Belmont Village Hollywood

Allegation investigated: Facility staff are providing resident services without the resident's consent

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this facility to investigate the above allegation. LPA met with Executive Director Janelle Topete and explained the reason for the visit. LPA conducted a physical plant tour at 10:05 AM, requested copies of facility documents relevant to the investigation at 10:40 AM, interviewed staff and residents between 11:00 AM to 12:30 PM and reviewed records between 12:30 PM to 2:00 PM. It was alleged that Resident #1 (R1) has not agreed for staff to assist R1 with managing own medication and staff took all of R1's medication. LPA's record review today revealed R1 was hospitalized on 08/29/23 and was discharged to a skilled nursing facility (SNF) for rehabilitation and came back to the facility on 09/22/23. Upon re admission, R1 was assessed by the SNF physician and stated that R1 was unable to manage own medication on R1's medical assessment form (LIC 602). (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Further review of facility medication management assessment done also on 09/22/23, confirmed that R1 was not able to manage own medication. R1 was informed about the new assessment and the charges that went with it effective 09/22/23 and again on 10/19/23. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 31-AS-20231017141047

Allegation investigated: Resident was diagnosed at the hospital for a drug overdose. Staff sometimes administer medications directly into the residents mouth.

Licensing Program Analyst (LPA) LaQueena Lacy conducted a subsequent complaint visit for the above allegation on 08/22/2023 at 11:04am to conduct additional interviews and deliver investigative findings. LPA met with Janelle Topete and explained the purpose of the visit. #1. Resident was diagnosed at the hospital for a drug overdose. It is alleged that resident #1 (R1) received an overdose of an unknown substance due to R1 was found with “pinpoint pupils, and in an alerted state. To investigate the above allegation, LPA requested documents relevant to the investigation including but not limited to staff and resident rosters, Physician Report and Resident Assessment and Service Plan at 2:05pm and began interviews with staff at approximately 2:16pm on 03/11/2022. Interviews with staff #1 (S1) revealed they were not aware that R1 was alleged to have been overdosed at the facility and was not informed by anyone that it had occurred. Continued on LIC9099C Unsubstantiated R1 was sent to the hospital when they began experiencing shortness of breath and informed staff they could not breathe. During the investigation upon record review of R1s medical report R1 admitting diagnoses to the hospital on 02/25/2022 was Acute on chronic Hypercapnic and Hypoxemic Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD) Exacerbation, and Chronic Heart Failure with Preserved Ejection Fraction (HFPEF). At the time of the investigation LPA observed R1s physician report, their primary diagnoses are HRPEF and COPD. Based on interviews, observations, and record review there is not enough corroborating evidence to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED at the time of this investigation. #2. Staff sometimes administer medications directly into the residents mouth. It is alleged that staff stated that sometimes medication is placed directly into the resident’s mouth and sometimes they take it on their own. To investigate the above allegation, LPA began interviews with staff at approximately 2:16PM on 03/11/2022. Additional staff and resident interviews were conducted on 08/22/2023 at 11:33am between 1:10pm. Interviews with eight (08) out of (08) residents revealed they get their medication from the medication room or staff deliver it to their rooms. They receive their medication in a small cup or by a spoon which is placed in their hands, or they take it by spoon. They affirm they have not had their medication placed in their mouth by staff and have not witnessed staff place medication into another residents mouth. Interviews with S2 affirm they have never placed medication into a resident’s mouth, and they are aware residents have the right to refuse medication. S2 stated that R1 has tremors, and they would assist R1 with medication by placing their hand under R1 hand to prevent shaking. At the time of the investigation, LPA observed medication being distributed to residents in a cup then into their hand and the resident places their medication in their mouth. Upon record review of R1 physician report R1 is not able to administer their own prescription medication, and Cedar Sinai discharge summary R1 has tremors of the jaw and hands. Based on interviews, observations, and record review there is not enough corroborating evidence to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED at the time of this investigation. No health and safety hazards are noted during this visit. No deficiencies cited. Exit interview conducted and copy of report and appeal rights issued.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 31-AS-20220310132329

Allegation investigated: Resident tested for drugs he is not taking.

