Centinela Assisted Living Centre

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Case Management visit. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and LPA temperature was checked. LPA Bunker met with Social Worker Elizabeth Hernandez and spoke to Administrator Gwen Craig via telephone and explained the purpose of today's visit. Regarding the labor strike involving personnel at the facility. Gwen and Elizabeth stated the facility is fully staffed and it's the Skilled Nursing Segment as opposed to the Assisted Living division that is striking. Gwen and Elizabeth stated their employees are adhering to a stipulation that confines their strike activities solely to their designated lunch breaks, refraining from any cessation during operational hours. Gwen and Elizabeth stated their staff refused to strike because they said the union isn't doing anything to support or benefit them. Gwen stated there are no interruptions at the facility in its daily operation. There were no deficiencies cited Exit interview conducted.the state’s words, verbatim · CDSS document, Jul 11, 2023

Allegation investigated: Staff are not ensuring that resident is administered their medication as prescribed.

On 5/16/2023 Licensing Program Analyst (LPA) Felisa Shirley and Licensing Program Manager (LPM) Stephanie Cifuentes conducted an initial unannounced complaint visit at this facility. LPA Shirley and LPM Cifuentes arrived at the facility and spoke to Social Services Director Elizabeth Hernandez to explain the purpose of the visit it to investigate the allegation listed above. LPA and LPM were granted access to the facility. Administrator Gwendolyn Craig arrived later to join the visit. The investigation consisted of the following: On 5/16/2023 LPA Shirley and LPM Cifuentes met with Social Services Director Elizabeth Hernandez. LPA and LPM interviewed Resident 1- Resident 5 (R1-R5) and attempted to interview Staff 1-Staff 5(S1-S5). LPA and LPM reviewed and requested copies of the following records: client Roster, staff roster and staff schedule, physicians’ assessments, medication administration records, physicians orders for residents 1-5. Con'd on 9099C Unsubstantiated The investigation revealed the following: Allegation: Staff are not ensuring that resident is administered their medication as prescribed. It is alleged that facility residents are not being given their medications by facility staff. On 5/16/2023 from 10:00am-11:50am LPA Shirley and LPM Cifuentes reviewed 5 resident records and 5 electronic medication administration records. A review of facility records shows that medications were given to facility residents in the correct dosage and at the correct times. Very few clients showed that they did not receive medications and upon further review it was noted that those whose records did have dates when a medication was not administered had corresponding notes showing medications were refused by clients, or depending on the record reviewed, some were not prescribed until later dates. On 5/16/2023 from 11:50am-2:00pm LPA Shirley and LPM Cifuentes interviewed Resident 1-Resident 5 (R1-R5). Of those residents interviewed, 4 out of 5 residents stated facility staff had not missed dispensing their medications. On 5/16/2023 from 11:50am-2:00pm LPA Shirley and LPM Cifuentes interviewed Staff 1-Staff 5(S1-S5). Out of those interviewed, 5 out of 5 staff stated residents had not missed any medications. During the course of the interviews, it was noted that some residents have refused medications and have later asked staff to administer medications, but due to the medication guidelines, medication could no longer be administered. 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. 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. A printed copy of this report was left with the Administrator Gwendolyn Craig, whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, May 16, 2023 · control 11-AS-20230515114039

Type of visit: Required - 1 Year

On 5/2/23, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Elizabeth Hernandez, Social Worker, explained the purpose of today’s visit and were allowed entrance to the facility. The facility is an RCFE licensed for (60) ambulatory and (36) non- ambulatory residents. Facility has no hospice waiver. LPA and staff were later joined by administrator Gwendolyn Craig. The facility is a one-story structure located in a residential neighborhood. LPA Shirley and Administrator Gwendolyn Craig toured the physical plant. LPA observed the kitchen to be clean and sanitary and all appliances were operable. The facility has a sufficient supply of perishable and non-perishable foods. The pantry was well stocked. The refrigerators were clean and well stocked. LPA observed a shaded patio. During the visist, LPA observed all staff were wearing face coverings. An exit interview was conducted and a copy of this report was left with the Administrator Gwendolyn Craig, whose signatures on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, May 2, 2023

Allegation investigated: Facility staff did not dispense medication as prescribed

On 10/26/2022, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced initial complaint visit at the facility above. LPA met with Elizabeth Hernandez, Social Services Director and explained the purposed of the visit is to gather information for the allegation listed above. The investigation consisted of the following: On 10/26/2022, LPA conducted a tour of facility grounds, reviewed records and interviewed staff and residents. LPA Agard requested the following documents which were received at the time of visit: 1) staff roster, 2) resident roster, 3) medication administration for R1. cont on 9099C Substantiated The investigation revealed the following: Regarding the allegation… Facility staff did not dispense medication as prescribed. It’s being alleged that a resident did not receive a psychotropic medication for several days. LPA interviewed 5 out of 67 residents. 4 out of 5 denied the allegation. R2-5 all unanimously agreed that they have not had any issues with medication being given as prescribed. R1 states, “I was at the assisted living and they didn’t have my meds for 15 days. I was hallucinating. When I asked them where my meds were, they told me that they were short staff and they didn’t have time to order them.” During interviews with staff, LPA interviewed 4 out of 17 in total. 4 out of 4 could not confirm the allegation to be true. S1 states, “I wouldn’t know what really happened because I was out on leave during that time.” S2 states, “R1 may have missed the first two days of medication because we have to wait for the doctor to send the work orders.” S3 states, “There were no staff shortages while R1 was here. We went live with our new medical system Point Click Care (PCC) in April 2022. The staff are having some difficulties with the system and they are not clicking that they give the meds. They may have given it to R1, but they didn’t document it.” S4 denies ever giving meds to R1, “I’m not aware of R1 missing any medication. I don’t recall mentioning anything to them. I don’t recall giving R1 any meds.” During record review, LPA reviewed a staff schedule for the current month that coincides with the staff interviewed. LPA reviewed a resident roster, dated 10/19/2022, that coincides with the residents interviewed. LPA Agard reviewed the medication record for June and July 2022 for R1. LPA observed medication was given by S2 and S4. LPA observed, on some days, all medications was missed for several days during both months. This includes the specific psychotropic medication prescribed for daily administration. LPA observed it was not given during the first 20 days per the medication record review. Based on LPA’s observation, interviews conducted, and record review, 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 Chapter 8 is being cited (please see LIC9099D.) An exit interview was conducted. Plans of correction were developed. A copy of this report and appeal rights were given.the state’s words, verbatim · CDSS document, Oct 26, 2022 · control 11-AS-20221019155514

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 16, 2022

87465 Incidental Medical and Dental Care C)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: Based on a record review, LPA observed LPA observed, on some days, all... medications was missed for several days during both months. This includes the specific psychotropic medication prescribed for daily administration. LPA observed it was not given during the first 20 days per the medication record review.the state’s words, verbatim · CDSS document, Oct 26, 2022

Plan of correction: Administrator will re-train all staff on the facility’s medication systems. Including but not limited to medical system Point Click Care (PCC). Re-training of all medication technicians must be conducted by POC due date and copies of training with sign-in sheet must be sent to LPA via fax or email.

Allegation investigated: Resident is not receiving prescribed diabetic medicine at the facility. Licensee did not safeguard resident personal possessions. Staff speak inappropriately to resident

Investigation Revealed the following. On 10/12/2022 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Administrator Gwendolyn Craig. LPA explained the purposed of the visit is to deliver findings on the allegations listed above. The investigation consisted of the following: On 9/20/2022 LPA Randle toured facility grounds, reviewed facility files and interviewed staff (S1-S2) and residents (R1). On 10/12/2022 LPA Randle spoke with staff (S1-S4) and residents (R2-R7). LPA requested and received the following files: Staff roster, resident roster, and other documents relevant to the investigation. Unsubstantiated Allegation: Resident is not receiving prescribed diabetic medicine at the facility. The complainant alleges resident it’s not receiving prescribed diabetic medication. LPA spoke to administrator Gwendolyn Craig who stated resident has refused on several occasions to attend required necessary medical appointments in order to have diabetic medication renewed. Administrator added that resident has switched physicians on several occasions which has impeded the continuity of care for the resident. LPA has interviewed R1 who acknowledged that they switched physicians on several occasions and will probably switch again to a physician that is closer to where she resides, R1 also acknowledged that they have missed medical appointments regarding the reissue of their medication. LPA interviewed residents (R2-R7) regarding the allegation of not receiving medication. Resident interviewed all stated (R2-R7) they receive their medication on time daily without incident. LPA interviewed staff (S1-S3) regarding allegation all stated there were no delays in receiving medication. Based on information gathered, the department did not find sufficient evidence to support allegation " Resident is not receiving prescribed diabetic medicine at the facility. Allegation: Licensee did not safeguard resident personal possessions. The complainant alleges facility did not safeguard resident’s personal possessions. LPA interviewed resident (R1) regarding the allegations. R1 stated that they had given away an article of clothing however she maintains that her coat is missing , LPA asked R1 if her locks were broken or in disrepair on her door R1 stated that her locks work fine, LPA ask R1 if she could have left items at the other facility, R1 stated “I didn’t think so”. LPA interviewed (R2-R7) and asked if they had any property stolen or missing items those interviewed R2-R7 stated in the facility they feel safe and the facility keeps their property safe. LPA interviewed staff (S1-S4) regarding allegation,S1-S4 had not been made aware of any personal property or items missing at any time by R1, R1 indicated that she never told anyone or staff that any items were missing Based on information gathered, the department did not find sufficient evidence to support allegation " Licensee did not safeguard resident personal possessions. Allegation: Staff speak inappropriately to resident The complainant alleges staff speak inappropriately to residents. LPA spoke with staff S1-S4 who stated they are not speaking to residents, inappropriately. LPA spoke with residents (R2-R7) regarding the allegation staff speak to residents inappropriately those interviewed 6 out of 6 stated staff were not speaking to residents inappropriately. Based on information gathered, the department did not find sufficient evidence to support 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 allegations: Resident is not receiving prescribed diabetic medicine at the facility. Staff speak inappropriately to resident. Licensee did not safeguard resident personal possessions. 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 Administrator Gwendolyn Craig and a hard copy was provided.the state’s words, verbatim · CDSS document, Oct 12, 2022 · control 11-AS-20220912155843

