been beeping for two (2) weeks. LPA/RA Ceniceros toured the facility and videotaped the wired smoke detectors located in the hallway above the fire doors and did not hear the sound of beeps from their direction. LPA/RA spoke to Staff #1 (Maintenance Director, Carlos Aguirre) who indicated that the facility has a wired fire alarm system with smoke detectors throughout the facility. LPA/RA Ceniceros spoke with residents (R1-R7) in regards to smoke detectors being in disrepair; and, the majority stated he/she had not noticed beeping sounds coming from the smoke detectors. LPA/RA Ceniceros spoke with facility staff (S1-S9) regarding the smoke detectors in disrepair; and, the majority had not heard the smoke detectors to be inoperable with beeping sounds. Based on information gathered through interviews, observations, and records review, the Department did not find sufficient evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided to Administrator Susana Fuentes.the state’s words, verbatim · CDSS document, Mar 10, 2022 · control 11-AS-20211217144410

Allegation investigated: Facility is not following COVID-19 guidelines. Resident is being illegally evicted. Facility is retaliating against resident for making complaints.

On 03/10/22 at 8:00 a.m. Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros, conducted an unannounced subsequent complaint investigation visit regarding the above-mentioned allegations. LPA Stephanie Cifuentes conducted the initial 10-Day visit on 12/21/21. Staff #1 (Mari Banuelos, Med Tech) confirmed that the facility had no new COVID cases nor do any of the residents have symptoms and LPA/RA was allowed entry into the facility. LPA/RA Ceniceros spoke with Administrator Susana Fuentes (via telephone) approx. 8:15 a.m. and was later met by Administrator (Suzanna Fuentes) approx. 9:00 a.m. LPA/RA at that time explained the purpose of today's visit. The investigation consisted of the following: LPA/RA conducted interviews with (9) facility staff and (7) residents. LPA/RA Ceniceros and Administrator Fuentes conducted an inspection of the facility’s physical plant for health and safety measures; observation of state-issued License and Administrator Certificate are (Report continued on LIC 9099C) Unsubstantiated posted in a prominent place, sufficient 60-day supply of required personal protective equipment; reviewed R1's physician's report, medication administration record, cash resources (from 01/01/20 - 01/21/22), trust transaction history (from 01/01/19 - 03/10/22); incident reports (dated 11/20/20, 09/08/21, 10/13/21, 10/20/21, 11/18/21,12/08/21, 12/26/21, 01/20/22); behavioral contracts (dated 11/25/19 & 02/16/21); correspondence (dated 10/20/21 & 11/19/21) e-mailed to assisted-living waiver program social worker/supervisor, 30-Day Eviction Notice (dated 02/02/22), Summons Unlawful Detainer-Eviction (dated 03/10/22). Allegation: Facility is not following COVID-19 guidelines: The complaint alleges that Resident #1 had requested to be tested in its room on 11/23/21; and, it was done. On 12/01/21, Resident #1 requested to be tested (again) in its room; however, Administrator Fuentes advised that only the residents who cannot walk to the Activity Room (located on the first floor) will be tested in his/her room. At that time, Resident #1 was advised that if a resident is able to walk then the resident shall come to the Activity Room (located on the 1st floor) for his/her testing; otherwise, a resident can choose to go elsewhere to be tested at will. On 12/08/21, Resident #1 walked to the Activity Room (located on the 1st Floor) for its COVID testing. LPA/RA Ceniceros spoke with residents (R1-R7) in regards to testing in the Activity Room (located on the 1st Floor) rather than it their room; and, the majority residents stated that he/she has not had an issue with receiving his/her test by walking to the facility's Activity Room. LPA/RA Ceniceros spoke with facility staff (S1-S9); and, it was explained that the residents did not mind