Licensing Program Analyst (LPA) LaQueena Lacy conducted a subsequent complaint visit for the above allegation on 08/22/2023 at 11:04am to deliver investigative findings. LPA met with Administrator Janelle Topete and explained the purpose of the visit. It is alleged that resident #1 (R1) toxicology was positive for TCA’s (antidepressants). To investigate the above allegation, LPA requested and obtained copies of facility files and documents including but not limited to the staff and resident rosters, physician report, and medication administration record on 03/09/2022 at 11:32am. LPA interviewed staff and residents at approximately 11:52am between 2:26pm. Interviews with six (06) out of eight (08) resident confirm that medication is kept in the med room and only staff give them medications. Six (06) out of (08) residents affirm no residents have given them any medications and they do not share their medications with other residents. At the time of the inspection, LPA observed the medication room locked and inaccessible to residents. Continued on LIC9099C. Unsubstantiated LPA observed resident’s medications in bubble packs rubbered banded together and separated by each resident. Residents with additional medications (gels, ointments and inhalers etc.) are maintained in a separate plastic bin for each resident. LPA observed prescribed narcotics inaccessible to residents stored in a locked cabinet cupboard in the nurse office. The assigned LVN on shift was observed to be in position of the key to the narcotics medication. During the course of the investigation LPA reviewed medical records on 05/22/2023 at approximately 2:55pm, which identified R1 toxicology report positive for Tricyclic Antidepressants (TCAs) and noted concerns for either human error or lab error and suggested repeat test. Hospital staff spoke with facility staff, but no noted follow-up requested. Although the toxicology results were positive hospital staff did not perform or request follow-up testing for R1. Based on interviews, observations and record review, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. No health and safety hazards are noted during this visit. No deficiencies cited. Exit interview conducted and copy of report and appeal rights issued.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 31-AS-20220307153524

Allegation investigated: Staff do not assist resident with toileting needs. Staff do no do ensure resident's showering needs are met. Facility has lack of water supply.

Licensing Program Analyst (LPA) LaQueena Lacy conducted a subsequent complaint visit for the above allegation on 08/22/2023 at 11:04am to deliver investigative findings. LPA met with Administrator Janelle Topete and explained the purpose of the visit. #1. Staff do not assist resident with toileting needs. It is alleged that R1 was told by staff to urinate and defecate on themself. To investigate the above allegation LPA requested and obtained copies of facility files and documents including but not limited to staff and resident rosters, physician reports and PAL Approach Chart and Service Plan at 12:32pm. LPA interviewed the ED at 12:37pm, additional interviews with staff and residents were conducted at approximately 2:10pm. Interviews with seven (07) out of eight (08) incontinent residents confirm they have not been told to urinate or defecate on themselves. They confirm staff assist them with their toileting needs and they are checked on Continued on LIC9099C. Unsubstantiated often to see if they need assistance with toileting. Interveiws with staff revealed that R1 has a catheter, and they affirm that incontinent residents are checked on every two (02) hours and have not told any residents to defecate or urinate on themself. During the time of the investigation upon record review, LPA observed the April 2023 PAL Approach Chart and Service Plan, R1 received assistance for incontinent care every (02) hours or as needed for toileting and catheter continence each shift. Based on interviews, observations, and record review there is not enough corroborating evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. #2. Staff do not ensure resident's showering needs are met. It is alleged that resident #1 (R1) hasn't bathed in 2 years. LPA conducted an interview with R1 at 2:47pm when asked if they refused showers? R1 stated “I don’t remember”. LPA asked if S2 gave them a sponge bath this morning? R1 replied “they probably did, but I don’t know”. At the time of the investigation seven (07) out of eight (08) residents confirm “they receive 3 showers per week”. Interviews with staff revealed that R1 refuses showers. S2 confirm that they give R1 a sponge bath in the mornings because they refuse showers when asked by staff. During the investigation LPA observed the April 2023 PAL Approach Chart and Service Plan, R1 receives a sponge bath during the first shift, but refuses a shower during second shift. Based on interviews, observations, and record review there is not enough corroborating evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. #3. Facility has lack of water supply. It is alleged that the facility is lacking water supply. To investigate the above allegation, LPA interviewed seven (07) out of eight (08) residents confirm they have not had any issues or disruptions with the water supply. Interviews with staff confirm they have not had any issues or disruptions with the water supply. Continued on LIC9099C. At the time of the investigation LPA observed (08) random bathrooms all to have a working water supply. LPA tested toilets, sinks and bathtubs all observed to be operating and functioning properly. Based on interviews, and observations there is not enough corroborating evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. No health and safety hazards are noted during this visit. No deficiencies cited. Exit interview conducted and copy of report and appeal rights issued.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 31-AS-20230425084540

