Victor Royale

Allegation investigated: Staff failed to provide appropriate care and supervision to resident after the fall. Staff did not provide medical assistance to resident in a timely manner. Insufficient staff to meet the needs of the resident(s).

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on th above allegations that were investigated by DSS/CCLD Investigations Branch (IB) Investigator Laura Garcia. The purpose of the visit was explained to Administrator Peter Babaian. The investigation consisted of: On 5/12/2022, LPAs Galarza and Yating Yang conducted a 24-hour health and safety check that included a physical plant tour of the facility, and review of resident (R1's) file. The following documents were obtained: Identification and Emergency Information, Preplacement Appraisal, Resident Appraisals, Physician Reports, Psychiatric Evaluation/Notes, Medication Administration Record (MAR), Admission Agreement, Assisted Living Waiver/Individual Service Plan, incident reports [5/5/2022 & 10/18/2021], notes, resident roster, LIC 500 Personnel Report, and Death Report. A police report was not obtained during the initial visit. Investigations Branch obtained Glendale Fire department, Police records, County of Los Angeles Department of Medical Examiner- Coroner Autopsy Report and Registrar- Certificate of Death. A nurse consult was obtained. ****Narrative continues next page.***** Substantiated Allegation: Staff failed to provide appropriate care and supervision to resident after the fall. It is alleged that on 5/5/2022, resident (R1) sustained 2 falls. The 1st fall occurred at approximately 7:30 PM while being provided incontinence care by caregiver (S1) in the facility common bathroom. The 2nd fall was unwitnessed and occurred in the resident's room at approximately 8:00 PM - 8:30 PM. While staff (S1) was changing R1’s diaper in the common bathroom the resident fell to the ground. The resident was unable to get up on their own or with S1’s help due to their size. Caregiver/Staff (S1) used the Hoyer Lift to pick the resident up from the floor, and then proceeded to walk the resident back to their room. Facility staff failed to use proper equipment and follow equipment use guidelines when assisting R1 with incontinence care that resulted in the first fall in the bathroom. Staff placed R1 in the bed and returned to check on the resident at approximately 8:00 PM – 8:30 PM. Staff (S1) found the resident face down on the ground beside the bed. Staff (S1) stated that they decided to place a pillow under the head, so the resident did not get hurt, since R1 was likely to fall again. Staff (S1) stated the resident only replied “okay". Based on interviews with staff on duty, staff 9S1) and CNA/staff (S2) did not provide appropriate care and supervision after both falls. Review of evidence indicates that staff (S1) placed resident in a harmful situation by placing a pillow under the head (partially covering the face) and left the resident on the floor. Emergency personnel observed the resident's bed did not have any bed rails. Proper safety measures were not in place. Allegation: Staff did not provide medical assistance to resident in a timely manner. It is alleged that facility caregiver (S1) and Certified Nurse Assistant (CNA)/Staff (S2) failed to provide timely medical attention by not rendering or initiating CPR when resident (R1) was not responsive. The facility failed to seek timely medical attention when R1 fell the 2nd time and was found on the floor. Emergency Medical Services (EMS) were not called almost two (2) hours after resident (R1's) 2nd fall, instead staff (S1) placed a pillow under the resident's head. Based on the photo, the resident was left on the floor in compromised position that appears to show R1 in prone position with left arm underneath body and right arm extended out in downward position. Caregiver staff (S1) reported both falls to CNA on duty. The 1st fall occurred at approximately 7:30 PM. The 2nd fall occurred at approximately 8:00 PM – 8:30 PM. At approximately, 9:30 PM, caregiver returned to the room to check on the resident because 2 other residents were heard screaming from R1's room. The resident was still laying on the ground with head on the pillow. Staff (S1) allegedly placed their index finger under the resident’s nose to see if any air was coming out from the nose. Staff (S1) stated the they felt air and left without providing further aid. According to staff interviews, staff (S1) reported the falls to Certified Nurse Assistant (CNA)/staff (S2). Sometime between 9:00 PM - 9:30 both staff went to check the resident. CNA stated that they stood by the door while staff (S1) checked on the resident and stated that staff (S1) reported the resident was okay. At 10:11 PM staff called EMS and reported to dispatcher that the resident was conscious. At 10:14 PM, EMS personnel arrived at the facility and found the resident "Dead on Arrival". Time of death was 10:17 PM. Paramedics determined the resident had been deceased longer six minutes. ***Narrative continues next page.**** Allegation: Insufficient staff to meet the needs of the resident(s). It is alleged that the facility did not have staff of adequate number and skill to provide care to the residents. When Emergency Medical Services (EMS) arrived staff delayed in allowing emergency responders crew into the facility. In addition, it is alleged that staff did not provide 911 emergency response dispatchers accurate information pertaining to resident's condition. Staff interviews revealed that during the afternoon shift staff (S1) is usually assigned to the front desk and when residents require immediate assistance it become very difficult to assist the residents. The findings indicate that on Saturdays and Sundays staff (S1) is the only person working from 2:00 PM - 10:00 PM; which includes providing the residents with meals, passing out medications, offering them snacks, and changing diapers for all the residents in need. In addition, the graveyard shift (10:00 PM - 6:00 AM sometimes has only one (1) staff working, and two hourly checks are not always performed. Staff interviewed acknowledged that due to staffing shortages, neglect and lack of supervision are likely. On May 5, 2022, both staff on duty (S1) and (S2) failed to provide medical assistance (CPR) or conduct a body assessment on resident (R1). On the resident (R1's) Appraisal/Needs and Services Plan dated 12/3/2020, it states the resident is at risk for falling, needs assistance with daily activities, and daily monitoring/observation will be performed. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22 and Health and Safety Code. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM. The issuance of a civil penalty is being considered based on Health & Safety Code HSC §1569.49(e) – (f), if the department determines the serious bodily injury was due to neglect. Exit interview was conducted with Peter Babaian. A copy of the report and appeal rights were provided. Allegation: Questionable Death. It is alleged that resident (R1) died at the facility due to neglect of care. On 5/5/2022, at approximately 8:00 PM - 8:30 PM caregiver staff (S1) found the resident laying in a prone position with face down but did not pick-up the resident, only placed a pillow under its head, and left the resident on the floor. Night shift staff placed a 911 emergency call until 10:11 pm. The decedent was found dead by emergency responders. Resident (R1) had bruising on their lower back that led further under the diaper, had a fresh cut on back, and had a visible dislocated left shoulder. A picture was taken, and appears to show R1 in prone position with his left arm underneath and right arm extended out in downward position. Left knee bent with left foot darker color extending pass their ankle. Based on County of Los Angeles Department of Medical Examiner- Coroner Autopsy Report (5/8/2022) and Registrar- Certificate of Death records the cause of death is listed as "Natural". Other conditions contributing but not related to immediate cause of death listed Diabetes Mellitus and lymphoma. There is insufficient evidence to substantiate death as autopsy report ascribe cause of death to Arteriosclerotic Cardiovascular Disease and manner of death as natural. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted with Peter Babaian. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 28-AS-20220510135636

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 13, 2023

Incidental Medical and Dental Care (a) ...The plan...shall provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange...for medical care... appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on documents reviewed and interviews conducted, facility staff failed to call Emergency Medical Services (EMS) personnel in a timely manner. Staff called 911 EMS approximately 2 hours after 2nd fall was discovered. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Administrator shall submit in writing how this deficiency will be addressed, understanding of regulation, and facility procedures regarding timely medical care. 1.Submit plan by tomorrow. 2. Submit proof of staff training by Oct. 19,2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 13, 2023

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on document review and interviews conducted, on May 5, 2022 facility staff failed to meet the needs of resident (R1) after 2 fall incidents; by not conducting body assessments or providing adequate supervision subsequent to falls. This posed an immediate safety risk to this resident in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Administrator agreed to (1.) submit a plan of correction that addresses staff scheduling and supervision of residents. When applicable resident’s care plans shall be updated, and staffing scheduling shall be reevaluated. (2.) Submit proof of staff training i.e., needs and services of residents, resident care, and supervision.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Oct 19, 2023

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.....the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met evidenced by: Based on record review on May 5, 2022, R1 had 2 falls, (one in incontinence care room & the other in their room); staff did not provide appropriate care and supervision after both falls. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Administrator agrees to conduct training with all staff regarding observation of residents and changes in condition. When changes in condition are observed residents shall be assessed and records and Appraisals Needs and Services plan shall be updated.

Allegation investigated: Staff did not prevent a resident from causing an injury to another resident Staff yell at the residents while in care Staff did not ensure a resident was taking prescribed medications Staff do not provide a comfortable temperature for the residents Staff speaks inappropriately towards a resident

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent visit for the above noted allegations. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that staff did not prevent a resident from causing an injury to another resident. Resident #1 (R1) accused another resident of purposefully backing into them and causing them to fall and get hurt. To investigate this allegation on 10/12/2023 between 10:50AM and 11:30AM, staff interviews were initiated. Interviews revealed that facility was not aware of Resident #1 (R1) being injured by another resident. It is possible that Resident #2 (R2) got too close to R1 and accidently bumped into them. Between 2:00PM and 2:20PM, LPA attempted to interview R1, but they were unable to identify who backed into them or when the incident occured. Based on interviews there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Unsubstantiated It was alleged that staff yell at the residents while in care. To investigate this allegation, LPA interviewed facility staff and residents. Staff interviews revealed that staff do not yell at residents. Some residents are hard of hearing and they need to raise their voice in order to be heard. Between 2:20PM and 2:55PM, ten percent of the residents were interviewed. Resident interviews revealed that staff do not yell at them and that they are nice. Based on interviews there is not sufficient information to verify this allegation. Thus, this allegation is UNSUBSTANTIATED at this time. It was reported that staff did not ensure a resident was taking prescribed medications. To investigate this allegation, between 10:50AM and 11:30AM, staff interviews were conducted. Interviews revealed that R1 refuses to take this medication as prescribed by their doctor. Staff can not force R1 to take their medications since it is their personal right to refuse. Between 2:00PM and 2:20PM, LPA spoke to R1. R1 stated that they do not like taking too much medication and that sometimes they refuse it. Based on interviews there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. It was alleged that staff do not provide a comfortable temperature for the residents. To investigate this allegation between 10:50AM and 11:30AM, staff interviews were conducted. Interviews revealed that the air conditioning board burned about a month in a half ago and that it was immediately fixed. Only the right side of the facility was affected by this. The A/C not functioning was reported in the morning and the following day it was fixed. Between 3:00PM and 3:15PM, LPA conducted a facility walk through. The facility temperature measured on the thermometer was 77 degrees. LPA felt fresh air throughout the facility. The facility was not hot and staff told LPA that the AC is functioning once again. Based on interviews and observation there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. It was reported that staff speaks inappropriately towards a resident. To investigate this allegation staff interviews were conducted between 10:50AM and 11:30AM. Staff interviews reveal that staff are professional and respectful towards residents in care. Between 2:00PM and 2:20PM, LPA interviewed R1. Interview revealed that R1 was upset at staff because they thought someone stole their belongings. Staff were trying to calm them down and reassuring them that no one took their belongings. R1 denied that staff spoke to them inappropriately. Based on interviews there is not sufficient information to verify this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 31-AS-20230829112003

Allegation investigated: Staff did not ensure facility is insect free

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that staff did not ensure facility is insect free. On 10/12/2023 between 10:50AM and 11:30AM, staff interviews were initiated. Staff interviews revealed that when the administrator is present the entrance door and patio doors are left open. It is possible that flies enter the building. Between 11:30AM and 11:45AM, facility records were reviewed. Records revealed that a pest control company comes bi-monthly to the facility. Between 1:00PM and 1:30PM, LPA toured resident bedrooms. In room 14, LPA observed many flies. Some flies were alive and others were dead. Resident #1 (R1) was alseep at the time and was not able to be interviewed. Based on observation there is sufficient information to verify the allegation. Therefore, the allegation will be SUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued. Substantiatedthe state’s words, verbatim · CDSS document, Oct 12, 2023 · control 31-AS-20231004153247

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 26, 2023

87303-Maintenance & Operation (a) The facility shall be clean, safe sanitary and in good repair at all times. Maintence shall include provision of maintence services and procedures for the safety and well-being of residents, employees, and visitors. This requirement was not met as evidenced by: LPA observed many flies in resident room #14. LPA observed both flies that were dead and alive. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: The licensee shall place fly strips in room #14 in order to deter flies. This citation has been cleared on this visit. Administrator placed the strips in room #14 during this visit..

Allegation investigated: Facility phone is in disrepair.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. Upon entry, LPA met with the Executive Director, Peter Babaian, and explained the reason for the visit. --- Facility phone is in disrepair. It was alleged that one of facility’s phones is in disrepair and phone wire was cut. To investigate the allegation, on 09/27/2023 at 10:00 AM, LPA conducted a physical plant tour, interviewed one (01) staff at around 11:30 AM and interviewed one (01) resident at 12:30 PM. During the physical plant tour LPA observed that resident pay phone in cottage #2 was in disrepair, however, the resident phone near reception area was in working condition. (CONT. on LIC9099-C) Substantiated During interviews with Staff #1 (S1), they stated that pay phone in cottage #2 is temporarily not working because it was recently renovated, and they are waiting for the company that manages the phones to come and reconnect them. S1 also added that residents have easy access to a portable phone located near the lobby. During interview with Resident #1 (R1), they stated phone was in working order, noticed telephone wire was exposed and confirmed that phone does not work. Based on observations and interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. However, although one phone was found to be in disrepair, there is a working portable phone located near the lobby that residents have reasonable access to, to both make and receive confidential calls. Therefore, a citation will not be issued at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued. During interviews with Staff #1 (S1), they stated resident has sufficient storage space and a closet. S1 added that R1 does not allow staff to enter their room which poses a challenge to maintain it. S1 believes R1 is referring to a desk which is not the facility’s responsibility to replace. S1 stated that R1 is free to purchase a new desk at any time, but due to the desk’s current poor condition, it should be removed as it poses a potential safety hazard to R1 and staff. During interview with Resident #1 (R1), they stated a request for replacements of the desk was made but nothing came of it. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 27, 2023 · control 31-AS-20230925155857

Allegation investigated: Staff does not administer resident's medication as prescribed

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA conducted physical plant tour at 9:40 AM, requested copy of facility documents relevant to the investigation at 10:02 AM and interviewed staff and resident between 10:30 AM to 1:00 PM. It was alleged that Resident #1 (R1)'s medication was not given to R1 as prescribed by R1's physician. LPA's record review today at 11:20 AM revealed that R1's physician's prescription state that the particular medication was ordered to be taken orally once a day with no specific time to be taken. Further review also revealed that R1 did not miss any medication for the last three (3) months. LPA's interview with R1 on 06/22/23 at 10:45 AM revealed that R1 took the prescribed medication on the day in question (06/21/23) with an approximate delay of about an hour which is well within the time frame of medication administration. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA's interview with staff also revealed that the reason for the delay was that R1's morning medication was wrapped and sealed all together and the medication staff has to be present when opened to ensure that R1 takes all of R1's medication while in the facility as R1 did not go to the day program on the day in question (06/21/23) because when R1 is at the day program, staff at the program monitors R1 medication intake. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 31, 2023 · control 31-AS-20230621160636

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced case management visit to the facility. The purpose of today’s visit was to serve the Order to Licensee of Immediate Exclusion from Facility for Staff #1 (S1). and Staff #2 (S2) An investigation by the California Department of Social Services was conducted and it was determined that S1 and S2 violated California Code of Regulations Title 22 for personal rights. On today's visit LPA met with Licensee Peter Barbaian and explained the reason for the visit. Licensee was provided with copies of the Order to Licensee of Immediate Exclusion and Order to Individual for Immediate Exclusion letters and Government Code 11522. Exit interview held. A copy of the report was provided to Licensee Peter Barbaian.the state’s words, verbatim · CDSS document, Aug 28, 2023

Allegation investigated: Licensee does not maintain facility in good repair Facility is not allowing residents to use the outdoor telephone comfortably and freely.