Allegation investigated: Facility staff is withholding resident's cash resources

On 9/26/2022 at 10:30 a.m. Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced visit to deliver the findings of the complaint with the above allegation. LPA identified himself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Gwendolyn Craig. LPA conducted interviews with Administrator (S1) and reviewed documents from the facility such as admission agreement, discharge report, and resident's financial detail statement including any other pertinent documents such as undelivered closing check dated 9/14/2022 remaining in the file and not given to resident at discharge. Resident was discharged on 11/18/2021 Findings: Based on interviews and records reviewed, the preponderance of evidence standard has been met. LPA finds the alleged violation did occur; therefore, the allegation is SUBSTANTIATED. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. This poses a potential risk to Health and Safety or personal rights to clients/residents in care. Exit interview held with Administrator Gwendolyn Craig. A copy of the report and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Sep 26, 2022 · control 11-AS-20220921164228

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(i) · Plan of correction due date: Sep 26, 2022

Upon discharge of a resident, all cash resources, personal property and valuables of that resident which have been entrusted to the licensee shall be surrendered to the resident... This requirement is not met as evidenced by: Based on interviews conducted and information gathered the licensee failed to return personal property (money) to resident which had been entrusted to the licensee not surrendered to the resident.the state’s words, verbatim · CDSS document, Sep 26, 2022

Plan of correction: Administrator to submit proof of payment back to authorized representative for Resident 1 by POC due date. 9/28/2022

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA's) Stephanie Cifuentes and Antonia Alvizar visited facility for an unannounced case management visit to cite deficiencies that were noted during annual visit. LPA Cifuentes met with staff and explained the reason for todays visit. LPA conducted covid-19 risk assessment, based on staff response the facility is clear of Covid-19 infection. During visit on 7/5/2022 LPA's Cifuentes and Alvizar noted the following: -Water in communal bathroom for rooms 57 and 58 is 148.3F Water in room 18 was 122F. Water in room 8 measured at 96F Exit interview conducted Deficiency cited on LIC809D. A copy of this report and appeal rights are being provided to Gwendolyn craig administrator.the state’s words, verbatim · CDSS document, Jul 5, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jul 6, 2022

Maintenance and Operation Faucets used by residents for personal care such as shaving and grooming shall deliver hot water...the temperature of hot water used by residents to attain a temperature of 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 evidenced by: Based on obsevation, on 7/5/2022 LPA's Cifuentes and Alvizar noted that water in communal bathroom for rooms 57 and 58 is 148.3F Water in room 18 was 122F. Water in room 8 measured at 96F. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 5, 2022

Plan of correction: Administrator will track water temperature for next 24 hours and submit log to CCLD via fax/email by POC due date.

Type of visit: Required - 1 Year

On 7/5/2022, Licensing Program Analyst (LPA’s) Stephanie Cifuentes and Antonia Alvizar conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA’s met with Medical Technician Victoria Calderon, explained the purpose of today’s visit and were allowed entrance to the facility. The facility is an RCFE licensed for (60) ambulatory and (36) non- ambulatory residents. Facility has no hospice waiver. LPA and staff were later joined by administrator Gwendolyn Craig. The facility is a one-story structure located in a residential neighborhood. LPA’s Cifuentes, Alvizar and staff Victoria Calderon toured the physical plant. During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, sign in and out logs for visitors and staff are present in the facility. Due to time constraints, visit will be completed at a later date. An exit interview was conducted, and a copy of this report was provided to Gwendolyn Craig, Administrator.the state’s words, verbatim · CDSS document, Jul 5, 2022

Type of visit: POC

Licensing Program Analyst (LPA) Stephanie CIfuentes conducted a case management - POC visit to follow up on the citation issued on 5/17/2022. LPA met with Medtech Victoria Calderon and explained the reason for the visit. The facility has failed to comply with the POC that was issued on 5/17/2022. The facility failed to meet this requirement and is still not incompliance. 1) 87303(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. The facility has failed to comply with the POC that was issued on: 5/17/2022. LPA conducted a walk through and front doors of the facility are still not operational. Civil Penalties assessed and an exit interview was conducted. A copy of their appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 21, 2022

Allegation investigated: Staff did not provide a safe environment for residents in care

On 6/16/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint visit at this facility. LPA spoke with staff 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 6/16/2022 LPA conducted a tour of facility grounds and reviewed records for staff and residents. LPA conducted interviews with staff (S1-S5), and residents (R1-R7). LPA Cifuentes requested and received the following documents: Client roster, staff roster and other documents relevant to the investigation. Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not provide a safe environment for residents in care The complainant alleges that staff are not keeping residents safe as the front doors of the facility are broken and no one is monitoring who is entering and exiting the facility. LPA noted that facility has double doors and that left door was not locked and could be pulled open, while right door could not be opened from the inside or the outside. There were no staff stationed in lobby at the time LPA walked in, but staff appeared within a few minutes. Lobby area has a table and chair where a staff person sits at, also available are sing in longs for visitors and staff as well as a wall thermometer. Per administrator Gwendolyn Craig, front door is broken and has to be completely replaced. A contractor has been called, door has been measures and has been ordered. While they wait for the repair, a staff person has been assigned to sit near the front doors twenty-four hours a day, seven days a week. The staff will leave to sign in and out for lunch and for restroom breaks. LPA Cifuentes interviewed residents (R1-R7) regarding the allegations and of those interviewed, 4 out of 7 stated they feel safe and there is someone stationed in front of the broken door. LPA interviewed staff (S1-S5) regarding the allegation. Of those interviewed 4 out 5 stated there are facility staff stationed by the front doors. Based on information gathered, the department did not find sufficient evidence to support allegations " Staff did not provide a safe environment for residents 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 and appeal rights forms were provided to Medtech Victoria Calderon.the state’s words, verbatim · CDSS document, Jun 16, 2022 · control 11-AS-20220614133156

Allegation investigated: Facility door is in disrepair

On 5/27/2022, Licensing Pogram Analyst (LPA) Lourdes Montoya conducted an unannounced 10-day complaint visit at this facility. Upon arrival, LPA called the facility to conduct a risk-assessment. LPA spoke with Medication Technician (MedTech) Victoria Calderon who confirmed the facility is Covid-19 free. LPA met with MedTechVictoria Calderon and Administrator Gwendolyn Craig joined the visit shortly after. LPA explained the purpose of today's visit. The investigation consisted of the following: LPA toured the facility with MedTech Calderon, interviewed Administrator Gwendolyn Craig, Medication Technician Victoria Calderon and Receptionist Hailey Garrett. LPA obtaied a copy of the resident roster and staff roster. Report continued in LIC 9099C Substantiated Investigation Revealed the following: ALLEGATION: Facility door is in disrepair It is alleged that the facility door is in disrepair. The Reporting Party (RP) reported that the front main door lock has not been working for a month and a half. RP is concerned about the residents' safety. Based on interviews with Staff (S1-S3), the front main door has been broken and does not lock. S1 revealed the door has been broken since 4/22/2022. LPA observed the front main double glass door on the main entrance does not lock. Based on LPA’s records review, observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “Facility door is in disrepair" is found to be Substantiated. Based on LPA Montoya's records review, the facility was already cited for the same door (broken front double glass door) on 5/17/2022 and the Proof of Correction is due on 6/14/2022. Therefore, no additional citation will be issued during today's visit. An exit interview was conducted and a copy of the report was provided to Administrator Gwendolyn Craig.the state’s words, verbatim · CDSS document, May 27, 2022 · control 11-AS-20220526144438

Allegation investigated: Resident is not being allowed visitation

On 5/17/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint visit at this facility. LPA spoke with Social Services Elizabeth Hernandez 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 5/17/2022 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, incident reports and other documentation relevant to the investigation. Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident is not being allowed visitation The complainant alleges that staff is not allowing visitors to enter the facility for visitation. LPA reviewed facility files and spoke with administrator. Per administrator Gwendolyn Craig, facility allows full visitation indoors and outdoors, staff check for covid-19 vaccination or tests before entry. LPA Cifuentes interviewed residents (R1-R6) and of those interviewed, 3 out of 6 stated visitations was not allowed and one of them said they did not know. LPA interviewed staff (S1-S7) regarding the allegation. Of those interviewed 3 out 6 stated visitation was not currently allowed indoors, and 2 added that they were not sure, but that they had seen no visitors inside of the facility. Based on information gathered, the department did find sufficient evidence to support allegations " Resident is not being allowed visitation.” Based on interviews conducted and records reviewed 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 conducted and a copy of the LIC 9099 and appeal rights forms were provided to Administrator Gewndolyn Craig,the state’s words, verbatim · CDSS document, May 17, 2022 · control 11-AS-20220512164519

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: May 31, 2022

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights… To have their visitors...permitted to visit privately during reasonable hours and without prior notice... This requirement was not met as evidenced by: Based on interviews LPA noted that facility residents are not being allowed indoor visitation. This violation possesses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2022

Plan of correction: Licensee will review latest PIN, post visitation policy on front door, contact families to update them of change and submit copy of visitation policy to CCLD via fax by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Stephanie Cifuentes visited facility for an unannounced Case Management Visit to issue deficiency noted during investigation of complaint control number: 11-AS-20220512164519. LPA Cifuentes met with staff and explained the reason for todays visit. LPA conducted covid-19 risk assessment, based on staff response the facility is clear of Covid-19 infection. During visit on 5/17/2022 LPA Cifuentes noted that facility had double doors in front of facility. When LPA tried the door on the right side it was noted that door is in disrepair and does not lock. Exit interview conducted Deficiency cited on LIC809D and a copy of this report and appeal rights are being provided to Elizabeth Hernandez-Social Services.the state’s words, verbatim · CDSS document, May 17, 2022

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

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation on 5/17/2022 LPA Cifuentes noted that facility door is in disrepair. This violation possesses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2022

Plan of correction: Administrator will repair door and ensure there is sufficient security for the residents at night while the door is bein repaired. Video of repaired door will be submitted to CCLD via fax by POC due date.

