Bella Vista

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility LPA met with Administrator Ian Baker who assisted with the visit. The facility is licensed to serve elderly residents age 60 and above. Fire clearance was approved for seventy-two (72) non-ambulatory residents. Hospice was approved for ten (10) residents. Currently one (1) residents are on Hospice. During today's visit, LPA used the CARE Tool to complete the Required - 1 Year inspection. The physical plant was toured by LPA and Ian. The interior and exterior physical plant was inspected. There is only one entrance being utilized at the facility. A tour of the two story facility includes: All business offices and the kitchen, located on the first floor and second floor consist of resident rooms, bathrooms, common restrooms, common shower rooms, medication room, laundry room, storage room, activity/television room, beauty shop, library and a dining room. The kitchen was inspected. LPA observed kitchen equipment to be clean and in working condition. LPA observed the food supply stored at the facility. There was a sufficient perishable and non-perishable food supplies for residents in care. No pesticides or poisons were stored in the food areas. Sharps are stored in kitchen which is inaccessible to residents. Disinfectants and cleaning solution was located in the Janitor's closet. LPA observed random rooms: Room # 3,15,18 and 22 were inspected residents are on the second floor and all rooms have signal systems (tested and operable) and bathrooms. All selected bedrooms were furnished with required furniture. Some bedrooms have private bathrooms and some have shared bathrooms. Bathrooms were clean and sanitary and LPA tested the hot water was tested. Hot water tested and measured between 106.3-113.5 which is within Title 22 regulations. Laundry room is accessible to residents and laundry room contains pad locked lockers which have laundry products, disinfectants and cleaning solutions inaccessible to clients. LPA observed several storage rooms that were kept locked and maintained extra linen, towels, bedsheets, and blankets. (Continuation on LIC 809-C) The facility has central air and heating accommodations, facility maintained at a comfortable temperature. Fire extinguishers were observed throughout the facility and were fully charged and in compliance. LPA observed multiple pull switch fire alarms throughout the facility which are hardwired to the Fire Department of Pasadena. Carbon monoxide detectors were observed to be operational. Smoke detectors are hardwired to the Fire Department of Pasadena, during LPA's inspection company Cosco Fire Prevention tested the smoke detectors which were operable. The front yard of the facility is well landscaped and has a leveled walkway to the entrance. The outdoor area was enclosed and no bodies of water were observed. Shaded area was provided by trees, and patio coverings. All residents medications were centrally stored and locked in Medication Room and LPA reviewed four (4) resident's medication and medication record book, no deficiencies were observed. LPA interviewed 4 residents and 2 staff as part as the annual inspection. LPA reviewed 5 resident's files and 4 staff files, all had appropriate documentation. Administrator certificate is still pending for renewal, LPA was provided with proof of application submission. Documentation(s) collected LIC9214 Application for Administration Certification and ACS Application Pending list shows Administrator's application was received on 1/18/23. Applications are backup per ASCP Centralized Application Bureau. Fire Drill conducted on: 5-12-23 Liability insurance expires: 10-01-23 Per California Code of Regulations, Title 22, no deficiencies were observed and cited during this visit. Exit interview held with Administrator Ian Baker and a copy of report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 21, 2023

Allegation investigated: Staff interacted with a resident in an inappropriate manner.