Licensing Program Analysts (LPA) Ashley Calderon conducted an unannounced visit to investigate the above allegations. This report supersedes report dated 8-01-23. The purpose of the visit was discussed with Administrator Peter Babaian. On the initial visit conducted on 11/22/22, the investigation consisted of LPA Calderon obtaining staff and resident roster. Touring physical plant of the facility with Assistant Administrator Alise Nazarian.LPA Calderon alongside with Alise toured common restrooms in main building, common restroom in cottage 1515, residents rooms, outdoor patio/telephone areas. LPA interviewed residents #1-#5 (R1-R5) and interviewed staff: Administrator, Assistant Administrator and Staff #1 (S1) and Staff 2 (S2). Continuation on 9099-C. Unsubstantiated On visit 8/1/23, the visit consisted of the following: LPA Calderon obtaining staff and resident roster. LPA Calderon along side with Staff #3 (S3) toured random resident rooms and residents private bathrooms, in main building: Rooms #:12,21, 25, 28, and 29. Main building shower rooms were observed. LPA tested call system. LPA observed cottage 1511 unoccupied by residents. LPA observed cottage 1515 :common restroom, and residents rooms #:2,3,4 and 5. LPA observed kitchen and LPA interviewed handyman worker who was present at the facility during the time of visit. On 8/15/23 LPA Calderon visit consisted of the following: LPA interviewed Assistant Administrator and Administrator, Staff #1 (S1) and Staff #2 (S2). LPA interview residents #1- resident #4 (R1-R4), Attempt to interview resident #5 (R5). LPA observed the telephone areas. Regarding allegation: Licensee does not maintain facility in good repair. LPA interviews with staff: Assistant Administrator and Administrator stated facility in good repair when facility requires repairs third party assistance is called and are hired to repair, fix and provide maintenance. Interview with S1 and S2 denied the above allegation and stated that the facility is in good repair. S1 on 11/22/22 interview, stated facility had recent remodels done. Interviews with residents on 11/22/22, revealed the following: 3 out of 5 residents interviewed: R1, R3 and R4 alleged that the cottage room common bathroom toilet has issues flushing at times and stated facility has no other issues regarding disrepair's in the facility. 4 out 5 residents during interview with LPA Calderon stated not aware if call system is operable as they do not use system. On 8/1/23 LPA Calderon interviewed facility handyman that does maintenance for the facility and handyman stated facility communicates with handyman regarding repairs that the facility requires when fixing is needed. Handyman stated working with the facility for about 18-20 years and facility provides on going repairs when needed. LPA Calderon alongside with S3 observed random resident rooms in the main building and observed running hot water, lights being operable, room furniture in good condition, operable toilet with lids, and call light system operable. LPA observed common restroom in cottage 1515 having toilet paper rod holder, toilet lid in place, toilet flushing properly, and running hot water. LPA observed common showers in main building having adequate lighting, running hot water, and operable call system in place. LPA Calderon observed kitchen appliances being operable. LPA observed bathrooms during visits on 11/22/22 and 8/1/22, being operable. However, the investigation did not reveal the licensee does not maintain facility in good repair, there is no evidence to support the above allegation. Therefore, the allegation is deemed unsubstantiated per Title 22 Regulations, Division 6, Chapter 8. (Continuation 9099-C...) Regarding allegation: Facility is not allowing residents to use the outdoor telephone comfortably and freely. LPA Calderon interviewed Assistant Administrator, Administrator, S1 and S2 all who denied the above allegation and stated all three phones are available for the residents use, and phones can be used comfortably and freely and there is privacy upon using the telephones. LPA interviews revealed that R2-R4 all residents have access to a phone and to use the phones comfortably and freely and there is no issues with sandbags located in patio near the outside telephone. R1 during interviewed stated facility provides alternative phones for residents to use comfortable and freely but at times outside telephone may have supply items in the way of reaching the phone. LPA observed location of the phones, 3 phones facility provides for residents in care , 1 phone is in the cottage building hallway, 1 in the patio and another is a wireless phone located in the front desk. LPA observed phones being available to the clients in care and phones can be used comfortable and freely. LPA observed outside phone patio having chairs near the phone for residents comfort and use. However, the investigation did not reveal the licensee does not maintain facility in good repair, there is no evidence to support the above allegation. Therefore, the allegation is deemed unsubstantiated per Title 22 Regulations, Division 6, Chapter 8. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. A copy of this report was provided to Administrator Peter Babaian.the state’s words, verbatim · CDSS document, Aug 15, 2023 · control 28-AS-20221118144931

Allegation investigated: Staff did not report incident to the appropriate agencies.

Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced initial 10day complaint visit on 08/03/2023, LPA arrived at the facility at 9:20am. At approximately 9:58am LPA met with Administrator Peter Babaian and explained the purpose of the visit. LPA conducted a physical plant tour at 10:07am. It is alleged that the facility failed to report an altercation between resident #1 (R1) and resident #2 (R2) to the appropriate agencies. LPA requested and obtained copies of facility files and documents including but not limited to the staff and resident rosters, physician reports and appraisal/needs and service plan at approximately 10:19am. LPA began interviews with the Administrator, staff, and residents at approximately 10:30am between 11:56am. During the investigation the the administrator confirmed they did not report the alleged incident to the appropriate agencies because they conducted an internal investigation and could not Continued on 9099C. Substantiated conclude the alleged incident occurred. LPA informed the administrator per reporting requirements and as a mandated reporter their duty is to report incidents accordingly to the appropriate agencies. Although the administrator completed the required reporting forms to the appropriate agencies at the time of the investigation Based on interviews, observations and record review, there is enough evidence to prove the alleged violation did occur, therefore the allegation is SUBSTANTIATED at this time. No health and safety hazards are noted during this visit. Deficiency cited, exit interview conducted and a copy of report and appeal rights issued. Interviews with staff confirm they were not told by any residents regarding the incident and did not witness the altercation. During the investigation LPA observed cameras in the facility common areas, per the administrator the camera system has been inoperable for about a month and was not operating at the time of the alleged incident. LPA observed the surveillance system in the administrator office to be non-functional at the time of the investigation. Upon record review of a photograph of R1s bruise it could not be concluded when or how the bruise was obtained. Based on interviews, observations, and record review, there is a not enough corroborating evidence to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards are noted during this visit. No deficiencies cited, exit interview conducted. Copy of report, and appeal rights issued.the state’s words, verbatim · CDSS document, Aug 3, 2023 · control 31-AS-20230725120049

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Aug 17, 2023

87211 Reporting Requirements(c)Any suspected physical abuse that does not result in serious bodily injury... shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency...This requirement is not met as evidenced by: Based on interviews, observation and record review the licensee failed to ensure that suspected physical abuse was reported to the appropriate agencies in a timely manner.the state’s words, verbatim · CDSS document, Aug 3, 2023

Plan of correction: At the time of the visit the administrator complete the appropriate required reporting forms and submitted to the appropriate agencies. The administrator will conduct an in-service on reporting requirements and mandated reporting and submit by email to LPA by POC due date.

Allegation investigated: Licensee does not maintain facility in good repair

Licensing Program Analysts (LPA) Ashley Calderon conducted an unannounced subsequent complaint visit to investigate the above allegation. The purpose of the visit was discussed first with Assistant Administrator Alise Nazarian and later with Administrator Peter Babaian. On the initial visit conducted on 11/22/22, the investigation consisted of LPA Calderon obtaining staff and resident roster. Touring physical plant of the facility with Assistant Administrator Alise Nazarian.LPA Calderon alongside with Alise toured common restrooms in main building, common restroom in cottage 1515, residents rooms, outdoor patio/telephone areas. LPA interviewed residents #1-#5 (R1-R5) and interviewed staff: Administrator, Assistant Administrator and Staff #1 (S1) and Staff 2 (S2). Contunuation on 9099-C. Unsubstantiated On todays visit 8/1/23, the visit consisted of the following: LPA Calderon obtaining staff and resident roster. LPA Calderon along side with Staff #3 (S3) toured random resident rooms and residents private bathrooms,in main building: Rooms #:12,21, 25, 28, and 29. Main building shower rooms were observed. LPA tested call system. LPA observed cottage 1511 unoccupied by residents. LPA observed cottage 1515 :common restroom, and residents rooms #:2,3,4 and 5. LPA observed kitchen and LPA interviewed handyman worker who was present at the facility during the time of visit. Regarding allegation: Licensee does not maintain facility in good repair. LPA interviews with staff: Assistant Administrator and Administrator stated facility in good repair when facility requires repairs third party assistance is called and are hired to repair, fix and provide maintenance. Interview with S1 and S2 denied the above allegation and stated that the facility is in good repair. S1 on 11/22/22 interview, stated facility had recent remodels done. Interviews with residents on 11/22/22, revealed the following: 3 out of 5 residents interviewed: R1, R3 and R4 alleged that the cottage room common bathroom toilet has issues flushing at times and stated facility has no other issues regarding disrepair's in the facility. 4 out 5 residents during interview with LPA Calderon stated not aware if call system is operable as they do not use system. On 8/1/23 LPA Calderon interviewed facility handyman that does maintenance for the facility and handyman stated facility communicates with handyman regarding repairs that the facility requires when fixing is needed. Handyman stated working with the facility for about 18-20 years and facility provides on going repairs when needed. LPA Calderon alongside with S3 observed random resident rooms in the main building and observed running hot water, lights being operable, room furniture in good condition, operable toilet with lids, and call light system operable. LPA observed common restroom in cottage 1515 having toilet paper rod holder, toilet lid in place, toilet flushing properly, and running hot water. LPA observed common showers in main building having adequate lighting, running hot water, and operable call system in place. LPA Calderon observed kitchen appliances being operable. LPA observed bathrooms during visits on 11/22/22 and 8/1/22, being operable. However, the investigation did not reveal the licensee does not maintain facility in good repair, there is no evidence to support the above allegation. Therefore, the allegation is deemed unsubstantiated per Title 22 Regulations, Division 6, Chapter 8. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. A copy of this report was provided to Administrator Peter Babaian.the state’s words, verbatim · CDSS document, Aug 1, 2023 · control 28-AS-20221118144931

Allegation investigated: Facility staff did not respond to resident council recommendation within 14 calendar days.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPA met with the Administrator, Peter Babaian, and explained the reason for the visit. --- Facility staff did not respond to resident council recommendation within 14 calendar days. It was alleged that Administrator did not respond timely to a written recommendation for extra snacks to be served in the afternoons when resident council meetings are held. To investigate the allegation, on 06/02/2023 at 10:00 AM, LPA interviewed the Administrator. Resident #1 (R1) was not available for an interview. The Administrator stated, a letter was received on May 15, 2023, recommending that snacks be served during resident council meetings, but a written response regarding any action or inaction was not provided as he was still discussing the matter with owners of the facility. (CONT. on LIC 9099-C) Substantiated Based on the information revealed during interviews, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No health and safety hazards were noted during the visit. An exit interview was conducted, and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 2, 2023 · control 31-AS-20230530082614

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.157(c) · Plan of correction due date: Jun 9, 2023

Health and Safety Code section 1569.157 provides:(c)If a resident council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to those concerns or recommendations within 14 calendar days. This requirement is not met as evidenced by; Based on interviews, the facility did not respond to resident council’s written recommendation within 14 days which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2023

Plan of correction: The Administrator will respond to the written recommendation by the POC due date, will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to Health and Safety Code section 1569.157; The written letter must be sent to the LPA by the POC due date.

Allegation investigated: Staff allows residents to access hazardous area on facility premises.

At 10:00am, LPAs Mariana Agban and Angela Paunshkina initiated a complaint investigation for the allegation listed above. LPAs met with the Administrator, Peter Babaian, and explained the purpose of this visit. LPAs conducted a physical plant walk through, at approximately 10:20am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPAs did not observe any immediate health and safety issues during the visit. LPAs conducted interview with the Administrator, Administrator Assistant, two (2) staff members, and five (5) residents and reviewed facility records from 10:30am to 12:00pm. LPAs also obtained copies of pertinent documents relevant to the investigation. Continue on LIC9099-C Unsubstantiated Allegation: Staff allows residents to access hazardous area on facility premises. It was alleged that the Administrator told Resident #2 (R2) that it was "OK" to help staff in the burnt cottage that occurred in November of 2022. To investigate this allegation, during a physical plant tour at 10:30am, LPAs observed that the burnt cottage has a fence around it and on the main entrance a cable rope (4-digit), was also observed. Administrator Assistant informed LPAs that only staff members have a code to access the burnt cottages. In addition, interview with the Administrator revealed that R2 used to reside in one of the units on a burnt side of the cottages and was temporarily moved to the other side until the repair is complete. Due to some of the residents belongings still continue being stored on a partially damaged cottage area the residents ask the staff to gain access to remove necessary items. Interviews with the Administrator, Administrator Assistant, two (2) caregivers confirmed that previous cottage tenants gain access to their belongings only under the facility staff supervision. Moreover, four (4) out of five (5) residents denied ever seeing the entrance to the burnt cottage being accessible to residents in care. Based on information obtained through interviews and observation this allegation is deemed Unsubstantiated. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 26, 2023 · control 31-AS-20230420141840

Allegation investigated: Resident wandered away from the facility due to lack of supervision

On 03/22/2023 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Agard was met first by Alise Nazarian, Assistant Administrator, and then by Peter Babaian, Administrator. LPA explained the purpose of this visit was to gather information, interviews and deliver findings for this complaint. The investigation consisted of the following: on 02/13/2023 LPA Agard initiated a complaint investigation. LPA toured the physical plant and requested records. The following records were requested: 1) staff roster, 2) resident roster, 3) needs and services plan for R1, 4) physician report for R1, 5) Identification and emergency contact information and 6) police report. All records were received at the time of visit. Cont. on 9099C Substantiated The investigation revealed the following: Regarding the allegation… Resident wandered away from the facility due to lack of supervision. It’s being alleged a resident walked out of the facility unsupervised and remains missing. LPA Agard interviewed 2 out of 16 staff in total. 2 out of 2 were able to confirm the allegation. S1 states, “R1 left and never came back. We called the police the same day. We’ve called the hospital. Every 2-3 days we call the police to get updates but still nothing. R1 didn’t say anything or sign out. They are independent in the community.” S2 states, “that day when staff checked, R1 wasn’t there. We checked everywhere. We waited a few hours to make sure because our residents go out. We called hospitals, the police department and so far, we haven’t heard anything. The police can’t even find them. During interviews with residents, LPA interviewed 5 out of 54 residents in total. 2 out of 4 confirmed the allegation. R1 was unavailable for an interview. R2 states, “I only know that they said were going to “Alvarado near MacArthur Park.” R3 states, “I’m not sure, the last time they eloped was about a year ago. They found them in some place called Alvarado near a park. R4-5 were unable to speak on the allegation. During a record, LPA reviewed R1’s physician report dated 01/01/2022 which indicates resident is unable to leave the facility unassisted. LPA reviewed R1’s resident appraisal dated 06/01/2022 which indicates residents need for special observation/ night supervision and help with moving about the facility. LPA reviewed R1’s needs and services plan dated 01/01/2022. Under the section functioning skills, it states: “R1 needs support with activities of daily living, is not able to go outside and needs assistance with medical and financial management. Based on the interviews with staff, residents and a record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is (are) found to be Substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D. An exit interview was conducted, and a hard copy was provided with appeal rights. See LIC 9009-D on the next pagethe state’s words, verbatim · CDSS document, Mar 22, 2023 · control 28-AS-20230210163900

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Mar 29, 2023

Personnel Requirements – General (d)All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by: observation, interviews conducted and record review. A resident that required supervision was able to elope from the facility unsupervised and remains missing. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 22, 2023

Plan of correction: Administrator shall review the regulation 87411 and residents' Physician's Report. Administrator shall submit the list of residents who cannot leave the facility unassisted and the plan to ensure those residents do not elope by POC due date. Plan can be submitted via fax or email to LPA.