Allegation investigated: Staff do not properly assist residents with their medication management Staff yelled at a resident in care The facility is in disrepair Resident was inappropriately touched while in care

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Monday, April 18, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone spoke to Administrator Gwen Craig and conducted a Risk Assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker met with Med Tech Cinthia Burgos LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: During the course of the investigation LPA Bunker interviewed staff 1-5 (S1-S5) and residents 1-6 (R1-R6), LPA Bunker asked questions relevant to the nature of the complaint. LPA Bunker requested copies of R1's records, Medications, Admission Agreements, Consent for Emergency Medical Treatment, Identification and Emergency Information, Personal Rights, House Rules, Resident Roster, and Personnel Report. Med Tech Cinthia and LPA Bunker observed the resident's medication and reviewed records. LPA Bunker observed Cinthia dispensing medication to residents according to their physician's directions. We toured and observed room #22 patio door. the patio sliding door was operable at the time of today's visit. See continued LIC9099 page 2 Unsubstantiated Continued LIC9099-C page 2 Allegation #1: The staff does not properly assist the resident with their medication management: Staff 1-5 (S1-S5) and resident 2-6 (R2-R6) stated staff does properly assist residents with their medication. Staff stated that R1 was admitted to the above facility on 08/25/2021. (R1) was a former resident of Maywood Healthcare & Wellness a skilled nursing home. Staff stated they are administering R1's medications according to her doctor's orders. The facility has four (4) trained Med Techs that assist residents with medication. The Administrator stated their Med Techs are trained and dispensed medications according to the resident's physician's order, some of the residents have instructions from their doctors and they safely handle their own medications. S1-S5 and R2-R6 stated the allegation is false. Allegation #2 Staff yelled at a resident in care: Staff 1-5 (S1-5) and residents 2-6 (R2-6) stated staff does not yell at residents in care. Residents are treated with dignity and respect. S1-S5 and R2-R6 stated the allegation is false. Allegation #3 Facility is in disrepair: Staff 1-5 (S1-S5) stated that R1's patio door is working properly and is maintained in working condition. R1 will knock the sliding screen off the rail and staff is constantly putting the screen back on the rail. We toured R1's room #22 and observed the sliding patio door working on 11/08/2021 and 04/18/2022 the patio door is operable and in working condition. Allegation #4 Resident was inappropriately touched while in care: Staff 1-5 (S1-S5) and residents 2-6 (R2-R6) stated none of the residents in placement is inappropriately touched. S1-S5 and R2-R6 stated that they never witness any resident inappropriately touching another resident. S1-S2 stated R1 mentioned the incident to staff, but didn't want staff to do anything about it. R2 stated he never touched R1 on the legs inappropriately and R1 is a liar and is lying. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Investigation revealed the following: LPA Bunker conducted interviews with staff 1-5 (S1-S5) and residents 2-6 (R2-R6) they all stated staff dispenses medications according to the resident's physician's directions. LPA observed R1 medications and found no evidence to support the allegations. S1-S5 and R2-R6 stated the staff does not yell at residents in care. R1 admitted that she yelled and curses at the facility staff. The facility is not in disrepair and is cleaned, disinfected, and sanitized twice a day and as often as needed. S1-S5 stated If something at the facility is broken the maintenance staff will repair it immediately. S1-S5 stated R1 keeps breaking the sliding patio screen door and maintenance repairs it. S1-S5 stated that R1 keeps knocking the screen door off the rail. On 11/08/2021 and 04/18/2022, we observed the sliding patio door and screen it was working in an operable condition during the visit. S1-S5 and R1-R6 stated they never witness any resident inappropriately touching R1. S1-S2 stated R1 mentioned the inappropriately touching incident to staff, but R1 did not want staff to do anything about it. During the interview, R2 stated he never touched R1 on the legs inappropriately and R1 is a liar and is lying. R2-R6 interviewed stated that they are all happy with how they are treated by the facility staff and they had no problems or complaints. R2-R6 stated if they need assistance with anything staff is always available to assist. R2-R6 stated staff provided them with the necessary care and supervision. S1-S5 and R2-R6 were interviewed and they all denied the allegations. 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. LPA Bunker provided Administrator Gwen Craig with copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC811. An exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 18, 2022 · control 11-AS-20211029152115

Allegation investigated: Staff administered incorrect medication for a resident while in care Staff did not meeting a resident's diabetic needs while in care

On 3/9/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint visit at this facility. LPA spoke with Social Services Elizabeth Hernandez 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 allegations listed above. The investigation consisted of the following: On 3/9/2022 LPA conducted a tour of facility grounds and reviewed facility records. LPA conducted interviews with (5) staff members (S1-S4), and (5) residents (R2-R6). LPA Cifuentes requested and received the following documents: Client roster, staff roster, incident reports and other documentation relevant to the investigation. Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff administered incorrect medication for a resident while in care The complainant alleges that facility gave R1 incorrect dose of insulin. LPA reviewed facility documents, An order was received on 1/10/2022 changing R1’s medication dosages. LPA reviewed medication administration record and noted that for February of 2022, wrong dosage of medication was being administered to resident R1. LPA Cifuentes interviewed residents (R2-R6). R1 was unavailable for interview. Of those interviewed, one stated they took their medication themselves, three stated they had no issues with medications and one was unsure. LPA interviewed staff (S1-S4) regarding resident medications. All four staff stated they had heard of a resident being given incorrect medication. Based on information gathered, the Department did find sufficient evidence to support the allegation mentioned above. Allegation: Staff did not meeting a resident's diabetic needs while in care The complainant alleges that R1 blood sugar was not properly monitored during their time at facility, it should have been checked three times per day. LPA reviewed medication administration record for R1 for month of February, which only shows 6am blood sugar check routinely completed, the check before lunch only occurred 10 times and the check before dinner only occurred twice in the month. LPA spoke with residents (R2-R6) regarding the allegations. R1 was unavailable for interviews. Of those interviewed, two out of five stated they had diabetes, but there were no issues with their insulin. LPA Cifuentes interviewed staff (S1-S4) regarding diabetic residents. S2 stated residents blood sugar is always checked and logged in MAR. Based on information gathered, the Department did find sufficient evidence to support the allegation mentioned above. Based on information gathered, the department did find sufficient evidence to support allegations " Staff administered incorrect medication for a resident while in care,” and “Staff did not meeting a resident's diabetic needs while in care.” Based on interviews conducted and records reviewed 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 conducted and a copy of the LIC 9099 and appeal rights forms were provided to Social Services Elizabeth Hernandezthe state’s words, verbatim · CDSS document, Mar 9, 2022 · control 11-AS-20220302160402

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 10, 2022

Incidental Medical and Dental Care Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews and record reviews LPA noted that R1's was given the incorrect dosage of their medication. LPA also noted that physician requested blood sugar be noted four times dailly, which was not completed. This violation possesses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 9, 2022

Plan of correction: Administrator will conduct staff training regarding medication adminstration for diabetes residents with qualified medical proffesional. Licensee will send CCLD a copy of training outline as well as sign in sheet via fax by POC due date.

Allegation investigated: Medication error

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, February 22, 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 Gwen Craig. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: LPA Bunker interviewed staff 1-3 (S1-3), and residents 1-6 (R1-6), LPA Bunker asked questions relevant to the nature of the complaint. At 2:00 P.M., Administrator Gwen Craig and LPA Bunker toured the medication room, observed the resident's medication and MARS in the meds room, and reviewed records. Administration records, documentation, and observation of R1's records observed indicated the facility is administering the resident's medications correctly. However, R1 went home for a home visit with his wife and was given one (1) bottle of R2's medication by mishap. See continued LIC9099-C page 2 Substantiated Continued LIC9099 page 2 LPA Bunker requested pertinent documentation regarding the above allegation. (Physician's Report, Medical Administration Record, Admission agreement, Appraisal/Needs and Services Plan, Personnel Report, Resident's Roster, Special Incident Report, Corrective Action Memo, and Ongoing In-Service Medication Training) Allegation: Medication error Investigation revealed the following: Interviews were conducted with the staff 1-3 (S1-3), and residents 1-6 (R1-R6). The Administrator stated that it is true that one of the Med Techs accidentally gave R1's wife one bottle of Risperidone 1 MG Tab medication that was for R2 when R1 went home with his wife for a weekend visit. Staff stated R1 did not take R2's medication. R1's wife brought R2 medication back to the facility. R2 did not miss taking any of his medications. R2 had an extra supply of medications, VA provides residents with three (3) monthly supplies of medications. Administrator Gwen Craig self-reported the Special Incident Report to all the appropriate agencies in a timely manner within Title 22 Regulations required time frame prior to the complaint allegation. Ms. Craig stated the Med Tech was given a Corrective Action Memo and received ongoing In-Service Medication Training. The Residents interviewed stated they were happy and staff is providing them with the necessary care and supervision, their daily needs are being met and they had no problems at the facility. Residents stated the Med Techs always dispense their medications according to their physician's directions. Based on LPA’s observations, interviews that were conducted, and records reviewed, 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 LIC9099-D. Appeal Rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC9099-D Confidential Names LIC 811 were provided to Administrator Gwen Craig. Exit interview conducted.the state’s words, verbatim · CDSS document, Feb 22, 2022 · control 11-AS-20220215153134

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 22, 2022

87465 (c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. The Med Tech accidentally gave resident 1's wife a bottle of resident 2 Risperidone medication by mistake when he went home with his wife for a weekend visit. The violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2022

Plan of correction: The deficiency was corrected prior to today's visit. Staff self-reported the special incident report regarding medication error, Med Tech received corrective action and she was retrained on medications.