Licensing Program Analyst (LPA) Ashley Calderon made an unannounced complaint visit regarding the allegation above and met with Administrator Ian Baker. The purpose of the visit was discussed. On todays visit, LPA interviewed Administrator, Staff #3 and Staff #4 (S3, and S4). Telephonically interviewed Staff #1 (S1) and attempt to interview Staff #2 (S2). LPA interviewed Residents #1-#4 (R1,R2,R3 and R4). LPA interviewed Lantherman Regional Center Service Coordinator via telephonically. Regional Center will provide a Corrective Action Plan to LPA Calderon via email when report is readily available. LPA Calderon collected R1's Physician Report, Individual Program Plan, Pre-Placement Appraisal and Appraisal Needs and Service Plan. LPA from R1 collected letter regarding above incident. Ian on 5/26/23 submitted to Licensing a Unusual Incident Report (UIR) -LIC 624. LPA collected Personal Right training's from S1, and S2. see 9099-C... Substantiated Regarding allegation: Staff interacted with a resident in an inappropriate manner. Based on interviews conducted by LPA Calderon with Administrator Ian Baker stated S1 did admit to doing inappropriate hand gestures towards R1 but was not intentional. Ian stated gesture was inappropriate and staff training will occur. Interview with S1 admitted doing the hand gesture towards R1 and at the time did not preserve R1 would take it offensively. Interview with S3 stated staff have treated residents inappropriately commenting things towards residents that are lack of respect and not professional. LPA interviews with Residents, R1 reported the hand gesture that was done by S1 was inappropriate/ wrong and made R1 feel uncomfortable. Interview with R3 stated staff have interacting inappropriately asking personal questions. UIR sent to Licensing reported by Ian Baker, reporting incident occurring on 5/20/23. Interviews with staff and resident and record review collaborate with this allegation. Deficiencies were cited per Title 22 Division 6 Chapter 8 see 9099-D. Appeal rights and copy of this report was provided to Ann Hamilton. An exit interview conducted.the state’s words, verbatim · CDSS document, Jun 1, 2023 · control 28-AS-20230524172942

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Jun 30, 2023

Personal Rights of Resident in all Facilities. Each resident shall be accorded dignity in his/her personal relationships with staff, residents and other persons. On 6/1/23 LPA Calderon interviewed staff(s) and resident(s). S1 admitted hand gestures and that at the time did not think R1 would take offensively. R1 stated gesture and how matter was approached was inappropriate felt that S1 made her feel uncomfortable.the state’s words, verbatim · CDSS document, Jun 1, 2023

Plan of correction: Per Administartor reported that S1 was out on a leave, and training in sexual harrasment training will occur. Licensee/ Administrator will go over Personal Right Regulations 87468.1 and sexual harrasment training will provide proof to LPA Calderon by 6/30/23.

Allegation investigated: Facility staff did not ensure that resident received adequate showers while in care. Facility staff did not ensure that resident was adequately fed while in care. Facility staff did not ensure that resident's room was cleaned while in care.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint visit to investigate the allegations listed above. LPA met with Administrator, Ian Baker and explained the reason for the visit. The investigation consisted of the following: LPA Calderon alongside with Baker toured the two story facility, kitchen, dining area, residents rooms #7,8, 9,11, 12, 16,17,18 22, 25, and 33 and observed (6) six common shower rooms. LPA Calderon observed AM snack time and lunch. Interviews were conducted with Ian Baker, Staff #1-3. LPA Interview Residents #1, #2, #3 and #4 (R1 -R4) LPA reviewed and obtained a resident and staff roster. LPA reviewed Resident #1’s (R1) records: Special Incident Reports, Pre Placement Appraisal, Needs and Service Plan, Three Doctor Notes, Inventory List, Weight Chart, and Discharge Document. Continuation on LIC9099C... Unsubstantiated In regards to allegation: Facility staff did not ensure that resident received adequate showers while in care. LPA Calderon interview with staff Ian Baker, S1-S3 all denied the above allegation stated R1 was able to shower on their own and resident's who need assistance are being provided showers. Interview with residents: R1 denied the above allegation and stated they were responsible in taking their own showers and preferred showering once a week. R3 and R4 denied above allegation and stated showers are being provided and staff assist residents with showers for those who need assistance. LPA Calderon observed functioning and clean showers throughout the second story, a total of six common showers. LPA reviewed R1's Pre-Placement Appraisal and Needs and Service Plan which states R1 is independent and can perform all activities of daily living independently and does not need help with bathing. In regards to allegation: Facility staff did not ensure that resident was adequately fed while in care. LPA interviews with staff Ian Baker, S1-S3 all denied the above allegation stated residents are encouraged to eat their food and there are food replacements if needed. Interview with residents: R1 denied the above allegation and stated they provided food but the food served wasn't their preference. R3 and R4 denied the above allegation and stated they are provided food. R3 stated meal replacement is provided when asked. LPA reviewed R1's Pre-Placement Appraisal and Needs and Service Plan which states R1 is independent and can perform all activities of daily living independently and does not need assistance with eating. LPA observed staff going around the hallway and to each residents room door letting residents know meals are ready and encouraging them to go to the dinning room for snack time and lunch time. LPA observed adequate perishable and non perishable food items in the kitchen. In regards to allegation: Facility staff did not ensure that resident's room was cleaned while in care. LPA interview with staff Ian Baker, S1-S3 all denied the above allegation stated residents rooms are cleaned daily. LPA interviews with residents: R1 denied the above allegation and stated staff would clean their room. R3 and R4 denied the above allegation and stated rooms are cleaned every day. LPA toured residents room's and common areas and observed clean rooms, house keepers cleaning, facility appeared in clean and sanitary condition for residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. Exit interview held with Administrator Ian Baker and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 5, 2023 · control 28-AS-20230425091406