receiving his/her test in the facility's 1st floor Activity Room. Administrator Fuentes stated that when it first struck on or about October 2021, the residents were receiving tests in his/her room; however, since it was lifted on or about January 2022, residents returned to the facility's Activity Room (located on the 1st floor) to receive his/her test. Unless a resident couldn't walk, the contracted nurse would test the resident in his/her room. During LPA Cifuentes initial 10-Day visit on 12/21/21, it was observed that residents and facility staff were wearing his/her face mask and practicing social distancing. In addition, LPA/RA Ceniceros observed the residents and facility staff wearing his/her face mask during this visit. Allegation: Resident is being illegally evicted: The complaint alleges that while Resident #1 was receiving a test on 12/08/22 by the contracted nurse that (Report continued on LIC 9099C) Resident #1 was told that the facility was looking to evict the resident; as a result that the resident wanted to be tested in its room on 12/01/21; since it was done by the contracted nurse on 11/23/21. Administrator Fuentes stated that R1 has had behavioral issues with facility staff and residents that the facility began documenting incidents and reporting to LPA Stephanie Cifuentes; and, Licensing approved the 30-Day Eviction Notice. [RA Ceniceros reviewed the "Behavioral Contract" (dated 11/25/19) that listed issues that involved R1 of incidents (dated 06/16/19, 06/29/19, 07/15/19, 08/23/19, 09/05/19, 10/23/19, 10/28/19, 11/15/19, 11/19/19); and, serious incidents (dated 11/10/20,) regarding R1's aggressive act to another resident & staff. An incident had occurred (dated 11/10/20) involving R1 displaying aggressive behavior towards another resident & staff. R1 gave the facility a letter that he "quit" that he was not going to help with daily calendar or feed the fish anymore. An updated "Behavioral Contract" (dated 02/16/21) was created for R1 due to recent problems and inappropriate behavior. Administrator Fuentes indicated that Assisted-Living Waiver Social Worker (Shimika Blackwell) was notified (via e-mail, dated 10/20/21) and Assisted-Living Waiver Supervisor (Aida Sixtos) was notified (via e-mail, dated 11/19/21); and, the Long-term Care Ombudsman. Administrator Fuentes stated that R1 has continued to verbally harass facility staff and intimidating the residents. Instructions have been directed to facility staff to call 9-1-1 (Gardena Police Department) if need be due to R1's aggressive behavior. LPA/RA Ceniceros spoke with residents (R1-R7) in regards to having knowledge of a resident being evicted from the facility; and, the majority were unaware. LPA/RA Ceniceros spoke with facility staff (S1-S9) regarding a resident being evicted; and, the majority were unaware. Allegation: Facility is retaliating against resident for making complaints: The complaint alleges that Resident #1 is being treated differently by not being welcomed anymore and was followed by an eviction notice - believed to all be retaliatory in nature. LPA/RA Ceniceros spoke with residents (R1-R7) in regards to facility retaliating against him/her or another resident; and, the majority of these residents indicated that the facility has not used retaliating tactics against him/her or observed at another resident. LPA/RA Ceniceros spoke with facility staff (S1-S9) regarding facility retaliating against a resident; of which, he/she has not observed retaliation towards a resident. Based on information gathered through interviews, observations, and records review, the Department did not find sufficient evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided to Administrator Susana Fuentes.the state’s words, verbatim · CDSS document, Mar 10, 2022 · control 11-AS-20211216155411

Allegation investigated: Facility do not provide transportation to medical appointments. Resident was injured in while in care. Staff did not provide adequate services to resident in care.