Type of visit: POC

Licensing Program Analyst (LPA) Pamela Bunker, conducted an unannounced POC visit. LPA Bunker met with Administrator Gwen Craig. LPA Bunker informed staff that the purpose of today's visit was to ensure that the “B" deficiencies cited on 01/03/2022 during the Complaint visit dated 01/03/2022 control number 11-AS-20211230151609 was corrected as required and is now in compliance according to Title 22 Regulations. We observed the following deficiency: 87303 (a) Maintenance and Operation: Room #36 roof was repaired. The deficiency was corrected prior to today's visit. The deficiencies initially cited have been corrected and cleared. Therefore, no civil penalties were assessed. LPA Bunker provided staff with a letter of Deficiency Citations Cleared.the state’s words, verbatim · CDSS document, Jan 3, 2022

Allegation investigated: Resident is not receiving prescribed diabetic medicine at the facility.

On 11/19/21 , Licensing Program Analysts (LPAs) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by assistant administrator Elizabeth Hernandez LPA explained the purpose of today's visit was to gather information on the allegation above. The administrator Gwendolyn Craig was made aware of the visit and was able to join the visit. The investigation consisted of the following: An interview was conducted three (3) staff, and (6) residents. A review of the current staff and resident roster and resident #1 (R1's) service records and other pertinent records was reviewed. A tour of the physical plant was conducted during the visit. Evaluation Report continues LIC9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident is not receiving prescribed diabetic medicine at the facility. The detail on the allegation states resident #1 (R1) is not given her insulin shots. The complainant reports that administrator Gwendolyn Craig and a caregiver informed (R1) on 11/12/21 that they can no longer provide the resident with her insulin shots. (R1) was informed that she has to administer the shots on her own. The complainant states the medical orders were from (R1's) physician. The Department interviewed (R1) and was informed that she refuses to do her insulin as she did find comfort in doing it herself. According to (R1) she is capable of doing so but refuses as she bruises herself and that staff would assist her injecting Lantus insulin twice daily. According to (R1) she has not seen her primary care physician in two (2) years and that is no new orders are in place stating that she had to do the insulin injections herself. (R1) claims that the facility refuses to show her any doctor's orders in writing. (R1) states she is not being assisted by any home health agency and does not require to be on one. According to (R1's) service records, (R1) was admitted on 08/25/21 at this facility. (R1) was a former resident of Maywood Healthcare & Wellness a skilled nursing home. At the nursing home (R1) was accustomed to being assisted by nurses with her daily insulin injections. According to (R1's) Physician's Report (LIC 602A) dated 8/24/21, (R1's) can administer her injections. Physical evidence indicates on (R1's) Admission Orders can manage her medications including Metformin and Lantus to manage her health condition. Reports from (R1's) primary care physician revealed visits were conducted to conduct medical evaluations on 09/10/21,10/08/21 and 11/04/21 in which disputes (R1's) claim that she has not been seen by her primary care doctor in two years. According to (R1's) progress notes, (R1) had done Latus Insulin self-injections in the early part of September 2021 and will substitute Metformin to monitor her blood sugar levels. Interviews with the administrator (S1) and staff #2 (S2) both dispute (R1's) claim that she was being assisted with her insulin injections. (S1-S3) claim that they do not give injections as the action would b in violation of Title 22 regulations. However, they will ensure that a sufficient amount of mediation, testing equipment, syringes, needles, and other supplies are maintained. They provide a hand-over-hand service to (R1). (S1-S3) all claim they continue to monitor (R1's) blood level daily. Evaluation Report continues on LIC 9099-C An interview with (R1's) primary care physician's witness #1 (W1) states that they will work with (R1) to reassess her medical condition to have home health come and assist with the insulin injections weekly. (W1) disputes (R1's) claim that she had been neglected in care by her primary care physician. (W1) states we have records of all the visits conducted with (R1). (W1) reports that (R1) is reluctant to follow the physician's orders and will not hold the facility in any way responsible for (R1)'s refusal for medical care. The Department review (R1's) Medication Administration Records and found them accurate and to be maintained in order. Interviews were conducted with residents #2-#4 (R2-R4) all conducted their insulin injections and states they have no issues with the staff. The staff does not assist with the actual injections of insulin. Interview with residents #5-#6 (R5-R6) both claims the staff is very responsive and in assisting with their medications and have never been denied of their medications. Based on the Department’s observation, interviews, and a review of service records that were conducted, the Department found there is no evidence to support the allegation mentioned above. The Department’s investigation consisted of an inspection of the facility, observation, review of (R1’s) service records, and other pertinent documents relevant to this case, interviews conducted and found no evidence to corroborate the allegations mentioned above. Based on the information gathered, there is no evidence to support the allegations: "Resident is not receiving prescribed diabetic medicine at the facility". Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Gwendolyn Craig and a copy of the report was provided by email.the state’s words, verbatim · CDSS document, Nov 19, 2021 · control 11-AS-20211116143349

Allegation investigated: Staff failed to provide adequate food service Insufficient staff to meet the needs of the residents Staff are unable to communicate with residents due to a language barrier Staff mismanaged resident's medication. Staff not responding to residents call button Facility is unclean

On 11/17/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent unannounced complaint visit to deliver the complaint findings. LPA Montoya called the facility and spoke with Director of Social Services Elizabeth Hernandez to conduct a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA Montoya met with Elizabeth Hernandez and explained the purpose of the visit. The investigation consisted of the following: A tour of the facility on 12/2/2021 and 8/4/2021; interviews with the administrator, staff, and residents on 7/21/2021, 7/27/21 and 8/4/2021; and review of resident records on 7/27/2021 and 8/4/2021. REPORT CONTINUED IN LIC 9099C Unsubstantiated The investigation revealed the following: Based on record review, the Admission Agreement shows Resident #1, the alleged victim, was admitted to the facility on February 4, 2020. According to Appraisal/Needs and services plan dated 2/11/2020, Resident #1 refused to review and participate in the appraisal. Allegation: Staff failed to provide adequate food service It is alleged that Staff failed to provide adequate food service. The department attempted to interview Residents (#1-#11); Resident #1 was not available for interview because he was out of the facility; Residents (#2-#10) were available for interview; two (2) Residents (#11 and #12) refused to be interviewed. The department’s interview revealed out of nine (9) interviewed residents, eight (8) Residents (#2, #3, #4, $5, #6, #7, #8 and #10) are satisfied with the facility’s food service. Only one (1) Resident (#9) stated food service is not good. Staff #1 and #2 disclosed there is only one resident who keeps complaining about the facility’s food service, but this resident does not take or eat the food provided by the facility. Staff #3, the kitchen supervisor, explained sometimes residents make special requests and the kitchen staff always try to accommodate all residents and ensure the food services are beyond satisfactory. Staff #4-6 reported they have not heard complaints from resident about the facility’s food service. Per department’s review, it is noted in the facility’s Resident Dining Details Report that Resident #5, who stated in the interview the food service is bad, has food allergies and supplements/food preferences. This report was created and maintained to meet the residents’ special needs and requests, according to the Dietary Supervisor (Staff #3). The department also observed in the facility’s Summer Menus that the facility maintains a daily diet of quality and quantity necessary to meet the needs of the residents. Based on LPA’s observations, interviews, and records review, LPA did not find sufficient evidence to support the allegation mentioned above. Allegation: Insufficient staff to meet the needs of the residents It is alleged the facility has insufficient staff to meet the needs of the residents. The department attempted to interview Residents (#1-#11); Resident #1 was not available for interview because he was out of the facility; Nine Residents (#2-#10) were available for interview; two Residents (#11 and #12) refused to be interviewed. interview with nine residents (#2-#10) revealed the facility has sufficient staff to meet their needs. Staff #1-#6 stated there is sufficient staff in all shifts to meet the needs of the residents. Review of the Personnel Report indicated the facility has three work shifts and there is sufficient staff to meet the needs of the residents. Based on LPA’s observations, interviews, and records review, LPA did not find sufficient evidence to support the allegation mentioned above. Allegation: Staff are unable to communicate with residents due to a language barrier It is alleged staff are unable to communicate with residents due to a language barrier. The department attempted to interview Residents (#1-#11); Resident #1 was not available for interview because he was out of the facility; Nine Residents (#2-#10) were available for interview; two Residents (#11 and #12) refused to be interviewed. The department’s interview revealed Residents #2-#8 are able to communicate with residents without a language barrier. Residents #9 and #10 claimed caregivers are unable to communicate well with them because the caregivers only speak Spanish. Staff #1-#6 stated they communicate well with residents. The department’s interview with Staff #1-#6 revealed they communicate well, and no language barrier was observed. Based on LPA’s observations, interviews, and records review, LPA did not find sufficient evidence to support the allegation mentioned above. REPORT CONTINUED IN LIC 9099C Allegation: Staff mismanaged resident's medication. It is alleged staff mismanaged resident’s medication. The department attempted to interview Residents (#1-#11); Resident #1 was not available for interview because he was out of the facility; Nine Residents (#2-#10) were available for interview; two Residents (#11 and #12) refused to be interviewed. Residents (#2-#10) revealed in interviews that staff did not mismanage their medications. Staff (#1-#2) stated they did not receive a complaint regarding mismanagement of resident’s medication. Staff (#3) refused to make comments regarding this allegation. Staff (#4-#6) revealed in interview that no residents are having problems receiving their medications. Based on LPA’s observations, interviews, and records review, LPA did not find sufficient evidence to support the allegation mentioned above. Allegation: Staff not responding to residents call button It is alleged the Staff not responding to residents call button. The department attempted to interview Residents (#1-#11); Resident #1 was not available for interview because he was out of the facility; Nine Residents (#2-#10) were available for interview; two Residents (#11 and #12) refused to be interviewed. The department’s interview revealed Residents (#2, #3, #5, and #7) do not use the call button in their bedroom. They said they prefer to go to the front desk for assistance. Residents (#6 and #8) stated facility staff respond quickly when they use the call button for assistance. Resident (#4), whose bedroom is #6A, reported the call button in the bedroom is inoperable. Resident #9 reported he does not have a call button in his bedroom. Resident (#10) stated the call button in her bedroom (# 35B) does not work. Staff #1 mentioned the dashboard of residents’ call buttons is located in the office/front desk and staff respond quickly to residents’ calls. Staff (#1) also reported the call buttons in bedrooms #1, #35 and #38 are not operable. Staff #2 reported staff respond quickly to residents’ calls unless but there are call buttons that are not working. Staff #3 refused to make comments regarding this allegation. During the department’s tour of the facility on 7/21/2021, it was observed that some bedrooms have broken call buttons but residents whose call buttons are operable stated staff respond quickly to their calls. Based on LPA’s record review, the facility has an ongoing repair plan of the broken call buttons. Based on LPA’s observations, interviews, and records review, LPA did not find sufficient evidence to support the allegation mentioned Allegation: Facility is unclean It is alleged that the facility is unclean The department attempted to interview Residents (#1-#11); Resident #1 was not available for interview because he was out of the facility; Nine Residents (#2-#10) were available for interview; two Residents (#11 and #12) refused to be interviewed. All nine interviewed resident (#2-#10) revealed the facility is clean. Staff #1 and #2 stated they did not receive a complaint regarding this allegation. Staff #3 refused to make comments regarding this allegation. Staff (#4-#6) stated the facility is clean every day. Based on LPA’s observations, interviews, and records review, LPA did not find sufficient evidence to support the allegation mentioned Based on information gathered, LPA did not find sufficient evidence to support the allegations, “Staff failed to provide adequate food service”, “Insufficient staff to meet the needs of the residents”, “Staff are unable to communicate with residents due to a language barrier”, “Staff mismanaged resident's medication”, “Staff not responding to residents call button”, REPORT CONTINUED IN LIC 9099C and “Facilityis unclean”. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are Unsubstantiated. No deficiencies were cited. An exit interview was conducted. A hard copy of the report was provided to Elizabeth Hernandez.the state’s words, verbatim · CDSS document, Nov 17, 2021 · control 11-AS-20201123090721