Allegation investigated: Lack of supervision resulting in resident causing injury to another resident in care. Resident has access to a hazardous item. Staff did not safeguard resident's personal belongings. Resident does not have access to the bathroom.

This is a corrected verison of previous complaint report dated 03/06/2023. Verbiage was corrected on LIC 9099-C. Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit stemming from initial 10-day complaint visit conducted on 06/22/2021, by LPA’s Luis Mora and David Sicairos. LPA Ramirez met with Administrator Peter Babaian and explained the reason for the visit. The investigation consisted of: LPA reviewed the allegations with Administrator Peter Babaian. LPA requested and obtained copies of Register of Facility Clients/Residents (LIC 9020), Personnel Report (LIC 500), Unusual Incident/Injury Report (LIC 624), and other pertinent documentation regarding this investigation. LPA conducted four (4) Staff (S1 – S4) and four (4) Resident (R1- R4) interviews and attempted interviews of Residents (R5 – R6). See 9099-C for continuation… Unsubstantiated Allegation: “Lack of supervision resulting in resident causing injury to another resident in care.” It is alleged on or about 06/10/2021, R5 received an injury from R6 due to lack of supervision. Four (4) out of the four (4) staff interviewed confirm R5 did receive an injury from R6. Four (4) out of the four (4) residents interviewed deny this allegation. LPA reviewed Unusual Incident/Injury Report (LIC 624) dated 06/10/2021 which documented the alleged burn to R5’s hair by R6. R5 refused medical treatment. LPA was able to verify local law enforcement was called on 06/10/2021 and R6 did not return to facility after 06/10/2021. R5 has since passed away and R6 was transferred to another facility to better meet needs and services. LPA could not locate R6 and was unable to interview. LPA Ramirez was able to obtain DA Case Number 41226218 and verified through the Los Angeles County District Attorney's Office that charges against R6 were not upheld. Allegation: “Resident has access to a hazardous item.” It is alleged on or about 06/10/2021, R6 had access to a hazardous item that caused injury to R5. Four (4) out of four (4) staff deny this allegation however, staff did acknowledge that residents in care do smoke cigarettes and require a lighter to light their cigarettes. S2 denied facility staff had prior knowledge that R6 would use or could use a lighter in a hazardous way on or around 06/10/2021. LPA could not locate any pertinent documentation that suggested R6 could not safely possess lighter while in care. Allegation: “Staff did not safeguard resident's personal belongings.” It is alleged on or about 06/10/2021, R6 stole items from R5’s room. Four (4) out of the four (4) staff interviewed denied this allegation. Four (4) out of the four (4) residents interviewed denied this allegation. LPA could not locate any pertinent documentation to support this allegation. Allegation: “Resident does not have access to the bathroom.” It is alleged on or about 06/10/2021, R5 was unable to access restroom due to R6 locking door and prohibiting access to R5. Two (2) out of the four (4) staff interviewed denied this allegation. S1 acknowledged R6 and R5 had a “Jack and Jill Bathroom” and R6 did lock the bathroom door so R5 would not walk in while R6 was occupying the restroom. According to S4, staff reminded R6 to unlock connecting bathroom door so R5 may gain access. Four (4) out of the four (4) residents interviewed deny this allegation. According to S1, this incident only occurred once and was addressed immediately. LPA could not find any other supporting evidence to suggest this allegation continued or occurred after R6 was addressed. 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2023 · control 28-AS-20210614155032

Allegation investigated: Resident caused injury to another resident due to staff's lack of supervision

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at 10:35 am. Upon arrival LPA Smith observed Resident #1 (R1) as they headed from residential bungalow area to the main facility. LPA observed R1 grabbing hold of a parked vehicle for balance and then hold side of wall as they entered the facility. LPA met with Administrator at approximately 10:45 am and disclosed purpose of visit. During initial visit on 01/09/2023, LPA Smith conducted tour of physical plant, requested documents relevant to the investigation, conducted interviews with staff and interviewed R1. Resident caused injury to another resident due to staff's lack of supervision It was alleged that a resident caused injury to another resident due to staff's slack of supervision. Interviews with ten (10) out of ten (10) staff reveal that there is staff supervising dinning areas and other common areas within the facility. Unsubstantiated (Cont. From 9099) Four (4) out of ten (10) staff reveal when meals are being served the food servers are monitoring the dining area. Interviews with five (5) out of (5) residents revealed that they have supervision in dining room and in common areas. Interview with R1 revealed that they sometimes see staff in the dining room but not always. R1 also revealed that even though they use a walker they are ambulatory and can balance with arms out to the side. Interview with Resident #2 (R2) they have not pushed or harmed R1. R2 states tapped R1 on arm to request room for their walker and then R1 lost balanced and fell as R1 does not use their walker all the time. R2 states they have Multiple Sclerosis (MS) and need to have room when using their seated walker. Physician’s reports reveal R1 has severe hip arthritis and poor balance directly related to their hip arthritis and R2 physicians report reveal R2 has MS. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 28-AS-20230104081859

Allegation investigated: Licensee does not ensure facility doors are kept in good repair Licensee allows residents to access hazardous area on facility premises

On 03/15/2023 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegations. LPA Agard was met first by Alise Nazarian, Assistant Administrator, and then by Peter Babaian, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. The investigation consisted of the following: On 02/01/2023, LPA toured the physical plant. LPA requested the following records: 1) staff roster, 2) resident roster. All records were received at the time of visit. cont on 9099 Unsubstantiated The investigation revealed the following: Regarding the allegation… Licensee does not ensure facility doors are kept in good repair. It’s being alleged the facility has a back door that is in disrepair and is being locked with use of a cord tied around the door handles from the inside of the building. LPA interviewed 5 out of 54 residents in total. 1 out of 5 confirmed the allegation. R2-5 all denied the allegation. Agreeing that they have no issues going in and out of the facility nor observing the facility doors to be obstructed. During interviews with staff, LPA Agard interviewed 2 out of 16 in total. 0 out of 2 were able to confirm the allegation. S1 states, “the doors are not broken, blocked off, tied or locked to the residents.” S2 states, “there are no issues with the doors. They are never tied locked because the residents need to be able to come in and out of the main building.” Regarding the allegation: Licensee allows residents to access hazardous area on facility premises. It’s being alleged the facility has a vacant cottage that is currently vacant due to fire damage. The vacant cottage is currently not being locked which is a safety concern as other residents could potentially enter the unsafe building.” 1 out of 5 confirmed the allegation. R2-5 denied going to this area of the facility grounds or observing any other residents go into these premises. R4 states, “there is no reason for us to go in there… there is nothing in there. It had a fire and we know not to go in there.” During interviews with staff, 0 out of 2 confirm the allegation. S1 states, “Residents are not allowed in there and if they go in there it is without our permission. As you can see it’s blocked off. There is no furniture in the building so no one should be in there.” S2 states, “We have architects that are accessing the building, but no residents go inside there. The insurance company is about to start repairs.” During a facility tour, LPA Agard did not observe any facility doors to be in disrepair. LPA did observe a set of facility doors held open by bricks. LPA observed the concrete below that door seal to be too low to use a pull-down door stop. LPA advised the facility Administrator to obtain a thick rubber door stop to hold doors in place as an alternative. LPA observed cottage to be vacant and blocked off for usage. LPA also observed yellow caution tape. Based on LPA’s observation, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Mar 15, 2023 · control 28-AS-20230130154427

Allegation investigated: Lack of supervision resulting in resident causing injury to another resident in care. Resident has access to a hazardous item. Staff did not safeguard resident's personal belongings. Resident does not have access to the bathroom.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit stemming from initial 10-day complaint visit conducted on 06/22/2021, by LPA’s Luis Mora and David Sicairos. LPA Ramirez met with Administrator Peter Babaian and explained the reason for the visit. The investigation consisted of: LPA reviewed the allegations with Administrator Peter Babaian. LPA requested and obtained copies of Register of Facility Clients/Residents (LIC 9020), Personnel Report (LIC 500), Unusual Incident/Injury Report (LIC 624), and other pertinent documentation regarding this investigation. LPA conducted four (4) Staff (S1 – S4) and four (4) Resident (R1- R4) interviews and attempted interviews of Residents (R5 – R6). See 9099-C for continuation… Unsubstantiated Allegation: “Lack of supervision resulting in resident causing injury to another resident in care.” It is alleged on or about 06/10/2021, R5 received an injury from R6 due to lack of supervision. Four (4) out of the four (4) staff interviewed confirm R5 did receive an injury from R6. Four (4) out of the four (4) residents interviewed deny this allegation. LPA reviewed Unusual Incident/Injury Report (LIC 624) dated 06/10/2021 which documented the alleged injury to R5 by R6. LPA was able to verify local law enforcement was called on 06/10/2021 and R6 did not return to facility after 06/10/2021. LPA was unable to interview R5 and R6. Allegation: “Resident has access to a hazardous item.” It is alleged on or about 06/10/2021, R6 had access to a hazardous item that caused injury to R5. Four (4) out of four (4) staff deny this allegation however, staff did acknowledge that residents in care do smoke cigarettes and require a lighter to light their cigarettes. S2 denied facility staff had prior knowledge that R6 would use or could use a lighter in a hazardous way on or around 06/10/2021. LPA could not locate any pertinent documentation that suggested R6 could not safely possess lighter while in care. Allegation: “Staff did not safeguard resident's personal belongings.” It is alleged on or about 06/10/2021, R6 stole items from R5’s room. Four (4) out of the four (4) staff interviewed denied this allegation. Four (4) out of the four (4) residents interviewed denied this allegation. LPA could not locate any pertinent documentation to support this allegation. Allegation: “Resident does not have access to the bathroom.” It is alleged on or about 06/10/2021, R5 was unable to access restroom due to R6 locking door and prohibiting access to R5. Two (2) out of the four (4) staff interviewed denied this allegation. S1 acknowledged R6 and R5 had a “Jack and Jill Bathroom” and R6 did lock the bathroom door so R5 would not walk in while R6 was occupying the restroom. According to S4, staff reminded R6 to unlock connecting bathroom door so R5 may gain access. Four (4) out of the four (4) residents interviewed deny this 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 6, 2023 · control 28-AS-20210614155032

Allegation investigated: Resident sustained a bruise while in care Facility staff did not seek timely medical care for resident Staff are locking the fire exit doors Facility did not keep hot water temperature within allowable range. Facility staff are harassing resident Facility not upholding resident's admission agreement Facility's auditory signal system is not working properly

Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent complaint visit to deliver investigation findings for the above stated allegations. LPA met with Assistant Administrator Alise Nazarian and explained the reason for the visit. The investigation consisted of: During the initial visit conducted on 3/3/21, LPA conducted a telephone interview with Administrator Peter Babaian, Staff Martha Marcheque, Staff Maria Lacayo and Staff Jorge Perez. LPA requested/ received copies of Staff and Resident Rosters. On 03/15/22, LPA conducted interviews with Administrator Peter Babaian, Assistant Administrator Alice Nazarian, Staff 1 (S1) and Residents 1-5 (R1-5). LPA requested and received copies of Staff and Resident Rosters. LPA reviewed R1's file and obtained copies the following documents: Admission Agreement, Resident Appraisal dated 1/1/21, Identification and Emergency Information dated 3/5/21, Physician's Report for Residential Care (See LIC9099C for continuation) Unsubstantiated Facilities for the Elderly (RCFE) LIC602A dated 5/19/21, Appraisal/ Needs and Services Plan dated 1/1/21 and 1/1/22, Two letters addressed to R1 dated 3/10/22 and 3/15/22, Unusual Incident/ Injury Report LIC624 dated 2/28/22 and 3/25/21. LPA also conducted a tour of facility which included observations of common areas, lobby, Resident Cottage 1511 and bathroom. LPA tested water temperature and observed a reading of 111F. On 02/27/23, LPA collected copies of Staff/ Resident Rosters, reviewed 5 Resident files and collected copies of documents pertinent to the investigation. LPA conducted a tour of facility which included observations of common areas, facility lobby/ main entrance, all facility exits, Resident Cottages 1511 and 1515, designated smoking area and random resident rooms. LPA tested the water temperature in resident bathrooms and observed readings between 108F to 111F. LPA additionally observed and tested the signal system switches and tested the signal systems in random resident rooms. Investigation revealed the following: Regarding allegations, Resident sustained a bruise while in care and Facility staff did not seek timely medical care for resident, it is alleged a facility resident (R3) pushed another facility resident (R1) in the facility lobby in front of Facility Staff, Martha Marcheque. It is alleged that this incident occurred in October 2020 and that Staff Martha Marcheque took pictures of R1's bruised hip. R1 was allegedly not taken to see their doctor and R1 is currently limping from the pain on their hip. Interviews conducted with facility administrator, Staff Martha Marcheque and additional facility staff revealed that there was not an incident in which R3 pushed R1. Staff Marcheque denies that she witnessed R3 push R1 on or around October 2020 or at any other time and also denied taking pictures of R1’s hip area. Staff stated that if any facility resident suffers a fall or has any type of accident, facility staff will immediately provide affected resident(s) with first aid and if a higher level of care is needed, they will transport the resident to the hospital, urgent care or take the resident to their primary physician. R3 denied pushing R1. LPA reviewed facility Unusual Incident/ Injury Report LIC624s from October 2020 to present and did not observe a report of any altercation between R1 and R3 resulting in an injury to R1. Interviews conducted with 4 out of 5 residents revealed that they have not observed any resident push another facility resident and they also stated that if they need timely medical care it is provided to them. Based on interviews conducted with facility staff, residents and LPA record review, there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff are locking the fire exit doors, it is alleged that there are five fire exits at the facility that are locked by facility staff and residents cannot use them as fire exits. Interviews with facility staff revealed that facility exits are not locked and stated that facility exit doors are accessible for residents and staff when needed. Administrator stated that fire drills are conducted every 3 months and stated that since the investigation of Complaint Control #: 28-AS-20200623152228, staff are no longer locking any doors. He stated that during the height of the COVID19 pandemic the front door was being locked but they are no longer doing that. Interviews conducted with 4 out of 5 residents revealed that they have not observed that any of the facility doors are locked and stated that they are able to use facility exit doors. 1 resident stated that in June 2020, CCLD had Substantiated an allegation of Staff are locking the main entrance door. LPA observations revealed that facility exit doors are not locked and LPA reviewed fire drill report dated XX/XX/22. Based on interviews conducted with facility staff, residents, LPA observations and record review there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility did not keep hot water temperature within allowable range, it is alleged that faucet water in resident’s restroom takes a long time to heat up and once the water does heat up the water is then too hot for residents to use. Interviews with staff revealed that facility water temperature is kept with Title 22 regulations of 105 -120 F. Staff stated that water heats up at an adequate time and does not take a long time to heat up. Staff deny that once the water heats up it then becomes too hot for residents use. Interviews with 4 out of 5 residents revealed that they are satisfied with the water temperature at the facility. They stated that the water never gets so hot that they cannot use it. LPA tested the water temperature in 3 resident bathrooms and observed that the temperatures were within Title 22 regulations. Water temperature tested between 105 – 120 degrees Fahrenheit. Based on interviews conducted with facility staff, residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility staff are harassing resident, it is alleged that two facility staff, Jorge Perez and Maria Lacayo, harass R1 multiple times by telling R1 to "hurry up" while R1 is limping in the facility hallways. Interviews conducted with facility staff, Jorge Perez and Maria Lacayo revealed that they do not harass R1 or any other facility resident. Staff Lacayo and Perez deny ever telling R1 to hurry up while R1 is walking around in the facility. They stated that the facility hallways are large enough to give residents space to walk while the staff are tending to their duties. Administrator and facility staff deny that facility staff harass R1 or any other facility resident and stated that staff always treat all facility residents with respect. Interviews conducted with 4 out of 5 residents revealed that staff do not harass them and have not seen staff harass R1. LPA observed staff interacting with facility residents including R1 and did not observe staff harass any facility resident. Based on interviews conducted with facility staff, residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility not upholding resident's admission agreement, it is alleged that the facility is not upholding the admission agreement by allowing R3 to smoke in their room instead of the assigned smoking area(s). Interviews conducted with facility administrator and Staff revealed that residents that smoke are only allowed to smoke in the designated smoking areas and at no time are ever allowed to smoke in their rooms. Staff stated that there are some residents that do smell like smoke when they come into the facility after smoking but are never allowed to smoke inside the facility or their bedrooms. Administrator stated that the facility upholds resident’s admission agreements at all times and stated that if a resident is not adhering to or breaking any facility rules proper follow up and action will be taken. Interviews conducted with 4 out of 5 residents revealed that they have not seen any facility resident smoke inside the facility bedrooms and stated that people that smoke do so in the designated smoking areas. 1 out of 5 residents denied smoking in their room and stated that they only smoke in the designated smoking area. LPA observed residents smoking in designated smoking areas during the tour and did not observe any resident smoking in a nonsmoking area. Based on interviews conducted with facility staff, residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility's auditory signal system is not working properly, it is alleged that the auditory signal from the signal system at the facility has not been working and/or the noise is very low that staff cannot hear it. Residents only get assistance by walking to the main lobby and tracking staff down. Interviews conducted with Administrator and facility Staff revealed that the facility’s auditory signal system is working properly. They stated that resident bathrooms have a signal system/ pull cord. Staff interviews also revealed that some of the signal systems function either by a cordless switch or a switch that has a cord integrated. Interviews with 4 out of 5 residents revealed that they are aware as to how the signal switches and cords operate and stated that the signal system is properly working. LPA toured the facility bathrooms, observed and tested the signal system switches. LPA also observed and tested the signal systems in random resident rooms. All tested signal systems were operable. Based on interviews conducted with facility staff, residents, and LPA observations, there was not enough supportive evidence to concur with the reported 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. Exit interview held. A copy of the report was provided to Assistant Administrator Alise Nazarian.the state’s words, verbatim · CDSS document, Feb 27, 2023 · control 28-AS-20210301151101

Allegation investigated: Staff inappropriately completed resident's Physician Report Resident is not notified to participate in care plan

On 01/25/2023 Licensing Program Analyst (LPA) Troy Agard conducted an initial complaint investigation at the above facility to address the following allegations. LPA Agard was met first by Alise Nazarian, Assistant Administrator, and then by Peter Babaian, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. The investigation consisted of the following: LPA toured the physical plant. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA requested the following records: 1) staff roster, 2) resident rosters, 3) needs and services plan for R1, 4) physician report for R1. All records were received at the time of visit. cont on 9099C Substantiated The investigation revealed the following: Regarding the allegation… Staff inappropriately completed resident's Physician Report. It’s being alleged the facility is completing sections of the physician report that should be completed by the resident or physician. LPA interviewed 5 out of 54 residents in total. 1 out of 5 confirmed the allegation. R2-5 all state not being aware of the allegation, their physician’s report or a combination of both. R2 states, “I don’t know what a physicians report is and have never seen one so I can’t say.” R4 states, “I’ve never seen that form but why would I need it. I don’t know about the allegation.” R1 states, “they don’t follow the direction of how to fill out the form. When I was given the form, it was not blank. They fill in a lot of things that were supposed to be left blank. I notice the licensee is S2, but it supposed to be the Limited Liability Company (LLC) and not a person.” During interviews with staff, LPA Agard interviewed 3 out of 16 in total. 0 out of 3 were able to confirm the allegation. S1 states, “we usually give R1 a blank form to give to their doctor and bring it back completed.” S2 states, “physician reports we don’t touch. R1 takes it and brings it back.” R3 states, “I complete the top section like height, weight and blood pressure. The back pages are completed by the doctor.” Regarding the allegation: Resident is not notified to participate in care plan. It’s being alleged the facility is not notifying residents about their needs and services plan meetings. 4 out of 5 confirmed the allegation. R2-4 were all unable to confirm they have participated in the collaboration of creating their needs and services plans. R2-4 were all unaware of what the needs and services plan was prior to LPA explaining it and what the plan entails. R1 states, “they haven’t been doing that over the years. They are supposed to do it yearly or if a significant change happened. They haven’t been coming to me and they haven’t been doing the interviews.” During interviews with staff, 2 out of 3 confirm the allegation. “S1 states, R1 never asked to be a part of it.” R3 states, “I complete the LIC 625. It depends on the resident. Some are smart and alert about what I’m asking. Some of them don’t understand or don’t want to talk. It depends on the resident. S1 does the report for R1.” During a record review, LPA Agard observed parts of a physician’s report dated January 2023, that was given to the resident for completion, to be inaccurate or some sections were completed by the facility that should have been completed by the doctor. LPA observed no changes to these sections, but the facility has reported changes to resident’s overall health and ability to ambulate. Thus, making the pre-fill physicians report inaccurate. Based on interviews conducted, LPA observed and interviewed some residents that have the capability of participating in their needs and services plan be completely unaware of the document’s existence or purpose. Residents were not able to confirm having a needs and services meeting annually or as needed. Based on the interviews with staff, residents and a 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) and Chapter (8) are being cited on the attached LIC9099-D. An exit interview was conducted, and a hard copy was provided with appeal rights. See LIC 9009-D on the next pagethe state’s words, verbatim · CDSS document, Jan 25, 2023 · control 28-AS-20230123083331

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(e) · Plan of correction due date: Feb 23, 2023

Personal Rights At the request of the Department, and immediately if the request is made during an inspection, a licensee shall provide the Department with a confidential list of residents that includes the language(s) read by each resident, which is to be kept confidential to the extent permitted by law. This list shall be maintained in an accurate and current status at all times. This requirement was not met as evidence by: based on record review, sections of the LIC 602 was completed by the facility that should have been completed by the resident or physician. This poses a potential risk to clients in carethe state’s words, verbatim · CDSS document, Jan 25, 2023

Plan of correction: Facility will discontinue completing sections of the LIC 602 and obtain an updated copy of R1’s physician report. The report must be completed by R1’s Physician. Proof of correction must be sent to LPA via fax or email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87467(a)(3) · Plan of correction due date: Feb 23, 2023

Resident Participation in Decision-making: The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement was not met as evidence by: Based on interviews conducted: Residents have not been participating in the needs and services plan assessments. This poses a potential risk to clients in care.the state’s words, verbatim · CDSS document, Jan 25, 2023

Plan of correction: Facility will conduct a review of the needs and services plan with R1 collaboratively and any resident with the capability moving forward. Facility must submit an updated plan for R1 via fax or email by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of conducting the required annual inspection, using the Infection Control tool to evaluate the facility. LPA Maldonado met with staff Amy Smbatuni and explained the purpose for the visit. LPA conducted a tour of the physical plant with Amy, observed the food supplies, COVID-19 procedures, and reviewed resident and staff files, and resident's medications. The facility has an approved mitigation plan on file. Assistant Administrator Alise Nazarian and Administrator Peter Babaian arrived shortly after to assist with the visit. The facility is a one-story building located in a residential area. It is licensed to serve (60) elderly residents, ages 60 and over, of which (49) may be non-ambulatory and (4) may be bedridden in rooms# 11 and #28 only. The property also has (2) cottages, #1511 & #1515 reserved for ambulatory residents only and has a hospice waiver approved for (6). The building consists of a living room, kitchen, dining room, 29 resident bedrooms with restrooms, common showers and bathrooms with required grab bars and non-skid mats, a laundry room/storage located in the basement, and a shaded patio in the backyard with seating. The cottages are located across the back yard and each have 4 bedrooms with a shared bathroom/shower, which had the required grab bars and non-skid mats. LPA observed resident bedrooms# 4, 7, 23, and 29 to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. Each room had a bathroom and were observed to have a toilet with the required grab bars and a wash basin. The water temperature was tested in the bathrooms of each room observed and in cottage# 1511, and measured between 113*F-119*F, which is in compliance with Title 22 Regulations. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. During the food inspection, LPA observed several canned food items to have expiration dates of October 2022- December 2022, and some of those cans appeared inflated and others were popped and spilling. Staff stated were unaware as some of the food had just arrived in their recent food delivery from the company they regularly order from. (Report continued on LIC809-C...) Several fire extinguishers were observed throughout the building and in the cottages to have current inspections and were fully charged. All sharps were observed to be locked and inaccessible in the kitchen. Cleaning supplies were locked and inaccessible, stored in cabinets in the basement and in a storage shed in the back yard. All laundry and kitchen equipment was operational and in good repair. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit. LPA observed a 30-day supplies of Personal Protective Equipment (PPE) stored in the basement, storage shed in the backyard, and in a hallway closet. Siganage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing. Communal hand washing stations were fully stocked with liquid soap and automatic hand dryers. Resident handwash sinks, located in their room bathrooms, were observed to not have liquid soap or paper towels- they had cloth towels and bar soaps. There is one central entry point for universal entry screening, as required by the COVID-19 guidance. (5) random resident files were reviewed and had updated emergency contact information and health screenings. (3) random staff files were reviewed and had Criminal Background Clearances, health screenings, and proof of required annual training and certifications. (5) resident medications were reviewed and are documented properly and administered as prescribed. Per California Code of Regulations, Title 22, and Health and Safety Codes, deficiencies were observed and will be cited on the LIC809-D. An exit interview was conducted with Administrator Peter Babaian and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 20, 2023

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: Staff do not follow COVID-19 protocol

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Peter Babaian and explained the reason for the visit. LPA conducted physical plant tour at 9:45 AM, requested facility documents at 10:10 AM and interviewed residents and staff between 10:30 AM to 1:10 PM. LPA's observation during physical plant tour between 9:45 to 10:10 AM revealed that the staff are wearing masks even the contractors working inside the facility and all Covid posters are posted all over the facility including the main entrance door. LPA also observed that the facility has 30 day supplies of PPE in their storage. LPA was screened during entrance. LPA also observed that there were hand sanitizers installed along the hallways of the facility and in the Cottage alone, there were three (3) working hand sanitizers installed. Further, all common bathrooms have liquid hand soap and a working hand dryer installed. LPA's interview with five (5) residents or 10% of the current census also revealed that they were provided all hygiene supplies by the facility regularly. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 27, 2022 · control 28-AS-20221221141050

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ashley Calderon conducted a unannounced case management visit in relation to an fire damage that was reported to Community Care Licensing. Upon arrival, LPA met with LVN Amy Smbapuni and explained the purpose of the visit. Shortly after, the Administrator Peter Babaian arrived and assisted with the visit. On today's visit, LPA interviewed Administrator, staff #1(S1), resident #1 (R1) and interviewed repair contractor via telephonically. LPA toured the cottage building number #1511 with Amy and observed cottage was locked and inaccessible to the residents. LPA observed no residents were living in the cottage and all residents based on interview with Babaian and Smbapuni were relocated to the main building the day fire incident that occurred on 11/02/22. LPA collected supportive documents: Insurance Company Claim documentation, RestCon Environmental of Southern California and VIC's Inc CA Contractor. Administrator stated on 11/02/22 Fire Department came to put out the fire meanwhile staff safety removed all residents and used the fire extinguisher to help control the fire. Administrator stated no residents or staff members were injured. Administrator reported that a total of six residents were relocated and five rooms are inaccessible until repairs are completed for the health and safety of the residents .In addition on 11/02/22, Glendale Community Development Building and Safety placed a unauthorized entry sign in front of the cottage building and sign states the structure / site has been damage and is unsafe. On 11/03/22, Glendale Fire Department Specialist Eric Briggs toured the cottage to investigate how the fire occurred, no report was provided. Administrator stated on 11/7/22, a repair contractor named Jacob Harold from Four Seasons Remolding and Design provided and estimate on repairs needed. Administrator stated repairs will start once Insurance Company Carrier called Seneca Insurance Company completes the investigates on the open claim #22KKN026 which is in progress. No deficiencies observed during the visit. Exit interview conducted and a copy of the report was provided to administrator Peter Babaian.the state’s words, verbatim · CDSS document, Dec 22, 2022

Allegation investigated: Facility staff locked resident out of facility.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit at the facility for the purpose of investigating the above-mentioned allegation. LPA Maldonado met with assistant administrator Alise Nazarian and explained the purpose for the visit. During the visit, LPA Maldonado requested a copy of the resident and staff roster. LPA also interviewed Staff#1-3 (S1-S3) and Residents# 1-5 (R1-R5). The investigation revealed the following: (Report continued on LIC9099-C...) Unsubstantiated Regarding allegation- Facility staff locked resident out of facility. It is alleged that R1 was locked out of the facility in the patio area by S3 for a total of 5 minutes, while S3 mopped. In interviews conducted with S1-S2, it was stated they have no knowledge of the incident occurring, as it was not witnessed, nor reported. During the interview conducted with R1, R1 states the incident was not reported to staff as a complaint had already been filed with Licensing and R1 did not want to hinder the investigation that would later occur. When asked about the incident, S2 denied the allegation stating R1 is a problematic resident who reports false allegations and is trying to make S3 seem like a bad person. During interviews conducted with R1-R5, (4) of (5) residents denied witnessing the R1 being locked outside in the patio. (4) of (5) residents also denied witnessing S3 locking R1, or any other resident, out of the facility. LPA observed and inspected the sliding door that leads to the patio where R1 alleges to have been locked and tried to lock the door. LPA found that the lock on the door is difficult to close, after trying multiple times to lock it with one hand. LPA had to use 2 hands to position the door to where it would lock correctly. Based on LPA's interviews and observations, the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during today's visit. An exit interview was conducted with Alise Nazarian and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 15, 2022 · control 28-AS-20221208095540

Allegation investigated: Staff failed to address resident hitting another resident.