On 3/8/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint visit at this facility. LPA spoke with Administrator Susana Fuentes via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to deliver findings on the allegations listed above. The investigation consisted of the following: On 2/4/2022 LPA conducted a tour of facility grounds and reviewed records for staff and residents. LPA conducted interviews with (6) staff members (S1-S6), and (6) residents (R1-R6). LPA Cifuentes requested and received the following documents: Client roster, staff schedule, shower schedule and other documents in relation to the investigation. Continued on 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility do not provide transportation to medical appointments. The complainant alleges that facility told them transportation could not be provided for R1 to doctor’s appointment. Per Administrator Susie Fuentes, facility does not have a van to provide transportation, but they do assist residents in setting up their transportation, whether that is Lyft, Uber or whatever medical arrangements need to be made. LPA Cifuentes spoke to staff 1 (S1) who stated R1 and their children usually handled their medical transportation, but that recently R1’s family called facility asked them if they could help schedule transportation to a medical appointment. Per S1, they called several insurance companies and the doctor, then later received a call from the family at the end of the day stating they had already arranged the medical transportation. S2 added that family requested a second transportation appointment, which facility arranged for them, but family then wanted to cancel. LPA spoke to R1, who stated family arranged medical transport for them. LPA Cifuentes interviewed residents (R1-R6) regarding transportation to medical appointments. Two stated they handled transportation themselves, two stated family handled transportation, one stated their doctor came to the facility and the last stated they did not know. LPA interviewed staff (S1-S6) transportation to medical appointments. Three put of the six stated that facility assisted with transportation, two stated they were not sure one refused to answer. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. Allegation: Resident was injured in while in care. The complainant alleges that R1 was bitten by bugs while at facility, which caused a skin infection and hospitalization. LPA Cifuentes reviewed incident reports from last year, and found one report stating that R1 was hospitalized, but not from an incident that cause an injury. LPA also reviewed pest control reports from that time period and found no reports of bedbugs in the facility over the past several months. LPA spoke to R1 regarding an injury sustained while in care. Per R1, a friend fell on their leg, but they did not mention a skin infection. LPA spoke with residents (R2-R6) regarding the allegations. Of those interviewed, five out of five stated they had not been injured while in care. LPA Cifuentes interviewed staff (S1-S6) regarding residents being injured while in care. Out of those interviewed, six out of six reported that residents had not been injured while in care. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. Continued on 9099-C Allegation: Staff did not provide adequate services to resident in care. The complainant alleges that R1 is not receiving baths/showers. LPA spoke to administrator Susie Fuentes regarding allegation. Administrator Fuentes stated facility has a shower schedule and she has not received any complaints about someone not being showered, not receiving assistance with ADL’s or not being groomed. LPA interviewed residents (R1-R6) about the services they ae receiving. Of those interviewed, four out of six residents stated they handle their ADL’s on their own, one stated staff assisted them and one stated no one helped them and they needed assistance. LPA interviewed staff (S1-S6) about services provided to residents. Six out of six staff stated they provided residents with assistance bathing and grooming. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. The Department’s investigation consisted of an inspection of the facility, observation, analysis of records, incident reports, and interviews conducted and found no evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Susie Fuentes and a hard copy of the report was providedthe state’s words, verbatim · CDSS document, Mar 8, 2022 · control 11-AS-20220131144606

Allegation investigated: Resident harassing another resident at facility.