Allegation investigated: Facility failed to address the pest infestation. Facility is not reporting scabies outbreak.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced and met with Ian Baker. The purpose for the visit was explained. The investigation consisted of the following: LPA obtained the staff and resident rosters, pest control service reports, and toured the facility. Random rooms were selected to inspect. Interviews were held with the Administrator, 4 Staff, 4 Residents, and a private caregiver. The investigation revealed the following: Allegation – Facility failed to address the pest infestation. According to the administrator, there has not been any reports of bed bugs or cockroaches at the facility. He acknowledged that there was an infestation of bed bugs a few years ago and after that case, the facility continued with pest control services for bed bugs. Unsubstantiated He stated the pest control exterminator comes twice a week and sprays 5 rooms on each visit as a preventative measure for bed bugs. Another pest control company comes once a month to spray the facility for roaches and rodents. In addition, a bed bug heater was purchased to use in the event there is a report of bed bugs. LPA interviewed 4 other staff and they stated the bed bugs issue is under control. They have not observed any bed bugs nor roaches at the facility lately. They also stated that the exterminator checks and sprays for bed bugs twice a week. The staff clean and spray the rooms daily as well as changing the bedsheets often. LPA interviewed 4 residents and a private caregiver during the visit today and all stated they have not seen any bedbugs or cockroaches. During the tour, LPA selected 5 random rooms to inspect and did not observe any pests. Based on the pest control reports, interviews, and observation, staff are taking measures to prevent any infestation of pests at the facility. Allegation - Facility is not reporting scabies outbreak. Per the administrator, he is not aware of any residents having scabies at this facility. He stated there was a case roughly 2 years ago and has not heard of any since. Staff interviewed also stated they have not received any reports from residents being itchy or having rashes. The Residents and private caregiver interviewed today stated they do not have scabies and do not have any rashes on them. Per the Pasadena Public Health department, there is no known scabies outbreak at the facility. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Baker. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 28, 2023 · control 28-AS-20230420113910

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Yating Yang and Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility LPAs met with the Licensee representative Ann Hamilton and were later joined by the Administrator Assistant Monique Jordan who assisted with the visit. The facility is licensed to serve elderly residents age 60 and above. Fire clearance was approved for seventy-two (72) non-ambulatory residents. Hospice was approved for ten (10) residents. Currently NO residents are on Hospice. During today's visit, LPAs used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies were reviewed. The interior and exterior physical plant was inspected. There is only one entrance being utilized at the facility. COVID -19 related materials were posted on the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. A tour of the two story facility includes: All business offices and the kitchen, located on the first floor and resident rooms, bathrooms, common restrooms, shower rooms, medication room, laundry room, linen cabinets, activity/television room, beauty shop, library and a dining room, located on the second floor. During today's visit, LPAs toured the physical plant areas inside and out to ensure there are no health and safety hazards and Physical Plant is in compliance with Title 22 Regulations. The facility has central air and heating accommodations. LPAs toured the second floor and randomly selected #9 resident rooms. All selected bedrooms were furnished with required furniture with operational call lights. Some bedrooms have private bathrooms and some have shared bathrooms. The auditory chimes at the exit doors were tested during the visit. Continue on LIC 809C The bathrooms were observed to be clean, operational and equipped with grab bars and paper supplies. The hot water temperature was tested throughout the facility and measured within compliance of Title 22 Regulations. The kitchen was inspected. LPAs observed kitchen equipment to be clean and in working condition. LPAs observed the food supply stored at the facility. There was a sufficient quantity of the various perishable and non-perishable food supplies. No pesticides or poisons were stored in the food areas. The fire extinguishers were observed to be fully charged and in compliance LPAs observed multiple pull-switch fire alarms throughout the facility. Smoke/carbon monoxide detectors were observed to be operational. The front yard of the facility is well landscaped and has a leveled walkway to the entrance. The outdoor area was enclosed and no bodies of water were observed. All residents medications were centrally stored and four of them were reviewed and the medications were administered as prescribed. The following deficiencies were observed during this visit: 1. Two bottles of the laundry detergent were found in the laundry room left accessible to residents, which poses immediate health and safety risks to the residents in care. 2. One private bathroom in room #20 has no running hot water. The staff will move the resident to another room temporarily until the plumber fixes the issues The plumber is scheduled to come out on 9-8-22 The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D) An exit interview was conducted and a copy of this report was provided to the Director along with the Appeals Rights.the state’s words, verbatim · CDSS document, Sep 7, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Sep 7, 2022