***This report supersedes the one dated 10/13/22 to correct the regulation code issued.*** Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA met with Assistant Administrator, Alise Nazarian, and explained the purpose of the visit. LPA obtained copies of the staff roster, resident roster, staff training log, and documents pertaining to Resident #1. LPA interviewed the Administrator, 4 Staff, and 6 Residents. Regarding allegation – Staff failed to address resident hitting another resident. It is alleged that the Administrator nor staff checked on the residents after Resident #1 (R-1) hit Resident #2 (R-2). Per the Administrator, he was not aware of the incident until yesterday when it was reported by the staff. According to staff interviews, they believe the incident was or should be reported by the staff on duty who has/have knowledge about it right away to the Administrator. However, this was not done. Substantiated All 4 Staff heard about the incident the following day from other residents, but assumed it was reported to the Administrator. 3 out of 4 Staff stated that R-1 can be verbally aggressive towards staff and residents and had arguments with other residents. They said that the incidents involving R-1 were reported to the Administrator but not sure if anything was done about them. Administrator Babaian acknowledged that R-1 has difficulty getting along with some Staff and some residents. R-1 can be loud and verbal which may appear to be disruptive in the facility. He had spoken to R-1 about the tone of voice being used and given verbal warnings. No written warnings had been issued yet until the Administrator completes his investigation of this incident. LPA interviewed 6 residents today. R-1 denied getting aggressive or hitting R-2 sometime last week. R-2 reported that resident was hit in the face by R-1 last Thursday. 2 residents witnessed the incident and saw R-1 swinging at R-2 repeatedly, but was not sure if R-2 was hit in the face. They stated the staff on duty heard the commotion but did not intervene nor checked on the residents. Some of the staff and residents do not feel safe with R-1’s increase of aggressive behavior. Based on interviews conducted, 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. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 30, 2022 · control 28-AS-20221006090702

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 7, 2022

87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews, Staff did not report R-1's aggressive behavior to the Administrator which poses a potential health and safety and personal rights to residents in care.the state’s words, verbatim · CDSS document, Nov 30, 2022

Plan of correction: The Administrator shall conduct a staff training to ensure the proper protocol to take when they hear or witness a resident on resident altercation. This log shall be submitted to LPA by POC due date 12/7/22.

Allegation investigated: Facility staff did not clean up feces on floor of the facility.

Licenising Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint visit to the above facility. LPA Calderon met wirh Alise Nazarian, assistant administrator and discussed the purpose of todays visit. LPA Calderon and Alise toured the common areas of the physcial plant, toured main facility and the two cottages on premesis.LPA Calderon collected staff and residents roster, and interviewed resident and staff. Continuation on 9099C... Unsubstantiated ***This is an amended report*** Today's investigation revealed the following. In regards to the allegation facility staff did not clean up feces on floor of facility. It was alleged that in the cottages a resident appeared to be smearing feces and facility should be afforded safe, clean and comfortable accommodations. LPA toured with Alise Narzarian the cottage building, the hallways, common spaces and observed the facility was clean and sanitary. LPA Calderon interviewed staff and residents. 5 out of 5 staff who were interviewed stated the facility is cleaned every day. 4 of 5 staff interviewed denied the allegation and stated they were not aware of the incident stated in the allegation in regards to feces on the floor. S3 stated it was brought up to S3's attention that a resident mentioned that there was feces being smeared on the floor in the cottage building and S3 told housekeeping staff to see if cleaning is needed. S3 did not observe feces on the floor. LPA Calderon interviewed S4 and S5 both denied being aware of cleaning the feces and being aware of the incident. 5 out of 5 residents during interviews with LPA denied seeing feces on the floor. R3 stated a resident did tell R3 about the feces on the floor and when R3 looked in the area that the feces was allegedly at, R3 did not observe any feces on the floor. R1 stated seeing a resident on the floor which appeared to be smearing stuff on the floor but R1 was not sure what is was and if it was feces. R1 stated there was no odor. 5 out of 5 resident stated the facility is kept clean, and cleaning happens regularly. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. A copy of this report will be emailed to Peter Babaian, signature will be on hard copy.the state’s words, verbatim · CDSS document, Nov 3, 2022 · control 28-AS-20221028142050

Allegation investigated: Staff are not providing privacy for when using the phone.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint visit to the above facility. LPA Calderon met with Alise Nazarian, assistant administrator and discussed the purpose of todays visit. LPA Calderon and Alise toured the physical plant to locate telephones used for residents. Telephones are located in 3 different areas in the facility. One pay phone in the outside patio , second payphone in the cottage located in the 1511 building and a wireless phone located in the front desk area. LPA Calderon collected staff and residents roster, House Rules /Admission Agreement packet regarding telephone policy. LPA conducted interviews for both resident and staff. Continuation on 9099C... Unsubstantiated *** This is amended report. *** Today's investigation revealed the following. In regards to the allegation: Staff are not providing privacy for when using the phone. Interviews conducted with residents showed that 5 out of 5 residents stated that there is no problem with privacy when using phone. 3 out of 3 residents stated they have their own phones and facility provides places for privacy and have had no phone use privacy issues. When interviewing staff 4 out of 5 staff said residents have areas to use phone for privacy within the facility. S3 stated facility has a cordless phone for residents to use in certain areas like resident rooms, patio, and lounge areas to provide privacy while using the phone. During interviews, S3 stated the cordless facility phone is the facility property, resident when using facility phone should remain on facility premises because of safety concerns , and if privacy is needed resident can communicate with staff and staff will provide privacy options. S1 stated in regards to phone privacy, phones within the facility for residents to use are all in locations were privacy is provided . LPA reviewed the facility House Rules in regards to the phone policy and on page 6 it states: The facility phone is available to residents if they do not have their own phone to making and receiving calls. LPA Calderon with Alisa Nazarian toured facility to locate facility phones that are available for residents. LPA observed phone locations are in areas were privacy is provided. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited. A copy of this report provided to Peter Bababian via email, signature on hard copy.the state’s words, verbatim · CDSS document, Nov 3, 2022 · control 28-AS-20221026113558

Allegation investigated: Staff failed to address resident hitting another resident.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA met with Assistant Administrator, Alise Nazarian, and explained the purpose of the visit. LPA obtained copies of the staff roster, resident roster, staff training log, and documents pertaining to Resident #1. LPA interviewed the Administrator, 4 Staff, and 6 Residents. Regarding allegation – Staff failed to address resident hitting another resident. It is alleged that the Administrator nor staff checked on the residents after Resident #1 (R-1) hit Resident #2 (R-2). Per the Administrator, he was not aware of the incident until yesterday when it was reported by the staff. According to staff interviews, they believe the incident was or should be reported by the staff on duty who has/have knowledge about it right away to the Administrator. However, this was not done. All 4 Staff heard about the incident the following day from other residents, but assumed it was reported to the Administrator. Substantiated 3 out of 4 Staff stated that R-1 can be verbally aggressive towards staff and residents and had agreements with other residents. They said that the incidents involving R-1 were reported to the Administrator but not sure if anything was done about them. Administrator Babaian acknowledged that R-1 has difficulty getting along with some Staff and some residents. R-1 can be loud and verbal which may appear to be disruptive in the facility. He had spoken to R-1 about the tone of voice being used and given verbal warnings. No written warnings had been issued yet until the Administrator completes his investigation of this incident. LPA interviewed 6 residents today. R-1 denied getting aggressive or hitting R-2 sometime last week. R-2 reported that resident was hit in the face by R-1 last Thursday. 2 residents witnessed the incident and saw R-1 swinging at R-2 repeatedly, but was not sure if R-2 was hit in the face. They stated the staff on duty heard the commotion but did not intervene nor checked on the residents. Some of the staff and residents do not feel safe with R-1’s increase of aggressive behavior. Based on interviews conducted, 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. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 13, 2022 · control 28-AS-20221006090702

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Oct 20, 2022

Personnel Requirement - General (d) All personnel shall be given on the job training...(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by: Based on interviews, Staff did not report R-1's aggressive behavior to the Administrator which poses a potential health and safety and personal rights to residents in care.the state’s words, verbatim · CDSS document, Oct 13, 2022

Plan of correction: The Administrator shall conduct a staff training to ensure the proper protocol to take when they hear or witness a resident on resident altercation. This log shall be submitted to LPA by POC due date 10/20/22.

Allegation investigated: Staff did not prevent resident from making inappropriate comment(s) to another resident. Staff did not ensure resident was provided with a seat during mealtime.

Licensing Program Analyst (LPA) V. Maldonado made an unannouced initial complaint visit at the facility for the purpose of investigating the above mentioned allegations. LPA Maldonado met with Assistant Administrator Alise Nazarian and explained the purpose for the visit. Administrator Peter Babaian arrived shortly after and assisted with the visit. During today's visit, LPA obtained a copy of the resident and staff roster, interviewed Residents #1-5 (R1-R5) and Staff #1-4 (S1-S4), and obtained copies of the following documents for R1-R5: Facesheet, Physician's Report, and Needs and Services Plan. Regarding allegation: Staff did not prevent resident from making inappropriate comment(s) to another resident. (Report Continued on LIC9099-C...) Unsubstantiated During interviews conducted with S1-S4, (1) of (4) staff stated that some residents have expressed that they do not like to have R1 around at the time they are eating because R1 smells due to poor hygiene. R1 does not comply with bathing or changing of clothes. It is noted per R1's Needs and Services Plan that R1 has refused in the past to comply with this and continues to refuse, resulting in complaints from other residents to the administrator. (3) of (4) staff interviewed denied having witnessed, or have knowledge of an incident where a resident made inappropriate comments to another resident in care. During interviews conducted with R1-R5, (4) of (5) residents denied witnessing or having knowledge of an incident where a resident made inappropriate comments to another resident in care. Regarding allegation: Staff did not ensure resident was provided with a seat during mealtime. During interviews conducted with S1-S4, (2) of (4) staff do not recall an incident where a resident was not provided with a seat during mealtime. S1 stated that S1 recalls an incident that occurred between R1 and R2 during dinner time a few weeks ago. S1 states that R1 came to S1 office to inform S1 that R2 was not allowing R1 to have a seat at the table where R2 was, although the seat was available. S1 states S1 went to the dining room to investigate what occurred and was informed by R2 that R2 did not want R1 to sit at that table because R1 "smelled". S1 states that there were other seats available for R1 to sit at, however R1 was adamant about sitting at that particular seat. S1 states S1 gave R1 the option of waiting for that table to become unoccupied if R1 really wanted that seat. S1 states S1 saw R1 go wait by the dining room entrance door and S1 left the dining room after that. S1 could not confirm if R1 sat down to have dinner after the incident. S3 stated to have witnessed the incident and states that R1 always has particular seats R1 would like to sit at, and if not possible, R1 will wait until the seat becomes available. S3 could not recall if R1 sat down to have dinner that day. During the interview conducted with R1, it was stated that the issue was not resolved by S1 as R1 would have liked. R1 states that after S1 gave R1 the option of waiting for the table to become unoccupied, R1 decided to try another table- which is the table designated for non-ambulatory residents. R1 states R1 was standing at the table and waited to be served; however the server never brought R1 food. R1 stated that after 2 attempts of trying to sit to have dinner, R1 decided to leave and not have dinner at all. During interviews with R1-R5, (3) of (5) residents stated to to not recall such incident where a resident was not provided a seat during mealtime. (1) of (5) residents stated to recall the incident, but could not confirm whether R1 was sat or was provided a seat during mealtime. 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. Per Title 22, California Code of Regulations, no deficiencies were cited during today's visit. An exit interview was conducted with Administrator Peter Babaian and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 11, 2022 · control 28-AS-20221003114934

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Wong conducted a unannounced case management visit in relation to complaint #28-AS-20220628163253. Upon arrival, LPA met with LVN Amy Smbapuni and explained the purpose of the visit. Shortly after, the administrator Peter Babaian arrived and assisted with the visit. On today's visit, LPA interviewed administrator, three staff and five residents and all residents report no staff ever hit or pushed any residents in the facility or they never witnessed any staff hit residents in the facility. All residents also indicated staff would never leave them alone in shower or during diaper change. Administrator also reported that there's no way staff would leave resident alone in shower or diaper changing. Administrator stated that he's always on top of these type of work behaviors and he would not allow these things happened in the facility. Administrator also reported he did realize the personnel conflicts between S1 and S2 and other coworkers too. Administrator did try his best to work with them but he cannot please every coworkers. And staff also have their own characters and thoughts. No deficiencies observed during the visit. Exit interview conducted and a copy of the report was provided to administrator Peter Babaian.the state’s words, verbatim · CDSS document, Sep 21, 2022

Allegation investigated: Staff member yells at residents.

Licensing Program Analyst (LPA) Elizabeth Irra conducted an intial 10-day complaint visit to investigate the above allegation. LPA met with Alise Nazarian (Assistant Administrator) and discussed the purpose of today's visit. Peter Babaian (Facility Administrator) arrived at approximately 10:10 A.M.. During this investigation, LPA ontained a copy of the staff roster, resident roster, sign-in sheet for resident rights/bullying training (dated 08/08/22), a letter dated April 27, 2022 issued to S-4 (written warning) and reviewed S-4's file . LPA interviewed the Assistant Administrator, Facility Administrator, Staff #1 through Staff # 4 (S-1 through S-4) and interviewed Resident #1 through Resident #5 (R-1 through R-5). Refer to LIC 9099C for the continuation of this report. Substantiated Allegation: Staff member yells at residents. (4) ouf of (6) interviewed staff indicated they have either witnessed or have received reports in regards to S-4 yelling at residents. Facility Administrator indicated S-4 was given a written warning in regards to S-4's behavior (verbal abuse) and tardiness on April 27, 2022. (2) out of (6) interviewed staff indicated S-6 does not yell and is "just loud". (4) out of (5) interviewed residents indicated S-4 yells at residents. Staff and resident interviews corroborates this allegation. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. Exit interview conducted, a copy of Appeal Rights and a copy of this report was provided to Peter Babaian.the state’s words, verbatim · CDSS document, Sep 2, 2022 · control 28-AS-20220826152859

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 5, 2022

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This standard is not met as evidence by: (4) ouf of (6) interviewed staff indicated they have either witnessed or have received reports in regards to S-6 yelling at residents. (4) out of (5) interviewed residents indicated S-6 yells at residents.the state’s words, verbatim · CDSS document, Sep 2, 2022

Plan of correction: Facility Administrator provided staff training on Resident Rights on 08/08/2022 (copy provided). Facility Administrator to provide a written statement in regards to actions that will be taken pertaining to S-6. Written statement to be provided to LPA Irra by POC due date. Civil Penalties issued (repeat violation).

