Our Sweet Home Inc. #2

Type of visit: Required - 1 Year

At 09:00am Licensing Program Analysts (LPAs), Angela Panushkina and Mariana Agban conducted an unannounced annual inspection at the facility mentioned above. LPAs were greeted by the staff, Hermon Ledesma, who granted access to the facility. Administrator arrived shortly after and LPAs explained the reason for the visit. At 9:20am, LPAs conducted a tour of the facility and the following was observed: Infection control: The facility had submitted and approved Mitigation Plan and Infection Control Plan. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPAs observed all trash can throughout the facility have fitted lids. Kitchen: At approximately, 09:25am LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. There is a fire extinguisher in the kitchen and it was last purchased on 08/24/22. Medications: At approximately, 9:35am LPAs observed medications are centrally stored and locked in a kitchen cabinet and inaccessible to residents in care. LPAs also observed a First Aid Kit complete with the required items as per Title 22 Regulations. Bedrooms: There are five (5) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were Continue on LIC809-C tested and observed to be operational. Staff bedroom is located by the living room. Bathrooms: At 9:45am LPAs observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 118.0°F. LPAs observed appropriate grab bar and non-skid mat. LPAs observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Common Areas: The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Outside areas: At approximately, 10:00am LPAs toured the outside area of the facility. LPAs also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents. The garage: Laundry area is located by the attached garage and kept locked and inaccessible to residents. Extra PPE supplies and food storage was also observed. Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:15am they were tested and observed to be operational. Between 10:15am to 11:45am, LPAs reviewed records of five (5) residents and two (2) staff. Resident and staff records appeared to be complete and updated. Administrative: LPAs collected Certificate of Liability Insurance and LIC500. No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.the state’s words, verbatim · CDSS document, Mar 17, 2023

Allegation investigated: Staff are mishandling resident's finances

At approximately, 12:30pm Licensing Program Analysts (LPAs), Angela Panushkina and Joscelyn Martinez arrived at the facility in response to the above mentioned allegations. LPAs met with Tina Arutyunyan, Administrator, and explained the reason for the visit. LPAs conducted a physical plant walk through to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit. To investigate the above allegation, LPAs interviewed the Administrator, one (1) out of one (1) staff member, three (3) out of three (3) residents and reviewed the records. A review of records received revealed that licensee was insured and bonded to handle residents P&I funds. In lieu of P&I logs, the Licensee/Administrator provided hand-written receipts (LIC405) with R1’s signature. Licensee/Administrator Unsubstantiated did maintain adequate safeguards and records for residents cash resources. Moreover, records reviews revealed that R1 did receive the full amount of P&I, including the full amount for the month of June 2022. Interview with S1 revealed that receipts are being provided to residents when asked to purchase items, groceries, etc. Interviews with R1 revealed that the P&I money received from the Administrator, for the month of June 2022, was used to make to make small purchases. R1 was also aware of the full amount received and deposited into the account and had a full knowledge of signing the document (LIC405). Based on information obtained through interviews and record reviews this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of the report given to the Administrator.the state’s words, verbatim · CDSS document, Jun 16, 2022 · control 31-AS-20220609132619

Type of visit: POC

Licensing Program Analysts (LPAs) Tuesday Cabiness and Joselyn Martinez conducted a POC visit and met with Administrator Tina Arutyunyan who was informed the reason of the visit. The reason of today's visit, was to clear the citations/deficiencies that were issued during the office meeting on 04/26/2022. The Administrator submitted the POC's when they were due on 05/10/2022, and LPA re-reviewed and discussed with the Administrator the documents and cleared the plan of corrections. Administrator informed LPA, that the new banking account that was opened, will be used for P&I purposes only, and was opened under the corporation of Our Sweet Home. LPA reviewed the banking document, in which the amount for R1 for Our Sweet Home # 2, was deposited. According to the Administrator, because the account is new, she has to wait for the first banking statement, which will be issued in (30) days. Once the Administrator has the statement, she will submit a new LIC405, (Record of Client/Resident's Safeguarded Cash Resources) form for resident # 1 (R1), showing the amount of money that is owed for R1. The Administrator will ensure, that R1 is aware of the balance, with a date and signature from R1 and the Administrator. The Administrator will submit a copy of the new P&I log for R1, attached with the banking statement and submit to LPA. Administrator informed LPA that R1 is able to handle R1's own finances, and she will no longer be responsible for R1's personal expenses. Administrator also stated, that she will not keep petty cash at the facility, since the resident will be given the money monthly. LPA also received the Administrator's statement that was required, regarding how moving forward, P&I will be disbursed for R1. LPA will follow up with Administrator within the next couple of weeks, for the bank statement and the signed P&I log for R1. Exit interview conducted.the state’s words, verbatim · CDSS document, May 17, 2022