Allegation investigated: Facility does not provide adequate food service.

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, October 26, 2021. 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 Gwen Craig. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: During the investigation, LPA Bunker interviewed staff 1-4 (S1-S4), and residents 1-7 (R1-R7), LPA Bunker asked questions relevant to the nature of the complaint. Staff and residents stated the facility has a new Nutrition & Dietetics Food Service Manager. Staff stated the residents have complained about the food portions. S1-S4 and residents R1-R7 stated the issues with the food were corrected and no longer a problem. Staff stated the incident was self-reported to Community Care Licensing promptly. See continued LIC9099-C page #2 Substantiated Continued LIC9099-C page #2 Allegation: The facility does not provide adequate food service. Staff and residents stated residents were not provided adequate food. The problem was corrected. LPA Bunker observed the facility's food. The facility has an ample supply of perishable and non-perishable food. The administrator reported a special incident report regarding food service prior to the complaint. Investigation revealed the following: Interviews were conducted with staff 1-4 (S1-S4) and residents 1-7 (R1-R7). During the interviews, S1, S2, S3, stated the facility has a new nutritionist & dietician food service manager she was serving the resident a small portion of food based on the facility menu for Centinela Skilled Nursing Facility next door shares the same kitchen and cooks. The nutritionist & dietician food service manager was not aware assisted living had a separate menu from the skilled nursing facility. She has corrected the problem and residents are receiving the required amount of food and beverages. R1, R2, R3 stated they were not receiving enough food. R4, R5, R6, R7 stated they are receiving enough food. R1 is the only resident that stated he is not receiving evening snacks and go to bed hungry. All seven residents stated the food service problem is now resolved. S1-S4 and R1-R7 stated residents are now receiving the quantity of food to meet residents' needs. Based on LPA’s observations, interviews that were conducted, and records reviewed, 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 LIC9099-D. Appeal rights were discussed, and copies of LIC9099, LIC9099-C, LIC9099-D, and LIC811 were provided to the Administrator Gwen Craig Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 26, 2021 · control 11-AS-20211020132720

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Oct 27, 2021

87555 (a) Food Services: The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared, and served in a safe and healthful manner. The facility did not provide adequate food service. The violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2021

Plan of correction: The deficiency was corrected prior to today's visit.

Allegation investigated: Staff will not transport resident Administrator is harassing the resident

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, September 22, 2021, at 10:10 A.M., LPA Bunker met with Administrator Gwen Craig. 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 Gwen Craig. LPA Bunker explained the purpose of today's visit. The Investigation consisted of the following: Interviews conducted with staff 1-4 (S1-4) and Residents 2-6 (R2-6). Staff and residents stated residents are provided transportation, and the Administrator is not harassing any of the residents. The complainant stated the issue was resolved and he had no problem with transportation or harassment. Staff and residents denied the above allegations. See continued LIC9099-C page 2 Unsubstantiated Continued LIC812-C page 2 Allegation #1: Staff will not transport resident Interviews with staff 1-4 (S1-S4) all claim that the accusation is false and that (S3) is an excellent worker and well experienced and trained. Based on the information gathered, there’s no evidence to collaborate the allegation mentioned above. Interviews with Residents 2-6 (R2-R6) revealed they all have utilized the transportation services provided in-house and felt safe during their transport services. (R2-R6) all claim that (S3) conducts himself professionally, communicates well and is committed to safety on the road. Allegation #2: The administrator is harassing the resident Interviews were conducted with staff 1-4 (S1-S4) and residents 2-6 (R2-R6). During the interviews, staff and residents stated that they had no problem with the Administrator, she does not harass residents. Residents stated they are being treated with dignity and respect by the Administrator and staff. Investigation revealed the following: LPA Bunker conducted interviews with staff 1-4 (S1-S4) and residents 2-6 (R2-R6) they all stated staff does transport residents to their appointments. LPA observed staff personnel files and found no evidence to support the allegations. Staff and residents stated the Administrator does not harass any of the residents. Residents stated that they are all happy with how they are treated by the Administrator and they had no problems. Residents stated if they need assistance with anything staff is available to assist. Residents stated staff provided them with the necessary care and supervision. Staff and residents interviewed denied allegations. 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. LPA Bunker provided Administrator Gwen Craig with copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC811. An exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 22, 2021 · control 11-AS-20210903085057

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Pamela Bunker, conducted an unannounced POC visit. LPA Bunker met with Administrator Gwen Craig. LPA Bunker informed staff that the purpose of today's visit was to ensure that the “A" deficiencies cited on 08/14/19 during the complaint visit for Complaint Report dated 08/06/19, control number 11-AS-20190806162338 was corrected as required and is now in compliance according to Title 22 Regulations. We observed the following deficiency: 87506 (c) (1) Resident Records: The resident's files are no longer on the bookshelf in the receptionist/office area. The resident's binders with confidential information were removed to a safe locked room inaccessible to residents. Records are secured, safeguarded, and confidential. The deficiencies initially cited have been corrected and cleared. Therefore, no civil penalties were assessed. LPA Bunker provided staff with a letter of Deficiency Citations Cleared. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Sep 22, 2021

Allegation investigated: Staff did not provide adequate assistance to meet necessary medical needs of the resident.