Allegation investigated: Facility did not properly reappraise the resident.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Asst. Administrator (A2) and was later met by Administrator (A1) Peter Babaian. LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of today's visit is to conduct a subsequent visit and to deliver the findings pertaining to the above-mentioned allegation. An initial 10-Day visit was conducted by LPA Nicol Wesley on 01/19/22. LPA/RA Ceniceros interviewed (between 9:50 a.m - 10:15 a.m.) two (2) staff members and one (1) resident in care. LPA/RA reviewed and requested pertinent documentation: Admissions Agreement (updated 01/31/13) Emergency I.D. & Information (updated 04/22/22), Physician's Report (dated 04/19/22), Appraisal/Needs & Services Plan (updated 01/01/21) for Resident #1. Unsubstantiated Regarding Allegation #1: this investigation revealed that Resident #1 is ambulatory with reduced mobility currently which is due to severe right-hip arthritis. A review of the resident's Physician's Report (dated 04/19/22) by the primary care physician (PCP) documents that Resident #1's diagnosis are "none" for first and secondary diagnosis. Interviews conducted corroborated that Resident #1 is walking around without any assistance but poor balance is noticeable and the resident is using a walker. A review of Resident #1's Appraisal/Needs & Services plan (dated 01/01/21) documented that Resident #1 has seen a specialist for right-hip arthritis and is awaiting surgery. Based on the evidence gathered and interviews conducted and records reviewed, 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 of OTHER: Facility did not properly reappraise the resident is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Administrator Administrator (Peter Babaian).the state’s words, verbatim · CDSS document, Sep 1, 2022 · control 28-AS-20220110081057

Allegation investigated: Council is not being allowed to meet without a staff person present.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Asst. Administrator (A2) and was later met by Administrator (A1) Peter Babaian. LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of this visit is to conduct a subsequent visit and to deliver the findings pertaining to the above-mentioned allegation. An initial 10-Day virtual visit was conducted by LPA Nicol Wesley on 05/06/21 (via telephone) with Administrator Peter Babaian due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros interviewed (between 8:15 a.m - 9:15 a.m.) three (3) staff members and three (3) residents in care. LPA/RA reviewed pertinent documentation: Admissions Agreement, Emergency I.D. & Information, Appraisal/Needs & Services Plan, Personal Rights for Resident #1; Minutes of Resident Council Meeting. Unsubstantiated Regarding Allegation #1: this investigation revealed that the two (2) facility administrators stated that resident council meetings are usually attended by a staff member in order to take notes and pass the concerns along to management. They stated that residents are allowed to meet (without staff) and staff can leave the meeting if asked to do so. Based on interviews conducted with Resident Council Board Members, the majority corroborated that there is not a concern with a facility staff member being present during the meeting; however, it's usually not the case that facility staff member remains for the whole resident council meeting. Due to COVID-19, the formal resident council meetings were not taken place in person; however, they have now resumed to in-person meetings. Resident council meetings require facility staff, but informal meetings take place among residents without facility staff present. Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF CARE: Resident sustained multiple pressure injuries while in care is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Administrator Administrator (Peter Babaian) and Asst. Administrator (Alise Nazarian).the state’s words, verbatim · CDSS document, Sep 1, 2022 · control 28-AS-20210429151909

Allegation investigated: Facility is not properly addressing insect issue

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegation. On today's visit, LPA met with Administrator, Peter Babaian who assisted with today's visit. Regarding the allegation that the facility is not properly addressing insect issue, the investigation consisted of: Interview(s) with Administrator, Staff #1, Resident #1 - Resident #5, tour of facility, and review of pest control invoices. LPA also spoke to LA County Public Health Environmental Health Specialist regarding recent visit to the facility. Administrator stated that none of the residents have stated there was a problem with bed bugs. He said that the facility has a contract with a pest control service, and they come to the facility twice per month. He said that following the LA County Public Health visit, the facility has had (2) visits from the Pest Control service on 8/12/22 and 8/16/22, to address the bed bug issue. Administrator provided copies of reports from the visits. LPA observed that the reports indicated that the following rooms were treated for bed bugs: Rooms 10 and 12 in the main building, and Bungalow 1511 Rooms #1 - Room #5. Staff #1 stated that she toured the facility with LA County Public Health and also observed bed bugs in Bungalow 1511, Rooms #1- #4. Staff #1 stated that they treated Room #5 in Bungalow #1511 as a precaution. Substantiated LPA did not observe bed begs in the rooms toured on today's visit. LPA observed 3 cockroaches crawling in the door frame of bathroom in Room #2. Staff #1 also observed the cockroaches and asked the facility maintenance person to spray the area. Residents interviewed were unable to corroborate the allegation. Four out of five residents interviewed stated that they have not observed bed bugs or cockroaches at the facility. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Mr. Babaian. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 17, 2022 · control 28-AS-20220810083632

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Aug 24, 2022

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: Based on interviews and documents reviewed, bed bugs and cockroaches were recently observed at the facility, which poses a potential health and safety risk to residents in care. LPA observed cockroaches in Room #2 bathroom on today's visit.the state’s words, verbatim · CDSS document, Aug 17, 2022

Plan of correction: Licensee shall provide proof of treatment of bed bugs and cockroaches and plan to prevent the pests from spreading in the facility. The proof shall be submitted to LPA Rea by POC due date of 8/24/22.

Allegation investigated: Facility does not allow residents to wash their clothing Residents bathroom emergency system does not have a pull cord

Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with S-1 and discussed the purpose of today's visit. During this investatigation, LPA obtained the staff roster and resident roster. LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). LPA also conducted a tour. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Facility does not allow residents to wash their clothing. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). (3) staff out of (3) indicated they have not received any requests from residents requesting to wash their own clothes. (5) out of (6) residents indicated the facility staff wash their clothing and that they have not requested staff to allow them (residents) wash their (residents) own clothing. Staff and resident interviews do not corroborate this allegation Allegation: Residents bathroom emergency system does not have a pull cord. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). Staff interviews revealed, resident bathrooms have a signal system. Staff interviews also revealed that some of the signal systems function either by a cordless switch or a switch that has a cord integrated. Interviewed residents indicated they are aware as to how the signal switches and cords operate. LPA also toured the bathrooms, observed and tested the signal system switches. LPA also observed and tested the signal systems in random resident rooms. All tested signal systems were operable. Staff interviews, resident interviews and tour do not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, copy of appeal rights and a copy of this report was provided to the Facility Administrator. Allegation: Facility is not following COVID protocol. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). LPA also conducted a tour. LPA observed COVID postings throughout the facility. Staff interviews revealed that residents are reminded to maintain social distancing. Interviewed staff also indicated meal times and social activities are staggered to ensure that social distancing is practiced. Staff indicated there are hand sanitizer stations throughout the facility and that there is ample PPE supplies (masks) available. Interviewed Residents indicated there are COVID postings throughout the facility, staff remind residents of social distancing, there are hand sanitizing stations throughout the facility. (5) out of (6) interviewed residents also indicated the staff provide face masks upon request. During LPA’s tour, LPA observed hand sanitizer stations throughout the premises. However, LPA observed all hand sanitizer stations to be empty in cottages 1511 and 1515. Based on facility tour, this allegation is corroborated. Allegation: Facility does not maintain a comfortable temperature in resident's room. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). (1) staff out of (3) indicated the indoor temperature on the cottage 1511 and 1515 at times feels hot. (4) out of (6) residents indicated the indoor temperature in cottage 1511 and 1515 feels hot. At approximately 11 A.M, LPA toured cottages 1511 and 1515. In cottage 1511, room#1, the room temperature measured 89.2* and in room #4 the temperature measured at 89.6*. LPA also observed resident rooms to have a small fan and some had air conditioning units on their windows. However, the indoor temperature exceeded Title 22 requirements. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted, copy of appeal rights and a copy of this report was provided to the Facility Administrator.the state’s words, verbatim · CDSS document, Aug 11, 2022 · control 28-AS-20220804131712

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: Aug 11, 2022

The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter: Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California This standard is not met as evidence by: During facility tour, LPA observed all hand sanitizer stations to be empty in cottages 1511 and 1515.the state’s words, verbatim · CDSS document, Aug 11, 2022

Plan of correction: Administrator to ensure all hand sanitizer stations have hand sanitizer liquid at all times. CORRECTED AT TIME OF VISIT.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(2) · Plan of correction due date: Aug 15, 2022

Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This standard is not met as evidence by: At approximately 11 A.M,, LPA toured cottages 1511 and 1515. In cottage 1511, room#1, the room temperature measured 89.2* and in room #4 the temperature measured at 89.6*. In cottage 1515, room #5, the temperature measured at 89.2*.the state’s words, verbatim · CDSS document, Aug 11, 2022

Plan of correction: Administrator to provide a written plan as to how this deficiency will be rectified and how this facility will maintain indoor temperature comfortable as per 87303(b)(2) and provide this to LPA Irra by POC due date of 08/15/2022.

Allegation investigated: Staff did not treat resident with respect and dignity.

Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegation listed above today. During today’s visit, LPA met with Administrator, Peter Babaian. LPA explained the purpose of today's visit regarding the above-mentioned allegation. Investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #3 (S3); interviews of residents from resident#1 (R1) through resident #3 (R3); reviewed resident#1’s record reviews, and a facility tour. LPA obtained copies of the Staff and Resident Rosters; and resident files of resident #1 (R1) with relevant information. In regard to allegation: “staff did not treat resident with respect and dignity," it was alleged that staff yelled at resident and flipped resident off. The investigation revealed that two (2) out of three (3) residents could not corrob orate the allegation. Residents stated staff did not yell at residents but would talk loudly and raised voice. During the visit, LPA heard staff talked loudly to residents. (-continued in LIC 9099 C-) Substantiated One (1) out of three (3) residents stated staff yelled at resident and flipped resident off. Two (2) out of three (3) staff denied the allegation. One (1) out of three (3) staff interviews revealed staff witnessed staff flipped resident off. Therefore, staff did not treat resident with respect and dignity. Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D An exit interview was conducted with Administrator. A hard copy of this report and appeal right were provided.the state’s words, verbatim · CDSS document, Aug 10, 2022 · control 28-AS-20220802142516

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 22, 2022

(a)Residents in all residential care facilities for the elderly shall ....have personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of: Per interviews conducted, staff did not treat resident with respect and dignity. Based on interviews and observation, the Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 10, 2022

Plan of correction: Licensee will review and train staff per Title 22 Regulations, Section 87468.1. Licensee will ensure that staff are receiving the required in-service trainings according to the Regulation. Administrator will provide a copy of names and signatures of all staff in attendance of trainings. POC is due to CCL by 08/22/22

Allegation investigated: Facility does not have all required posted signs in the facility

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegation. On today's visit, LPA met with Administrator, Peter Babaian who assisted with today's visit. Regarding the allegation that facility does not have all required posted signs in the facility, the investigation consisted of : Interview with Administrator, Staff #1, as well as facility tour and review of facility wall posting(s). Administrator and Staff #1 stated that they recently removed some of the posted signs, because they were redecorating the facility, and adding wall paper to the facility. Administrator stated that the redecorating was completed approximately 2-3 months ago. LPA observed that the Ombudsman poster was posted on a white board in the hallway. LPA observed that all required postings were not posted on today's visit : Residents' Rights, Community Care licensing report(s), Resident council information, non discrimination notice, and admission agreement was not posted, nor was a notice of the availability of the admission agreement by request. Administrator posted required signs during the visit. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Mr. Babaian. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 8, 2022 · control 28-AS-20220801153004

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e)(2) · Plan of correction due date: Aug 8, 2022

(2) The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility. This requirement was not met as evidenced by: LPA Rea observed that the facility did not have admission agreement posted or notice of availability on today's visit.the state’s words, verbatim · CDSS document, Aug 8, 2022

Plan of correction: Administrator posted during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(c)(1) · Plan of correction due date: Aug 8, 2022

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility. This requirement was not met as evidenced by: LPA Rea observed that the personal rights, nondiscrimination notices, and complaint information were not posted on today's visit.the state’s words, verbatim · CDSS document, Aug 8, 2022

Plan of correction: Administrator posted during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(7) · Plan of correction due date: Aug 8, 2022

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (7) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding care and services to be provided, according to Health and Safety Code section 1569.80 and involve persons of their choice in this planning... make informed decisions and choices. This requirement was not met as evidenced by: LPA observed that resident council meeting information was not posted on today's visit.the state’s words, verbatim · CDSS document, Aug 8, 2022

Plan of correction: Administrator posted during visit.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.38(a) · Plan of correction due date: Aug 8, 2022

Posting of licensing reports; disclosure to new residents (a) Each residential care facility for the elderly shall place in a conspicuous place copies of all licensing reports issued by the department within the preceding 12 months, and all licensing reports issued by the department resulting from the most recent annual visit of the department to the facility.... shall provide the telephone number and address of the appropriate district office. This requirement was not met as evidenced by: LPA Rea observed that Community Care licensing reports were not posted as required during today's visit.the state’s words, verbatim · CDSS document, Aug 8, 2022

Plan of correction: Administrator posted during visit.

Allegation investigated: Staff failed to prevent resident from AWOL’ing from facility. Staff is admitting residents who need a higher level of care.

Licensing Program Analyst (LPA) V. Maldonado made a subsequent unannounced complaint visit at the facility regarding the above mentioned allegations. LPA Maldonado met with assistant Administrator Alise Nazarian and Administrator Peter Babaian, and explained the purpose for the visit. During today's visit, LPA Maldonado toured the physical plant with assistant administrator Alise Nazarian. A copy of the resident and staff roster were requested, as well as a copy of the following documents for Resident# 1 (R1): Admission's agreement, Physician's report, identification and emergency information, Preplacement Appraisal, Needs and Services Plan, Medication Administration Records (MARs) for September 2020, and the Plan of Operations- Absentee Notification Plan for Missing Residents. Administrator, assistant adminstrator, Staff# 1 (S1), and Residents# 2-6 (R2-R6) were also interviewed. Report Continued on LIC9099-C... Unsubstantiated Allegation- Staff failed to prevent resident from AWOL’ing from facility. During interviews conducted with administrator, assistant administrator, and S1, (3) of (3) staff state that the majority of the residents are allowed to leave the facility unassisted. The residents who require assistance are transported in the facility vehicle by staff or by their responsible parties. Staff interviewed stated they did not fail to prevent residents from AWOL'ing from the facility. After review of R1's records, it was discovered that R1 was able to leave the facility unassisted, per R1's physician's report. After review of the facility's Plan of Operations, it was discovered that the policy indicates that all residents are encouraged to sign out and sign in upon their return at the log that is kept at the reception desk. During interviews conducted with R2-R6, (5) of (6) residents state they are aware of the facility policy to report anytime they leave/return to the facility. Allegation- Staff is admitting residents who need a higher level of care. During interviews conducted with administrator, assistant administrator, and S1, (3) of (3) staff stated all residents, prior to being admitted to the facility, go through a series of evaluations and interviews to determine compatibility with current residents and the care needs that the facility provides, per the facility's Plan of Operations- Intake Procedure for Placement in an RCFE. Staff interviewed stated they do not admit residents who need a higher level of care. During interviews conducted with R2-R6, it was stated that (6) of (6) residents feel that the facility has compatibility between current residents and their care needs. Residents interviewed stated that all staff assist them with their needs. After review of C1's records, it was discovered at C1 met the criteria stated in the intake procedure for placement at the facility, per the facility's plan of operations. Based on interviews, observations, and record reviews, although the allegations may have happened or are 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 administrator Peter Babaian and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 5, 2022 · control 28-AS-20200909154000

Allegation investigated: Staff are not assisting residents with medical appointments