Care of Persons with Dementia The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by; During today vist, LPAs oberserved two bottles of the laundry detergent in the laundry room left accessible to residents, which poses immediate health and safety risks to the residents in care.the state’s words, verbatim · CDSS document, Sep 7, 2022

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Sep 9, 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: During today visit, LPAs observed one private bathroom in room #20 has no running hot water. The staff will move the resident to another room temporarily until the plumber fixes the issues The plumber is scheduled to come out on 9-8-22the state’s words, verbatim · CDSS document, Sep 7, 2022

Allegation investigated: Facility staff do not follow Covid-19 quarantine protocols. Facility staff do not follow Covid-19 PPE protocols.

Licensing Program Analyst (LPA) Christine Wong conducted an initial complaint investgiation to address the above allegations. LPA met wtih receptionist Linda Whitlock and and explained the reason of the visit and and administrator arrived shortly and assisted with the visit The investigation consisted of the following: LPA interviewed the administrator, three staff (S1-S3) and four residents (R1-R4) and obtained copy of documents included residents' and staff roster, staff training log for the infection control dated on 7/28/2020 and use of PPE dated on 1/18/2022 and visitors sign in log from July 6 to July 19, 2022 The investigation revealed of the following: Allegation#1 "Facility staff do no follow Covid-19 quarantine protocols. LPA interviewed four residents, three out of four residents denied the allegation and reported no residents walked around during their quarantine or isolation. (See LIC 9099C for continuation) Unsubstantiated Residents reported the Covid-19 positive residents were all stay in their isolation room and only staff went inside and assisted them. LPA interviewed staff and all denied the allegation and reported some residents are mentally incapability and they do not understand about Covid-19, so some may attempt to come out of the isolation room but staff usually would check on them every 5 minutes and ensure they stay inside the isolation room without coming out from the quarantine. Allegation#2 "Facility staff do not follow Covid-19 PPE protocols." LPA interviewed four residents and all denied the allegation and reported staff did wear the Personal Protective Equipment (PPE) while going inside the isolation room. Staff also denied the allegation and reported they do wear the PPE inside the isolation room and take it off and throw away the PPE while coming out from the isolation room. LPA also observed the staff did wear PPE while going inside the isolation room and there's also a appropriate PPE is located outside of isolation room to prevent contamination with the virus. Based on the interviews conducted with residents and staff, documents reviewed and LPA's observation, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held. A copy of the report and appeal was provided. While LPA arrived the facility, LPA observed the staff did not wear mask while talking to the visitor, although there's a divider between the staff and visitor. Also the visitor did not wear the face mask probably which the mask was not covering the nose and staff did not remind the visitor to put the mask on to cover the nose. Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found Substantiated. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Ian Baker Administrator and a copy of the report, LIC 9099D, and Appeal Rights was providedthe state’s words, verbatim · CDSS document, Jul 20, 2022 · control 28-AS-20220713171930

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(c)(1)(F) · Plan of correction due date: Aug 3, 2022

87470 nfection Control Requirements (c)An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The infection control plan shall include of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. The requirement is not met as evidenced by: LPA observation, LPA observed S2 did not wear mask while talking to the visitor which posed an potential risk to residents in care.the state’s words, verbatim · CDSS document, Jul 20, 2022

Plan of correction: The administrator will ensure the facility is following infection control plan and the administrator will retrain the staff about the infection control and send the staff training log to LPA by POC due date.