Allegation investigated: Facility staff sexually abused Resident #1 (R1) Uncleared adult working in the facility

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation to deliver the findings for the above noted allegations. The initial visit was conducted 01/17/2020 by LPA Brian Balisi. Today, the LPA met with Allyson Young and explained the reason for the visit. On 01/17/2020, the Department received a complaint in which it was alleged that Resident #1 (R1) was sexually abused by Staff #1 (S1). At 3:00 p.m. that day, LPA Brian Balisi conducted the initial complaint visit and toured the facility with Building Engineer, Deborah Kroeplin. Between 3:00p.m. – 4:30p.m., the LPA interviewed facility staff and reviewed and obtained copies of pertinent documents relevant to the investigation. A subsequent visit was conducted by LPA Balisi on 01/21/2020. Between 12:23p.m. – 3:30p.m., the LPA conducted additional interviews with facility staff, and reviewed and obtained documents relevant to the investigation. On 3/16/2022 between 8:30a.m. – 2:00p.m., Unsubstantiated Continued from 9099 LPA conducted a second subsequent visit; at which time, LPA conducted interviews with additional staff, former staff and a family member of R1. LPA also reviewed and obtained copies of additional documents pertinent to the investigation. On 03/23/2022, the case was referred to Community Care Licensing Divisions Investigations Branch (IB) to obtain the forensic exam results and police report pertaining to R1. On 04/08/2022, IB Investigator Sonia Sandoval received and reviewed forensic exam records from the Rape Treatment Center. Moreover, on 05/03/2022, IB Investigator Sonia Sandoval received and reviewed police report from Los Angeles Police Department (LAPD). After numerous attempts 1/21/2020 at 2:30pm , 3/16/2022 at 1:30pm, 4/21/2022 at 4:30pm, 4/23/2022 at 3pm,to contact S1, on 05/27/2022, between 2:30p.m. and 4:00p.m., LPA interviewed S1. Information gathered during the course of the investigation revealed that no current or former staff has ever witnessed S1 sexually abuse R1. The IB investigator’s review of the forensic exam records from the Rape Treatment Center revealed that on 04/05/2019, a forensic exam was conducted on R1, which resulted in no positive findings that a rape had occurred. Interview with a family member of R1 revealed that R1 was admitted into the hospital on approximately 04/05/2019, for an infection in their private area. The family member stated that hospital staff informed them that there was no physical evidence, such as abrasions or tissue damage on R1, to indicate that sexual abuse had occurred. Furthermore, hospital discharge records revealed there was not enough evidence to confirm that sexual abuse had occurred. Belmont Village Hollywood management, which included Executive Director and Human Resources conducted an internal investigation, which included interviewing sixteen (16) staff members who had worked with S1 and R1. Per records reviewed, facility internal investigation concluded on 04/19/2019. Additionally, a review of the internal investigation revealed that S1 denied all allegations of sexual abuse against R1. Based on all information gathered during the internal investigation facility was unable to substantiate the allegation. Furthermore, the IB Investigator’s review of LAPD police report revealed that R1 was unresponsive to LAPD officer’s questions during their investigation. The LAPD officer was informed by R1’s family member that due to R1’s diagnosis, R1 did not respond to anyone. The family member further revealed to the officer that R1 was admitted to the hospital due to an unusual discharge from R1’s private area. The report also indicated that approximately four (4) months ago, R1 was experiencing the same unusual discharge and treated for an infection. Continued from 9099-C S1 denied any sexual abuse had occurred with R1 while S1 was employed at this facility. Furthermore, S1 denied ever assisting R1 with the lights turned off in R1s room, and also denied ever being witnessed by any staff member, assisting R1 with the lights turned off in R1s room. Additionally, S1 provided a signed declaration denying any wrongdoing or sexual abuse against R1. Based on the information gathered during the course of the investigation, the Department does not have sufficient evidence to support the allegation that R1 was sexually abused by S1. Therefore, the above allegation has been deemed UNSUBSTANTIATED at this time. It was also alleged that there were two (2) staff who lacked a criminal record clearance and association to the facility that were working in the facility. The