Allegation investigated: Facility is financially abusing resident

An in-person office meeting was conducted at the Monterey Park Adult and Senior Care Regional Office (MP ASCRO). A Regional Manager (RM) Araceli Ramirez, Manager of Audit Department Jacqueline Juarez, Licensing Program Analysts (LPAs) Tuesday Cabiness, Rosaura Valenzuela, Yelena Avetisyan, and Licensing Program Manager (LPM) Naira Margaryan from the Woodland Hills South Adult and Senior Care Regional Office (WHS ASCRO), LPAs Mary Flores and Noemi Galarza, LPMs Lisa Hicks, Stefanie Coronel from Monterey Park ASCO and Licensee/Administrator Tina Arutyunyan, with Administrator Akop Ekimyan were present at the time of this meeting; and was informed the reason of the meeting. On August 23, 2021, the Woodland Hills Adult and Senior Care office received a complaint alleging facility was financially abusing resident #1 (R1), by retaining R1’s personal and Substantiated incidental funds (P&I). It was also alleged that, R1 was requesting specific items, and the Administrator/Licensee was billing Department of Health Services (DHS) for items R1 was requesting. R1 revealed the items were never requested or received, although the items were billed to DHS. On September 01, 2021, from 10am to 1pm, LPA Wendell Smith initiated the investigation, and conducted interviews with resident #1 (R1) and resident # 2 (R2). LPA Smith also requested various records to be reviewed. The Administrator/Licensee Tina Arutyunyan was contacted telephonically, in which, specific documents were requested: bank records from January 2019 to present; P&I records for all residents who received assistance with their finances, and verification of a valid and current surety bond. According to records received and reviewed, it was determined, that the Administrator/Licensee did not have a valid or current surety bond to handle residents P&I funds. In lieu of the P&I records, the Administrator/Licensee submitted hand-written receipts without residents’ signatures and attached receipts for expenditures. The handwritten receipts submitted, documented an excessive and inflated number of expenditures for special food, charges for cable channels, grooming items/services, clothing, and furniture. Residents interviewed during the initial complaint visit, denied receiving those items and LPA Wendell Smith did not observe described clothing and furniture in the facility. It was determined the Licensee/Administrator misappropriated residents personal & incidental (P&I) funds and did not maintain adequate financial records or expenses for residents’ cash resources. The Licensee/Administrator co-mingled the residents’ (P&I) funds with facility funds, without obtaining a surety bond to handle residents’ cash resources. On September 20, 2021, the complaint was referred to Community Care Licensing Division (CCLD) audit department for further review of the Administrator/Licensee trust and financial accounts. The complaint was assigned to auditor manager Jacqueline Juarez, who reviewed and completed an audit investigation. Auditor Juarez conducted interviews with the County of Los Angeles, Department of Health Services, Housing for Health-Enriched Residential Care Program, and a representative from Brilliant Corners. The auditor obtained information pertaining to the placement of residents to the facility; the programs and their involvement with the residents; the issuance of payments for residents, and the relationship with the Administrator/Licensee. The auditor also reviewed all documents and information obtained by the Regional Office in relation to the complaint. It was revealed, the Administrator/Licensee is issued a monthly lump sum payment for the residents enrolled with Brilliant Corners. There was a signed agreement between the Administrator/Licensee and a Brilliant Corner representative. The agreement specified how the payments for the residents should be allocated for their expenses, such as (rent, personal incidentals, and enhanced services). On March 08, 2022, the audit investigation concluded that the Licensee/Administrator misappropriated residents personal & incidental (P&I) funds; failed to maintain adequate safeguards and records for residents’ cash resources and comingled the residents personal and incidental funds with facility funds. Overall, the investigation revealed that the Administrator/Licensee did not comply with Licensing requirements and regulations, pertaining Safeguards for Residents Cash Resources, Personal Property and Valuables. The Administrator/Licensee also did not obtain a surety bond prior to handling residents’ cash resources. Additionally, the Administrator/Licensee provided Brilliant Corners and DHS inaccurate and inflated expenses of expenditures for R1. Based on the information obtained, the allegation of financial abuse is Substantiated at this time. Citations and deficiencies were discussed with the Licensee/Administrator. Exit interview, appeal rights, and a copy of report was issued.the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 31-AS-20210823141159