On 7/21/22 at 9:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with S1 and explained the purpose of the visit. At 10:15 Administrator Peter Babaian joined the visit. The investigation consisted of the following: During today’s visit LPA toured the facility with S1, obtained the resident/ staff roster, and obtained a copy of S1-S6 LIC-602. The investigation reveals the following: Regarding “staff is not assisting residents with medical appointments”, it is alleged that residents have not received a second booster. 6/6 residents confirmed staff assists residents with medical appointments and COVID vaccinations. Report Continued on LIC9099c Unsubstantiated 2/6 Residents confirmed they do not need assistance with making medical appointments but witnessed residents stating facility assists with medical appointments. Administrator confirmed facility doctor visit the facility once a week and the facility psychiatrist visit the facility once or twice a month. According to administrator, 99% of the residents receive medical care from facility doctor. The residents who have private doctors can make their own appointments, but facility will assist when needed. Administrator confirmed residents has not received 2nd COVID booster but has reached out to LA county care facility/ department of public health to schedule an appointment. The administrator stated the department of public health are backed up and is waiting for them to schedule the appointment. 3/3 staff stated they help make medical, dental, transportation and personal appointments for residents. 3/3/ Staff also confirmed facility doctor visit the facility once a week. File review revealed LIC-602 for residents is up to date and residents can leave the facility unattended. Based on LPA's interviews, investigation revealed: 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 conducted with Peter Babaian and a copy of this record provided.the state’s words, verbatim · CDSS document, Jul 21, 2022 · control 28-AS-20220714083638

Allegation investigated: Staff do not make the phone available frequently. Staff did not provide adequate first aid. Staff do not intervene when resident is bullied. Admission Agreement is not adhered to

Licensing Program Analyst (LPA) Calderon initiated a subsequent unannounced complaint investigation for the allegations listed above. LPA met with Administrator Peter Babian and explained the purpose of the visit which was to deliver investigation findings. On 03/24/21, LPA Tao conducted a telephonic initial visit, during visit, LPA interviewed Staff #1, Staff #2, Staff # 3, and Resident #1 and obtained copies of resident roster and staff schedule. LPA Tao requested copies of the following documents, Resident#1’s (R1) Face sheet, physician report, admission agreement, appraisal -needs and services plan, incident reports for March 2021 related to R1, training logs regarding residents’ rights, wound care, first aid, residents being bullied and staff #1’s &#2 first aid certificates. Continued on LIC 9099-C Unsubstantiated On 07/14/22, LPA Calderon toured physical plant with Staff Nazaran and observed working telephones that are accessible to residents and fully stocked first aid kits that are not accessible to residents. LPA interviewed residents #3-7 (R3-7), and interviewed Staff #1,#4-8 (S1, S4-S8). On 07/15/22, LPA Calderon attempted to interview S3, S9 and R2 and received S3 and S4 first aid training . Regarding the allegation " Staff do not make the phone available frequently " LPA obtained the telephone policy and toured and observed three (3) different areas in the facility that have telephone that are accessible for residents to use. Interview with 5 of 7 residents indicated that telephone are available for resident use and staff do not restrict resident use unless resident are waiting to use the telephone. Interviews with 7 of 9 staff indicate that telephone are available for resident use and staff do not restrict the resident from using the telephone. It was also revealed that R1 was informed by staff that if other residents needs to use the telephone, for R1 to limit the time spent on the telephone call in order for other residents to have access. 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. Regarding the allegation "Staff did not provide adequate first aid " On todays, LPA Calderon toured the physical plant and observed First Aid Kits were located Med Room and Front Desk and were fully stocked. Interviews with 5 of 7 residents revealed that staff provide residents with first aid as needed. Interviews with 7 of 9 staff revealed the first aid kits are fully stocked and staff are trained to provide first aid to residents. LPA Calderon reviewed 03/15/21 incident report and police report #21-3417. Per the incident report, on 03/15/21, an incident occurred where R1 sustained a scratch due to an altercation with R2 and R1 called local law enforcement with staff being aware. Per the police report # 21-3417, Staff 3 provided R1 with first aid and did not observe any serious injury and document the incident. Per the police report, the officer spoke with R1 at the facility and offered medical treatment which R1 refused. 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. Regarding the allegation: Staff do not intervene when resident is bullied. Per the details, it was alleged that a resident followed another resident in the facility to intimidate the resident and a resident pushed a resident to the floor in front of staff who did not intervene. Interviews with 3 of 7 residents revealed resident are insulted or bullied by other residents, however, staff were not present and were not made aware at the time of the incident. Interviews with 3 of 7 residents revealed they are not aware of residents being bullied by other residents. Interview conducted with R1 revealed that staff were not present during the 03/15/21 incident between R1 and R2. R1 also indicated that other resident bullied R1 in the facility. On 03/24/21, LPA Tao made an attempt to interview R2 and on 07/14/22 & 07/15/22, LPA Calderon attempted to interview R2, however R2 was not available at the time. Interviews with 7 of 9 staff revealed that staff do not recall an incident where R1 was pushed to the floor by a resident and staff did not intervene. The investigation revealed that staff intervene if they see a resident is being bullied or needs assistance and staff were not aware of the 03/15/21 incident between R1 and R2. The investigation did not reveal any evidence to support that staff do not assist residents who are being bullied. 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. Regarding the allegation: Admission Agreement is not adhered to. It was alleged that the facility is not following the admission agreement, residents are smoking inside the facility, transportation schedule for shopping is not being provided to residents, no planned activities are being conducted, residents do not get mail and facility is not safe. Interviews with 5 of 7 residents revealed residents were not aware of staff not adhering to the admission agreement and staff follow the admission agreement. 1 of 7 residents was not available for interview. Residents states the facility has an outside are for smoking and the facility does not allow resident to smoke inside the facility, staff give resident their mail, staff assist with transportation and provide residents with activities. Interviews 1 of 7 residents stated that staff do not follow the admission agreement. Interviews with 7 and 9 staff revealed that staff follow the admission agreement. Staff stated resident have outside are designated for smoking and resident are not allowed to smoke inside the facility. Staff have observed residents smoking in the facility and intervene by directing the residents to smoke outside. Staff state the residents are provided with mail and do not withhold the mail. Facility has a full-time activities director who schedules activies for resident on a daily basis and the Monthly Activities Calendar is posted in a common area of the facility for resident to view. Staff state that residents are able to schedule transportation for shopping with staff as needed. Staff state the facility is safe, staff check on residents as needed. LPA Calderon toured the facility on 07/14/22 and did not observe the facility to have any health and safety issues. The investigation did not reveal any evidence to support that staff are not adhering the to the admissions agreement. 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 Administrator Peter Babian. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 15, 2022 · control 28-AS-20210319083138

Allegation investigated: Staff did not keep resident's bathroom clean & sanitary Staff is retaliating against resident for complaining

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Administrator Peter Babaian and explained the reason for the visit. The investigation consisted of the following: LPA obtained a copy of the residents and staff rosters, conducted a tour of the facility and interviewed the Administrator, Staff 1 - Staff 3 (S1 - S3) and Resident 1 - Resident 6 (R1 - R6). The investigaion revealed the following: regarding the allegation "staff did not keep resident's bathroom clean & sanitary", it is alleged that S2 refused to clean smeared feces in a private bathroom inside a shared resident bedroom. Other staff were asked to do it, but also refused. The administrator and staff interviewed denied the allegation and stated that none of the staff have denied to clean any bathroom. (CONTINUED TO LIC 9099C) Unsubstantiated The administrator and staff also stated that S2 is physically attacked by one of the residents in that shared bedroom whenever S2 attempts to go inside to clean. S2 has to wait until the resident leaves the room in order for her to rush in there and clean. The smeared feces in the bathroom was cleaned on 07/08/22 because the resident went on an outing and S2 took this opportunity to finally clean the bathroom and also the bedroom. Interview conducted with the roommate revealed that S2 is physically attacked and the other resident does not allow the staff to do their job and clean their room or bathroom. Interviews conducted with other residents revealed that S2 does a good job in cleaning their rooms and bathrooms and has never refused to do so. LPA toured the facility and observed that the bathroom in question is clean. LPA also observed S2 and other staff cleaning other bedrooms and bathroom. Regarding the allegation "staff is retaliating against resident for complaining ", it is alleged that S2 was the one that smeared the feces in the bathroom because S2 is angry at the resident for complaining. The administrator and staff interviewed denied this allegation and stated they don't know who smeared the feces. Interview conducted with the roommate revealed that S2 was not the one that smeared feces in their bathroom. The smeared feces was accidentally done by the roommate. The roommate did not notified the staff when it happened because the staff would have noticed when they do their routine cleaning, but the feces lasted there for about 3 days because the other resident in that bedroom was not allowing S2 or any of the staff to go in the room or bathroom to do their routine cleaning. The other resident physically attacks the staff when they enter to clean. 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. Exit interview conducted and copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 12, 2022 · control 28-AS-20220707144303

Allegation investigated: Staff hit resident Staff handled resident in a rough manner Resident sustained injuries while in care Staff threatened residents Staff made inappropriate comments towards resident Staff did not safeguard residents personal belongings

On the above date, Licensing Program Analyst (LPA) Christine Wong conducted an intiail 10 days complaint which included the 24 hours healthy and safety check. LPA met with Assistant Administrator Alise Nazarian and explained the reason of the visit and she also assisted LPA with the visit. The investigation consisted of the following: A physical plant tour of the facility was conducted. No health and safety issues were observed. LPA also interviewed seven residents (R1-R7), administrator and five staff (S1-S5) and also obtained copy of residents roster, staff roster and incident report for R1 and reviewd the residents' diaper changing log book The investigation revealed of the following: Allegation#1 " Staff hit resident." LPA interviewed seven residents and six out of seven residents denied the allegation and reported they never seen any staff hit resident. LPA interviewed the victim and also denied any staff was hitting him in the facility and reported it never happened. (See LIC 9099C for continuation) Unsubstantiated LPA also interviewed staff and all denied the allegation and stated that if its really happened. They would report it immediately. Based on interviews and observations, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED Allegation#2 "Staff handled resident in a rough manner" LPA interviewed seven residents and five out of seven residents denied the allegation and reported staff never handled them on a rough manner and pushed them hard. LPA interviewed six staff and all denied the allegation and reported no resident ever complained staff handled them roughly and also they never seen any staff handled resident in a rough manner. Administrator also reported that staff received training on how to handle resident. Staff also reported they would never force any resident to take the medication and its violating the human right. If resident refused to take the medication, they would just report it to their primary physician. Based on interviews and observations, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED Allegation#3 "Resident sustained injuries while in care" LPA interviewed seven residents and six out of seven residents denied the allegation and reported they never had any injury or sustained any injury in the facility. The victims also reported they never got any head or eye injury or any scratches from the staff. LPA also did not observe any residents had any scratches on their face. LPA interviewed staff and also denied the allegation and reported there's no incident reported or filed lately because of residents had or sustained any injuries. Based on interviews and observations, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED Allegation#4 "Staff threatened residents" LPA interviewed seven residents and four out of seven residents denied the allegation and reported staff never threatened them. Staff are nice to them and they never did that to them or other residents. LPA interviewed staff and they all denied the allegation and reported they never heard any staff threatened residents or no residents ever complained staff threatened them. They are all happy with the staff. Based on interviews and observations, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Allegation#5 "Staff made inappropriate comments towards resident" LPA interviewed seven residents and six out of seven residents denied the allegation and reported the staff are nice to them and respectful to them. LPA interviewed staff and denied the allegation and reported the administrator are very strict on that and very on top of it. The staff also never witnessed any staff made inappropriate comments to residents. Based on interviews and observations, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED Allegation#6 "Staff did not safeguard residents personal belongings" LPA interviewed seven residents and four out of seven residents denied the allegation and reported they never lost anything in the facility. LPA interviewed the staff and staff reported that they would send two staff to assist resident to search their rooms. Sometimes it may be under their bed, pillow or in the drawer. Staff also stated that its clothes items and they maybe in the laundry room. Based on interviews and observations, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted with Peter Babaian and a copy of this report and appeal rights provided. Residents reported their diapers always got wet and soiled and staff did not come and change them on time. LPA also review the residents' diaper changing log book and indicated some residents did not get diaper change after 6 hours or only twice a day. Based on LPA's record review and interview, 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 1 are being cited on the attached LIC 9099D. Exit interview conducted with Victor Mora and a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 30, 2022 · control 28-AS-20220628163253

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Jul 14, 2022

87625 Managed Incontinence (b)the licensee shall be responsible for the following:(3)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. The requirement is not met as evidenced by: LPA interviews and 4/7 residents reported they always got soiled or wet diaper and record review. Some residents only got changed twice a daythe state’s words, verbatim · CDSS document, Jun 30, 2022

Plan of correction: The administrator will ensure the incontience residents are kept clean and dry and will send a plan how to make sure residents would not have soiled or wet diaper for extended long period of time.

Type of visit: Case Management - Deficiencies

On the above date, Licensing Program Analysts (LPAs) Christine Wong conducted a 24 hours health and safety check. During the visit, LPAs toured the facility and observed the hot water temperature measured at Room#1, #4 and #11 between 1341 and 136.7 degrees F which is beyond the required 105 - 120 degrees. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation. An exit interview was conducted and a copy of the Facility Evaluation Report and Appeal Rights were provided to Administrator Peter Babaianthe state’s words, verbatim · CDSS document, Jun 30, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jul 1, 2022

87303 Maintenance and Operation (e)(2) Faucets used by residents for personal care ..... 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). The requirement is not met as evidenced by: based on LPAs observation, LPA observed the hot water temperature was measured at Rm#1, #4 and #11 are beyond the required 105-120 degrees F which poses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2022

Plan of correction: The facility will ensure the hot water temperature will be between 105 degree F and not more than 120 degree F and the administrator will lower the tempature on the water heater send the copy of hot water temperature report to LPA for the upcoming 7 days

Allegation investigated: Staff does not post Ombudsman poster.

On 6/21/22 at 10:05 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Peter Babaian(Administrator) and explained the purpose of the visit. Investigation consisted of the following: During today’s visit LPA toured the facility with assistant administrator, obtained resident/ staff roster, remodeling invoice dated 10/26/2021- 2/10/22 and photo of remodeling sign posted outside dining room. LPA interviewed residents R1- R7. LPA Interviewed administrator, Staff S1- S3. The investigation reveals the following: In regard to "Staff does not post Ombudsman poster.", it is alleged that the facility does not have the Ombudsman poster posted in the facility. During the visit LPA toured the facility and was not able to locate the Ombudsman poster. LPA observed a signed posted by dining room confirming remolding started August 16th, 2021. Administrator confirmed poster was removed during facility remodeling on March or April of 2022. Report Continued on LIC 9099C Substantiated Administrator also confirmed the remodeling finished last Wednesday 6/15/22 and has ordered replacement posters. Administrator affirmed required postings will be completed next Friday 7/1/22. 7/7 residents stated that they have seen the Ombudsman poster a year ago or they have never seen the poster. 3/3 Staff interviews confirmed the Ombudsman poster was taken down due to remodeling. 1/3 staff stated postings was removed about a year ago while 2/3 staff stated they are unsure of the date the postings was removed. Based on LPA observation and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D. Exit Interview Conducted with administrator/ Appeal Rights Provided / A Copy of the Report Issuedthe state’s words, verbatim · CDSS document, Jun 21, 2022 · control 28-AS-20220615161924

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(10) · Plan of correction due date: Jul 1, 2022

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) residents in…shall have all of the following personal rights: ... The licensee shall post the telephone numbers and addresses for the local offices of the … ombudsman program,... This requirement is not met as evidenced by Based on observations, interviews the licensee did not comply with the section cited above by not having the Obudsman poster posted, which poses an pontiential health, safety, or Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 21, 2022

Plan of correction: Licensee shall ensure the required postings are posted in a location that is easily accesible to residents and provide picture proof of the required postings to LPA by POC date.

