Our Sweet Home Inc. #3

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Panushkina conducted a Case Management - Incident visit. LPA met with Administrator and explained the reason for the visit. On 05/04/23, the Department received a self-reported incident report stating that Resident #1 (R1) had left the facility on 05/03/23 and did not return. The incident was reported to police. During today's visit, LPA conducted a physical plant walk through, at approximately 9:00am, 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. LPA conducted interview with the Administrator and two (2) staff members. LPA also obtained copies of R1's facility records. Upon review of the physician's report dated 02/15/2023, the report states that R1 has dementia and is not able to leave the facility unassisted. Interview with the Administrator and two (2) staff members revealed that R1 lived at the above facility for almost three (3) years and was very happy with the place. All staff denied seeing changes in R1's behavior. Interview with S1 revealed that on a day of an incident, at approximately 6:30pm, R1 asked S1 to change the TV channel. S1 also informed LPA that around 7:00pm S1 checked on R1 again and observed R1 exercising. When S1 checked on R1 around 7:15pm, S1 observed R1 left the facility through the window and staff lost track of R1. S1 immediately contacted the Administrator and the law enforcement regarding the incident. R1 is still missing and Administrator currently does not have any updated information on R1's whereabouts. LPA will conduct a follow up visit regarding this incident. Exit interview conducted and copy of this report signed and issued.the state’s words, verbatim · CDSS document, May 5, 2023

Type of visit: Required - 1 Year

At 09:30am 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, Saturnina Reyes who granted access to the facility. Administrator arrived shortly after and LPAs explained the reason for the visit. At 9:40am, 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. LPA observed all trash can throughout the facility have fitted lids. Kitchen: At approximately, 09:45am 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 03/17/22. Medications: At approximately, 10:00am LPAs observed medications are centrally stored and locked in the cabinet in a caregivers room 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 kitchen. Bathrooms: At 10:15am 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 117.3°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 76°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, 10:30am LPAs toured the outside area of the facility. Facility has a swimming pool that is fenced all around with a gate and kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around its parameters. 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 10:55am they were tested and observed to be operational. Between 11:00am to 2:00pm, LPAs reviewed records of six (6) residents and four (4) staff. Resident and staff records appeared to be complete and updated. Administrative: LPA 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 13, 2023

Allegation investigated: Sexual Abuse

This is an addendum of the previous Licensing Report issued on 5/17/2022. Licensing Program Analyst (LPA) Rosaura Valenzuela conducted a subsequent complaint investigation visit to the facility. LPA met with Staff who was administrator's designee. The purpose of the visit was discussed. It was reported that Resident #1 (R1) was being sexually abused. During the initial visit, on 09/01/2021, R1 was interviewed and appeared to be confused and disoriented. R1’s statement regarding sexual abuse was inconsistent and without a reasonable basis. At the time of the subsequent visit on 05/17/2022, between 10:25am and 10:40am, LPA Valenzuela spoke with Staff #1 (S1), who indicated that R1 has medical diagnoses that affects their judgement. R1 has a history of making up stories. R1 never disclosed to S1 about sexual abuse. On 5/17/2022 at 10:45am, LPA Valenzuela reviewed R1's physician's report, which indicated that in addition to a Dementia diagnosis, R1 has other mental health problems. A review of the physician report and other facility records verified the information received from staff. Based on interviews and record review there is no sufficient information to verify this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 27, 2022 · control 31-AS-20210901125210

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Sexual Abuse

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted a subsequent complaint investigation visit to the facility. LPA met with Staff Zeny Reyes. The purpose of the visit was discussed. It was reported that a Resident is being sexually abused. During the initial investigation on 9/01/2021 at 10:00am, LPA Patrick Shanahan initiated resident interviews. Interviews revealed that one (01) out of six (06) residents is being sexually abused. Resident #1 (R1) stated that at night strangers come into their room and try to sexually assault them. The alleged abuse usually occurs at night between 8:00pm and 8:30pm. On 5/17/2022 at 10:45am, LPA Valenzuela reviewed R1's physician's report. Records revealed that R1 has a primary diagnosis of Alzheimer's disease with a secondary diagnosis of schizophrenia. LPA was not able to interview R1, since they no longer reside at the facility. Between 10:25am and 10:40am, staff interviews were initiated. Interviews revealed that approximately four months ago, while taking an early morning walk, R1 spoke to a police officer and requested to speak to a judge. The officer deemed R1 to be very confused and took them to the hospital for a psychiatric evaluation. Continue on 9099-C Unsubstantiated Based on interviews and record review, there is not sufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, May 17, 2022 · control 31-AS-20210901125210

Allegation investigated: Financial Abuse.