On 03/08/22 at 8:07 a.m. Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros, conducted an unannounced subsequent complaint investigation visit regarding the above-mentioned allegation. LPA Stephanie Cifuentes conducted the initial 10-Day visit on 10/07/21. LPA Cifuentes spoke with Administrator Suzanna Fuentes (via telephone) prior to entering the facility to conduct risk assessment questionnaire; and, she was informed that facility had no COVID cases nor do any of the residents have symptoms. LPA/RA was allowed entry into the facility by Staff #1 (Office Manager, Cynthia LN). LPA/RA was later met by Administrator (Suzanna Fuentes) at 9:05 a.m. and explained the purpose of today's visit. The investigation consisted of the following (related to Complaint Control Number: 11-AS-20211004115959): LPA Cifuentes on 10/19/21 interviewed Administrator Suzanna Fuentes, six (6) staff members (S1-S6), six (6) residents (R1-R6), reviewed residents records (R1-R6), current staff members & residents rosters, and incident reports (dated 03/02/21, 03/03/21). (Report continued on LIC 9099C) Substantiated Allegation: Resident harassing another resident at facility: The complainant alleges that R1 is being harassed by R2. On September 11, 2021 LPA Cifuentes received witness statements stating R2 was calling several residents names and making derogatory remarks towards them. On 10/04/21, LPA Cifuentes received a faxed incident report documenting an incident of aggression between R1 and R2. LPA viewed a video of the incident between R1 and R2. LPA spoke with residents (R1-R6) regarding harassment and 4 out of 6 stated they had witnessed harassment between residents. LPA spoke with staff (S1-S6) regarding harassment between residents and 4 out of 6 staff stated that they had witnessed harassment between residents. Based on the information gathered, the department did find sufficient evidence to support the allegation of"Resident harassing another resident at facility". Based on interviews conducted and records reviewed the preponderance of evidence standard has been met; therefore, the above-mentiond allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Administrator Suzanna Fuentes. LPA/RA Ceniceros reviewed additional documents provided by Administrator Fuentes: staff roster, client roster, staff schedule, activity schedule calendars (October 2021 to present), Admission Agreements for R1-R2, Physician's Reports for R1-R2, Appraisal/Needs & Services Plan for R1-R2, I.D. and Emergency Information for R1-R2, activities calendar schedule (October '21 - March '22); observed residents during A.M. and P.M. activities. Allegation: Facility retaining residents that require a higher level of care: The complaint alleges that Administrator is admitting residents that require a higher level of care and not meeting the needs of residents in assisted living. LPA/RA Ceniceros spoke with residents (R1-R9) regarding their needs being met by facility staff and the majority residents agreed that their needs are being met by facility staff in assisted living. Administrator Fuentes confirmed their current census is 72 residents and currently their are approximately ten (10) dementia resident. LPA/RA Ceniceros spoke with facility staff (S1-S6) regarding residents needs being met and 6 out of 6 facility staff say that they have not received complaints from assisted-living residents regarding their needs not being met. Allegation: Facility staff are restraining resident(s) in care: The complaint alleges that Resident #7 is very active and loves to engage in artistic activities; which the resident can't do now; and, the staff are not able to handle the care needs of the dementia residents. LPA/RA Ceniceros spoke with residents (R1-R9) regarding their needs being met by facility staff and the majority assisted-living residents agreed that their needs are being met by facility staff and have not witnessed facility staff restraining residents in care. Administrator Fuentes confirmed their current census are 72 residents and there are approximately ten (10) dementia residents. LPA/RA Ceniceros spoke with facility staff (S1-S6) and the majority deny that facility staff are restraining dementia residents. Allegation: Residents are not being provided activities while in care: The complaint alleges that residents are not being provided activities while in care. LPA/RA Ceniceros toured the activities room and observed approximately 15 residents participating in activity in the morning 10:15 a.m. watching a movie and afternoon at 1:20 p.m. playing Bingo. LPA/RA observed the posted March 2022 Activity Calendar (photo). LPA/RA reviewed the past monthly activity calendars (October 2021 - current). LPA/RA Ceniceros spoke with residents (R1-R9) regarding the activities provided at the facility and the majority indicated that because of COVID some of their activities where stopped; however, now that COVID has been lifted, the facility is providing activities; such as, Arts & Crafts, Movie, Bingo, Music, Kareoke, Exercise, and their outings into the community.) Allegation: Staff do not answer the facility phones: The complaint alleges that facility staff do not answer the facility phones. LPA/RA called the facility by pressing the outside call button - prior to arrival at 8:00 a.m. and someone answered the phone. LPA/RA observed facility staff seated at the front desk at all times during this visit and answering incoming calls. LPA/RA spoke with random residents (R1-R9) who indicated that whenever they've called the facility's front desk (via cell) that his/her call was being answered by facility staff. Allegation: Staff do not respond to resident(s) call buttons: The complaint alleges that when residents use their call buttons to summons facility staff that their calls are not answered in a timely manner. LPA/RA randomly toured eight (8) residents rooms and tested the call button box in Rooms #11, 17, 19, 20, 30, 36, 38, 47; and, LPA/RA observed the front desk answer the call in a timely manner. LPA/RA inspected the computerized call button main station (video) and observed its operation. LPA/RA spoke with residents (R1-R9) regarding their calls being answered in a timely manner by facility staff and the majority agreed that there wasn't an issue with their call button box being answered in a timely manner. LPA/RA spoke with facility staff (S1-S6) and the majority agreed that facility staff man the call button main station 24/7 by facility staff working the morning, afternoon or graveyard shift. Based on information gathered through interviews, observations, and records review, the Department did not find sufficient evidence to support the allegation mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided to Administrator Suzanna Fuentes.the state’s words, verbatim · CDSS document, Mar 8, 2022 · control 11-AS-20211005161649