Allegation investigated: Resident was hit by another resident breaking resident's eye glasses

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Resident was hit by another resident breaking resident's eye glasses". Upon arriving at the facility, LPA met with Administrator / Ian Baker who assisted with the visit. LPA Katrdzhyan conducted a prior visit to this facility on 8/31/2020, in reference to the allegation listed above. The investigation consisted of interviews of various persons to include the Administrator, Service Coordinator / Armine Toomanian from Frank D Lanterman’ s Regional Center (FDLRC) and Residents 1 and 3 (R1 and R3). LPA was unable to interview Resident 2 (R2) as R2 no longer resides at this facility and her whereabouts are unknown at this time. Also, copies of the following documents were obtained and reviewed in reference to R1 and R2; • Functional Capability Assessment • Appraisal/Needs and Services Plan • Physician’s Reports Unsubstantiated The investigation revealed the following; Allegation: Resident was hit by another resident breaking resident's eye glasses. The details of this allegation states that R2 hit R1 which led to R1's glasses to be broken. According to the Unusual Incident/Injury Report submitted by the facility, on 1/28/2019, at approximately 9:45am, R2 went into R1's room and knocked the glasses off of R1's face. Based on record reviews and interviews conducted, there were no witnesses to the incident. R1 could not recall what caused R2 to go into her room and knock her glasses off of her face. This was an isolated incident and R1 did not sustain any injuries. R1's glasses were broken as a result of the incident but R1 received replacement glasses after seeing an Optometrist. After the incident, R2 was taken to Sherman Oaks Hospital for a psychiatric evaluation and did not return. R2's whereabouts are unknown at this time. Per the Administrator, there have been no prior incidents involving R1 and R2 and both residents do not require one to one supervision. According to the Appraisal/Needs and Services Plan for R1, R1 has a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) and is fully independent. According to the Appraisal/Needs and Services Plan for R2, R2 is able to follow instructions and is described as outgoing and interacts well with others. Per the Administrator, FDLRC did not conduct an investigation regarding the incident involving R1 and R2. Although the incident happened involving R1 and R2, the facility staff could not have done anything different to prevent the incident from happening. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 28, 2022 · control 28-AS-20200824092728

Allegation investigated: Staff did not prevent an inappropriate interaction between clients while in care.

Licensing Program Analyst's (LPA's) Vasallo and Mora conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with administrator, Ian Baker and explained the reason for the visit. The initial complaint visit was conducted on 8/25/21. The investigation consisted of the following: Interviews were conducted with 6 staff and 4 residents. LPA reviewed Resident #1’s (R1) records and obtained a resident and staff roster. Camera footage was reviewed for the night of 8/18/21 when the incident allegedly occurred. Staff from R1’s previous facility were also interviewed. The investigation revealed the following: It’s alleged R1 was inappropriately touched by Resident #2 (R2) at the facility. Allegedly R2 touched R1’s breasts. Allegedly the incident occurred on 8/18/21. LPA reviewed camera footage from the cameras located in the hallway. R1 and R2 had rooms next to each other. Continued on 9099C. Unsubstantiated At 12:02 am R2 is seen in the hallway and then enters R1's room. R2 was in the room approximately 5 seconds and walks back to his/her room. A few seconds pass and R2 is seen exiting his/her room again and entering R1's room again. R2 is there again another 5 seconds and walks out and back to his/her room. R1 is then seen entering R2’s room at 12:03 am. R1 is seen leaving R2’s room at 12:05 am and back to his/her room. No other movement was seen that night. Residents interviewed deny ever witnessing R2 harass R1 or anyone else in the facility. R1 indicated the incident did occur but reported there were no other witnesses. R2 denied the allegation and indicated that R2 and R1 were friends. Staff interviewed indicated they never witnessed the incident and reported that R2 does not have a history of such behavior. Administrator from R1’s previous facility was interviewed. That administrator reported that R1 had a history of fabricating stories of sexual encounters with strangers. Allegedly R1 made those allegations on a regular basis and would often call police. Police responded to the facility after this allegation was made. Police interviewed both R1 and R2 and there were no arrests made. Police provided the facility with report numbers from previous times R1 made allegations at the previous 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. Exit interview held. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2021 · control 28-AS-20210819104644