LPA’s record review of the employee files for S1 and Staff #2 (S2), revealed that both employees were cleared and associated to work at the facility, at the time of the investigation. The LPA record review of the Facility Personnel Report revealed that personal identifying information such as Date of Birth, Driver’s License and Social Security number for S1 and S2 matched what facility had on file for each employee. The LPA’s interviews with current and former staff revealed that S1 was the only employee with the name mentioned as an uncleared adult. Based on the interviews and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegation that there are ‘Uncleared Adult(s) working in the facility’. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Report issued and sent via email. Continued from 9099 LPA conducted a second subsequent visit; at which time, LPA conducted interviews with additional staff, former staff and a family member of R1. LPA also reviewed and obtained copies of additional documents pertinent to the investigation. Information gathered during the course of the investigation revealed that the first suspected sexual abuse/inappropriate behavior by Staff #1 (S1) was reported to the facility management on 06/29/2018. Additionally, a second allegation of sexual abuse/inappropriate behavior was reported on 10/04/2018. Records reviewed and interviews conducted revealed that the facility conducted an internal investigation regarding the alleged incidents between 06/29/2018 and 07/03/2018. However, facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) or Suspected Dependent Adult/Elder Abuse form (SOC341) to the all appropriate agencies for either of the above incidents. Based on all information gathered, the above allegation, “facility failed to meet reporting requirements” is deemed SUBSTANTIATED at this time. It was further alleged that facility staff failed to seek resident timely medical attention. It was reported that facility failed to obtain appropriate medical attention after the initial suspected sexual abuse allegation. Interviews conducted and records reviewed did not reveal any evidence that R1 was evaluated by any medical professional after the suspicions that R1 may have been sexually abused. Based on interviews and documentation obtained and reviewed, the Department has sufficient evidence to support the above allegation. Therefore, the above allegation that, ‘Facility staff failed to seek resident timely medical attention’ has been deemed SUBSTANTIATED at this time. It was further alleged that the facility failed to protect resident from harm. It was reported that after the suspected concerns regarding inappropriate behaviors was reported, management continued to let S1 assist R1. Information gathered during the course of the investigation revealed that concerns of possible sexual abuse/inappropriate behaviors was initially reported on 06/29/2018. Continued from 9099-C Records reviewed and interviews conducted revealed that the facility conducted an internal investigation regarding the alleged incidents between 06/29/2018 and 07/03/2018. The internal investigation conducted reflected that there was no indication that S1 was spending inappropriate time with any resident. However, management was to continue monitoring S1. A second allegation of sexual abuse/inappropriate behavior towards R1 by S1 was reported to management on 10/04/2018. Information gathered during the course of the investigation revealed that S1 was never reassigned to a different department, even though there was an allegation of sexual abuse/inappropriate behavior towards R1 by S1 on two different occasions. Furthermore, review of the employee file for S1 revealed that S1’s last day of onsite was 03/31/2019. Facility “Daily Check-in” logs further revealed that S1 was providing care and supervision to R1 up to 03/31/2019, which was nine months after the initial allegations. LPA interview with Executive Director revealed S1 was suspended on 4/5/2019, as the facility conducted an internal investigation for the sexual abuse allegation. Interview further revealed that S1 did not return to work for this facility at the conclusion of their investigation. Based on the information gathered, the Department does have sufficient evidence to support the above allegations. Therefore, the allegations that “facility failed to protect resident from harm” has been deemed SUBSTANTIATED at this time. Citations issued (please see 9099-D), appeal rights given, exit interview conducted. Report issued and sent via email.the state’s words, verbatim · CDSS document, Jun 27, 2022 · control 31-AS-20200117130958