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Mar 22, 2022

Personal RIghts of Residents All Facilities 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 was not met as evidenced by: Based on LPA/RA Cifuentes on 10/19/21 observations and interviews, the facility did not insure residents in the facility were free from intimidation or abuse. This poses a potential Health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 8, 2022

Plan of correction: Administrator will submit a plan to LPA/RA Ceniceros on how they will prevent any resident-on-resident harassment in the future and submit to LPA/RA by POC due date on 03/22/2022.

Allegation investigated: Facility has a leaking pipe

On 3/8/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced complaint investigation at the facility listed above. LPA spoke with Administrator Susana Fuentes via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit was to investigate the allegations listed above and was granted access to the facility. The investigation consisted of the following: LPA Cifuentes conducted a tour of facility grounds. LPA spoke with administrator, reviewed facility files and interviewed staff 1 -Staff 6 (S1-S6) and Residents 1-resident 6 (R1-R6). LPA also received staff roster, resident roster, invoice for plumbing repair. Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility has a leaking pipe The complainant alleges that a pipe at the facility, which runs to out to the back of the facility grounds, was leaking feces. LPA Cifuentes toured the outside of facility and saw no broken or uncovered pipes, LPA did however find a red pipe stopper covering one of the pipes leading out of the building. LPA Cifuentes received a copy of invoice for Live Plumbing Sewer and Drains, which confirms work was done at the facility on 3/3/2022. LPA called and spoke to Hugo from Live Plumbing Sewer and Drains, who confirmed the that he snaked the line and pulled paper towels, tree roots and face masks from the sewage line and replaced the cap on the pipe. LPA Cifuentes spoke with administrator Susie Fuentes, who stated that a pipe at the facility did not leak, the stopper for one of the pipes outside popped off. The plumber was called immediately, and the matter was taken care of that day. LPA interviewed residents (R1-R6) regarding leaking pipe. Of the residents interviewed, four out of six stated that they were not aware of any leaking pipes, and six out of six stated there are no issues with the facilities plumbing. LPA interviewed staff (S1-S6) regarding leaking pipes. Of those interviewed, two out of six staff stated there was a leaking pipe at the facility and four out of six stated they had head about an issue with the plumbing. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R-1)'s service records, incident report, and interviews conducted and found no evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Susie Fuentes and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 8, 2022 · control 11-AS-20220228091331

Allegation investigated: Staff did not administer medication to resident.

On 2/17/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint investigation at the facility listed above. LPA spoke with staff Susana Fuentes via telephone call prior to entering the facility to conduct risk assessment questionnaire and was informed that facility had no COVID cases nor do any of the clients have symptoms. LPA arrived at facility and was greeted by staff. LPA explained the purposed of the visit was to investigate the allegation listed above and was granted access to the facility. The investigation consisted of the following: LPA interviewed Administrator Susie Fuentes, five (5) staff (S1-S6) and six (6) residents (R1-R6). LPA inspected the facility. LPA reviewed resident records along with the current staff/resident roster and other documents in association with the allegation. Continued on 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not administer medication to resident. The complainant alleges that R1 had to call staff to receive their evening medication. LPA reviewed MAR for R1, which does not show any evening medications missed or refused for the month of February. LPA Cifuentes spoke to S1, who states R1 has not refused any evening medication while they have been on shift during the month of February, but that they did leave early on 2/9/2022 and left the medication for R1 ready to be given to them by the caregiver. LPA spoke with residents (R1-R6) regarding the allegation and 4 out of 6 stated staff had not failed to give them medications. One of the 6 declined to answer. LPA spoke with staff (S1-S5) regarding medications and 5 out of 5 stated facility staff never failed to give residents medications, with S1 adding that residents had refused their medications in the past.. Based on information gathered, the department did not find sufficient evidence to support allegation the allegation. The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegation: " Staff did not administer medication to resident.” Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a hard copy of the report was provided to Susana Fuentes, Administrator.the state’s words, verbatim · CDSS document, Feb 17, 2022 · control 11-AS-20220210144354