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87216(a) · Plan of correction due date: May 10, 2022

Bonding: (a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file, or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: The Licensee will obtain a required surety bond. A proof of adequate bond will be submitted to CCL BY POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87215 · Plan of correction due date: May 10, 2022

Commingling of Money: Money and valuables of residents entrusted to the licensee of one community care facility licensed under a particular license number shall not be commingled with those for another residential care facility for the elderly of a different license number, regardless of joint ownership.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee agrees to provide a copy of the bank statement showing P & I funds have been deposited into a trust account. Submit by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: May 10, 2022

Safeguards for Resident Cash, Personal Property, and Valuables. (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by not retaining receipts for items purchased with residents P&I which posed a personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: The Licensee will refund P&I funds to two (1) residents of Brilliant Corners as described in Audit report and furnish Regional Office and Brilliant Corners proof of repayment. The documents must be provided to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(c)(1) · Plan of correction due date: May 10, 2022

(c) Every facility shall account for any cash resources entrusted to the care or control of the licensee or facility staff. (1) Cash resources include but are not limited to monetary gifts, tax credits and/or refunds, earnings from employment or workshops, and p ersonal and incidental need allowances from funding sources such as SSI/SSP. This requirement is not met as evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by not distributing P & I funds to residents (R1), and not keeping proper records of funds entrusted to her which posed a personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee agrees to: 1. Pay back residents (R1) P & I amounts due. Licensee owes: Resident (R1) $3,159; Submit proof (bank statements) that the amounts due were issued to R1.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(e) · Plan of correction due date: May 10, 2022

(e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability the licensee incurs in the use of his own or the facility's funds and valuables. This requirement was not met evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by commingling facility funds with personal and incidental funds. This posed/poses a personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee/administrator agrees to open a bank trust account for the residents P&I and deposit residents' P & I funds into the trust account only. Facility bank account should not have any residents' P&I monies. Provide copies of bank statements showing P & I funds have been deposited into a trust account.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2-3)(d) · Plan of correction due date: May 10, 2022

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (3) Ability to maintain or supervise the maintenance of financial and other records (5) Good character and a continuing reputation of personal integrity. This requirement was not evidenced by: Based record review and interview conducted during the audit investigation the Licensee failed to maintain accurate financial records; and provided DHS and CCL inaccurate documentation and information.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training related to the cited section as well as all other sections cited on this report Verification of scheduled training with the trainers credentials will need to e submitted by 4/29/2022 and completed by 5/13/2022.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87207 · Plan of correction due date: Apr 27, 2022

False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facilitythe state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training related to the cited section as well as: 87408: Denial or Revocation of a Certificate; 87777: Exclusions: Personal Rights.

Type of visit: Office

An office meeting was held at the Monterey Park Adult and Senior Care Regional Office (MP ASCRO) to deliver the Final Findings of a Trust Audit Report involving the following facilities: Skyhill Quality Living #2 197609098: [complaint investigation - 31-AS-20210823141159) Skyhill Quality Living 197608910, Our Sweet Home Inc 197607711, Our Sweet Home Inc #2 197608083, and Our Sweet Home Inc #3 197608084, Attendees present during the meeting were: Licensee/Administrator Tina Arutyunyan, CCLD Regional Manager Aracely Ramirez, CCLD Audit Department Manager, Jacqueline Juarez, Licensing Program Manager(s) Lisa Hicks, Naira Margaryan, Stefanie Coronel, and Licensing Program Analyst(s) Noemi Galarza, Mary Flores, Yelena Avetisyan, Tuesday Cabiness, and Rosaura Valenzuela. The purpose of the meeting was explained to Licensee Ms. Arutyunyan. On 08/23/2021 Community Care Licensing Division (CCLD) received complaints against all above noted facilities operated by the same Licensee. The complainant was alleging financial abuse of the residents' Personal and Incidental (P&I) funds. An initial investigation visit was conducted on 09/01/2021. As a part of the complaint investigation, the complaints were referred to the CCLD Audit Department for a Trust Audit. The audit investigation conducted by Jacqueline Juarez concluded the following: * The Licensee/Administrator Misappropriated residents Personal and Incidental (P&I) funds. Multiple residents did not have access to, or were not distributed P&I funds. * The Licensee/Administrator failed to maintain adequate safeguards and records for residents' cash resources. Proper documentation for expenditures was not maintained. * The Licensee/Administrator Commingled the residents P&I monies with facility funds. See 809-C for report continuation. On today's date, CCLD Audit Manager Jacqueline Juarez delivered findings on the Trust Audit Report and discussed required plan of corrections (POCs). The Licensee/Administrator was notified that she will need to complete the following: * Refund all residents' enrolled in the Brilliant Corners program the amounts identified in the Trust Audit report and submit proof of repayment. * Provide proof of Surety Bond that covers each facility license and not the corporation. * Submit a written plan on how they will distribute P&I funds to residents and bank statements showing that P&I funds have been deposited in a separate trust account. * Submit an updated Plan of Operation reflecting the changes in population that will be served. On 10/05/2022 Licensee/Administrator will need to submit to the Audit Section the LIC 405’s and corresponding receipts for each facility to ensure proper record keeping. The deficiencies related to complaint allegation also were discussed at the time of this visit and were disclosed in the final complaint investigation report delivered to the Licensee Representative at the time of this Office meeting. See Subsequent visit report of the Complaint Control Number (31-AS-20210823141159). Also noted, Administrator/Licensee was offered to participate in the Technical Assistance Program offered by the Department and was informed that the facility plan of operation must be updated to identify that the acceptance of the residents placed by Brilliant Corner. The updated information must be submitted to CCL by 05/10/2022. Exit interview was conducted and a copy of this report was issued to the Licensee/Administrator.the state’s words, verbatim · CDSS document, Apr 26, 2022