On 09/17/21, Licensing Pogram Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent complaint visit at this facility. LPA met with the Administrator Gwendolyn Craig and the Director of Social Services Elizabeth Hernandez and explained the purpose of today's visit was to collect information and deliver findings. The investigation consisted of the following: Interview with Gwendolyn Craig, staff #3 (S3) witness #1 (W1), (R1)'s service records and other pertinent records in association with this allegation. A tour of the facilty was conducted. Evaluation Report Continue on LIC-9099-C Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not provide adequate assistance to meet necessary medical needs of the resident. The details on this allegation state the facility did not allow for (R1) to have access to transportation for medical appointments. (R1) reports the staff is not allowing him access to transportation vehicles. On 07/13/21, the staff refused transportation assistance for his medical appointment. An interview with the administrator revealed (R1’s) in-house transportation was terminated on 07/12/21. The reason was due to personal conflicts between (R1) and (S3). The administrator took immediate action to de-escalate strife between the resident and staff by terminating (R1)’s in-house transportation services. A decision the administrator felt was necessary as it created an unstable environment for both parties involved and other residents transported to their daily appointments. An interview with (S3) revealed that (R1) was dissatisfied with his services and it created an uneasy work setting between the resident and staff. The administrator stated the (R1) had alternative transportation assistance with Access Services. However, (R1) claims the services are not reliable. According to the administrator, in-house transportation services resumed for (R1) on 08/13/21 after an alternative plan was put in place. Based on interviews and records reviews, there is sufficient evidence to support the allegation mentioned above had violated Title 22 regulations. Based on interviews that were conducted record reviews, 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 9099-D. INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility staff transports residents in an unsafe manner. It is alleged that staff #3 (S3) is unsettling, throws tantrums, and drives dangerously. The Department conducted interviews with residents #2-#10 (R2-R10, staff #1-#10 (S1-S10) and witness #1 (W1) a review of (S3)’s personnel file and found there no evidence to support the allegation mentioned above. An interview with (S3) states his primary duties are to transport residents to medical/dental appointments and that secondary duties are operational tasks for management. (S3) reports that he has been an employee for two and half years and claims that he had no complaints about his services nor how his driving performance. (S3) claims that he has a clear record with no driving violations. (S3) reports he has completed In-Service Ethics, Sensitivity, First Aid, CPR and Defensive and Safety Training. Interviews with (R2-R10) revealed they all have utilized the transportation services provided in-house and felt safe during their transport services. (R2-R10) all claim that (S3) conducts himself professionally, communicates well and is committed to safety on the road. Interviews with (S1-S10) and (W1) all claim that accusation is manufactured and that (S3) is an excellent worker and well experienced and trained. Based on the information gather, there’s no evidence to collaborate the allegation mentioned above. Resident does not receive medication delivery in a timely manner. The detail of the allegation indicates the (R1) does not receive his medication delivery in a timely manner. Interviews conducted with staff #1-#2 (S1-S2) indicated (R1) is self responsible for his medications and does not need assistance with medication administration and that medications are sent to the facility by mail. (S1-S2) all stated that the mail is delivered to the resident the same day it arrives. The mail is delivered by USPS mail and is distributed by the administrator, med tech, or caregivers. The resident also comes to the front office to retrieve their mail. The administrator also stated that mail is received by the receptionist at the skilled nursing annex. Evaluation Report continues on LIC 9099-C The administrator then handles will separate it and gives the Assisted Living residents their mail daily. The administrator states, the mail delivery time may vary depending on the holiday that will affect the distribution process. The administrator claims the facility has no control over the USPS or any other mail services with the delivery schedules. A review of (R1)’s service records, confirms that (R1) is self-responsible for medications and refills. Interviews conducted with (R2-R10) reported they have no concerns with their mail and that it is being delivered timely. All the residents interviewed, there have been on knowledge with late mail delivery and stated they all had no difficulties receiving their medications timely. Based on the information gather, there’s no evidence to support the allegation mentioned above. Facility has insufficient staffing to meet the resident’s needs. The details of the allegation state there is insufficient staffing to meet resident #1 (R1)’s needs. Staff is not providing appropriate care and supervision to the residents while in care. On 7/14/2021 the Department interviewed residents #2-10 (R2-R10) regarding care and supervision. All the residents indicated that their needs are being met. When one calls for assistance, the staff provides them with what is needed. Information provided by residents states there is always staff around to provide you with care to assist with assisted daily living activities. During the interview with the administrator, she indicated that there is always staff on shift to provide care and supervision. The administrator states staffing availability for the following shifts: eleven (11) morning shift; seven (7) swing shift; five (5) graveyard shift the numbers do not include kitchen staff. The administrator claims that during any staffing crisis; the staff is crossed trained to assist immediately with any job function. The administrator provided proof to verify staff is cross-trained. Interviews were conducted with (S1-S10) all confirmed that there is sufficient staffing in each shift to accommodate residents with required needs and they are crossed trained if needed for any staffing crises. An interview with witness #1 (W1) indicated there has been no hint to (R1) not being care for or supervised timely and states the staff is doing the best they under circumstances have to assist with a variety of needs. A review of (R1)’s service records indicated the resident is very much independent and requires minimal assistance with care or supervision. Based on the information collected, there’s no evidence to collaborate the allegation mentioned above. Evaluation Report continues on LIC 9099-C The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R-1)'s service records, and interviews conducted and found no evidence to support the allegations: "Facility staff transports residents in an unsafe manner", "Resident does not receive medication delivery in a timely manner", "Facility has insufficient staffing to meet the resident’s 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 Elizabeth Hernandez and a copy of the report was provided by email.the state’s words, verbatim · CDSS document, Sep 17, 2021 · control 11-AS-20210709155908

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(2) · Plan of correction due date: Sep 24, 2021

87465 Incidental Medical and Dental Care (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation... medical or dental facility which will meet the resident's need. In providing transportation the licensee shall...make arrangements for this service. This requirement was not met as evidenced by: Based on interview and record review the licensee/Administrator failed to adhere to Title 22 regulations and terminated transportation services for (R1) and failed to meet resident’s needs. The violation poses a potential a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2021

Plan of correction: The licensee will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations with 87465 Incidental Medical and Dental Care Regulations. Plan of correction will be submitted by POC due date: 09/24/21. This violation was corrected during the visit on 09/17/21. The licensee issued for in-house transportation services to resume with (R1) and implemented an alternative plan to meet (R1)'s needs.

Type of visit: Case Management - Deficiencies

On 09/17/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit at this facility and met with the Administrator Gwendolyn Craig and the Department of Social Services Elizabeth Hernandez and explained the purpose of today’s visit is to conduct a plant inspection and health and safety check. The Department had received supplemental information on 07/19/21 for complaint #11-AS-20210709155908 after a 10-day visit was already conducted. Resident #1 (R1) was involved in a verbal exchange with staff #1 (S1). An investigation was conducted, and it included interviews with (R1) and (S1) and other staff members. (S1) admitted in the heat of verbal exchanges, he called (R1) an indecent word and that the facility failed to safeguard (R1) an environment free from verbal abuse. Based on interviews and records reviews, there is sufficient evidence to support the facility violated Title 22 Division 6 Chapter 8 regulations noted on LIC 809-D. A violation is issued, and an exit interview is conducted with Elizabeth Hernandez.the state’s words, verbatim · CDSS document, Sep 17, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(a)(2) · Plan of correction due date: Sep 24, 2021

87413(a)(2) Personnel – Operations (a) in each facility: (2) care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement was not met as evidenced by: Based on interview and record review an admission from (S1) who had verbal exchanges with (R1), failed to give (R1) an environment free from verbal abuse. The violation poses a potential a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2021

Plan of correction: The licensee will create a plan to ensure that all staff performs knowledge of and conforms to applicable laws, rules and regulations will 87413 Incidental Medical and Dental Care Regulations. Plan of correction will be submitted by POC due date: 09/24/21. The licensee corrected this violation during the visit on 09/17/21. The administrator investigated the incident with a statement in writing from (S1). The administration will continue to provide in-service training on ethics and a review of Title 22 87413 regulations.

Allegation investigated: Staff are not providing appropriate care and supervision to the residents while in care. Staff are not responding to residents alerts while in care.

Licensing Program Analysts (LPA) Jey Cardenas conducted a subsequent complaint visit to deliver findings for the allegations listed above. Upon arrival at the facility LPA conducted a risk assessment over the telephone with Med-Tech, Laura Lopez Based on the assessment, the facility is clear of Covid-19 infection. LPA met with administrator Gwendolyn Craig and the purpose of the visit was explained. Investigation consisted of: LPA Interviewed Administrator Gwendolyn Craig, eight (8) staff, and ten (10) residents , Obtained a copy of resident and staff roster, reviewed facility record files for resident #1 (R1) and obtained physicians report, admission agreement, and appraisal. Investigation Revealed the following: It is alleged that at approximately 5:00am/ 5:39am R1 was having trouble sleeping went to the front office/nursing station and there was no staff there, resident waited around for staff and no one showed. R1 contacted Reporting Party (RP) at that time, who then called facility number and staff didn’t pick up call. Unsubstantiated -Regarding allegation #1 Staff are not providing appropriate care and supervision to the residents while in care. On 7/14/2021 LPA interviewed ten (10) Residents regarding care and supervision. Seven residents (#1, #2, #3, #4, #5, #7, #9) indicate that their needs are being met. When they call for assistance, staff provides them with what they need. There’s always staff around to provide care. One resident (#6) is unsure if needs are being met. One resident (#8) indicates needs are not being met because staff doesn’t clip toenails, and resident hasn’t had a haircut. R8 says, “Ive gone a year without getting toenails clipped.” One resident (#10) indicates most of the time needs are met. During interview with Gwendolyn she indicates that there is always staff on shift to provide care and supervision. During the overnight shift (11pm- 7am) there is one (1) caregiver and one (1) med-tech on shift. Caregiver conduct room checks every two hours to check on residents. During interviews with staff, staff indicates that residents have not expressed concerns to them about lack of care and supervision. -Regarding allegation #2 Staff are not responding to residents’ alerts while in care. On 7/14/2021 LPA Cardenas interviewed ten (10) resident regarding above allegation, R1 states staff is responsive when assistance is requested. LPA asked if staff is quick to respond when called; R1 states “I guess so.” However, there was one time resident needed assistance and there was no one on duty. Resident was unable to remember when and time the incident took place. LPA asked if incident happened during the morning, afternoon, night, R1 couldn’t remember. R1 later stated that there is sufficient staff. Six residents (#2, #3, #4, #5, #7, #9 ) indicated that when they need assistance they call to staff and staff are very responsive. One resident (#6) indicates staff is responsive sometimes, it depends on the staff who is on shift. Two residents (#8, #10) indicated staff responds, but they take a while to come. A while ago R8 called through the room alert button and no one came. R8 stated alert button in bedroom doesn’t work. LPA conducted room check and found that bottom was operable. During interview with administrator, Gwendolyn she indicates that she hasn’t received many complaints about staff not responding to residents’ alerts. During council meetings resident did mention that there isn’t enough staff. Gwendolyn states she is working on hiring staff, and interviews are being scheduled. The over-night caregivers report to Gwendolyn that during the graveyard shift its usually slow and everyone is asleep. During interviews with staff; staff indicate that when residents need assistance, they call the call button and staff respond immediately. Residents also come to the office desk if they need assistance and staff renders assistance. Based on investigation gatherings, LPA did not find sufficient evidence to support the allegations, Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. Exit interview was conducted. A copy of the report to be provided to Administrator Gwendolyn Craig via email.the state’s words, verbatim · CDSS document, Aug 25, 2021 · control 11-AS-20210708161708