Allegation investigated: Facility is not assisting resident with transportation needs. Facility does not have required postings in public view.

On 1/21/2022 at 1:03 pm, Licensing Program Analyst (LPA)/ Susan Campos, initiated a subsequent complaint investigation visit for the allegations listed above. LPA was allowed entry into the facility by Administrator Susana Fuentes. LPA explained to Ms. Fuentes the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (6) staff members, and (6) residents on 1/20/22. In addition, on 1/20/22, LPA and Ms. Fuentes conducted an inspection, for health and safety of the facilities’ physical plant, and food supply, and also inspected (6) facility resident room call button box stations. LPA also reviewed the following documents provided by Gardena Retirement Center Administrator Susana Fuentes: LIC 500-staff roster, client roster, staff schedule, Incident Reports from December 2021 to present, and Facility Resident Transportation Services Plan . Report continued on LIC 9099C Substantiated Allegation: Facility is not assisting resident with transportation needs The investigation revealed, per LPA interviews, with (6) staff members, and (6) residents from the Gardena Residential Center, and also review of facility documents, that the facility, does not assist residents with transportation to medical appointments per admission agreement policy. S1 informed the LPA that the facility assists residents with transportation to their medical appointments. S1 also stated that the facility does not have a transportation van, but will assist residents with their medical transportation appointments, if requested, by using Lyft transportation services. S1 informed LPA, that most residents in the facility, handle their own transportation to their medical appointments, and do not ask S1 for assistance; however, if medical transportation is needed, then S1 states that will assist the resident with transportation, to their medical appointment. S1 informed, the LPA that the facility has a company Lyft account, that is used for resident medical appointment transportation trips. The facility will pay for resident transportation medical appointments, up to 5 miles distance from the facility. Also, S1 informed the LPA, that currently, there are only a few residents, that ask for medical transportation assistance, because resident family members, assist residents with transportation to their medical appointments or residents will call Access paratransit services to obtain transportation assistance to their medical appointments. In addition, the LPA interviewed (6) Gardena Retirement Center staff persons and 6 of 6 staff members interviewed, informed the LPA, that most facility residents make their own transportation arrangements, to their medical appointments using Access paratransit services or with family assistance. And also, 3 of 6 staff members, informed the LPA, that the residents pay for their transportation to their medical appointment when they use Access paratransit services or if the facility arranges for Lyft services. Furthermore, the LPA interviewed (6) residents, and 3 of 6 residents interviewed, informed the LPA, that they arrange their own transportation to their Medical appointments, and the other 3 of 6 residents interviewed informed the LPA that they do not have doctor appointments. Also 4 of 6 residents interviewed informed the LPA, that if S1 arranges Lyft services, for transportation to medical appointments, the resident is responsible for paying for the Lyft trip. The other 2 of 6 residents interviewed informed the LPA that they do not know, if the facility, provides transportation assistance for resident medical appointments. On 1/20/22, at 3pm, LPA reviewed the facility Resident Admission Agreement, and the agreement states on page 3, “In the event that Your family and/or Responsible Party are not able to, the community will make Report continued on LIC 9099C arrangements for transportation (within a 5 mile radius) for you in order to meet your necessary medical and/ or dental needs.” Per LPA interviews with facility staff and residents, the facility policy is not being implemented. Based on information gathered, the LPA did find sufficient evidence to support allegation " Facility is not assisting resident with transportation needs per admission agreement policy”. Allegation: Facility does not have required postings in public view The investigation revealed, per LPA observation, that the LPA did not observe, posting of required documents in the facility entry or lobby area. S1 informed the LPA, that S1 had taken down, the facility license, from the lobby hall wall, because the wall was being painted, and that the facility license would be placed, back on the wall, once the wall paint dried. The LPA informed S1, that when there are facility repairs, in the location, of the facility posted license, S1 will need to relocate the documents to another public view location, while the facility repair is taking place. S1 also informed the LPA, that in the past, there have been instances, of the removal of documents, placed on the lobby hall wall, and that, in the future, the facility will be using a glass case, in the lobby hallway, for required posted documents, in order to prevent these incidences from reoccurring. S1 informed the LPA, that video cameras have been re-positioned in the facility lobby hallway, in order to observe, the safety of all required posted documents. LPA informed S1, to please submit incident reports, to the Department of Social Service Community Care Licensing, for all cases of document tampering, and theft, and to immediately replace missing posted documents. On 1/20/22, at 1:10pm, LPA observed that the facility, did not have facility license, posted in public area. And on 1/20/22, at 1:20pm, S1 placed the license on the facility lobby hallway. Based on information gathered, LPA did find sufficient evidence to support allegation " Facility does not have required postings in public view ” Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Susana Fuentes, Administrator and a hard copy of a LIC 9099 and LIC 9099D was provided.the state’s words, verbatim · CDSS document, Jan 21, 2022 · control 11-AS-20220114104631