Type of visit: Required - 1 Year

At 12:10 p.m Licensing Program Analyst (LPA) Joscelyn Martinez conducted an announced annual inspection. Upon arrival LPA met with staff Hermon Ledesma and later met with Administator Tina Arutyunyan. A physical tour of the facility was conducted and the following was observed: Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPAs’ temperature and was asked to sign-in the visitor’s log. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPA Martinez observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Garbage cans have tight fitting covers in the kitchen. Sharps and medications are centrally stored in a locked area. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at 12:46 p.m. and appear to be functional. Fire extinguisher has a purchase date of 08/23/2021. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 72.0 F. Residents Rooms: There are six (6) rooms which five (5) are designated for resident use. There is one live in staff. All the residents’ bedrooms were toured and appear to be clean and properly furnished. LPAs observed additional bedding and linens sufficient for all of the residents. Trash cans in residents’ bedrooms did not have tight fitting lids. LPA stated they need to add tight fitting lids to the trash cans to all bedrooms. Bathrooms: There are three (3) bathrooms which of two (2) are designated for resident use. LPA observed all bathrooms to have grab bars and non-skid mats. At 12:50 p.m. the hot water was tested and measured at 130.8 F which is not in regulation. LPA Martinez reminded staff that water needs to measure between 105-120 degree Fahrenheit. One of the bathrooms floor around the toilet is in disrepair and needs to be changed. Garage: There is an additional laundry room that leads into the garage. The attached garage remains locked and is being used for additional storage. Garage is overfilled with bulk items and poses a risk to staff going inside. Chemicals are locked inside the garage. Outside areas: LPAs toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Outside patio is in disrepair. Patio floor is warped and lifted which poses a tripping hazard to the residents. LPA observed an old mattress, broken trash can bin, and a shopping cart near the side of the house. LPA Martinez stated these items need to be thrown out. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Mar 17, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Mar 18, 2022

Maintenance and Operation(e)(2) Hot water temperature controls shall be maintained to automatically regulate 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:Water temperature meaured at 130.8 degree F. Based on water temperature measurement, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 17, 2022

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Mar 31, 2022

8730 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Garage is overfilled with bulk items, Patio flooring poses a tripping hazard to the residents and one bathroom floor is in disrepair, which poses a health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 17, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced annual required visit. LPA met with facility staff and explained the reason for this visit. Administrator was contacted and made aware of the visit. A tour of the physical plant was conducted. All smoke alarms were tested and function properly. The fire extinguisher was functional. The carbon monoxide detector was tested and functions properly. Kitchen: The kitchen appeared clean and in good repair. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives and detergents were stored in locked drawers and cabinets. Properly labeled medications were locked in a cabinet near the kitchen, but medications were also observed on the counter and accessible to residents. Bedrooms: There were five bedrooms designated for residents' use. All bedrooms were clean, properly furnished and had sufficient lighting. Bathrooms: There were three bathrooms designated for residents' use. All bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was 115 degrees Fahrenheit. Common Areas: LPA did observe a staff member asleep in the garage. These included the living room and dining area. The common areas appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free from obstruction. Facility had all the required postings up regarding COVID-19 along with other required postings. No deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Sep 1, 2021