Allegation investigated: Staff forgets to provide resident with medication for outings Resident's hygienic care needs are not being met

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to conduct further investigation and deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Gwendolyn Craig, the facility administrator. The investigation consisted of following: Interviews and Record reviews. On 07/30/21, LPA Soto interviewed medical assistant Laura Lopez. On 08/16/21, LPA Soto interviewed Administrator Gwendolyn, S#3, R#1 – R#5. Toured rooms #2, #41, #23, and #16 and dining room, patio, and administrator office, and medication room. LPA Soto received the following documents on 08/16/21: Resident Roster, Staff Schedule, VA Medical report, needs and services plan, admissions agreement, and medication logs for R#1. Unsubstantiated Based on the LPA's investigation, the investigation revealed the following. For Allegation #1 - Staff forgets to provide resident with medication for outings. Interviews with administrator, S#1, & S#3, stated that they always give the residents their medication. R#1 needed their medication, but the Medicine Technician was out to lunch and R#1’s family member refused to wait 10 – 15mins to wait for the Medicine Technician to come back from lunch and still took R#1 for their outing anyway. They left without R#1 medicine. R#3, R#4, R#5 all sated that they get their medicine every day on time, never missed a dose. The interviews do not concur with the above allegation. Allegation #2 - Resident's hygienic care needs are not being met. Interviews with administrator, S#1, & S#3, they all stated that the residents that choose to bathe are always helped, there are those residents that are difficult and refuse to bathe. The staff cannot force them to look after their hygiene or make them do anything they do not want to do. R#1 becomes aggressive and refuses to deal with his own hygiene, even when administrator and staff try to encourage him to do so. Interviews with R#1, R#2, R#4, & R#5, stated they do not have any problems with meeting their own hygiene needs. R#3 requires help with their hygiene needs, the staff always helps R#3 with their hygiene needs. LPA Soto reviewed records and it revealed that R#1 does have mental condition that can make R#1 aggressive. The interviews and records reviewed do not concur with the above allegation. 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 Gwendolyn Craig, Administrator, and a hard copy was provided.the state’s words, verbatim · CDSS document, Aug 16, 2021 · control 11-AS-20210727102124

Allegation investigated: Staff fail to ensure residents receive mail in a prompt manner.

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to conduct further investigation and deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Gwendolyn Craig, the facility administrator. The investigation consisted of following: Interviews and Record reviews. On 07/30/21, LPA Soto interviewed medical assistant Laura Lopez. On 08/16/21, LPA Soto interviewed Administrator Gwendolyn, S#3, R#1 – R#5. Toured rooms #2, #41, #23, and #16 and dining room, patio, and administrator office, and medication room. LPA Soto received the following documents on 08/16/21: Resident Roster & Staff Schedule, mail procedures. Unsubstantiated Based on the LPA's investigation, the investigation revealed the following. For Allegation #1 - Staff fail to ensure residents receive mail in a prompt manner. Interviews with Administrator, S#1, & S#3, they all stated that the mail is delivered to the resident the same day it arrives. The mail is distributed by the administrator, medicine technician, or care givers. The residents also come to the front office to get their mail. The administrator also stated that mail is received by the receptionist at the skilled nursing side, she then separates it and gives the Assisted Living side their mail every day. Interviews with R#2, R#4, & R#5, stated that they always get their mail on time. The mail is never late. The LPA witnessed that the mail for 08/16/21 was reviewed, marked, and ready to be distributed. The interviews and records reviewed do not concur with the above allegation. 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 Gwendolyn Craig, Administrator, and a hard copy was provided.the state’s words, verbatim · CDSS document, Aug 16, 2021 · control 11-AS-20210720081934

Allegation investigated: Facility staff withheld money from the resident

On 8/4/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent unannounced complaint visit to deliver the complaint findings. LPA Montoya called the facility and spoke with Director of Social Services Elizabeth Hernandez to conduct a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. At around 2:30 pm, LPA Montoya met with Administrator Gwendolyn Craig and explained the purpose of the visit. The investigation consisted of the following: A tour of the facility and interviews with the administrator, staff, and residents on 7/21/2021 and 7/27/21; review of Resident #1’s admission agreement, physician’s report, Appraisal/Needs and Services Plan, and other facility records pertinent to the allegation above. REPORT CONTINUED IN LIC 9099C Substantiated The investigation revealed the following: Allegation: Facility staff withheld money from the resident. It is alleged the facility staff withheld money from the resident. Based on record review, the Admission Agreement shows the victim was admitted to the facility on August 14, 2020. Resident #1’s monthly SSI rate for all basic services is $1079.37. The agreement states that if the resident is not able to manage his finances or if he has no conservator, the administrator will manage and supervise his cash resources. The department attempted to interview eleven residents (#1-#11); nine (9) residents were available, but two (2) residents were not able to provide feedback. Resident (#9) refused to respond, while Resident (#11) was unavailable during the interview. During the department interview, the administrator (Staff #1) admitted there are 12 residents whose SSI/SSDI payment or private money have been withheld in July 2021 due to the facility’s Check system error and the facility’s inability to produce cash. Staff #1 stated the facility deposits the resident's check(s) and cash it out for them. Staff #1 admitted the facility withheld Resident #1’s checks in the amount of $200 dated June 22, 2021, and $138.00 dated June 23, 2021, from the County of Los Angeles, Public Administration – Public Guardian. Staff #1 stated the facility does not have available cash on hand to give to the residents, and there are no alternatives to obtain cash other than through the RFMS check system. Staff #1 revealed the cash resources of 12 residents payees have been given to them on July 30, 2021. Staff #1 added the facility gave $20.00 cash to Resident #1 on July 23, 2021. The Director of Social Services also admitted there are some residents who were affected by the Check System error, and their SSI/SSDI money has been withheld during July 2021. Residents (#2, #3, #5, #6, #7, and #4) provided feedback to the interviews and stated the facility does not handle their cash resources. Residents #8 and #10 explained the facility handles their cash resources, and they have not received their July SSI/SSDI payments as of July 27, 2021, due to the failure of the facility’s check system. Resident #1, the alleged victim, stated the facility withheld his July SSI payment and private money. Resident #1 was unable to provide the amount of the money owed to him by the facility. Resident #1 received his July SSI payment and private money on July 30, 2021 from the facility. Interviews and records review concur with the above allegation. Based on LPA’s observations, interviews, and records review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation. An interview was conducted with Gwendolyn Craig, the Administrator, and a hard copy was provided along with Appeal rights.the state’s words, verbatim · CDSS document, Aug 6, 2021 · control 11-AS-20210712084711

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(h) · Plan of correction due date: Aug 20, 2021

This report is being amended to correct the Section Number cited in Title 22. 87217 Safeguards for Resident Cash, Personal Property, and Valuables (h) Immediately upon admission, residents' cash resources entrusted to the licensee and not kept in the licensed facility shall be deposited in any type of bank, savings and loan or credit union account, which is maintained separate from the personal or business accounts of the licensee, provided that the account title clearly notes that it is residents' money and the resident has access to the money upon demand to the licensee. This requirement is evidenced by: Based on observation, records review and interviews, The administrator admitted twelve (12) residents including Resident #1 were affected by the Check system error and facility was not able to release their cash resources for July 2021 until July 30, 2021. The facility withheld Resident #1's monies in the amount of $200 dated June 22, 2021, and $138.00 dated June 23, 2021, from the County of Los Angeles, Public Administration – Public Guardian. Staff #1 stated the facility does not have available cash on hand to give to the residents, and there are no alternatives to obtain cash other than through the RFMS system. This poses a potential Health, Safety and/or Rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2021

Plan of correction: Licensee gave the twelve (12) resident payees their July SSI/SSDI/private money in cash on July 30, 2021. This was corrected prior to this visit.

Allegation investigated: Food is cold

On 8/4/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent unannounced complaint visit to deliver the complaint findings. LPA Montoya called the facility and spoke with Director of Social Services Elizabeth Hernandez to conduct a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. At around 2:30 pm, LPA Montoya met with Administrator Gwendolyn Craig and explained the purpose of the visit. The investigation consisted of the following: A tour of the facility and interviews with the administrator, staff, and residents on 7/21/2021 and 7/27/21; review of Resident #1’s admission agreement, physician’s report, Appraisal/Needs and Services Plan, and other facility records pertinent to the allegation above. REPORT CONTINUED IN LIC 9099C Unsubstantiated The investigation revealed the following: Allegation: Facility food is cold. It is alleged the facility food is cold. Based on record review, the Admission Agreement shows the victim was admitted to the facility on August 14, 2020. The department attempted to interview eleven residents (#1-#11); nine (9) residents were available but two (2) residents were not able to provide feedback. Resident (#9) refused to respond, while Resident (#11) was unavailable during the interview. During LPA’s interview, Resident #1, who is the alleged victim, stated that the facility food being cold is not his major concern. Resident #1 denied the food is cold and stated the food and the service have been better. Based on LPA’s interviews, five (5) Residents (#3, #4, #5, #8, and #10) denied the facility food is served cold while it is supposed to be hot. Two residents (#2 and #7) stated the food is sometimes served cold while it is supposed to be hot, but they don’t have any complaints. Resident #6 stated the food is always cold. Staff #1-#3 stated the food that is supposed to be hot is served hot/warm. They stated that the food is plated while it’s hot and kept in a thermal warmer to keep the food warm/hot. Staff #1 and #2 disclosed only Resident #11 continuously complains that food is cold. Staff #1 and #2 mentioned that the facility provided a microwave to Resident #11 in his bedroom, yet he still complains. They declared that Resident #11 frequently buys food and does not often eat the facility food. Based on LPA’s observations, interviews, and records review, LPA did not find sufficient evidence to support the allegation mentioned above. Based on information gathered, LPA did not find sufficient evidence to support the allegations, “Facility food is cold.” Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies were cited. An exit interview was conducted. A hard copy of the report was provided to Administrator Gwendolyn Craig.the state’s words, verbatim · CDSS document, Aug 6, 2021 · control 11-AS-20210712084711

Allegation investigated: Staff administered unprescribed medication to resident.