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87465(a)(2) · Plan of correction due date: Feb 7, 2022

87465Incidental Medical and Dental Care(a)(2)(a)...(2)The licensee shall provide assistance in meeting necessary medical and dental needs...y which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by: Based on interviews, and record review, on 1/20/22, LPA was informed, per interviews, by 4 of 6 residents and 3 of 6 staff persons, that the facility does not pay for resident medical transportation trips as stated in admission agreement, which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2022

Plan of correction: Administrator will fax to LPA a copy of the Gardena Residential Center - Resident Medical Transportation Plan, and also its notification plan to Resident and Staff. POC Due Date is 2/7/22 LPA Fax Number (323)981-1781

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87113 · Plan of correction due date: Jan 20, 2022

87113 Posting of License. The license shall be posted in a prominent location in the licensed facility accessible to public view. On 1/20/22 at 1:10pm, LPA observed that the Gardena Residential Center license was not posted in the lobby for public view.the state’s words, verbatim · CDSS document, Jan 21, 2022

Plan of correction: On 1/20/21, Administrator posted Gardena Retirement Center license on facility lobby wall.

Allegation investigated: Staff do not respond to resident's call button in a timely manner.

On 1/21/2022 at 2:40pm, Licensing Program Analyst (LPA)/ Susan Campos, initiated a subsequent complaint investigation visit for the allegation listed above. LPA was allowed entry into the facility by Administrator Susana Fuentes. LPA explained to Ms. Fuentes the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (6) staff members, and (6) residents on 1/20/22, and (2) staff members on 1/21/22. In addition, on 1/20/22, LPA and Ms. Fuentes conducted an inspection, for health and safety of the facilities’ physical plant, and food supply, and also inspected (6) facility resident room call button box stations. LPA also reviewed the following documents provided by Gardena Retirement Center Administrator Susana Fuentes: LIC 500-staff roster, client roster, staff schedule, Incident Reports from December 2021 to present, and Staff Call Button Response Procedures. Report continued on LIC 9099C Unsubstantiated Allegation: Staff do not respond to resident's call button in a timely manner The investigation revealed, per LPA interviews, with (8) staff members, and (6) residents from the Gardena Residential Center, and also review of facility documents, that staff respond to resident’s call button. S1 informed the LPA, that is not aware of a resident’s room call button not responded to by a staff person. In addition, S1 informed LPA that all call bottom signal requests, go to the facility main office, and the office manager or med techs, responds first by intercom, to the resident’s call box, and then asks the resident what assistance do they need, and also lets the resident know that a staff person will go to their room to assist. Additionally, the LPA interviewed (8) Gardena Retirement Center staff persons, and 8 of 8 staff members interviewed, informed the LPA, that the facility staff personnel, responds to the resident room call button signals. Also, 8 of 8 staff members, informed the LPA, that the staff, at the main office, once they receive a call button request, respond to the resident’s call button, first by intercom, asking the resident what assistance do they need, and also informing the resident, that a staff person is on their way to the resident’s room. Furthermore, 8 of 8 staff members, informed the LPA, that they are not aware of a resident call button request that was not answered by a staff person. In addition, the LPA interviewed S7 and S8, scheduled at the main desk on 1/15/22 during morning hours, and was informed that while stationed at the main office desk on 1/15/22, they did not receive a call button request from R1. Additionally, the LPA interviewed (6) residents, and 5 of 6 residents interviewed, informed the LPA, that they do not use the call button. On 1/21/22, at 1:40 pm, the LPA observed the facility front office video camera, for 1/15/22 from 10:45 am to 11:05am, and observed per video footage, two staff persons at the front desk area, and also other staff persons walking past the front desk area. In addition, on 1/20/22, the LPA also observed 6 facility resident room call button stations, and observed that all 6 resident room call button stations are operable. Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff do not respond to resident's call button in a timely manner” 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. An exit interview was conducted and a copy of the LIC 9099 was provided to Administrator Susana Fuentes.the state’s words, verbatim · CDSS document, Jan 21, 2022 · control 11-AS-20220118134839