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(c) · Plan of correction due date: Jun 28, 2022

87211(c) Reporting Requirements. Any suspected physical abuse that does not result in serious bodily injury... shall be reported...within twenty-four (24) hours. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as staff did not fulfill reporting requirements to appropriate parties, including Mandated Reporter requirements by reporting suspected abuse, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2022

Plan of correction: Licensee will review 87211 Reporting Requirements. Submit memo of understanding regarding reporting requirements, including Mandated Reporting, to CCL via email by COB 06/28/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jul 1, 2022

87465(a)(1) Incidental Medical and Dental Care. The Licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as Licensee did not arrange or assist in arranging for R1 to receive a medical examination after there were suspicions of sexual abuse, which poses as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2022

Plan of correction: Licensee will review 87465(a)(1) Incidental Medical and Dental Care. Submit memo of understanding regarding reporting requirements to CCL via email by COB 07/01/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(3) · Plan of correction due date: Jul 1, 2022

87468.1(3) Personal Rights of Residents in All Facilities. To be free from punishment, humiliation...interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as R1 was suspected to have been the victim of sexual abuse / inappropriate behaviors by S1 in 06/29/2018 , but S1 was still allowed to provide care and supervision towards R1 up until termination on 03/31/2019, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2022

Plan of correction: Licensee will review 87468.1(3) Personal Rights of Residents in All Facilities. Submit memo of understanding regarding reporting requirements to CCL via email by COB 07/01/2022.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) LaQueena Lacy & Gary Tan arrived at the facility at approximately 10:35am on 06/17/2022 to conduct a One (1) year Required Infection Control visit. LPAs meet with Adriana Sais and explained the purpose of this visit. The facility has an approved mitigation plan on file. A tour of the physical plant was conducted at 10:54am and the following was observed: The facility has a fire clearance for one hundred twenty-five (125) non ambulatory and twenty-five (25) bedridden with a hospice waiver for fifteen (15), and a dedicated Memory Care Unit equipped with approved delayed egress doors. The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE screening station is located at the receptionist desk upon entry equipped with sufficient PPE readily accessible, accushield thermometer and electronic sign in sheet, hand sanitizer, gloves, mask, at the time of visit. The facility maintains a temperature at 71 degrees Fahrenheit. The facility has fire extinguishers located throughout the facility to have a service tag dated 10/21/2021. The facility has four (4) floors, the 4th floor is currently occupying positive covid-19 residents, this area was observed to have the appropriate signage with PPE stations and trash cans located outside of the isolation rooms. The second floor is vacant and would be utilized for quarantining positive residents if necessary. Kitchen: At 11:04am LPAs observed the kitchen to be clean and free from obstruction. Appliances observed to be in good repair and functional. Sharps are stored inaccessible to residents which they do not have access to the kitchen. Refrigerated and frozen foods were stored at proper temperatures with sufficient amount of perishable and non-perishable food properly stored. LPAs observed the refrigerators and freezers to be stocked with a variety food. Continued on LIC809C. Bedrooms: At 11:21am LPAs were able to observe twelve (12) random rooms from the remaining floors that are not occupying positive covid-19 residents. All bedrooms observed to be appropriately furnished with sufficient lighting. LPAs observed appropriate bed linen and comforters on all beds. All bedrooms observed to be clean and clear from obstruction. Bathroom: At 11:21am LPAs observed (12) bathrooms located in the bedrooms. LPAs observed appropriate