Allegation investigated: Residents are not allowed to participate in their appraisal needs and services plan.

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Peter Babaian Administrator and explained the reason for the visit. The investigation consisted of the following: LPA Flores requested a copy of staff/resident roster. LPA interview resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6), administrator, staff #2(S2),#3(S3),#4(S4). Requested copies of identification and emergency information sheet, physician's report, appraisal/needs and service plan for R1,R2,R3,R4,R5 and assisted living waiver(ALW) individual service plan (ISP) for R1 from resident's files. The investigation revealed the following: Regarding allegation: Residents are not allowed to participate in their appraisal needs and services plan. It is alleged staff have not included resident in decision making regarding appraisal needs and service care plan. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with residents revealed 3 out of 6 residents stated not being able to recall whether or not participated in the appraisal needs and care plan process. 2 out of 6 residents stated to have not been a part of the appraisal needs and care plan. 1 out of 6 residents stated to not need care and not caring for a plan. Administrator stated that three staff meet with residents in the activity area and review the appraisal needs and care plan with residents, unless the residents are under ALW program, then social worker (SW) and nurse (LVN) meets with residents and after assistant administrator is provided a copy. 3 out of 3 staff interview stated to review the appraisal needs and care plan with the residents in the activity area as often as needed, per changes in condition or changes in care for residents needs. Documents review revealed 4 out of 5 appraisal needs and care plan were signed and dated 1/1/22 and 1 out of 5 had noted "resident refused to sign" and dated 1/1/22. ISP reviewed for R1 was signed and dated on 3/4/22. Phys cian's report reviewed noted 5 out of 6 residents need some assistance with a few daily living activities and 1 resident does not require any assistance. 6 out of 6 residents are self responsible allowing them to make decisions for themselves. Staff payroll list for 1/1/22 lists the staff responsible for appraisal needs and care plan worked on the day the appraisal needs and care plan were signed. 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. Exit interview was conducted with Peter Babaian Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 21, 2022 · control 28-AS-20220616144854

Allegation investigated: Facility refused to comply with resident's physician report Staff spoke to resident inappropriately

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegations. LPA met with Administrator, Peter Babaian who assisted with today's visit. Regarding the allegation that the facility refused to comply with resident #1's physician's report, the investigation consisted of Review of Resident #1's physician report, and Interview(s) with Administrator, Staff #1, Staff #2, and Resident #1 - Resident #5. Administrator and Staff interviewed stated that resident #1 resides in a cottage which is located behind the main building. Administrator and staff interviewed stated that the cottages are for ambulatory residents. Staff stated that resident #1's physician report dated 4/19/22 states that he is ambulatory, however he has been using a walker for the last couple of months due to reduced mobility. Staff indicated that they would prefer resident #1 move to the main building for his safety. However, they are not going to move resident #1 against his will. Unsubstantiated Regarding the allegation that staff #1 spoke to resident inappropriately, the investigation consisted of Interview(s) with Administrator, Staff #1, Staff #2, and Resident #1 - Resident #5. Administrator and staff interviewed denied the allegation. Staff #1 stated that she did not speak to resident inappropriately. Staff #2 stated that she was a witness to the conversation between Resident #1 and Staff #1, and denied that Staff #1 spoke inappropriately to resident. Residents interviewed were unable to corroborate the allegation. They stated that staff do not speak to residents inappropriately. Based on LPA's observations and interviews, investigation revealed: 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. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Administrator, Peter Babaian.the state’s words, verbatim · CDSS document, May 4, 2022 · control 28-AS-20220429103611

Allegation investigated: Staff handled a resident inappropriately Staff locked a resident in the patio Staff did not intervene during resident to resident conflict Staff do not safeguard table setting for residents in dining room Staff are interfering with resident phone calls

Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent complaint visit to deliver findings on the allegations listed above. LPA met with administrator Peter Babaian and explained the purpose of today's visit. An initial 10-day telephonic complaint visit was conducted on 12/28/2020 by Licensing Program Analyst (LPA) P. Rivas. A subsequent complaint visit was conducted on 12/10/2021 by LPA N. Margaryan. During the visit LPA Margaryan conducted interviews with the administrator, facility staff and residents regarding the allegations listed above. Continue 9099C Unsubstantiated The investigation revealed the following: Regarding the allegations of Staff handled a resident inappropriately and Staff locked a resident in the patio. It was reported that Resident 1 (R1) observed Staff 3 (S3) and Staff 1 (S1) threaten to lock Resident 2 (R2) in the patio if R2 refused to shower. It was also reported that R1 also observed S3 lock R1 out, causing S1 to argue with S3 regarding S1’s actions. R2 began to bang on the door at which time S3 unlocked the door. During the investigation interviews were conducted with R1, R2, S1 and S3. When interviewed R1 could not confirm if such an incident occurred, R2 denied he was locked in the patio. S3 denied locking R2 or any other resident in the patio and S1 denied witnessing R2 being locked in the patio by the S3 or any other facility staff. Based on the information obtained the allegation is Unsubstantiated at this time. Regarding the allegation of Staff did not intervene during resident to resident conflict. It was reported that sometime in December 2020 there was an incident with Resident 3 (R3) yelled at Resident 1 (R1) because R3 wanted to use the phone when it was being used by R1. It was also reported that R3 walked aggressively towards R1 and grabbed the phone from him which was observed by the S3. During the investigation interviews were held with the S3, R1 and R3. When interviewed R1 could not recall such an incident occurred but did state that R3 tries to restrict him from using the facility phone, however when interviewed R3 denied such an incident occurred and denied bothering/restricting anyone from using the facility phone. S3 also denied witnessing such an incident. Based on the information obtained the allegation is Unsubstantiated at this time. Regarding the allegation of Staff do not safeguard table setting for residents in dining room it was reported that staff allow other residents to remove the utensils from the table which prevents R1 from sitting at his usual table. During the investigation interviews were conducted with the facility administrator, staff, R1 and other facility residents. When interviewed R1 was questioning why he is unable to sit at his usual table during dinner. According to the administrator other residents do not want to dine or interact with R1 due to his hygiene and the staff cannot force the residents to do so. Other residents interviewed did not report concerns about not having utensils or having any problems with the dining. Based on the information obtained the allegation is Unsubstantiated at this time. Continue 9099C Regarding the allegation of Staff are interfering with resident phone calls it was reported that facility administrator angrily held a discussion with R1 about his phone use and that facility residents are limited now to 5 minutes on the phone. During the investigation interviews were conducted with the administrator, staff, R1 and other facility residents. When interviewed administrator denied speaking with R1 angrily about phone use or at any time. Administrator and all staff denied interfering with resident phone calls or allowing residents only 5 minutes to use the phone. When interviewed all residents except R1 denied staff interfering with their phone calls or only being allowed to use the phone for 5 minutes or any specific minutes. Based on the information obtained the allegation is Unsubstantiated at this time. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided to Administrator.the state’s words, verbatim · CDSS document, Apr 14, 2022 · control 28-AS-20201218154545

Allegation investigated: Resident not allowed telephone calls.

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Peter Barbarian administrator and explained the reason for the visit. The investigation consisted of the following: On 1/11/22 LPA Flores conducted initial visit and requested copies of resident and staff roster. LPA Flores observed facility's cordless telephone at front desk, pay phone in patio, pay phone at cottage accessible to residents in working condition. LPA interview residents #1(R1), #2(R2), #3(R3), #4(R4), #5(R5). LPA Flores requested copies of facility phone bills for the last 3 months to be email to LPA by end of day. On 4/11/22 LPA Flores requested copies of phone bills for the months of November 2021 - February 2022 and interviewed Staff #1(S1),#2(S2),#3(S3),and#4(S4). (CONTINUED LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation; Resident not allowed telephone calls. It is alleged resident's friend has called and they won't tell resident. Interviews with residents revealed 2 out of 5 residents have had access to facility's telephone when needed to make phones and have received telephone calls in cordless phone. 2 out of 5 residents stated they have their own cellphones and do not need to use the facility's telephone and 1 out 5 residents stated to not know there is a phone available as resident does not have anyone to call. Interviews with staff revealed 4 out of 4 staff interviewed stated residents take calls on cordless telephone and are allowed to make phone calls at all times. On 1/11/22 LPA toured the facility and observed two pay phones, one located in the patio and one located in the back cottage both with a dial tone and in working condition. LPA observed the cordless phone in the front lobby with a dial tone and being provided to a resident during the tour for a phone call in the patio next to the lobby. Administrator stated that the phone in the front lobby is available for residents to make phone calls and received calls at all times. LPA Flores reviewed the phone bills for the months of November 2021, December 2021, January 2022, and February 2022 which shows different phone lines which are connected to extensions to allow transferring calls to extension 107 for residents calls. Although the allegations may have happened or are valid, there is not a preponderance of evidence standard to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Peter Babaian Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 11, 2022 · control 28-AS-20220104154426

Allegation investigated: Resident was not provided with a 30 day notice to change rooms

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Peter Barbaian and explained the reason for the visit. The investigation consisted of the following: LPA Flores requested copies of staff/resident roster, Resident #1(R1) 30 day notice, admission agreeement, physician's report, appraisal needs and care plan, notices for room change. LPA Flores interviewed resident #1(R1),#2(R2),#3(R3),#4(R3),#5(R5),#6(R6) administrator, staff #2(S2),#3(S3),#4(S4). The investigation revealed the following: Regarding allegation; Resident was not provided with a 30 day notice to change rooms. It is alleged resident was not provided with a 30 day notice to change rooms. (CONTINUED LIC 9099C) Unsubstantiated Interviews with residents revealed the following 2 out of 6 residents have not move rooms, have not been requested, or requested to moved therefore do not know of the process. 2 out of 6 residents were not able to answer to questions due to cognitive skills. 1 out of 6 stated to have requested in writing to move rooms and move when a room was available and 1 out of 6 stated that a copy of notice was not provided when provided with the notice. Interviews with staff revealed 2 out 4 staff interviewed stated residents are notify prior to room change and if residents agree change happens. 2 out 4 staff stated that R1 was given a letter to notify of room change due to resident's changes in physical health. Administrator also stated resident was given a copy of 30 day on 3/15/22, however did not obtain a signature from R1 as a result on 4/5/22 provided another letter reinitiating the 30 days. Administrator stated R1 refuses to be assess by a physician to note change in physical condition and that the reason for the room is to ensure R1's safety as the cottage is licensed for non-ambulatory residents and staff have notice R1 becoming a fall risk and want to prevent further falls. LPA reviewed the following documents for R1's Admission agreement signed on 1/31/13. Appraisal Needs and Service Plan dated 2/23/22 notes resident refuses assistance and notes physical changes. Emergency and Identification Information form notes R1 is self-responsible. Letter to notify resident of room change dated 3/10/22 states change is due to changes in physical health and moved is to take place within a week. Second letter provided on 3/15/22 states the same reason and the move is planned for 4/15/22, (refer to complaint #28-AS-20220310140032). Third letter signed by R1 on 4/5/22 has updated move date to May 5th, 2022. LPA Flores advice administrator to ensure R1 is reassess by a primary physician and that facility contacts physician with current concerns, and changes in condition to ensure of proper assessment. Although the allegations may have happened or are valid, there is not a preponderance of evidence standard to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Peter Babaian Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 11, 2022 · control 28-AS-20220405121014

Allegation investigated: Staff are not providing adequate food service for residents Staff are not properly sanitizing dishes

Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint visit to investigate the above allegations. LPA met with LVN-Amy Smbatuni and explained the reason of the visit. Shortly after, the administrator Peter Babaian arrived. The investigation consisted of the following: LPA toured the kitchen and dining room. LPA interviewed six (6) residents (R1-R6) and administrator and four (4) staff (S1-S4) and obtained copy of the resident and staff roster and the menu for the week. The investigation revealed of the following: Allegation#1 "Staff are not providing adequate food service for residents." LPA interviewed six (6) residents and five (5) residents reported they always get enough food in the facility. They can have second plate if they want and they can get substitue choices if they do not like the food on the meun of the day. They were never being hungry or starving in the facility. (See LIC 9099C for continuation) Unsubstantiated Five (5) residents also reported they never experienced any shortages of dishes. LPA also toured the kitchen and observed there's at least two days perishable and seven days non-perishable food supply in the facility. Staff also reported no resident ever complained there's an inadequate food service in the facility. Staff stated that they always have sufficient food supply in the facility. LPA also toured the facility basement and kitchen, and observed there are sufficient plates, cups or utensils in the kitchen. And there are also additional brand new plates and disposable cups and plates in the basement. Allegation#2 "Staff are not properly sanitizing dishes" LPA interviewed six (6) residents and five (5) residents stated that all the plates, cups and dishes in the facility are clean. They never came across with the dishes in the facility are not clean. LPA also interviewed staff and staff reported they would rinse all the dishes with soap first and then put into the dishwasher for additional cleaning. Staff reported no resident ever complained the dishes are not clean in the facility. And they would not allow anything happened like that too. Based on interviews conducted with facility staff, facility residents and LPA observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are 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 right was provided to Administrator Peter Babaian.the state’s words, verbatim · CDSS document, Mar 21, 2022 · control 28-AS-20220318101341

Allegation investigated: Resident did not receive proper room change notice

Read the state’s words on page 2 of the record →

Allegation investigated: Facility is not keeping copies of the last 30 days of menus

Read the state’s words on page 2 of the record →

Allegation investigated: Facility administration is telling the resident he has to change his insurance to their insurance.

Read the state’s words on page 2 of the record →

Allegation investigated: Lack of supervision resulting in inappropriate interactions between resident's.

Read the state’s words on page 2 of the record →

Type of visit: Required - 1 Year

Read the state’s words on page 2 of the record →

Allegation investigated: Resident was pushed by another resident. Staff allow residents to smoke inside the facility. Resident was not accorded a healthful accommodation

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Deficiencies

Read the state’s words on page 2 of the record →

Allegation investigated: Resident changed another resident's diaper while in care Facility has inadequate record keeping Staff are not meeting the diapering needs of the residents Staff did not prevent a resident on resident altercation

Read the state’s words on page 2 of the record →

Allegation investigated: Staff pushed resident.

Read the state’s words on page 2 of the record →

Allegation investigated: Staff left resident in soiled clothing for an extended period of time.

Read the state’s words on page 2 of the record →

Allegation investigated: Staff engaged in a physical altercation with a resident while in care

Read the state’s words on page 2 of the record →

Allegation investigated: Staff did not assist resident with receiving medication.

Read the state’s words on page 2 of the record →

Allegation investigated: Facility is not conducting fire drills.

Read the state’s words on page 2 of the record →

Allegation investigated: Residents are not notified to participate in their appraisal needs and services plan.

Read the state’s words on page 2 of the record →