Type of visit: Case Management - Deficiencies

On 1/5/22, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced Case Management - Deficiencies visit to document deficiencies observed during investigation of a complaint with control number 11-AS-20211228090259. LPA spoke to the administrator Susana Fuentes and the purpose of today's visit was explained. During investigation. LPA Cifuentes noted that staff 1-staff 4( S1-S4) did not have current CPR/First Aid training California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D.. An exit interview was conducted and plans of correction were developed. A hard copy of this report and appeals rights were provided.the state’s words, verbatim · CDSS document, Jan 5, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Jan 21, 2022

Personnel Requirements - General Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: During complaint investigation, LPA Cifuentes did not observe current CPR/First aid training for Staff 1 - Staff 4. This posses a potential health and safety risk for clients in carethe state’s words, verbatim · CDSS document, Jan 5, 2022

Plan of correction: Licensee will ensure that staff complete CPR training and submit copies of certificates to CCL by POC due date via fax.

Allegation investigated: Staff are failing to meet residents' needs Resident wandered away while in care Staff speak to residents inappropriately Staff failed to provide adequate food service Staff failed to provide a safe and comfortable environment for residents Facility is disrepair

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Allegation investigated: Staff handled resident in a rough manor Resident is being harassed by another resident

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Allegation investigated: Illegal eviction

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Allegation investigated: Resident harassing another resident at facility

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Allegation investigated: Residents meals are late Residents bed is in disrepair

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Allegation investigated: Resident is malnourished. Staff sexually abused resident. Resident is being physically abused while in care. Staff administered incorrect medication to resident. Resident's hygiene needs are not being met.

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Allegation investigated: Staff is interfering with the residents hygiene needs Staff is not administering medications as needed Staff is not providing transportation services for the residents Staff is not providing comfortable accommodations for residents while in care Staff threatened a resident with eviction Staff are not properly providing care and supervision to the residents while in care

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Allegation investigated: Facility is in disrepair

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Allegation investigated: Resident sustained multiple falls while in care

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Allegation investigated: Facility not adhering to Admissions Agreement. Resident is not being allowed to smoke.

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Allegation investigated: Resident missed her medical appointment Staff refused to provide transportation for resident's medical appointments Staff failed to meet residents' hygiene needs

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Allegation investigated: Staff interfered with resident's daily living functions Residents not accorded dignity in their relationships with staff

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