On 7/27/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent unannounced complaint visit to continue the investigation and deliver the complaint findings. LPA Montoya called the facility and spoke with Administrator Gwendolyn Craig at around 10:53 am to conduct a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. At around 11:05 am, LPA Montoya met with Administrator Gwendolyn Craig and explained the purpose of the visit. The investigation consisted of the following: A tour of the facility and interviews with the administrator, staff, and residents on 7/21/2021 and 7/27/21; telephone interview of a witness, review of residents' admission agreement, physician’s report and Appraisal/Needs and Services Plan, Medication Administration Records (MAR), training records and other facility records pertinent to the allegation above. REPORT CONTINUED IN LIC 9099-C Substantiated The investigation revealed the following: Allegation: Facility staff administered unprescribed medication to the resident. It is alleged the facility staff administered unprescribed medication to the resident. Based on LPA's records review, Resident #1 was admitted at the facility on 6/8/2018. Preplacement record shows Resident #1 needs help with his medication. According to the Medical Record/Physician’s Report, Resident #1 has dementia; not capable of dispensing his own medication; and not capable of medical decision due to his dementia; a list of his active prescribed medications does not include melatonin. Resident #1’s Medication Administration Record dated 6/1/2021-6/31/2021 does not show Melatonin as one of his prescribed medications. There is no record that melatonin was prescribed to Resident #1 by his doctor. Per LPA’s review of the alleged perpetrator’s (Staff #3) personnel record, she was hired on 4/6/2020 and completed eight hours of hands-on shadowing training and eight hours of other training or instructions. During LPA’s interview, Resident #1, who is the alleged victim, willingly showed up for interview but refused to answer the questions. LPA was unable to obtain information from him. Residents #2-#10 stated they were not given unprescribed medications and have not heard any other residents given or administered unprescribed medications. However, the Administrator (Staff #1) and the Director of Social Services (Staff #2) admitted that Resident #1 was given two white sleeping pills called melatonin (3 mg) not prescribed to him by this doctor. An incident report dated 7/2/2021 and interview with Staff #1 indicate that a Medication Technician (Staff #3) administered two tablets of melatonin on 6/30/2021 and soon later Resident #1 experienced a side effect that sounds like a hallucination. According to facility’s narrative charting, Staff #3 administered the melatonin to Resident #1 because she was not aware that melatonin is not a house medication. Report continued in LIC 9099C LPA attempted to interview Staff #3 over the telephone, but Staff #3 told LPA that she was not available for interview due to a personal reason. LPA was not able to obtain statements from Staff #3. Staff #1 stated she gave Staff #3 an in-service training on 7/2/2021 regarding mismanagement of medications. LPA’s interview with Resident #1’s Power of Attorney Representative (Witness #1) revealed that Resident #1 experienced a side effect of visual hallucination after taking the melatonin. Witness #1 stated Resident #1 informed her that in his hallucination, he felt like he turned white like a ghost then turned into a black man; he had bumps on his skin, he felt like he was beaten up, and his eyes were swollen. The interviews and records review concur with the above allegation. Based on LPA’s observations, interviews, and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation. An interview was conducted with Gwendolyn Craig, the Administrator, and a hard copy was provided along with Appeal rights.the state’s words, verbatim · CDSS document, Jul 27, 2021 · control 11-AS-20210702092228

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(1)(2) · Plan of correction due date: Jul 28, 2021

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication.(2)The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Based on LPA's observations, interviews and records review, licensee failed to ensure staff administers nonprescription PRN medications according to regulations above. Administrator admitted that Staff #3 administered unprescribed melatonin to Resident #1 without contacting resident's physician. The administered medication caused Resident #1 a side effect of hallucination.the state’s words, verbatim · CDSS document, Jul 27, 2021

Plan of correction: LPA Montoya received a proof that Administrator/Licensee Gwendolyn Craig provided an in-service training on mismanagement of medication to Staff #3 on 7/2/2021. This deficiency has been corrected.

Allegation investigated: Facility is in disrepair.

On 07/21/21, Licensing Pogram Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent complaint visit at this facility. LPA met with Gwendolyn Craig, Administrator and explained the purpose of today's visit was to collect information and conduct staff interviews regarding the allegation mentioned above. The investigation consisted of the following: Interview with Gwendolyn Craig, Administrator and Elizabeth Hernandez, Social Service Director. A tour of the plant facilty on 07/14/21 and 07/21/21. Investigation Revealed the following: The complainant reported the front entry door is not working properly which causes delays for deliveries. The Department interviewed (R-1) and was informed that the facility is in disrepair with the front door is not working correctly. Evaluation Report Continue on LIC-9099-C Substantiated Interviews conducted with the Administrator (S-1) and Social Services (S-2) both reported the entry door is not working properly and it has not been maintained in working condition for approximately six months. The Department conducted a tour of the facility and observed the entry door on 07/14/21 and 07/21/21 unable to fully close. The entry door is a commercial grade double glass door. The left door does not close automatically and leaves a slight six inches half-open and must be shut manually. A door that has been left unshut and unattended is a security and safety issue. During the interview with the administrator confirmed she is aware of the concern and a replacement door or repair is scheduled to fix the problem. Based on LPA’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “Facility is in disrepair" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D. An exit interview was conducted with Gwendolyn Craig. The Rights were discussed, and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report to the Administrator.the state’s words, verbatim · CDSS document, Jul 21, 2021 · control 11-AS-20210709155908

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 4, 2021

87303 Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include the provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidenced by: LPA observed on 07/14/21 & 07/21/21 the front entry door did not operate properly. The left side of the double door did not shut completely and must shut manually. This is a violation that poses a potential Health and Safety or Personal Rights risk in residents in care.the state’s words, verbatim · CDSS document, Jul 21, 2021

Plan of correction: The administrator will ensure that the item listed under this deficiency have been corrected to ensure compliance with California Code of Regulations Title 22, Section 87303 and provide proof of correction to CCL by the POC due date: 08/04/21.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility door is too heavy for residents to open

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Elizabeth Hernandez, Social Worker The investigation consisted of following: Interviews, Record reviews, and Physical inspection. On 05/17/21, LPA Soto conducted interviews with the Administrator Gwendolyn, R#1 - R#6, S#2 - S#5. The LPA also requested copies of the following documents: Resident rosters, staff roster, kitchen, face sheets, Dietary restrictions, Pre-Appraisals, Logs of delinquent payments, Menu, Resident meal substitute request form, estimate from companies to replace dining room double doors, and Physician's Report. LPA and administrator toured the kitchen, dining room, double doors, food storage, back patio, rooms 6, 19, 27, 35, 37, 42, plate of food served, activity room, med room, nurses’ station, and administrators office. LPA attempted to open the dining double doors when the were closed, LPA Soto had a really hard time trying to open the double doors. Substantiated Based on the LPA's investigation, the investigation revealed the following. Allegation #1- Staff do not provide residents healthy food. On 05/17/21, Interviews conducted with Administrator and S#1 – S#5, stated that they facility provides healthy food. They serve fresh vegetables, fresh fruits, chicken, fish, and red meat. If the residents do not want or like what the facility is serving the have the option of asking for whatever they want to eat. All they do is fill out a meal substitute request form and they facility will try to provide them what they requested. Interviews with R#1 –R#6, stated the food is okay. They serve decent food. They all eat the food in the facility they have good portions also. They can ask for other foods, if they don’t like what they are serving for that day. LPA Soto observed the plate of food the facility served during lunch. It had protein, vegetables, and mashed potatoes. It was a well-balanced meal. The interviews, records, and LPA’s visual observation did not concur with the above 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 unsubstantiated An exit interview was conducted with Elizabeth Hernandez, Social Worker and a hard copy was provided. Based on the LPA's investigation, the investigation revealed the following. For Allegation #1 – Facility door is too heavy for residents to open. Interviews conducted with Administrator, S#1 -S#5, R#1 – R#6, stated that the double doors are too heavy to open when the doors are closed. When they are closed, they use the sides doors to into the building. Administrator stated that the facility was looking into replacing the doors with automatic doors. LPA Soto physical inspection of double doors determined that the double doors are too heavy to open and especially for residents that utilize wheelchairs. The interviews and physical inspection concur with the above allegation. Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation. An interview was conducted with Elizabeth Hernandez` , Social worker, and a hard copy was provided along with Appeal rights.the state’s words, verbatim · CDSS document, Jul 16, 2021 · control 11-AS-20210506100850

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 14, 2021

87303(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 was not met as evidence by:Based on dining diouble doors are hard to open which is poses a health and safety risk for the residents.the state’s words, verbatim · CDSS document, Jul 16, 2021

Plan of correction: Administrator will repair double door and send repair invoice to LPA Soto by email, fax, or mail. POC due date 08/10/2021.