An Office Meeting was held at the Monterey Park Adult and Senior Care Regional Office (MP ASCRO). The attendees present during the meeting were: CCLD Regional Manager Aracely Ramirez, A manager of the Audit Department Jacqueline Juarez, Licensing Program Manager (LPM) Naira Margaryan and Licensing Program Analysts (LPAs) Rosaura Valenzuela, Yelena Avetisyan and Tuesday Cabiness from Woodland Hills South Adult and Senior Care Regional Office (WH ASCRO), LPM's Lisa Hicks and Stephanie Coronel, LPAs Mary Flores and Noemi Galarza from MP ASCRO. At the time of this Office Visit a final finding of the investigation report was delivered to the Licensee Representatives Tina Arutyunyan and Akop Ekimyan by LPA Rosaura Valenzuela. On 08/23/2021, Community Care Licensing Department (CCLD) received a complaint alleging that the Licensee/Administrator was financially abusing the residents in care by retaining their Personal and Incidental funds (P&I). Continue on 9099-C Substantiated An initial 10-day complaint visit was conducted on 08/24/2021 by Licensing Program Analysts (LPAs) Patrick Shanahan and Nicholas Reed at which time interviews were held with four (04) out of six (06) residents and various records were requested for review. The Licensee/Administrator was contracted telephonically, and LPAs requested to submit the following documents: 1. Bank Records from past and current accounts for January 2019 to Present. 2. P&I logs for all residents who receive assistance with their finances. 3. Verification of a Valid and Current Surety Bond. A review of records received revealed that licensee was not insured and bonded to handle residents P&I funds. In lieu of P&I logs, the Licensee/Administrator submitted hand-written receipts without residents' signatures and attached receipts for expenditures. The handwritten receipts submitted for the residents documented excess expenditures for special foods, charges for cable channels, grooming items, grooming services, clothing and furniture. Residents interviewed during the 10-day complaint visit denied receiving those items and LPAs did not observe described clothing and furniture in the facility. On 09/20/2021, the complaint was referred to CCLD Audit Department for a Trust Audit and was assigned to Jacqueline Juarez, Audit Manager who investigated the following: Licensee/Administrator Misappropriated residents personal and incidental (P&I) funds. Licensee/Administrator did not maintain adequate safeguards and records for residents cash resources. Licensee/Administrator commingled the residents personal and incidental funds with facility funds. Licensee/Administrator handled residents cash resources prior to obtaining required surety bond. While conducting financial auditing pertaining to the allegation of financial abuse, Auditor Juarez conducted interviews with the Program Manager for the Quality Assurance Enriched Residential Program with the County of Los Angeles and with the representative of Brilliant Corners and discussed the audit of residents placed at the facility and to clarify how the payments are issued to the facility. Auditor inquired information regarding the programs and their involvement with the residents and the Licensee/Administrator Tina Arutyunyan. Auditor also conducted a review of all documents submitted to the Department relevant to the complaint. Continue on 9099-C Per information revealed from the interviews conducted by the auditor, the licensee was issued monthly lump sum payments for the residents enrolled in Brilliant Corners. The Agreement which was signed by the Licensee/Administrator and Brilliant Corners staff specifies how the amounts should be allocated (Rent, Personal and Incidental expenses, Enhanced Services). On 03/08/2022 an Audit investigation concluded that the Licensee/Administrator Misappropriated residents personal and incidental (P&I) funds, failed to maintain adequate safeguards and records for residents' cash resources and Commingled the residents personal and incidental funds with facility funds. Overall. the investigation revealed that the licensee/administrator did not comply with licensing requirements regarding a Safeguards for Residents Cash Resources, Personal Property and Valuables and failed to obtain a surety bond prior to handling residents cash resources. Additionally, the Licensee/Administrator provided Brilliant Corners and the Licensing Department inaccurate information/documentation. Based on the information obtained the Allegation of Financial Abuse is SUBSTANTIATED at this time. At the time of this visit the following deficiencies were cited and recorded on LIC 9099Ds. Exit interview was held, appeal rights were discussed, and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 31-AS-20210824093316

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 values 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: The licensee did not ensure to provide receipts for items purchased by using residents P&I funds. This poses a potential 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 four (04) 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

Safeguards for Resident Cash, Personal Property, and Valuables. (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 personal and incidental need allowances from funding sources such as SSI/SSP. This requirement is not met as evidenced by: Licensee did not ensure to be accountable for residents' cash resources. P&I funds were not safeguarded as required. This poses a potential rights violation to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee will implement policies and procedures regarding residents' cash resources and valuables. Copies of the policies and procedures will be provided to CCL by POC due date.

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

Safeguards for Resident Cash, Personal Property, and Valuables. (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 is not met as evidenced by: The Licensee did not ensure to separate residents' cash resources from facility finds. This poses a potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee will open a separate trust account for resident P&I funds. A document regarding a new bank account will be submitted to CCL by POC due date.