grab bars located in the shower and around the toilet. Non-skid mats are in the shower. The water temperature measured in range of 106.7 between 119.1 degrees Fahrenheit. Bathrooms are stocked and equipped with soap and paper towels. Hand towels are not shared. Medications: LPAs observed the Wellness Center at 11:46am located on the 3rd floor where the medication room is located observed to be storing medication in drawers with locks and cabinets. The medication drawers are locked and inaccessible to residents. The medication refrigerator is in another office located inside of the medication room to have a closed door and inaccessible to residents. The facility has two (02) first aid kits located in the medication room. LPAs observed (02) cabinets to be storing extra first aid supplies the second to be storing medications baskets filled with residents’ medications. There is also a bathroom located in the medication room not currently being used. Laundry Room: At 11:56am LPAs observed the laundry rooms located on each floor, observed to be clean and free from obstruction. These areas are accessible to residents to do their own laundry. Living, dining room and common areas: At 12:07pm LPAs observed these areas to be appropriately furnished with tables and chairs and adequate lighting to be neat and clean. The facility has a theater, a gym, a center for learning observed to be neat and clean and free from obstruction. LPAs observed multiple outdoor patio areas and the surrounding grounds of the facility which was clean and clear from debris and obstruction. These areas are equipped with owing and tables with chairs for seating and additional tables and chairs for lounging. At 12:37pm LPAs observed a Fire Department Fire Protection Equipment Performance Report with a retest dated 02/21/2021 with a passed result, the fire alarm system was tested and observed to be working, it is hard wired and interconnected throughout facility. The facility has fire sprinklers throughout the facility. The facility has a basement where the parking lot is located as well as an area fenced off that is storing PPE, incontinent supplies, wheelchairs, files, etc. which is inaccessible to residents. No bodies of water observed or located on the premises. No deficiencies cited, exit interview conducted, and a copy of report issued.the state’s words, verbatim · CDSS document, Jun 17, 2022

Allegation investigated: Toilet in disrepair

Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility on 03/30/2022 at 11:15am to conduct an initial 10 compliant visit. LPA Lacy met with Adriana Sais and explained the purpose of the visit. Physical Plant tour was conducted between 11:22am – 11:36am. It is alleged that the toilet is broken, and the resident cannot use it. To investigate the above allegation LPA conducted interviews with staff and residents at approximately 11:38am – 1:42pm. LPA requested copies of document relevant to the investigation at 11:36am. LPA spoke with eight (8) out of eighty-two (82) residents. Based on interviews seven (7) out of (8) resident would notify the front desk or S2 (Building Engineer) if any repairs needed to be done. Five (5) out of (8) residents feel that S2 responds to repair request quickly and in a timely manner. Three (3) out of (8) residents have not needed or had any repairs to their apartment. LPA observed nine (9) random rooms, all bathroom toilets were observed to be operational and functioning. During the investigation, S2 confirmed that a service request for room 311 was put in, S2 responded to the service request conducted an inspection and observed no malfunctions. Contiuned on LIC9099C Unsubstantiated A second request for the toilet was received, S2 inspected the toilet and observe a small amount of water on the floor, S2 contacted Homex Plumbing Rooter INC. LPA conducted a record review of Homex Plumbing Rooter INC, which S2 stated “was for the work performed on room 311's, toilet”. The work performed was for an easy turn emergency shutoff valve, and commercial pull/rest toilet. Based on interviews, observations, and record review, although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited, exit interview conducted, copy of report and appeal rights issued.the state’s words, verbatim · CDSS document, Mar 30, 2022 · control 31-AS-20220323080447

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) LaQueena Lacy conducted a subsequent Case Management visit, LPA arrived at the facility at 11:00am on 03/09/2022, regarding incident that occurred on 09/11/2021. LPA meet with Adriana Sais and explained the purpose of the visit. LPA conducted a physical plant tour at 11:12am. Woodland Hills South Adult and Senior Care Regional Office (WHASCRO) received an incident report involving the facility resident #1 (R1). Per Incident report on 09/11/2021, The nurse had given R1 an additional dose of a prescribed medication. On 12/23/2021 at 11:20am, LPA obtained documents relevant to the investigation. LPA conducted interviews with ED on 09/20/2021, and staff and R1 on 03/09/2022 between 11:51am and 2:24pm. Per ED, the nurse that administered the additional dose resigned from the position on 09/18/2021. ED admitted and Interviews confirmed that S1 administered an additional dose of a prescribed medication, and did not use the facility Accuflow computer system, that would tell staff exactly what medications are to be dispensed. During the investigation, upon record review of R1's facility file, medical records, and other relevant documents, R1 is to take the prescribed medication, one (1) tablet by mouth daily. R1 did not experience any complications due to the additional medication, and R1 was monitored on an hourly basis. Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit. See LIC 809-D. Exit interview conducted, copy of report and appeal rights issued.the state’s words, verbatim · CDSS document, Mar 9, 2022

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

87465(c)(2)Incidental Medical and Dental Care.If the resident's physician has stated in writing... facility staff designated by the licensee shall be permitted to assist the resident...Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on interviews and record review the Licensee did not ensure that Staff follow procedures when dispensing medications. This poses an immediate health and safety hazard to residents in carethe state’s words, verbatim · CDSS document, Mar 9, 2022

Plan of correction: Facility provided in service training for all medication dispensing staff regarding policy and procedures, medication management and three (3) check med pass. Proof of training was submitted during this visit. Citation cleared during visit.

Allegation investigated: Facility does not have hot water for the residents

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this facility to investigate the above allegation. LPA met with Executive Director Allyson Young and explained the reason for the visit. LPA conducted physical plant tour at around 9:45 AM, requested facility documents relevant to the investigation at 10:30 AM and interviewed staff and residents between 11:00 AM to 12:45 PM. It was alleged that there was no hot water in some residents' room. LPA interview with the Maintenance Engineer (ME) today at around 11:00 AM revealed that a certain section of the building has fluctuating hot water for about three (3) weeks now. LPA measured the water temperature at the affected section's rooms and measured at a range of 105.0°F to 115.0°F. Non-affected rooms were also measured at a range of 116.2°F to 119.8°F. Further interview with ME and Executive Director (ED) also revealed that they have called multiple plumbing companies to fix the problem to no avail, the hot water still fluctuates and they are continuously working on it to date. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA's interview with residents also revealed that they were offered to move to another room but did not want to so they were offered to use the vacant room's bathroom to shower or whatever they need it for, which some of the residents do. LPA's interview with the ED confirmed that they did offer not only to move or use vacant room's bathroom to shower but some compensation for the inconvenience. Based on the information gathered during this visit, the facility did what they supposed to and continue to do so to resolve the issue and offered alternative solutions to the affected residents, therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Feb 1, 2022 · control 31-AS-20220127100401

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced case management visit regarding the serious incident report that occurred 09/11/2021. At 11:00am LPA meet with Adriana Sais Director of Resident Services and explained the purpose of this visit. Upon meeting Adrianna LPA was informed that a staff member contacted the facility on 12/22/21 to notify of her positive test. Community Care Licensing had not yet been notified of the positive test, but the facility have notified California Department of Health of the positive Covid-19 employees. Mass testing for staff began on 12/22/21 and residents will began on 12/23/21. LPA requested and obtained documents relevant to the incident at 11:20am. Based on documents obtained LPA has determined that further investigation is required at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Dec 23, 2021

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit to deliver an immediate exclusion order to the facility on behalf of the Monterey Park Adult and Senior Care Office to this facility. LPA met with Adrianna Sais (Resident Services Director) and went over the Immediate Exclusion Order. Exit Interview conducted.the state’s words, verbatim · CDSS document, Aug 4, 2021