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 that 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. This requirement is not met as evidenced by: Licensee dud not obtain required surety bonds prior to handling residents cash resources. This poses a potential personal rights violation to residents in care.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 A · Section cited: CCR 87405(d)(1-7)(3) · Plan of correction due date: Apr 27, 2022

Administrator-Qualifications and Duties (d) 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. (3) Ability to maintain or supervise the maintain or supervise the maintenance of financial and other records. This requirement is not met as evidenced by: Licensee/Administrator did not ensure to maintain accurate financial records.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee will attend continued education classes provided for Administrators. By POC due date, the Licensee will secure the appointment to attend the classes and inform CCL about the attendance. The Licensee must register for the class by tomorrow.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 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 facility. This requirement is not met as evidenced by: The licensee did not ensure to provide accurate information and records to the LPAs and other agency representatives. This poses a personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee will provide a written statement explaining how they will ensure that, moving forward, no false statements or misleading information will be provided regarding the facility and the services provided by the facility. ,This written statement must be submitted by close of business day on 4/27/2022.

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: Our Sweet Home Inc 197607711, Our Sweet Home Inc #2 197608083, Our Sweet Home Inc #3 197608084, Skyhill Quality Living 197608910, Skyhill Quality Living #2 197609098. Attendees present during the meeting were: Licensee Representative Tina Arutyunyan, CCLD Regional Manager Aracely Ramirez, A Manager of CCLD Audit Department Jacqueline Juarez, Licensing Program Manager Lisa Hicks, Licensing Program Manager Naira Margaryan, Licensing Program Analyst(s) (LPAs) Yelena Avetisyan, Tuesday Cabiness, Rosaura Valenzuela, Naomi Garanza and Mary Flores. The purpose of the meeting was explained to Licensee Representatives. On 09/01/2021 Community Care Licensing Division 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, this complaint was referred to CCLD Audit Department for a Trust Audit. 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 money with the facility funds. See 809-C At the time of the meeting Auditor Jacqueline Juarez Delivered Financial Audit Report and discussed required plan of corrections. The Licensee/Administrator was notified that she will need to complete the following: * Refund all residents of Brilliant Corners the amounts identified in the report and submit proof of repayment. * Provide proof of adequate bonds for each facility. * 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. On 10/12/2022, 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 the 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-20210824093316. At the time of this visit the Licensee was informed that the facility plan of operation must be updated to identify the acceptance of the residents placed by Brilliant Corners. The updated information must be submitted to CCL by 05/10/2022.. The Licensees/Administrators were referred to participate to the Technical Support Program(TSP). The brochure regarding the TSP program was e-mailed to the Licensees at the time of this visit. At the time of this visit Licensee Representatives were informed that all facilities will be closely monitored and quarterly visits will be conducted to ensure that the facility is operating in compliance with Title 22 Regulations. Exit interview was conducted and a copy of this report was issued to the Licensee Representatives.the state’s words, verbatim · CDSS document, Apr 26, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced annual inspection. Upon arrival LPA met with staff and later met with Administrator Tina Arutyunyan. The purpose of the visit was explained. At 11:00 a.m LPA conducted a physical tour of the facility 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 LPA’s 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. Sharps and medications are centrally stored in a locked area. Garbage can has a tight-fitting lid in the kitchen. Smoke detectors/carbon monoxide are located throughout the facility. Smoke detectors and carbon monoxide detectors were tested at 11:25 a.m. and appear to be functional. Fire extinguisher has a purchase date of 03/17/2022. 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 are two (2) live in staff. Four (4) bedrooms are private and one (1) is shared. All the six (6) bedrooms were toured and appear to be clean and properly furnished. LPAs observed additional bedding and linens sufficient for all of the residents. Bathrooms: There are four (4) bathrooms which of three (3) are designated for resident use. LPA observed all bathrooms to have grab bars and non-skid mats. The hot water was tested and measured at 117.3 F. Garage: The staff bedroom leads into an attached garage. The staff bedroom is maintained locked and inaccessible to residents. Garage is used for additional storage and laundry area. Cleaning supplies are kept 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. The facility has a swimming pool that is locked and inaccessible to residents. No deficiencies cited. Exit interview conducted. Report signed and delivered.the state’s words, verbatim · CDSS document, Apr 4, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst's (LPA's) Patrick Shanahan and Nicholas Reed arrived at the facility in order to conduct an infection control annual. LPA's were greeted by facility staff and LPA temperatures were checked before being allowed entry. The facility is following all covid -19 protocols and signs reminding staff and residents to wash their hands were observed throughout the facility and in the restrooms. All residents temperatures are taken twice daily and are documented. A brief tour of the physical plant was conducted and no health and safety concerns were observed. The smoke alarms and carbon monoxide detectors were tested, and function properly. The kitchen was inspected and sufficient amounts of perishable and non perishable food was observed and properly stored. No health and safety concerns were observed during the visit. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Sep 1, 2021